Multi-Drug Resistant (MDR) Gram-Negative Organisms Extended-Spectrum Beta-Lactamase (ESBL) Producing Organisms AmpC Beta-Lactamase Producing

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1 Approved by: Multi-Drug Resistant (MDR) Gram-Negative Organisms Extended-Spectrum Beta-Lactamase (ESBL) Producing Organisms AmpC Beta-Lactamase Producing Organisms Carbapenem-Resistant Organisms (CROs) Carbapenem-Resistant Enterobacteriaceae (CREs) Carbapenemase-Producing Organisms (CPOs), eg. Klebsiella pneumoniae carbapenamase (KPC), New Delhi Metallo-beta-lactamase (NDM), Verona Integron-mediated Metallo-betalactamase (VIM) Other MDR Gram-Negative Organisms eg. CR Pseudomonas/Acinetobacter spp; Burkholderia spp. Vice President & Chief Medical Officer Corporate Policy & Procedures Manual VI-20 Date Approved February 12, 2016 Next Review (3 years from Effective Date) March 2019 Purpose Policy Statement Applicability Responsibility To provide guidance in the management of patients with multi-drug resistant Gramnegative organisms, including but not limited to those that produce ESBLs, AmpC betalactamases, and carbapenemases in healthcare facilities. Covenant Health Infection Prevention & Control is committed to patient/resident/client¹ safety at all levels of the organization by supporting and promoting an environment that encourages infection prevention and control best practices in the care and management of patients colonized and/or infected with multi-drug resistant Gram-negative organisms. This policy and procedure applies to all Covenant Health facilities, staff, members of the medical staff, volunteers, students and any other persons acting on behalf of Covenant Health. Covenant Health health care providers* are responsible for creating and sustaining an environment that supports an infection control program that effectively prevents transmission and healthcare-associated infections due to multi-drug resistant Gramnegative organisms. Principles 1. Background Beta-lactamase producing organisms were first isolated in the mid 1980s in Europe and have since been recognized as important healthcare-associated pathogens. Beta-lactamases are enzymes produced by Gram-negative bacteria (eg. Klebsiella pneumoniae, Escherichia coli) that break down certain antibiotics, rendering them useless and thus limiting treatment options. Risk factors for infection or colonization with beta-lactamase producing organisms include long term antibiotic exposure, prolonged ICU stay, severe illness, instrumentation or catheterization, and residents of long term care facilities. ¹Hereafter, all references to patients includes residents and clients. * see Definitions

2 VI-20 Page 2 of 9 Carbapenem-resistant organisms (CROs) were uncommon in North America until recently. Like beta-lactamases, carbapenemases are an enzyme produced by Gram-negative bacteria. CROs are problematic given the frequency in which they cause infections. A high mortality rate is associated with CRO infections. Risk factors for infection or colonization with a CRO are the same as those listed above for beta-lactamases but also include cross-border movement of patients due to travel, medical tourism and/or being a refugee. There are three classes of acquired carbapenemases found in Enterobacteriaceae, Pseudomonas species (spp.) and Acinetobacter spp. CROs may also be referred to as CPOs (Carbapenemase-producing organisms) or CREs (Carbapenem-resistant Enterobacteriaceae). New Delhi Metallo-beta-lactamase-1 was first described in 2009 in patients who had received medical care in New Delhi. Since then, most cases found outside of the Indian sub-continent have been linked to patients receiving medical care or cosmetic surgery in that region. NDM-producing organisms continue to spread throughout the world as people travel from country to country. Although most of the NDM-producing genes are found in Enterobacteriaceae this carbapenemase has also been reported from Acinetobacter spp, and in rare cases Pseudomonas aeruginosa. Most NDM-producing Gram-negative organisms are also resistant to most other antibiotics due to acquisition of other drug resistant genes on the NDM carrying plasmid. 2. Precautions Required The primary mode of transmission of multi-drug resistant Gram-negative organisms is via the hands of health care providers and on contaminated equipment (direct and indirect contact). Acute Care: Contact precautions are required at all times. Continuing Care: Additional precautions are required as per assessment of the risk of transmission (refer to #5 below, Personal Protective Equipment) and should be discussed with the infection control practitioner or designate. 3. Hand Hygiene Guidelines Refer to Corporate Policy# VI-10, Hand Hygiene. 4. Patient Hygiene Acute Care: Linen must be changed daily for all patients on Additional Precautions. o All patients on Additional Precautions must be bathed daily using soap and water or pre-packaged rinseless bathing washcloths (eg. Sage, etc.) Continuing Care: Linen must be changed on shower/bath day and as needed. o At minimum, resident personal hygiene must be maintained daily, i.e., wear fresh clean clothes daily, as needed pericare, daily bathing with soap and

3 VI-20 Page 3 of 9 water or pre-packaged rinseless bathing washcloths. Patients must have access to appropriate hand hygiene agents. 5. Personal Protective Equipment (PPE) Perform a Point of Care Risk Assessment (PCRA)* (see Related Documents section). Prior to every patient interaction, health care providers have a responsibility to assess the infectious risk posed to themselves, other patients, visitors, and other health care providers by a patient, situation or procedure. Acute Care: Contact precautions must always be followed in addition to routine practices. At a minimum, non-sterile gloves and an isolation gown must be worn when entering the patient s environment. Continuing Care: Routine Practices must always be followed. When a resident has been assessed as requiring Additional Precautions, follow the recommendations for the specific Additional Precaution (i.e. Contact Precautions). PPE is single-use only. When non-sterile gloves are used, hand hygiene must be performed prior to removing a pair from the box. 6. Communication of Additional Precautions Place contact precautions sign on the door and have personal protective equipment outside the room. Communication of a positive multi-drug resistant Gram-negative organism should be placed on the chart and care plan, or other appropriate location (but NOT on the patient s room door), in order to alert staff of the need for contact precautions in addition to routine practices. Additional Precautions must be followed by all persons entering the patient s room. Refer to sign on door for further information. Receiving unit / department / facility must be notified of the Additional Precautions required. 7. Accommodations Single room preferred; door may remain open. If a single room is unavailable, patients should ideally be at least two metres

4 VI-20 Page 4 of 9 (i.e., 6.6 feet) apart. If unable to keep patients two meters apart, separate patients with the greatest available distance allowed within the room space. The multi-drug resistant Gram-negative positive patient should have dedicated toileting facilities, i.e., commode chair or private bathroom, if available. Acute Care: The multi-drug resistant Gram-negative positive patient must be placed on Additional Precautions. Continuing Care: The multi-drug resistant Gram-negative positive resident must be assessed for Additional Precautions. Patients with the same strain of multi-drug resistant Gram-negative organism may be grouped together (cohorted) only with direction and approval from Infection Prevention & Control. When patients are cohorted, separate additional precautions must be maintained on each patient in the same room and with each patient encounter. Dedicated toileting facilities are also recommended, i.e., commode chair or private bathroom, if available. 8. Roommate Contacts Acute Care: When a patient has been identified to be colonized and/or infected with a multi-drug resistant Gram-negative organism: o Place any roommate who has been sharing a space with the patient identified with the multi-drug resistant Gram-negative organism for any length of time on Contact Precautions, and call Infection Prevention & Control for further instructions regarding need to screen roommate(s) and/or duration of contact precautions. o Separate additional precautions must be maintained on each patient in the same room with each patient encounter. Continuing Care: To be assessed on a case by case basis. 9. Equipment and Supplies Use single-use items whenever possible or dedicate non-critical patient care items (eg. blood pressure cuffs and stethoscopes) to a single patient when they are known to be colonized or infected with multi-drug resistant Gram-negative organisms. If it is not possible to dedicate equipment, patient items must be thoroughly cleaned and disinfected between uses with hospital-approved disinfectant. Minimize supplies taken into the patient s room. 10. Waste and Laundry Acute Care: Soiled laundry bag/bin must be located inside the patient s room.

5 VI-20 Page 5 of 9 Continuing Care: Soiled laundry bin/bag must be located as close to the point of use, as feasible Waste/garbage should be discarded into the general waste. Double-bagging for waste or laundry is not required unless the bag is leaking. Disposable meal trays are not required. 11. Environmental Cleaning Thorough routine daily cleaning is required with hospital approved detergent/ disinfectant as per Covenant Health or facility policy/procedure. Terminal cleaning of patient room is required when precautions are discontinued, as well as on discharge or transfer of the patient. 12. Patient Transport and Moving Within Acute Care Site Patient should remain in room unless essential medical/diagnostic/rehabilitative services are warranted. If patient leaves room: o does not need to wear gloves but must perform hand hygiene o should wear a clean hospital housecoat o must have all wounds covered. Alert receiving unit/department that patient is colonized and/or infected with a multi-drug resistant Gram-negative organism and Additional Precautions are required. It is recommended that the patient be accompanied by a health care provider. Health care provider transporting the patient must wear a gown and gloves. 13. Resident Flow/Activity in Continuing Care Resident may leave room with the following stipulations: o Must perform hand hygiene o Must be wearing clean clothing o If incontinent, must be wearing an incontinence product o Must have all wounds covered Instructions/Assistance should be provided to patient and documented regarding hand hygiene following toileting and prior to leaving the room.

6 VI-20 Page 6 of 9 Resident participation in group/recreational activities should not be restricted unless the resident is non-compliant with hand hygiene and/or personal hygiene, incontinent and/or wound drainage cannot be contained. 14. Patient Transport and Moving Outside Facility Information about the patient being colonized and/or infected with a multi-drug resistant Gram-negative organism and that Additional Precautions are required must be communicated directly to transport personnel and staff on the unit at the receiving site. If patient is attending an appointment, request that the patient be seen promptly so minimal time is spent in public waiting areas. 15. Acute Care Screening for Multi-Drug Resistant Gram-Negative Organisms Admission screening must be conducted as per the Covenant Health Antibiotic- Resistant Organism (ARO) Admission and Pre-Admission Screening and Testing Form (Acute Care/Acute Rehabilitation). In some instances screening for multidrug resistant Gram-negative organisms (i.e., CROs, etc.) may be required on admission at the discretion of Infection Prevention & Control. Screening for multi-drug resistant Gram-negative organisms may also be conducted at the discretion of care providers or when advised by Infection Prevention & Control. 16. Continuing Care Screening for Multi-Drug Resistant Gram-Negative Organisms Screening for multi-drug resistant Gram-negative organisms may be conducted when advised by Infection Control Professional (ICP) in discussion with the care providers. 17. Frequency of Screening for Positive Cases Routine screening not required. As per Infection Control Professional (ICP) request. 18. Documentation Communication that a patient is colonized and/or infected with a multi-drug resistant Gram-negative organism should be placed on the chart and care plan, or other appropriate location (but NOT on the patient s room door), in order to alert staff to Routine Practices and Additional Precautions (if required).

7 VI-20 Page 7 of 9 Document all education provided to the patient and family regarding multi-drug resistant Gram-negative organisms, hand hygiene and personal protective equipment. 19. Discontinuation of Precautions Contact precautions may only be discontinued in consultation with and under the order of Infection Prevention & Control. At present, there is minimal to no evidence to guide removal of precautions on patients colonized and/or infected with multi-drug resistant Gram negative organisms. As such, each case requires a case-by-case risk/benefit evaluation. Guidelines from the Public Health Agency of Canada recommend contact precautions for at least one year (quality of evidence: poor). 20. Patient Teaching Patients should be educated on the importance of performing hand hygiene. If patients are unable to mobilize to a sink, hand washing may be accomplished with a soapy wash cloth or alcohol-based hand rub (ABHR). All education regarding personal protective equipment, hand hygiene and multidrug resistant organisms provided to the patient/family must be documented in the patient record. Definitions Health care professional means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act [Alberta] or the Health Professions Act [Alberta], and who practices within scope and role. Health care provider means any person who provides goods or services to a patient, inclusive of health care professionals, staff, students, volunteers and other persons acting on behalf of or in conjunction with Covenant Health. Point of Care Risk Assessment (PCRA) an evaluation of the risk factors related to the interaction between a health care provider, the patient and the patient s environment to assess and analyze potential for exposure to infectious agents and identify risks for transmission. Related Documents The following resources are Covenant Health Corporate Policy #VI-10, Hand Hygiene Covenant Health Infection Prevention & Control Posters: Personal Protective Equipment Putting on (Donning) Personal Protective Equipment - Detailed Taking off (Doffing) Personal Protective Equipment - Detailed Covenant Health Corporate Policy# VI-10, Hand Hygiene.

8 VI-20 Page 8 of 9 Covenant Health Infection Prevention & Control Patient/Resident Teaching Materials: Beta-Lactamase Producing Organisms: Extended Spectrum Beta-Lactamase Producing Organisms, Carbapenemase-Resistant Enterobacteriaceae, and Amp C Beta-Lactamase Producing Organisms Frequently Asked Questions about Isolation Precautions Covenant Health Infection Prevention & Control Information for Staff: Beta-Lactamase Producing Organisms: Extended Spectrum Beta-Lactamase Producing Organisms, Carbapenemase-Resistant Enterobacteriaceae, and Amp C Beta-Lactamase Producing Organisms Covenant Health Infection Prevention & Control Additional Precautions Toolkits: Multi-Drug Resistant Gram-Negative Organisms Toolkit Covenant Health Infection Prevention & Control Routine Practices: Point of Care Risk Assessment Covenant Health IPC Diseases & Conditions Table: Recommendations for Management of Acute Care Recommendations for Management of Continuing Care Covenant Health Infection Prevention & Control Continuing Care Resource Manual: Clinical Care Admission Screening for ARO s Clinical Care ARO s Covenant Health Antibiotic Resistant Organisms Admission and Preadmission Screening and Testing Form Acute Care/Acute Rehabilitation Covenant Health Targeted MRSA/VRE Screening for Continuing Care Residents form Covenant Health Infection Prevention & Control Best Practice Guidelines: Patients/Residents on Additional Precautions Participation in Group Therapies: Occupational, Physical and Recreational References 1. Alberta Health Services IPC Surveillance Committee (2012). Provincial surveillance of Carbapenem-resistant organisms (CROs) (i.e., carbapenemase-producing organisms only) surveillance protocol. 2. Centers for Disease Control & Prevention (2009). Guidance for control of infections with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in acute care facilities. MMWR 58: Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE): 2012 CRE Toolkit (2012). Retrieved October 20, 2012 from: 4. Levy Hara, G., Gould, I., Endimiani, A., Ramon Pardo, P., et. al. (2013). Detection, treatment and prevention of carbapenemase-producing Enterobacteriaceae:

9 VI-20 Page 9 of 9 Revisions February 6, 2012 November 1, 2011 November 3, 2010 Recommendations from an International Working Group. Journal of Chemotherapy, 25 (3), Miller, D. (2014). Enterobacteriaceae. In APIC (Association for Professionals of Infection Control and Epidemiology) Text. Retrieved October 15, 2015 from: 6. Public Health Agency of Canada (PHAC) (2013). Routine practices and additional precautions for preventing the transmission of infection in healthcare settings. Retrieved October 20, 2015 from: 7. Provincial Infectious Diseases Advisory Committee (PIDAC) (2013). Annex A: Screening, testing and surveillance for antibiotic-resistant organisms (AROs) in all health care settings. Retrieved October 20, 2015 from: IPC_Annex_A_Screening_Testing_Surveillance_AROs_2013.pdf 8. Provincial Infectious Diseases Advisory Committee (PIDAC) (2012). Routine practices and additional precautions. Retrieved October 20, 2015 from: 12.pdf 9. Public Health Agency of Canada (PHAC, 2010). Guidance: Infection Prevention and Control Measures for Healthcare Workers in All Healthcare Settings: Carbapenemresistant Gram-negative Bacilli. Retrieved October 20, 2015 from: