Manitoba Guidelines for the Prevention and Control of Antibiotic Resistant Organisms (AROs)

Transcription

1 Manitoba Guidelines for the Prevention and Control of Antibiotic Resistant Organisms (AROs) January 2007 COMMUNICABLE DISEASE CONTROL

2 Methicillin-Resistant Staphylococcus Aureus (MRSA) Infection Control Guidelines for Manitoba were prepared by the MRSA Working Group. The document was approved by the Manitoba Advisory Committee on Infectious Diseases (MACID) on October 17, Revisions to the original document were made in 1998 by the MRSA Working Group and approved by the Manitoba Advisory Committee on Infectious Diseases (MACID) on February 18, Manitoba Infection Control Guidelines for Preventing the Spread of Vancomycin-Resistant Enterococci (VRE) were prepared by the VRE Working Group. The document was approved by the Manitoba Advisory Committee on Infectious Diseases (MACID) on June 19, The Manitoba Guidelines for the Prevention and Control of AROs (2006) will replace the existing Methicillin- Resistant Staphylococcus Aureus (MRSA) Infection Control Guidelines for Manitoba, 1999, and the Manitoba Infection Control Guidelines for Preventing the Spread of Vancomycin-Resistant Enterococci (VRE), These new guidelines were developed by the MACID Antibiotic Resistant Organism (ARO) Subcommittee. The ARO Subcommittee reports to the MACID Infection Control Subcommittee. The MACID Infection Control Subcommittee reports to the Manitoba Advisory Committee on Infection Diseases (MACID). This document was approved by the Manitoba Advisory Committee on Infectious Diseases (MACID) on June 15, The management of AROs continues to evolve, therefore, this guideline will be a working document with updates and revisions when current scientific evidence and literature require changes. The Winnipeg Regional Health Authority (WRHA) approved the inclusion of Routine Practices, Additional Precautions and Teaching Tools from their Infection Control Guidelines for the Management of Respiratory Infections. We would like to thank WRHA for their approval. The chair of the ARO Subcommittee Brenda Dyck, Program Director, Infection Prevention and Control WRHA Membership: Dr. Michelle Alfa Clinical Microbiologist, Microbiology Laboratory, St. Boniface General Hospital, Diagnostic Services of Manitoba Yvette Buchanan Infection Prevention and Control Grace General Hospital Joanne Diakiw Occupational & Environmental Safety & Health WRHA, Dr. John Embil Medical Director Infection Prevention and Control Program WRHA Nancy Gates Communicable Disease Co-ordinator WRHA Krystina Holota Infection Prevention and Control Concordia General Hospital Leslie Klass Infection Prevention and Control St. Boniface General Hospital Daria McLean Director of Services, Occupational & Environmental Medicine DOEM Health Sciences Centre Kathy Mestery Communicable Disease Control Manitoba Health, Dr. Lindsay Nicolle Infectious Disease Physician University of Manitoba Faye Penner Infection Prevention and Control Deer Lodge Centre, Dr. Pierre Plourde Medical Officer of Health WRHA Betty Taylor Manager, Personal Care Home Program, Infection Prevention and Control WRHA Genevieve Thompson Senior Infection Control Practitioner, Manitoba Health, Chair MACID Infection Control Subcommittee Ilana Warner Infection Prevention and Control Seven Oaks General Hospital i

3 Table of Contents I. Definitions 1 II. Introduction, Background, Epidemiology 4 III. Routine Practices and Additional Precautions 9 A. Routine Practices 9 1. Hand Hygiene Important Factors in Hand Hygiene When to Perform Hand Hygiene Patient, Visitor and Family Agents Used for Hand Hygiene Personal Protective Equipment Gloves Gowns Masks Eye Protection Goggles and Face Shield Accommodation Equipment Environmental Control/Housekeeping Specimen Collection Dishes Linen Waste Sharps 12 B. Additional Precautions Contact Precautions Additional Precautions for Acute Care and Surgical Centres Accommodation Gloves Gowns Hand Hygiene Equipment and Environment Patient Transport Patient and Family Teaching Visitors Additional Precautions for Long Term Care, Interim Care and Hospice 14 Affiliated with a Health Care Institution 2.1 Contact Precautions Accommodation Gowns/Gloves Hand Hygiene Equipment and Environment 15 ii

4 3. Infection Control Guideline Websites Public Health Agency of Canada Guidelines Centres for Disease Prevention and Control (CDC) Guideline Website Manitoba Health Communicable Disease Control (CDC) Unit Website Community and Hospital Infection Control Association (CHICA) Canada 15 IV. Notification and Reporting 16 A. Communication/Information 16 V. Education and Training of Health Care Workers 17 A. Education and Training 17 B. Information Sheets 17 VI. Education of Families and Visitors 18 A. Education 18 VII. ARO Infection Control Guidelines for Acute Care, Surgical Centres, Long Term Care 19 Facilities (LTCFs), Interim Care Units and Hospice Affiliated with a Health Care Institution A. MRSA Guidelines for Acute Care Facilities and Surgical Centres Identification/Notification of MRSA Surveillance Cultures Flagging/Deflagging of Patient Health Record Admission Screening Additional Precautions Patient Placement and Cohorting Hand Hygiene Gowns/Gloves/Masks/Eye Protection Equipment Linen/Dishes Needles/Syringes Lab Specimens Waste Disposal Environmental Control/Housekeeping Patient Health Record Personal Documents, e.g., Wills, Paneling Papers, Voting Duration of Infection Control Precautions Post Mortem Care Treatment or Decolonization Subsequent Cultures for Persistent Carriage Management of Contacts Diagnostic Procedures/Transfer of Patients Within the Facility Management of MRSA Positive Patient in the Operating Room Discharge/Transfer between Facilities Home Visits/Passes with Health Care Worker Companion or Family Visitors Including any Hospitalized Patients Visiting a Positive Patient Positive Patient Visiting other Patients 25 iii

5 15. Outpatient Service Patients Requiring Physical Rehabilitation Management of MRSA Positive Patients on Rehabilitation Units Management of MRSA Positive Psychiatry Patients on Psychiatry Units Outbreak Management Surveillance 26 B. VRE Guidelines for Acute Care Facilities and Surgical Centres Identification/Notification of VRE Surveillance Cultures Flagging/Deflagging of Patient Health Record Admission Screening Additional Precautions Patient Placement and Cohorting Hand Hygiene Gowns/Gloves/Masks/Eye Protection Equipment Linen/Dishes Needles/Syringes Lab Specimens Waste Disposal Environmental Control/Housekeeping Patient Health Record Personal Documents, e.g., Wills, Paneling Papers, Voting Duration of Infection Control Precautions Post Mortem Care Treatment or Decolonization Subsequent Cultures for Persistent Carriage Management of Contacts Diagnostic Procedures/Transfer of Patients Within the Facility Management of VRE Positive Patient in the Operating Room: Discharge/Transfer between Facilities Home Visits/Passes of Hospitalized Patient with Health Care Worker 32 Companion or Family 13. Visitors Including any Hospitalized Patients Visiting a Positive Patient Positive Patient Visiting other Patients Outpatient Service Patients Requiring Physical Rehabilitation Management of VRE Positive Patients on Rehabilitation Units Management of VRE Positive Psychiatry Patients on Psychiatry Units Outbreak Management Surveillance 33 iv

6 C. MRSA Guidelines for Long Term Care Facilities (LTCFs), Interim Care Units 34 and Hospice Affiliated with a Health Care Institution 1. Identification/Notification of MRSA Surveillance Cultures Flagging/Deflagging of Resident Record Admission Screening Additional Precautions Resident Placement, Cohorting and Activities Hand Hygiene Gowns/Gloves/Masks/Eye Protection Equipment Linen/Dishes Needles/Syringes Lab Specimens Waste Disposal Environmental Control/Housekeeping Resident Health Record and Personal Documents, e.g., Wills, Voting Duration of Additional Precautions Post Mortem Care Treatment or Decolonization Subsequent Cultures for Persistent Carriage Management of Contacts Diagnostic Procedures/Transfer of Residents Within the Facility Discharge/Transfer Between Facilities Home Visits/Passes with Health Care Worker Companion or Family Visitors including any Residents Visiting a Positive Resident Positive Resident Visiting Other Residents Management of MRSA Positive Residents on Rehabilitation Units Management of MRSA Positive Residents on Psychiatry Units Outbreak Management Surveillance 37 D. VRE Guidelines for Long Term Care Facilities (LTCFs), Interim Care Units 38 and Hospice Affiliated with a Health Care Institution 1. Identification/Notification of VRE Surveillance Cultures Flagging/Deflagging of Resident Record Admission Screening Additional Precautions Resident Placement, Cohorting and Activities Hand Hygiene Gowns/Gloves/Masks/Eye Protection Equipment 39 v

7 5.5 Linen/Dishes Needles/Syringes Lab Specimens Waste Disposal Environmental Control/Housekeeping Resident Health Record and Personal Documents, e.g., Wills, Voting Duration of Infection Control Precautions Post Mortem Care Treatment or Decolonization Subsequent Cultures for Persistent Carriage Management of Contacts Diagnostic Procedures/Transfer of Residents Within the Facility Discharge/Transfer Between Facilities Home Visits/Passes with Health Care Worker Companion or Family Visitors including any Residents Visiting a Positive Resident Positive Resident Visiting Other Residents Management of VRE Positive Residents on Rehabilitation Units Management of VRE Positive Residents on Psychiatry Units Outbreak Management Surveillance 41 E. Antibiotic Resistant Gram Negative Bacilli including Extended Spectrum Beta 42 Lactamase (ESBLs) Guidelines for Acute Care, Surgical Centres, Long Term Care Facilities (LTCFs), Interim Care Units and Hospice Affiliated with a Health Care Institution 1. Identification and Notification of Antibiotic Resistant Gram Negative Bacilli Flagging and Deflagging of Patient Record Admission Screening Additional Precautions Acute Care Facilities and Surgical Centres Long Term Care Facilities, Interim Care Units and Hospice 42 Affiliated with a Health Care Institution 4.3 Other Infection Control Management Practices 43 F. Vancomycin-Intermediate and Resistant Staphylococcus aureus (VISA/VRSA) 44 Guidelines for Acute Care, Surgical Centres, Long Term Care Facilities (LTCFs), Interim Care Units and Hospice Affiliated with a Health Care Institution VIII. ARO Infection Control Guidelines for Community Care 45 A. General Information 45 B. Transfers of ARO Colonized or Infected Clients To or From Facilities 45 C. Home Care Admission Home Arrangements Client Activities Hand Hygiene 45 vi

8 5. Personal Protective Equipment (PPE) Dishes, Glasses, Cups and Eating Utensils Laundry Garbage Cleaning Requirements Clients Care Equipment and Supplies Bathing 47 D. Group Homes for the Physically and Mentally Challenged 47 E. Doctors Offices/Outpatient Clinics/Dental Offices/Travel Clinics 47 F. First Responders 48 G. Community (Workplace, School, Daycare, Shelters, Hospice) 48 H. Community-associated MRSA (CA-MRSA) 48 IX. Occupational Health 51 A. MRSA Health Care Worker is Exposed to MRSA Health Care Worker is Colonized or Infected with MRSA Occupational Management of Health Care Worker in Outbreak Situation 52 B. VRE Health Care Worker is Exposed to VRE Health Care Worker is Colonized or Infected with VRE Occupational Management of Health Care Worker in Outbreak Situation 52 C. Other AROS 53 D. Public Health Agency of Canada Website for Occupational Health (PHAC) Guidelines 53 X. Appendix A. Steps for Outbreak Management 54 B. Fact Sheets Methicillin Resistant Staphylococcus Aureus (MRSA) 57 Fact Sheet for Health Care Workers Vancomycin Resistant Enterococci (VRE) 59 Fact Sheet for Health Care Workers Extended Spectrum Beta Lactamase producing Bacteria (ESBLs) 61 Fact Sheet for Health Care Workers Vancomycin Intermediate Staphylococcus Aureus (VISA) and 63 Vancomycin Resistant Staphylococcus Aureus (VRSA) Fact Sheet for Health Care Workers Methicillin Resistant Staphylococcus Aureus (MRSA) 65 Fact Sheet for Patient, Resident, Family and Visitors Vancomycin Resistant Enterococci (VRE) 67 Fact Sheet for Patient, Resident, Family and Visitors Extended Spectrum Beta Lactamase producing Bacteria (ESBLs) 69 Fact Sheet for Patient, Resident, Family and Visitors Vancomycin Intermediate Staphylococcus Aureus (VISA) and 71 Vancomycin Resistant Staphylococcus Aureus (VRSA) Fact Sheet for Patient, Resident, Family and Visitors vii

9 Testing for Methicillin Resistant Staphylococcus aureus (MRSA) 73 Fact Sheet for Patient and Family Testing for Vancomycin Resistant Enterococci (VRE) 74 Fact Sheet for Patient and Family C. Guidelines for Specimen Collection: Specimen Collection from Nares Procedure Specimen Collection for Wounds Procedure Specimen Collection for Rectum/Ostomy Procedure Nares and Rectal Specimen Collection Pictures 75 D. Routine Practices Hand Hygiene Quick Reference Chart Hand Hygiene Procedure Alcohol-Based Handrub Hand Hygiene Procedure Plain or Antimicrobial Soap 78 E. Additional Precautions Contact Precautions Procedures and Sign Donning Personal Protective Equipment Procedure Removal of Personal Protective Equipment Procedure Donning Personal Protective Equipment Sign Removing Personal Protective Equipment Sign Contact Precautions Sign (English) Contact Precautions Sign (Bilingual) 83 F. Surveillance Forms MRSA/VRE Screening Line Listing ARO Patient/Resident Management Form ARO Definitions MRSA VRE ESBL VISA/VRSA 90 G. Sample Letter Physician Notification of ARO 92 H. Transfer/Referral Form 93 I. Infection Control Guidelines for Health Care Workers in the Community, 95 Manitoba Health X1. References 97 viii

10 I. Definitions Additional Precautions Infection control precautions and practices required in ADDITION to Routine Practices. They are determined by the mode of transmission of selected microorganisms or clinical presentation. Administrative Controls Administrative controls include the development and adoption of policies and procedures that support Engineering Controls, e.g., negative pressure rooms to accommodate suspected or confirmed respiratory tuberculosis cases, the use of Work Practices, e.g., immunization of health care workers and personal protective equipment. Alcohol-Based Handrub An alcohol-based antiseptic with a minimum of 60 per cent alcohol that is applied to all surfaces of the hands to reduce the number of microorganisms present on the hands. Antibiotic Resistant Organism (ARO) A microorganism that has become resistant to commonly used antibiotics that have been used to inactivate it, e.g., MRSA, VRE. ARO Positive (MRSA, VRE, ESBL, VISA/VRSA) An individual who is positive for an Antibiotic Resistant Organism (ARO). ARO Suspect (MRSA, VRE, ESBL, VISA/VRSA) An individual who is exposed to an ARO case and will require surveillance cultures, e.g. roommate, ward contact. Cleaning The physical removal of foreign material, e.g. dust, soil, organic material such as blood, secretions, excretions and microorganisms. Cleaning physically removes rather than kills microorganisms. It is accomplished with water, detergents and mechanical action. Client Those individuals who receive care in the community. Cohorting Two or more individuals colonized or infected with the same ARO organism, placed/roomed to minimize their contact with other unaffected individuals on the same unit. Colonization The presence, growth and multiplication of an organism in or on a body site without signs or symptoms of infection. Colonized Individual who is positive for an ARO and has no signs and symptoms of infection caused by the organism. Contact An individual who may be exposed to an ARO case in which transmission can occur. Contact Precautions Precautions and practices that include single room or at least one metre between beds in multipatient/ resident rooms, with health care workers wearing gown and gloves for interactions that involve contact with the infected individual or their environment. Decolonization Therapy Topical and/or systemic antibiotic treatment administered for the purpose of eliminating ARO carriage in an individual. Dedicated Clean Person A dedicated individual who does not wear personal protective equipment and who assists during a procedure but does not have contact with the patient or any contaminated items. Deflagging A system to remove ARO status, e.g. VRE Positive, MRSA suspect, from the health record. Engineering Controls Engineering controls decrease health care workers exposure to the hazard by reducing the hazard at the source, e.g. negative ventilation pressure with 1

11 exhaust to the outside in a room for a person with tuberculosis, safety engineered needles. ESBL (Extended Spectrum Beta Lactamase) An enzyme produced by some species of enteric gram negative bacilli. ESBL has the ability to inactivate a wide range of beta-lactam antibiotics including penicillins and cephalosporins. ESBL Positive An individual who is positive for an Extended Spectrum Beta Lactamase (ESBL). ESBL Suspect An individual who is exposed to an individual positive for an Extended Spectrum Beta Lactamase and will require surveillance cultures, e.g. roommate, ward contact. Facility Includes any health care institution that cares for patients or residents, such as hospitals, personal care homes, day surgical centres and other health care agencies such as Cancer Care Manitoba. Facility Approved Disinfectant A disinfectant cleaner that has been approved by the facility or organization. Flagging A system using specific terminology to highlight information on a patient record, e.g. VRE Positive, MRSA Suspect. Hand Hygiene A general term that applies to handwashing, antiseptic handwash, antiseptic handrub, or surgical hand antisepsis. Handwashing The process of washing hands with soap (plain or antimicrobial) and water. Health Care Worker An individual who provides care to patients/ residents/clients in the health care workplace, e.g. nurses, physicians, allied health workers, emergency responders. Hospice A program that provides palliative care for terminally ill individuals. This can occur in an inpatient facility, special hospice facility affiliated with a health care institution or in the community. Infected An individual who is ARO positive and shows signs and symptoms of infection caused by that organism. Infection Tissue invasion by an organism with multiplication and overt signs and symptoms of infection (fever, increased white blood cell count, purulence, inflammation, etc.). Infection Control Precautions This includes Routine Practices and Additional Precautions. Infection Prevention and Control Infection Control and Infection Prevention and Control are used through out this document and represent each other. Interim Care Care in a residential or nursing home bed which is offered to a hospital patient who is fit and stable for discharge from his/her hospital bed but the placement/care package to support his/her long-term care is not immediately available. Isolation The physical separation of infected/colonized individuals from those uninfected for the period of communicability of a particular disease MRSA (Methicillin Resistant Staphylococcus aureus) Strains of S. aureus that are resistant to oxacillin, cloxacillin and cephalosporins. Some of these strains may also be resistant to aminoglycosides, erythromycin, quinolones and other antibiotics. MRSA Positive An individual who is positive for Methicillin Resistant Staphylococcus aureus (MRSA). MRSA Suspect An individual who is exposed to an individual positive for Methicillin Resistant Staphylococcus aureus (MRSA) and will require surveillance cultures, e.g. roommate, ward contact. Occupational Health Work Practices Occupational Health work practices include those actions intended to decrease the risk of health care worker s exposure to infection and disease. Outbreak of an ARO The occurrence of AROs with a frequency clearly in excess of normal expectancy. The number of cases indicating presence of an ARO outbreak will vary 2

12 according to the type of ARO, size and type of population exposed, previous experience or lack of exposure to the disease, and time and place of occurrence. Therefore, the status of an ARO outbreak is relative to the usual frequency of the disease in the same facility/area, among the same population, of an ARO. If an ARO outbreak is suspected, Pulse Field Gel Electrophesis (PFGE) microbiological testing should be done to determine the relatedness of the organisms. Patient An individual who receives care in a hospital or surgical centre. Personal Protective Equipment (PPE) Gloves, gowns, masks and protective eyewear are barriers used according to risk of exposure to prevent transmission. Resident An individual who resides in a long-term care facility/or interim care unit. Reusable Equipment (Non-critical) Patient/resident/client care equipment that can be reused on another patient/resident/client that either touches only intact skin, but not mucous membranes or does not directly touch them. Reprocessing of these items involves cleaning and/or low level disinfection with facility approved disinfectant, e.g. commode. Routine Practices A set of infection control precautions and practices used for all direct care regardless of their presumed infection status or diagnosis. Screening/Surveillance Cultures Cultures done in attempt to identify an ARO in an individual with risk factors for acquisition of the organism. Surgical Centre Out of hospital surgical center that performs surgery, usually day surgery. Terminal Cleaning Thorough cleaning of all surfaces and equipment within a room with facility approved disinfectant. This will include spot cleaning of visible soil on walls and removal of privacy curtains. VRE (Vancomycin Resistant Enterococci) Enterococci that have acquired resistance to vancomycin, the drug of choice for treating multidrug resistant enterococci infections. VRE Positive An individual who is positive for Vancomycin Resistant Enterococci (VRE). VRE Suspect An individual who is exposed to an individual positive for Vancomycin Resistant Enterococci and will require surveillance cultures, e.g., roommate, ward contact. VISA/VRSA VISA: Vancomycin intermediate S. aureus (also referred to as GISA; glycopeptides intermediate S. aureus). These isolates have a vancomycin MIC of 8 16 ug/ml. VRSA: Vancomycin resistant S. aureus. These isolates have a vancomycin MIC > 32 ug/ml. All the terms above are used to describe S. aureus strains with reduced susceptibility to vancomycin. S. aureus isolates that have a vancomycin MIC > 4ug/ml should be saved and sent to a reference lab (Cadham Provincial Laboratory and/or the National Microbiology Laboratory) for confirmatory testing. Visibly Soiled Hands Hands showing visible dirt or visibly contaminated with proteinaceous material, blood or other body fluids, e.g. fecal material or urine. 3

13 II. Introduction, Background, Epidemiology A. Introduction These guidelines have been developed by a working group of Infection Control, Infectious Diseases, Occupational Health, and Public Health specialists with expertise in acute tertiary and community hospital care, long-term care, and community-based care. These guidelines are intended as a framework for managing individuals colonized or infected with AROs in a variety of health care settings, and may be modified to accommodate the specific needs of the patient/resident/client population and services found in Manitoba health care facilities. Although not regulatory in scope, these guidelines may assist in standardizing infection control practices throughout the province and are intended for use by health care workers who have a responsibility for infection control practice. Each health care region is expected to develop its own ARO infection control policies and procedures based on these guidelines. The guidelines presented in this document are based on the collective experience of the working group members as well as the most recent evidence-based literature addressing best practices. The guiding principles used in developing these guidelines included: 1. Response to current challenges in limiting transmission within the health care system; 2. Reaffirmation of Routine Practices as the foundation for preventing the transmission of microorganisms during patient/resident/client care in all health care settings; 3. Providing evidence-based and best practice recommendations. Three major factors have influenced the development of these guidelines: The transition of health care delivery from hospitals to a variety of other settings, e.g. home care, ambulatory care, long-term care, group homes, short stay and day surgical centers with the need for flexibility and a pragmatic approach in adapting recommendations to all health care settings, while adhering to classical principles of infection control practice. Hence, these guidelines address the continuum of health care delivery; The continued transmission of antimicrobial resistant organisms, a problem that is not unique to hospitals but rather affects the continuum of care. These guidelines therefore attempt to consolidate the basic management approaches for all AROs, eliminating the need for separate pathogenspecific recommendations such as those previously issued in Manitoba for methicillin resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococci (VRE); The limited availability of infection control resources and the need to make the most efficient and effective use of those resources. This guideline reaffirms Routine Practices as the foundation for preventing transmission of infectious agents in all health care settings. Routine Practices are intended to apply and prevent transmission of microorganisms among all patients/residents/clients and health care personnel, regardless of the setting of care or proven or suspected diagnosis. Consistent observance of Routine Practices offers the greatest potential for preventing transmission of infectious agents. While specific AROs are addressed in this document, new AROs will continue to emerge and the basic practice for all of these will also be Routine Practices. Epidemiology AROs are increasingly being identified in Canadian health care facilities, posing clinical and infection control challenges. Although AROs are generally no more virulent than sensitive bacterial strains, they may be more difficult to treat. Furthermore, once introduced into the acute care hospital environment, AROs can be extremely difficult to eradicate. Although, the significance of AROs outside of acute care hospital settings, e.g. long-term care institutions, 4

14 home care, ambulatory care, is less clear. The general consensus is that infection control measures need not be as aggressive outside of acute care hospitals. The major current AROs of concern in Canada include MRSA, VRE, and multiply drug resistant gram negative bacteria. Staphylococcus aureus (S. aureus) are bacteria normally found in the nose and/or on the skin in up to 30% of healthy people. S. aureus can also cause a variety of infections, ranging from localized skin lesions, such as impetigo, boils or wound infections, to invasive disease. Methicillin resistant Staphylococcus aureus (MRSA) refer to strains of S. aureus that are resistant to oxacillin, cloxacillin, and cephalosporins. Some of these strains may also be resistant to aminoglycosides, erythromycin, quinolones and other antibiotics. Many MRSA infections can be effectively treated with commonly available oral antibiotics including tetracycline or sulfamethoxazole-trimethoprin either combined with rifampin or alone if the strain is susceptible. Parenteral glycopeptide antibiotics such as vancomycin and teicoplanin are also effective. Infections caused by MRSA are not inherently more serious than infections caused by methicillin sensitive strains of S. aureus (MSSA), but treatment of infections caused by MRSA may be less effective. Newer agents such as quinupristin-dalfopristin and linezolid are also available and effective. Most people with MRSA are carriers or colonized, and do not have infection, consistent with other strains of S. aureus. In 2003, in Canada, MRSA comprised a small but increasing proportion of all laboratory confirmed S. aureus infections. A summary of MRSA cases in 38 Canadian hospitals indicated that between 1995 and % of all S. aureus isolates were methicillin resistant. This was a rate of 5.1 cases of MRSA per 1,000 admissions with 38% of those patients developing infections. The majority of isolates were from patients who acquired MRSA in acute care hospitals (72%); while 7% were acquired in long term care facilities and 8% in the community.1 In 1999 the Canadian Nosocomial Infection Surveillance Project (CNISP) members developed criteria for the definition of epidemic MRSA strains, e.g., a strain that has been identified in five or more hospital sites or three geographic regions. Such strains were analyzed by PFGE and a nomenclature was proposed. Currently there have been nine epidemic strains characterized including: CAMRSA1, CAMRSA2, CAMRSA3, CAMRSA4, CAMRSA5, CAMRSA6, CAMRSA7, CAMRSA8 and CAMRSA9. CAMRSA1 is the most abundant and was first seen in Ontario in 1995, whereas CAMRSA5 is mostly seen in Western Canada. This nomenclature helps with the epidemiological tracking of strains that cause outbreaks across Canada.2.3 Strains of S. aureus that are intermediately (VISA) or completely resistant (VRSA) to vancomycin have been reported in North America, Europe and Asia, but are uncommon to date. Should VRSA become common, morbidity and mortality with S. aureus infection will likely increase. Vancomycin continues to be an important antimicrobial agent for treating infections caused by MRSA. The decreased susceptibility of VISA and VRSA strains to vancomycin leaves clinicians with few therapeutic options. Linezoid and quinapristin/dalfopristin are the only current agents. All VRSA isolates contain the vana vancomycin resistance gene. The vana gene is usually found in enterococci and typically confers high-level vancomycin resistance to these organisms. It is likely that the vana determinant is transferred via plasmids from enterococci to a resident MRSA strain, resulting in VRSA. The mechanism of decreased vancomycin susceptibility in VISA strains is not fully understood. VISA cells have thicker cell walls that contain many cell wall monomers capable of binding vancomycin extracellularly. Vancomycin must reach the cell membrane and bind to the growing cell wall complex to inhibit cell growth. There is significant concern about the spread of VISA and VRSA among patients/residents because of limited treatment options. If a VISA or VRSA is suspected, specific infection control precautions need to be initiated immediately by infection control personnel to decrease the risk of transmission to others. The infection control team must be urgently notified immediately when a VISA or VRSA is suspected. S. aureus colonization of the nose (anterior nares) occurs in up to 30% of normal healthy individuals. Colonization may also occur in the axillae, chronic or surgical wounds, decubitus ulcers, perineum, sputum, urine and invasive device sites such as intravascular catheters, gastrostomy and tracheostomy sites of hospitalized patients. Health care workers have higher rates of S. aureus colonization than do the general population, but MRSA colonization is uncommon even among health care workers. 5

15 Among hospitalized patients who acquire MRSA, 30-60% may develop an MRSA infection. However, only 5-15% of residents in long term care facilities are likely to develop infection following acquisition of MRSA and mortality due to MRSA infection in long term care settings is rare.4 Enterococci are bacteria that are normal flora in the gastrointestinal tract of healthy individuals. They may also be colonizing flora in the vagina, oral cavity, perineal area, hepatobiliary tract and upper respiratory tract. Human faeces contain the greatest quantity of enterococci, and the faecal-oral route is the usual route of transmission. Occasionally, enterococci are capable of causing invasive disease, particularly in severely immune suppressed patients. They are bacteria of usually low pathogenicity and cause infection primarily in the most vulnerable patients. Enteric bacteria may also contribute to the normal contamination of open wounds and decubitus ulcers, creating a reservoir for the organism. Despite the relatively low virulence of enterococci, they are significant nosocomial pathogens. Although E. faecalis is responsible for the majority of infections caused by enterococci, E. faecium has greater intrinsic resistance to multiple antibiotics and is the most commonly detected VRE.5 Enterococci have always had inherent resistance to many antibiotics and can readily acquire resistance to other antibiotics. Vancomycin-resistant enterococci (VRE) are enterococci that have acquired resistance to vancomycin, the drug of choice for treating multi-drug resistant enterococci infections. Newer drugs such as quinupristin-dalfopristin and linezolid are useful in treating serious infections with VRE. There is the possibility that the vancomycin-resistant gene present in VRE may be transmitted to other gram positive organisms, such as S. aureus, leading to the emergence of VRSA. Like MRSA, VRE is neither more pathogenic nor more virulent than other enterococci, e.g. it is not more likely to cause infection, nor does it cause more serious infection than other enterococci, but as with MRSA, treatment of serious VRE infection is more problematic due to the limited antimicrobial options. In the U.S. there has been a rapid rise in the incidence of infection and colonization with VRE. In 1989, 0.3% of enterococcal isolates were resistant to vancomycin whereas by % of the enterococcal strains isolated from ICU and non-icu settings were resistant to vancomycin.6,7 The Canadian Nosocomial Infection Surveillance Program received reports of 1,315 cases of VRE from sentinel hospital sites between 1994 and In 1999 and 2000, a rate of 0.19 per 1,000 admissions was reported, representing 0.55% of all enterococcal isolates.9,10,11 The majority (95%) of these isolates reflected colonization identified on screening in acute care settings infection is uncommon. The risk of infection following acquisition of VRE is not known at present, but infection is uncommon relative to colonization rates. Colonization usually lasts several months to years, or even indefinitely. Extended-spectrum beta-lactamase (ESBL) is an enzyme produced by some species of enteric gram negative bacilli. ESBL has the ability to inactivate a wide range of beta-lactam antibiotics including penicillins and cephalosporins. Microorganisms which produce ESBL often are also resistant to other classes of antibiotics. In Manitoba, these enzymes have been identified primarily in Escherichia coli and Klebsiella species. Colonization of the gastrointestinal tract and, less commonly, the respiratory tract is the most frequent presentation. Occasionally, infection with an ESBL-producing microorganism occurs, limiting treatment options with antibiotic therapy. Acquisition of AROs AROs are usually introduced into the health care setting by an unidentified, infected or colonized individual. Alternatively they evolve from previously susceptible organisms colonizing or infecting individuals following antibiotic exposure. Transmission most frequently occurs via the hands of health care workers that become transiently colonized while delivering care to patients/ residents/clients when removing gloves, or when touching contaminated surfaces. Contamination can also serve as a vehicle of transmission. Some patient characteristics may contribute to greater dispersal of AROs, including colonized or infected individuals with large, open, poorly healing wounds, profuse colonized tracheostomy secretions, uncontrolled fecal and urinary incontinence or, extensive desquaminating skin conditions. The efficiency of transmission of MRSA may be greater from individuals who have large colonized or infected wounds rather than with simple nasal colonization alone, by virtue of the number of organisms present. Similarly, VRE transmission is more likely to occur in VRE colonized persons with diarrhea or faecal incontinence, not capable of maintaining their personal hygiene. 6

16 Occasionally, transmission may occur from the environment through shared patient/resident/client care equipment, e.g., blood pressure cuffs, commodes, rectal thermometers, if inadequate disinfection occurs between individual use. Environmental cultures demonstrating widespread surface contamination in the rooms of those colonized or infected with VRE, and the observation that VRE is capable of prolonged survival on inanimate surfaces (up to seven days) suggests a role of the environment in transmission.9 Risk factors associated with acquiring AROs in the hospital environment include increased age, serious underlying medical conditions, e.g. renal insufficiency, dialysis, hematologic malignancies, immunosuppression, neutropenia, prolonged or previous hospitalization, intensive care unit stays, abdominal or thoracic surgery, recurrent use of broad-spectrum antibiotics, presence of invasive devices, e.g. urinary catheterization, gastrostomy, invasive vascular lines and, possibly, high patient to nurse ratios. In most instances, simple colonization with AROs is not associated with excess morbidity or mortality. On the other hand, infections associated with AROs may lead to serious consequences and ARO outbreaks often result in adverse outcomes as antimicrobial treatment options are often limited. In the case of ARO outbreaks, prompt identification of the organism and institution of specific infection control measures including screening of contacts should be implemented to limit transmission. Community transmission of MRSA is increasingly being documented in population clusters including athletes, military recruits, children, Pacific Islanders, Alaskan Natives, Native Americans, men who have sex with men, and prisoners. Recently a significant increase in MRSA infections have been identified in First Nations communities in northern Manitoba manifesting primarily as severe skin and soft tissue infections. In communities and facilities where AROs are endemic, it may no longer be possible to eliminate all cases regardless of the level of infection control resources. As the numbers of colonized and infected individuals increase, there is increased difficulty in providing Additional Precautions for all scenarios, problems in identifying sources of outbreaks, and the perception among clinical colleagues that infection control efforts at controlling the spread are more disruptive than effective. The need to wait hours for the results of screening cultures places further pressures on hospitals required to admit and transfer patients quickly. Nevertheless, it remains important to control the spread of AROs within acute care facilities. In acute care hospitals where the risk of infection with AROs is greatest, general infection control measures, e.g., Routine Practices, remain important, including hand hygiene, appropriate equipment cleaning, and decontamination of the environment. The addition of Contact Precautions and targeted interventions in selected clinical areas, for example intensive care units, burn units, oncology units or orthopaedic/trauma units may also be effective in preventing transmission of AROs. There are important differences between acute hospitals and long-term care facilities with respect to infection control recommendations. A long-term care facility is a resident s home and infection control precautions must be balanced with promoting an optimal, healthy lifestyle for the resident. Imposing precautions such as in acute care would interfere with social interaction and rehabilitative care and may result in isolation, depression, anger and even death. Clearly this is an undesirable practice. There are also differences between acute care hospitals and community-based health services. Home Care programs need to balance infection control precautions with promoting optimal, healthy lifestyles for clients. Evidence to date does not indicate clients who are colonized or infected with these microorganisms pose a health risk to health care providers, or to other household contacts. Routine Practices are the essential infection control measures recommended for all clients at all times. The following document addresses control of AROs in all Health Care settings through infection control guidelines for: 1. Routine Practices relevant to AROs 2. Organism-specific ARO practices (MRSA, VRE, ESBL, VRSA) 3. Institution/Facility/Agency-specific ARO practices 4. Management of ARO outbreaks 7

17 References for Introduction 1. Surveillance for methicillin resistant Staphylococcus aureus in Canadian Hospitals a report update for the Canadian Nosocomial Infection Surveillance Program. CCDR 2005: 31 (3) Simor et al. Characterization and Proposed Nomenclature of Epidemic Strains of MRSA in Canada. Canadian Journal of Infectious Diseases, Vol 10, No. 5: September/October 1999, Simor et al. Laboratory Characterization of Methicillin Resistant Staphlococcus aureus in Canadian Hospitals: Results of 5 years of National Surveillance, The Journal of Infectious Diseases, 186; September 2002, pp Mody L., Kauffman CA, McNeil SA, Galecki; AT, Bradley SF. Mupiricin-based decolonization of Staphylococcus aureus carriers in residents in 2 long-term care facilities: a randomized doubleblind placebo-controlled trial. Clin Infect Dis 2003; 37: Tendolkar PM, Baghdayan AS, Shankar N. Pathogenic enterococi: New developments in the 21st century. Cellular and Molecular Life Sciences 2003; 60: Centers for Disease Control and Prevention. Nosocomial enterococci resistant to Vancomycin United Sates Morbid Mortal Wkly Rep 1993; 42: Martone K.J. Spread of vancomycin resistant enterococci: Why did it happen in the United States? Infect Control Hospital Epidemiol 1998; 19: Conly J, et al. The emerging epidemiology of vancomycin resistant enterococci in Canada : results from the Canadian Nosocomical Infection Surveillance Program (CNISP) Passive Reporting Network. Can J Infect Dis 2001; 12: Johnston L, Conly J. The emerging epidemiology of vancomycin-resistant enterococci in Canada revisited. Can J Infect Dis 2000; 11: Conly J. Antimicrobial resistance in Canada. CMAJ 2002; 167(8): Recovery of vancomycin-resistant enterococci on fingertips and environmental surfaces. Infect Control Hosp Epidemiol 1995; 16:

18 III. Routine Practices and Additional Precautions A. Routine Practices The purpose of Routine Practices is to prevent the transmission of microorganisms between patients/ residents/clients or from patients/residents/clients to health care workers following direct contact with blood, body fluids or secretions, and moist body substances with non-intact skin or mucous membranes. Specific practices include hand hygiene, use of personal protective equipment (PPE), and patient management issues. Routine Practices when consistently adhered to, will optimize patient and health care worker safety by preventing the transmission of most infections. For Routine Practices patient will include patient/residents/clients. 1. Hand Hygiene Hand washing/hand hygiene reduces the number of microorganisms on the hands, and is the most important practice to prevent the spread of infection between patients or to health care workers. 1.1 Important Factors in Hand Hygiene: Hands must be washed with soap and water when hands are visibly soiled with blood, body fluids, secretions, excretions, and exudates from wounds. When hands are not visibly soiled, an alcohol-based handrub or wash with soap and water are both acceptable. Health care workers should be vigilant to avoid touching their face with their hands, as well as to avoid hand contact with mucous membranes, including the eyes. If the patient bathroom is used, avoid contamination of hands from potentially contaminated surfaces and objects after washing. Frequently missed areas of the hand include the thumbs, under nails, backs of fingers and hands. Fingernails: Artificial fingernails, gel nails, or extenders should not be worn. Natural nail tips should be no longer than centimeters (1/4 inch) long. Nail polish can be worn but should be removed when chipped. Hand Jewellery: Avoid wearing hand jewellery. Hand Lotions: Health care workers should be provided with lotion to minimize skin irritation that can occur with frequent hand washing/hand hygiene. Select only lotions that are compatible with hand hygiene products and gloves being used. Hand Hygiene or Soap Dispensers: Do not add fresh soap or handrub to a partially empty dispenser. The practice of topping up can lead to bacterial contamination of product. Reusable dispensers, if used must be emptied, washed and dried prior to refilling. Hand lotion bottles should not be reused. 9

19 1.2 When to Perform Hand Hygiene: Before: Direct, hands-on care with a patient. Performing invasive procedures. Handling dressings or touching open wounds. Preparing and administering medications. Preparing, handling, serving, or eating food. Feeding a patient. Beginning a shift or break. After: Contact with blood, body fluids, nonintact skin, and/or mucous membranes. Contact with items known or considered to be contaminated. Removal of gloves. Personal use of toilet or wiping of nose. At the end of each shift or break. Between: Procedures on the same patient where soiling of hands is likely, to avoid crosscontamination of body sites. 1.3 Patient, Visitor and Family Patient, visitor and family should be instructed in proper hand hygiene. The patient must perform hand hygiene before eating, after personal use of toilet and when soiled. 1.4 Agents Used for Hand Hygiene: Alcohol-Based Handrub: Must contain a minimum of 60% alcohol. Use in all clinical situations, except when hands are visibly soiled. NOTE: Alcohol-based handrubs do not inactivate the spores of C. difficile. Use as an alternate to plain or antimicrobial soap except when hands are visibly soiled. Plain Soap: For routine hand washing. Antimicrobial Soap: Before contact with invasive devices. Before performing any invasive procedures. Before contact with immunosuppressed patients. Before/after contact with patients on infection control precautions/isolation. Use in critical care areas: ICU, OR, Burn Unit, Dialysis, Intensive Care Nurseries. 2. Personal Protective Equipment (PPE) 2.1 Gloves Gloves are used as an additional measure to, not as a substitute for, hand hygiene. Clean, non-sterile gloves of appropriate size should be worn: For contact with blood, body fluids, secretions and excretions, mucous membranes, draining wounds, or nonintact skin. For handling items visibly soiled with blood, body fluids, secretions, or excretions. When the health care worker has open lesions of his/her hands. When indicated, gloves should be put on directly before contact with patient or just before the task/procedure requiring gloves. Gloves should be changed between care activities and procedures with the same patient, and after contact with materials that may contain high concentrations of microorganisms, e.g. after open suctioning of an endotracheal tube. Gloves should be removed prior to leaving the patient s room. 10

20 Hand hygiene must be performed immediately after removing gloves. Single-use, disposable gloves should not be reused or washed. Gloves should be selected based on the task and personal comfort and fit. NOTE: Health care workers with open skin lesions, dermatitis, or wrist splints or casts must be assessed by Occupational Health to determine fitness for work. 2.2 Gowns Routine use of gowns for patient use is not recommended. Gowns should be used to protect uncovered skin and prevent soiling of clothing during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions. Gowns should be large enough to overlap at the back. Sleeves should be to the wrist and cuffed for snug fit. A disposable impervious/water repellent apron may be used under the gown to prevent contamination of clothing from leakage of large volumes of blood, body fluids, secretions or excretions. Disposable impervious gowns are available and should be considered in these situations. When a gown has been worn, it should be removed in a manner which prevents contamination after completion of the patient care activity requiring its use. Gowns are to be worn once. Disposable impervious gowns are discarded and cloth gowns are laundered after use. 2.3 Masks Standard surgical/procedure masks should be worn where appropriate to protect the mucous membranes of the nose and mouth during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions. Masks are to be worn within one metre of a coughing patient. Discard a mask that is crushed, wet, or has become contaminated by patient secretions. Perform hand hygiene after removal of the mask. 2.4 Eye Protection Goggles and Face Shield Eye protection (goggles or face shield) should be worn where appropriate to protect the mucous membranes of the eyes likely to generate splashes or sprays of blood, body fluids, secretions or excretions during procedures and patient care activities. When removing eye protection, take care to avoid self-contamination. Prescription eyeglasses are not adequate for eye protection, as they do not provide protection from splashes or sprays. Eye protection (goggles or face shield) must fit over prescription glasses and protect the eyes from splashes or sprays. If reusable, eye protection must be easy to clean and cleaned in a manner to avoid contamination of the health care workers. 3. Accommodation Generally single rooms are not required for routine patient care. A single room with dedicated toilet facilities should be considered for patients who visibly soil the environment, e.g. draining wounds and fecal incontinence that is not containable. If this is not feasible, contact Infection Control for recommendations for cohorting. 11