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

21 4. Equipment Reuseable non-critical equipment that has been in direct contact with the patient must be cleaned with a facility-approved disinfectant before use on another patient. A routine cleaning schedule should be established, assigning responsibility and accountability for cleaning of the equipment, e.g. electronic thermometer, commodes. Equipment that is visibly soiled must be cleaned. Soiled patient care equipment must be handled in a manner that prevents exposure to the health care workers skin and mucous membranes and the contamination of clothing and the environment. Where possible, dedicated patient care equipment should be considered for ICU and other high-risk areas. Toilets must be cleaned regularly and when soiled. Bedpans must be reserved for use by a single patient and labelled appropriately. Mouthpieces, resuscitation bags, or other ventilation devices must be provided for use in facility areas where the need to resuscitate is likely to occur. Personal care supplies, e.g. lotions, creams, soaps, are not to be shared between patients. 5. Environmental Control/Housekeeping Procedures should be established for routine care, cleaning and appropriate disinfection of patient furniture and environmental surfaces with a facility-approved disinfectant. All horizontal and frequently touched surfaces should be cleaned daily and more often if soiled. Immediately clean all spills of blood and/or body fluids with a facility-approved disinfectant according to facility approved policy. 6. Specimen Collection All clinical specimens are considered potentially infectious and should be handled with appropriate care. All specimens must be placed in leak proof containers. Care must be taken to avoid contamination of the outside of the specimen container and the laboratory requisition. If contamination of the outside of the container occurs, the container must be cleaned with a facility-approved disinfectant prior to transport to the laboratory. Specimens should be transported to the laboratory according to facility policy. Practice hand hygiene after collecting and handling specimens. 7. Dishes There is no need for any special precautions for dishes. There is no need for disposable dishes. Hand hygiene must be performed after contact with dishes. 8. Linen Linen should be handled with a minimum of agitation and bagged at the site of collection in a manner that prevents contamination or soaking through. Double bagging is not routinely necessary. A second outer bag is only required to contain a leaking inner bag. 9. Waste Clinical waste should be contained in wasteholding bags that prevent contamination. Double bagging of waste is not required. 10.Sharps Used needles and other sharp instruments must be handled with care to avoid injuries during disposal or reprocessing. Used sharp items should be disposed of immediately in designated puncture-resistant containers located in the area where the items were used. 12

22 B. Additional Precautions Contact Precautions Additional Precautions are required when Routine Practices are not sufficient to prevent transmission of suspected or confirmed microorganisms. Contact Transmission Precautions These precautions reduce the risk of transmission of microorganisms by direct contact with a colonized/infected individual or indirect contact with contaminated items/environment. These precautions are warranted when extensive contamination of the environment is expected. 1. Additional Precautions for Acute Care and Surgical Centres Contact Precautions Contact Precautions are to be followed in addition to Routine Practices. Detailed precautions for specific organisms are outlined in Section VII. 1.1 Accommodation Special considerations A single room is preferable, as it may be difficult to maintain the recommended one metre physical separation between patients. In pediatric institutions where large numbers of patients requiring Contact Precautions are present simultaneously and where single rooms may be in short supply, single room accommodation is frequently not possible. If a room is to be shared, see iii below. i. Single room Door may remain open. Single room should have toilet and hand washing facilities. ii. Cohort: Patients known to be infected with the same organism may be grouped together. iii. Shared room: Maintain spatial separation of at least one metre between infected or colonized patient and other patients and their visitors. Roommates and all visitors must be aware of precautions to follow. Roommates should be selected for their ability and that of their visitors to comply with precautions. Roommates should not be at high risk of serious disease if transmission occurs. A single room is indicated if these conditions are not achievable. 1.2 Gloves Gloves should be worn before entering the room or patient s designated bed space. Gloves should be removed before leaving the room or the patient s dedicated bed space. 1.3 Gowns Gowns should be worn if clothing or forearms will have direct contact with the patient. Gowns should be worn if it is anticipated that clothing or forearms will be in direct contact with frequently touched environmental surfaces or objects and there is increased risk of the environment being contaminated, e.g. incontinent patient, diarrhea, or drainage from wound, colostomy or ileostomy not contained by dressing. Gown should be removed before leaving the room or bed space. 13

23 1.4 Hand Hygiene Before entering the room or bedspace: Remove gown and gloves and wash hands with antimicrobial soap or use alcohol-based handrub before leaving the room or bed space. After hand hygiene, take care not to contaminate hands before leaving the room. 1.5 Equipment and Environment Patient care equipment, e.g. thermometer, blood pressure cuff, pulse oximeter, should be dedicated to that patient. Avoid stock piling of patient items and equipment in patient room. Reuseable equipment that has been in direct contact with the isolated patient must be cleaned and reprocessed/ disinfected after use on patient and before use in the care of another patient. Toys and personal effects should not be shared with other patients. The patient health record should not be taken into the room. Special cleaning procedures may be required in outbreak situations. This will be determined by the outbreak management team. 1.6 Patient Transport Patient should be out of the room for medically essential purposes only. Maintain precautions during transport. Personnel in area to which patient is to be transported should be aware of precautions to follow. 1.7 Patient and Family Teaching Patients should understand the nature of their infectious disease and the precautions being used, as well as the prevention of transmission of disease to family and friends during their hospital stay and upon their return to the community. 1.8 Visitors Visitors should be instructed by a nurse before entering the room on the appropriate use of gown, gloves or other special precautions if indicated. The risk to the health of the visitor, and the risk of the visitor transmitting infection should be evaluated. The number of visitors should be kept to a minimum (usually no more than two). 2. Additional Precautions for Long Term Care, Interim Care Units and Hospice Affiliated With a Health Care Institution Contact Precautions Detailed precautions for specific organisms are outlined in section VII. 2.1 Contact Precautions should be used for: Acute diarrhea of likely infectious cause if uncontrolled (incontinent, stool cannot be contained in diapers or incontinence briefs and resident is not confined to bed) Extensive desquamating skin disorder with known or suspected infection or significant colonization. Draining, infected wound in which drainage cannot be contained by dressing. 2.2 Accommodation Efforts should be made to maintain a one-metre spatial separation between the infected resident and other residents and visitors. Participation in group activities should be restricted until the symptoms are resolved/treated. roommates and visitors must be aware of precautions to follow. 14

24 2.3 Gowns/Gloves Gowns and gloves should be used if direct contact with the resident is required or if direct contact with frequently touched environmental surfaces is anticipated and significant contamination of the environment is occurring (uncontrolled diarrhea, uncontained wound drainage, excessive skin desquamation). 2.4 Hand Hygiene Remove gown and gloves and wash hands or use alcohol-based handrub before leaving room. After hand hygiene, take care not to contaminate hands before leaving room. 2.5 Equipment and Environment All designated equipment and supplies should be identified and stored in a manner that prevents use by or for other residents. Environmental soiling should be minimized through use of wound dressings, incontinence products, tissues. 3. Infection Control Guideline Websites 3.1 Public Health Agency of Canada Guideline Website (PHAC) Website: e.html#infection Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care. Handwashing, Cleaning, Disinfection and Sterilization in Health Care 3.2 Centres for Disease Prevention and Control (CDC) Guideline Website Website: index.html Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings Hand Hygiene in Health Care Settings Investigation and Control of Vancomycin Intermediate and Resistant Staphylococcus aureus (VISA/VRSA) 3.3 Manitoba Health Communicable Disease Control (CDC) Unit Website Website: public health/cdc/ Infection Prevention and Control Program Section: Infection Control Guidelines for Health Care Workers in the Community Infection Control Guidelines for Community Shelters and Group Homes, April 2005 Fact Sheets for the Public Section: What you should know about Methicillin Resistant Staphylococcus Aureus (MRSA) What you should know about Vancomycin Resistant Enterococci (VRE) 3.4 Community and Hospital Infection Control Association (CHICA) Canada Website: 15

25 IV. Notification and Reporting A. Communication/Information Open and timely communication regarding the individual s ARO status, cultures and antimicrobial information is required between all settings and providers in health care. If an individual is transferred between facilities, there must be documentation of the individual s ARO status on the Transfer Referral Form. 16

26 V. Education and Training of Health Care Workers A. Education and Training All health care workers should receive training on an ongoing basis and be knowledgeable regarding Routine Practices and Additional Precautions as appropriate for their work activities. This should include but not limited to: The rationale for practices. Detailed information on the specific practices. When to initiate and discontinue Additional Precautions. When to contact Infection Control. B. Information Sheets Information sheets are a useful adjunct to providing consistent information. See Appendix B for Fact Sheets for Health Care Workers. 17

27 VI. Education of Families and Visitors All families and visitors must be aware of the appropriate practice of hand hygiene. Convenient access to hand hygiene must be available for all visitors. A. Education Patients with AROs and their family members are to receive appropriate information about AROs and preventive measures. These are included in Appendix B. 18

28 VII. ARO Infection Control Guidelines for Acute Care, Surgical Centres, Long Term Care Facilities (LTCFs), Interim Care Units and Hospice Affiliated with a Health Care Institution A. MRSA Guidelines for Acute Care Facilities and Surgical Centres 1. Identification/Notification of MRSA A system and criteria must be set up with laboratory support for reporting of positive patients. Each facility should assign responsibility for the following when a patient is identified as MRSA positive: Notify unit the patient is on. Notify Infection Control and, if applicable, the Health Information Department. Implement Contact Precautions. Identify on the patient record the MRSA status and Additional Precautions required. Provide MRSA Positive patient, family members and visitors with verbal instructions regarding MRSA and Contact Precautions as well as a Patient Information Sheet. 2. Surveillance Cultures to be Performed to Identify MRSA Nares Open wounds Refer to Appendix C for culturing procedures 3. Flagging/Deflagging of Patient Health Record A pt identification system, e.g. chart flagging must be in place for rapid identification of MRSA status on future admission, developed by Infection Control with Health Information. Appropriate procedures for deflagging must be developed and arranged by Infection Control in consultation with Health Information. It is recommended that health care records of MRSA contacts be deflagged between six and 12 months on direction by Infection Control. 4. Admission Screening Refer to Admission Screening Statement for MRSA and VRE for Acute Care Facilities and Surgical Centres. 5. Additional Precautions In addition to Routine Practices, place the patient on Contact Precautions. See page 12 for requirement for Contact Precautions. 5.1 Patient Placement and Cohorting Cohorting is the preferred patient placement if there is more than one positive MRSA patient. The room must have a separate toilet and hand wash facilities. Cohort in consultation with Infection Control. Cohort MRSA positive patients together regardless of strain. Patients being decolonized should be in a single room. Staff caring for cohorted patients must change gloves and perform hand hygiene between patients. Gowns do not need to be changed between patients unless visibly soiled. 19

29 If cohorting is not possible: place patient in a single room with separate toilet, and hand wash facilities with the door open. Door can remain open. Negative airflow is not required: Negative airflow rooms should be reserved for patients with airborne infections, e.g. tuberculosis. The patient is restricted to the room, except for necessary diagnostic or therapeutic services. In extraordinary circumstances if patients develop psychological problems attributable due to long-term isolation they might be allowed out of the room for short periods of time. This must be done in consultation with Infection Control. 5.2 Hand Hygiene Contact Precautions Refer to Appendix D for Hand Hygiene Quick Reference Chart and Hand Hygiene Procedures 5.3 Gowns/Gloves/Masks/Eye Protection Gowns Contact Precautions Refer to Appendix E for donning and removing of gown procedure Gloves Contact Precautions Refer to Appendix E for donning and removing of glove procedure Masks Masks are not routinely required for Contact Precautions Use masks only as directed for Routine Practices Eye Protection Goggles and Face Shield Eye protection goggles and face shield are not routinely required for Contact Precautions Use eye protection goggles and face shield only as directed by Routine Practices. 5.4 Equipment Contact Precautions 5.5 Linen/Dishes No special precautions required other than Routine Practices. 5.6 Needles/Syringes Routine Practices 5.7 Lab Specimens Dedicated Equipment Phlebotomy trays should not be taken into the room. All required equipment should be taken into the room at the start of the procedure. Deposit specimen into an impervious, sealable bag, e.g. Ziploc, upon removal from room, ensuring outside of bag does not become contaminated. 5.8 Waste Disposal Routine Practices 5.9 Environmental Control/Housekeeping Facilities must have detailed policies and procedures describing routine cleaning schedules, products used, methods, types of equipment, and departments or individuals who are responsible for cleaning. This must include thorough cleaning of the patient s environment and equipment a minimum of once per day and whenever soiled, with special attention to frequently touched surfaces, e.g. bed rails, call lights. Dedicated housekeeping equipment is required for each room with patients on Infection Control precautions. When the patient is discharged or moved to another room, or Contact Precautions are discontinued and the 20

30 patient remains in the room, terminal cleaning should be done. This includes: Thorough cleaning of all surfaces and equipment in the room with facility approved disinfectant. Bed privacy curtains, cloth or string light and call bell cords must be changed. Spot cleaning of visible soil on walls. Gowns and gloves must be worn until the terminal cleaning is completed. During an outbreak more extensive and frequent cleaning with facility approved disinfectant may be required. This will be determined by the outbreak management team Patient Health Record Should not go into a room with a patient on Infection Control precautions. If the health record is required to accompany the patient for tests or treatment it should be placed in a protective cover to prevent contamination. If the outside of chart becomes contaminated wipe with facility approved disinfectant Personal Documents: e.g. Wills, Paneling Papers, Voting Wipe table the document is to be signed on with facility approved disinfectant. Patient perform hand hygiene with alcohol-based handrub prior to signing. Patients should have a dedicated pen in the room. If not, after signing wipe the pen with a facility approved disinfectant Duration of Infection Control Precautions Contact Precautions can be discontinued once the following requirements are met: Three consecutive sets of negative screening MRSA cultures (nares, wounds as well as previously positive sites) at least one week apart. Refer to Appendix C for culturing procedures. Wait 48 hours after completion of effective antimicrobials before initial screening. If a patient is colonized, in only one site, e.g. wound, catheter/device exit site and the wound is healed or device removed, and other sites; e.g. nares are not initially colonized this patient can now be presumed to be no longer colonized with MRSA. When taking subsequent cultures to determine if the patient has become negative for MRSA ensure the patient has not received potentially effective antimicrobials during culture period that may affect MRSA growth, e.g. lead to false negative screen for MRSA. If any culture is positive, discontinue subsequent cultures maintain Contact Precautions and wait a month before reculturing again Post Mortem Care Place clean sheet on stretcher prior to entering room. Health care worker wears gloves and gown while attending the body. After the body is wrapped, place clean sheet around the body. Health care worker removes gloves and gown and performs hand hygiene before leaving room. Transport body to the morgue. The stretcher must be cleaned with a facility approved disinfectant before next use. Health care worker performs hand hygiene upon leaving the morgue. 21

31 6. Treatment or Decolonization Treatment of infections is determined by the attending physician in consultation with an Infectious Diseases Consultant as appropriate. Routine decolonization for MRSA is discouraged due to limited efficacy and potential for increased resistance. Decolonization treatment for MRSA may be considered on a case-by-case basis determined by clinical and epidemiological factors. This will be in consultation with Infectious Diseases and Infection Control. 7. Subsequent Cultures for Persistent Carriage Routine screening is not recommended for a positive patient who remains in hospital. The patient should be assessed on a case-by-case basis to determine when subsequent cultures are indicated. This should be done in consultation with Infection Control. Obtain cultures only when acute clinical symptoms, e.g. respiratory infection, wound drainage, develop. 8. Management of Contacts Isolation of contacts is not necessary unless cultures are positive. When doing screening cultures to determine if patient is negative for MRSA ensure the patient has not received potentially effective antimicrobials that may affect MRSA growth, e.g. lead to false negative screen for MRSA. If patient has received potentially effective antimicrobial within 48 hours of rescreening they must be rescreened again when the antimicrobials are discontinued. Screen close contacts of the index case that have a minimum exposure time of greater or equal to 24 hours in hospital. See Appendix C for culturing procedures. Screening cultures must be collected greater or equal to 48 hours post contact to index case to ensure optimal detection of MRSA. Close contacts are the roommates and bathroommates from date of admission of the case or to prior negative cultures of the case. No further screening if these contacts are negative. If any of the close contacts are positive expand screening to: All other patients on unit must have a minimum exposure time of contact to index case of greater than or equal to 24 hours in hospital. Screen other patients on unit from date of admission of the case or to prior negative cultures of the case. Screening cultures must be collected greater or equal to 48 hours post contact to index case to ensure optimal detection of MRSA. For selected cases with prolonged admission an alternate time frame might be selected in consultation with Infection Control. In a high risk unit, e.g. Open ICU, or Dialysis unit, screening of contacts with less than 24 hours exposure may be considered as determined by Infection Control. More frequent screening cultures may be necessary during an outbreak. 9. Diagnostic Procedures/Transfer of Patients Within the Facility Patients are restricted to their room, except for necessary diagnostic or therapeutic services. If the patient is transferred, the referring ward or clinic must notify the receiving department of the necessary infection control precautions required. During procedures a health care worker who has contact with the patient must maintain Contact Precautions. A dedicated clean person may be used to minimize environmental contamination. Patient Precautions for Transport Perform hand hygiene on leaving room. No gloves are required. Wear clean clothes, housecoat or cover gown. Wounds must be covered. 22

32 If the patient is to be transferred in a stretcher or wheelchair, it must be clean and covered with a clean sheet prior to entering room. After returning the patient to the room, the stretcher or wheelchair must be cleaned with a facility approved disinfectant before use in the care of another patient. If the patient is required to be transferred in a bed, the external bed surface must be cleaned with facility approved disinfectant prior to leaving the room. The bed and patient must be covered by a clean sheet. Health Care Worker Precautions for Transport Hand hygiene before leaving room. Put on clean gloves outside room. Put on clean gown outside room. Visitor Precautions for Transporting the Patient Hand hygiene before leaving room. Visitors are not required to wear gloves and gown outside the room. 10. Management of MRSA Positive Patient in the Operating Room (OR) Notification of positive patient must be received by the OR prior to the procedure, so the OR can schedule and appropriately manage the patient. Schedule the patient to allow for cleaning, e.g. first or last appointment of the day. Transport patient according to the following guidelines. Patient Precautions for Transport To and From the OR Perform hand hygiene before leaving the room. No gloves are required. Wear clean gown. Wounds must be covered. When the patient is to be transferred in a stretcher or wheelchair, it must be covered with a clean sheet prior to entering the room. After returning to the room, the stretcher/wheelchair must be cleaned with a facility approved disinfectant before use by another patient. If the patient is required to be transferred in a bed, the external bed surface must be cleaned with a facility approved disinfectant prior to leaving the room. The bed and patient must be covered by a clean sheet. Health Care Worker Precautions for Transport Perform hand hygiene on leaving room. Put on clean gloves outside room. Put on a clean gown outside room. In the Operating Room Remove unnecessary equipment from the theatre. Contact Precautions sign may be posted on the theatre door if needed. During the procedure a health care worker who has contact with the patient must maintain Contact Precautions. A dedicated clean person may be present to minimize environmental contamination. The patient health record and specific procedure forms needed for the procedure may be taken into the room. They should be kept on a clean designated table in a low traffic corner of the theatre and does not have contact with health care workers that have patient contact. Wear gloves when touching the patient. Wear gown if clothing will have direct contact with the patient or touch surfaces or objects in the theatre which may come into contact with the patient. Recover the patient in the theatre or in a separate, isolated, area in the Post Anesthetic Care Unit. After the case, clean surfaces that are visibly soiled or had contact with the patient or any contaminated health care worker. 11. Discharge/Transfer between Facilities It is the responsibility of the transferring facility to identify known MRSA positives and suspects when patients are being transferred. 23

33 MRSA Suspect The status of a MRSA Suspect patient must be documented on the patient s Transfer Referral Form. MRSA Positive Prior to discharge the receiving facility, physician and other involved health care agencies, e.g. Home Care, Physiotherapy, must be notified of the patient s MRSA status and treatment. Advise the patient of the importance of informing any health care worker of their MRSA status. MRSA Positive must be documented on the patient s Transfer Referral Form. The receiving ICP may request MRSA status, culture and antimicrobial information from the ICP at the transferring facility. This must be done by telephone or fax and recorded in the patient health record. The receiving facility does not require rescreening of known MRSA positive upon transfer. Positive MRSA status does not require an ambulance for transport. Other transportation systems, e.g. Stretcher Car Service may be used. Transfer patients by a transportation company with trained staff and the ability to follow proper appropriate Infection Control precautions. Patient Precautions for Transfer Have a clean stretcher or wheelchair covered with a clean sheet. Perform hand hygiene on leaving room. No gloves required. Wounds must be covered. Wear clean clothes, housecoat or cover gown. Health Care Worker Precautions for Transfer Hand hygiene before and after patient contact. Wear clean gloves and gown to be worn during transportation of patient. Transferring facility notifies transport service patient is on Contact Precautions. Transport Service Must Follow Contact Precautions, if indicated, to collect patient in their room and when leaving patient room. During transport to other facility follow Infection Control Guidelines for Health Care Workers in the Community. At receiving facility Transport Services follows Contact Precautions, if indicated, to place patient in their room and upon leaving patient room. Consider the wheelchair/stretcher used to transport the patient as contaminated. Disinfect vehicle surfaces and any equipment that was in contact with the patient with facility approved disinfectant. Clean sheets must be used for the next patient. 12. Home Visits/Passes with Health Care Worker Companion or Family Patient Precautions Hand hygiene on leaving room. No gloves required. Wear clean clothes. Wounds must be covered. Health Care Worker Precautions Accompanying Patient Separate transport person to take to the door of facility. Individual accompanying patient on the home visit meets patient at door of facility. Alcohol-based handrub must be available for hand hygiene of patient and health care worker during visit. Follow Manitoba Health Infection Control Guidelines for Health Care Workers in the Community. Equipment taken on visit should be bagged for return and then cleaned according to facility policy before care in the use of another patient. 24

34 Family Accompanying Patient Hand hygiene prior to leaving room. Equipment taken on visit should be bagged for return and then cleaned according to facility policy before care in the use of another patient. 13. Visitors Including any Hospitalized Patients Visiting a Positive Patient Visitors do not go from patient to patient giving direct care, therefore their risk of transmitting MRSA is minimal. The most important preventative measure for visitors is performing hand hygiene on entering or leaving the patient room. Visitors should ask for assistance in obtaining patient care supplies on nursing unit. 14. Positive Patient Visiting other Patients Patients restricted to room, except for necessary diagnostic or therapeutic services. In extraordinary circumstances visiting may be done for compassionate reasons following consultation with Infection Control. 15. Outpatient Service Patient Schedule patient to allow for cleaning of patient s room whenever possible, e.g. first or last appointment of the day. The patient must perform hand hygiene on arrival. Patient must have open/draining wounds covered. Place patient directly in the examination room, not to be left sitting in the waiting room. Patient should be told to not touch items/surfaces in examination room. Health Care Workers Health care workers must wear gown and gloves if they have direct patient contact, including transport of the patient. Place gowns in the regular laundry bag after use. Perform hand hygiene after removal of gown and gloves. Environment Individualize patient care equipment when ever possible. If equipment/supplies are to be shared between patients these items must be cleaned with a facility approved disinfectant before use on another patient. Minimize patient contact with items/surfaces in the exam room. Clean room surfaces that have had patient contact with facility approved disinfectant. This cleaning does not require Housekeeping Services, but can be safely performed by the clinic staff. Disposable gloves should be worn for use of facility approved disinfectant. No special precautions required for handling soiled linen or garbage. 16. Patients Requiring Physical Rehabilitation Patients requiring Physical Rehabilitation, e.g. Physiotherapy, Occupational Therapy in acute care settings should receive rehabilitation therapy as indicated by caregivers. Precautions required during rehabilitation must be developed in consultation with Infection Control. Schedule therapy during a time of minimal activity in the department. In a MRSA outbreak situation multiple MRSA positive patients could be scheduled at one time. Designate therapy to one area of the department. Transport the patient according to Diagnostic Procedures/Transfer within the Facility section. Dedicated equipment is desirable. If unavailable, shared equipment must be cleaned with facility approved disinfectant after use by a MRSA patient and before use in the care of another patient Communal equipment, e.g. parallel bars must be cleaned with facility approved disinfectant after use by an ARO patient and before use in the care of another patient. 25

35 If the patient requires rehabilitation on the unit outside their room, e.g. walking, this must be scheduled during a time of minimal activity on the unit. The patient must be accompanied by a health care worker or informed family. The patient must be educated and perform hand hygiene prior to leaving the room. 17. Management of MRSA Positive Patients on Rehabilitation Units MRSA positive Patients on rehabilitation units in acute care centres are to be managed according to acute care guidelines. 18. Management of Psychiatry Patients Follow Routine Practices for MRSA positive patients on Psychiatry Units. MRSA positive psychiatry patients must perform hand hygiene prior to leaving the unit. 19. Outbreak Management Refer to Management of Contacts Section #8 p.22. See Appendix A for Steps for Management of an Outbreak. 20. Surveillance Each Infection Control Department in a facility should maintain a line listing of patients screened for MRSA. This would enable the ICP to keep track of the screening that is being done in the facility. Each facility should maintain a form on every identified patient who is colonized/infected with MRSA in their facility. This enables the ICP to maintain a database of MRSA positive patients and prevalence in the facility. A screening line listing form and patient management form are included in Appendix F. Collection and storing of all relevant patient information must be consistent with PHIA. 26

36 B. VRE Guidelines for Acute Care Facilities and Surgical Centres 1. Identification/Notification of VRE A system and criteria must be set up with laboratory support for reporting of positive patients. Each facility should assign responsibility for the following when a patient is identified as VRE positive: Notify unit the patient is on. Notify Infection Control and, if applicable, the Health Information Department. Implement Contact Precautions. Identify on the patient record the VRE status and Additional Precautions required. Provide the VRE Positive patient, family members and visitors with instructions regarding VRE and Contact Precautions as well as a Patient Information Sheet. 2. Surveillance Cultures to be Performed to Identify VRE Rectal or ostomy. Refer to Appendix C for culturing procedures. 3. Flagging/Deflagging of Patient Health Record A patient identification system, e.g. chart flagging must be in place for rapid identification of VRE status on future admission, developed by Infection Control with Health Information. Appropriate procedures for deflagging must be developed and arranged by Infection Control in consultation with Health Information. It is recommended that health records of VRE contacts be deflagged between six and 12 months on direction by Infection Control. 4. Admission Screening Refer to Admission Screening Statement. 5. Additional Precautions In addition to Routine Practices, place the patient on Contact Precautions. See page 13 for requirement for Contact Precautions. 5.1 Patient Placement and Cohorting Cohorting is the preferred patient placement if there is more than one positive VRE patient. The room must have a separate toilet, hand wash facilities. Cohort in consultation with Infection Control. Cohort VRE positive patients together regardless of strain. Staff caring for cohorting patients must change gloves and perform hand hygiene between patients. Gowns do not need to be changed between patients unless visibly soiled. If cohorting is not possible: Place patient in a single room with separate toilet, and hand wash facilities with the door open. Door can remain open. Negative airflow is not required: Negative airflow rooms should be reserved for patients with airborne infections, e.g. tuberculosis. The patient is restricted to the room, except for necessary diagnostic or therapeutic services. In extraordinary circumstances if patients develop psychological problems attributable due to long term isolation they might be allowed out of the room for short periods of time. This must be done in consultation with Infection Control. 5.2 Hand Hygiene Contact Precautions. Refer to Appendix D for Hand Hygiene Quick Reference Chart and Hand Hygiene procedures. 27

37 5.3 Gowns/Gloves/Masks/Eye Protection Gowns Contact Precautions. Refer to Appendix E for donning and removing of gown procedure. Gloves Contact Precautions. Refer to Appendix E for donning and removing of glove procedure. Masks Masks are not routinely required for Contact Precautions. Use masks only as directed for Routine Practices. Eye Protection Goggles and Face Shield Eye Protection goggles and face shield are not routinely required for Contact Precautions. Use eye protection goggles and face shield only as directed by Routine Practices. 5.4 Equipment Contact Precautions. 5.5 Linen/Dishes No special precautions required other than Routine Practices. 5.6 Needles/Syringes Routine Practices. 5.7 Lab Specimens Dedicated equipment. Phlebotomy trays should not be taken into the room. All required equipment should be taken into the room at the start of the procedure. Deposit specimen into an impervious, sealable bag, e.g. Ziploc, upon removal from room, ensuring outside of bag does not become contaminated. 5.8 Waste Disposal Routine Practices. 5.9 Environmental Control/Housekeeping Facilities must have detailed policies and procedures describing routine cleaning schedules, products used, methods, types of equipment, and departments or individuals who are responsible for cleaning. This must include thorough cleaning of the patient s environment and equipment a minimum of once/day and whenever soiled with special attention to frequently touched surfaces, e.g. bed rails, call lights. Dedicated housekeeping equipment is required for each room with patients on Infection Control precautions. When the patient is discharged or moved to another room or Contact Precautions are discontinued and the patient remains in the room terminal cleaning should be done. This includes: Thorough cleaning of all surfaces and equipment in the room with facility approved disinfectant. Bed privacy curtains, cloth or string light and call bell cords must be changed. Spot cleaning of visible soil on walls. Gowns and gloves must be worn until the terminal cleaning is completed. During an outbreak more extensive and frequent cleaning with facility approved disinfectant may be required. This will be determined by the outbreak investigation team Patient Health Record Should not go into a room with a patient on Infection Control precautions. 28

38 If the health record is required to accompany the patient for tests or treatment it should be placed in a protective cover to prevent contamination. If the outside of chart becomes contaminated wipe with facility approved disinfectant Personal Documents: e.g. Wills, Paneling Papers, Voting Wipe table the document is to be signed on with facility approved disinfectant. Patient perform hand hygiene with alcohol-based handrub prior to signing. Patients should have a dedicated pen in the room. If not, after signing, wipe the pen with a facility approved disinfectant Duration of Infection Control Precautions Evidence indicates persons with VRE are often colonized permanently. Consideration may be given to modifying infection control precautions for a VRE positive individual who is capable of practicing good hygiene and has no gastrointestinal symptoms, e.g. vomiting, diarrhea. These modifications should include low-risk roommate, maintaining glove and gowning per Routine Practices and ambulation of patient with no restrictions. This should be done in consultation with Infection Control. This is not recommended during outbreak situations. If the patient develops gastrointestinal symptoms, e.g. vomiting, diarrhea, patient unable to practice good hand hygiene, or an outbreak occurs, Contact Precautions should be reinstated immediately Post Mortem Care Place clean sheet on stretcher prior to entering room. Health care worker wears gloves and gown while attending the body. After the body is wrapped, place clean sheet around the body. Health care worker removes gloves and gown and performs hand hygiene before leaving room. Transport body to the morgue. The stretcher must be cleaned with a facility approved disinfectant before next patient use. Health care worker performs hand hygiene upon leaving the morgue. 6. Treatment or Decolonization Treatment of infections is determined by the attending physician in consultation with an Infectious Disease Consultant. There is no effective decolonization. 7. Subsequent Cultures for Persistent Carriage No routine cultures recommended. 8. Management of Contacts Isolation of contacts is not necessary unless cultures are positive. Screen close contacts of the index case that have a minimum exposure time of greater or equal to 24 hours in hospital. See Appendix C for culturing procedures. Screening cultures must be collected greater or equal to 72 hours post contact to ensure optimal detection of VRE. Close contacts are the roommates and bathroommates from date of admission of the case or to prior negative cultures of the case. No further screening if these contacts are negative. If any of the close contacts are positive expand screening to: All other patients on unit must have a minimum exposure time of contact to index case of greater than or equal to 24 hours in hospital. Screen other patients on unit from date of admission of the case or to prior negative cultures of the case. Screening cultures must be collected greater or equal to 72 hours post contact to ensure optimal detection of VRE. 29

39 For selected cases with prolonged admission an alternate time frame may be selected, in consultation with Infection Control. In a high-risk unit, e.g. Open ICU, or Dialysis unit, screening of contacts with less than 24 hours exposure may be considered as determined by Infection Control. More frequent screening cultures may be necessary during an outbreak. 9. Diagnostic Procedures/Transfer of Patients Within the Facility Patients are restricted to their room, except for necessary diagnostic or therapeutic services. If the patient is transferred, the referring ward or clinic must notify the receiving department of the necessary Infection Control precautions. During procedures, a health care worker who has contact with the patient must maintain Contact Precautions. A dedicated clean person may then be used to minimize environmental contamination. Patient Precautions for Transport Perform hand hygiene on leaving room. No gloves are required. Wear clean clothes, housecoat or cover gown. Wounds must be covered. If the patient is to be transferred in a stretcher or wheelchair, it must be clean and covered with a clean sheet prior to entering room. After returning the patient to the room, the stretcher or wheelchair must be cleaned with a facility approved disinfectant before use in the care of another patient. If the patient is required to be transferred in a bed, the external bed surface must be cleaned with facility approved disinfectant prior to leaving the room. The bed and patient must be covered by a clean sheet. Health Care Worker precautions for Transport Hand hygiene on leaving room. Put on clean gloves outside room. Put on clean gown outside room. Visitor Precautions for Transporting the Patient Hand hygiene before leaving room. Visitors are not required to wear gloves and gowns when outside the room. 10. Management of VRE Positive Patient in the Operating Room (OR) Notification of positive patient must be received by the OR prior to the procedure, so the OR can schedule and appropriately manage the patient. Schedule the patient to allow for cleaning, e.g. first or last appointment of the day. Transport patient according to the following guidelines: Patient Precautions for Transport To and From the OR Perform hand hygiene before leaving the room. No gloves are required. Wear clean gown. Wounds must be covered. When the patient is to be transferred in a stretcher or wheelchair, it must be covered with a clean sheet prior to entering the room. After returning to the room, the stretcher/wheelchair must be cleaned with a facility approved disinfectant before use by another patient. If the patient is required to be transferred in a bed, the external bed surface must be cleaned with a facility approved disinfectant prior to leaving the room. The bed and patient must be covered by a clean sheet. Health Care Worker Precautions for Transport Perform hand hygiene on leaving room. Put on clean gloves outside room. Put on a clean gown outside room. In the Operating Room Remove unnecessary equipment from the theatre. Contact Precautions sign may be posted on the theatre door if needed. 30

40 During the procedure a health care worker who has contact with the patient must maintain Contact Precautions. A dedicated clean person may be present to minimize environmental contamination. The patient health record and specific forms needed for the procedure may be taken into the room. They should be kept on a clean designated table in a low traffic corner of the theatre and does not have contact with health care workers that have patient contact. Wear gloves when touching the patient. Wear a gown if clothing will have direct contact with the patient or touch surfaces or objects in the theatre which may come into contact with the patient. Recover the patient in the theatre or in a separate, isolated, area in the Post Anesthetic Care Unit. After the case, clean surfaces that are visibly soiled or had contact with the patient or any contaminated health care worker. 11. Discharge/Transfer between Facilities It is the responsibility of the transferring facility to identify known VRE positives and suspects when patients are being transferred. VRE Suspect The status of a VRE Suspect patient must be noted on the patient s Transfer Referral Form. VRE Positive Prior to discharge the receiving facility, physician, other involved health care agencies, e.g. Home Care, Physiotherapy, must be notified of the patient s VRE status and treatment. Advise the patient of the importance of informing any health care worker of their VRE status. VRE Positive must be noted on the patient s Transfer Referral Form. The receiving ICP may request VRE status, culture and antimicrobial information from the ICP at the transferring facility. This must be done by telephone or fax and recorded in the patient s health record. The receiving facility does not require rescreening of known VRE positive upon transfer. Positive VRE status does not require an ambulance for transport. Other transportation systems, e.g. Stretcher Car Service may be used. Transfer patients by a transportation company with trained staff and the ability to follow appropriate Infection Control precautions. Patient Precautions for Transfer Have a clean stretcher or wheelchair covered with a clean sheet. Perform hand hygiene on leaving room. No gloves required. Wounds must be covered. Wear clean clothes, housecoat or cover gown. Health Care Workers Precautions for Transfer Hand hygiene before and after patient contact. Wear clean gloves and gown during transportation of patient. Transferring facility notifies Transport Service patient is on Contact Precautions. Transport Service Must Follow Contact Precautions, if indicated, to collect patient in their room and when leaving patient room. During transport to other facility follow Infection Control Guidelines for Health Care Workers in the Community. At receiving facility Transport Services follows Contact Precautions, if indicated, to place patient in their room and upon leaving patient room. 31

41 Consider the wheelchair/stretcher used to transport the patient as contaminated. Disinfect vehicle surfaces and any equipment that was in contact with the patient with facility approved disinfectant. Clean sheets must be used for the next patient. 12. Home Visits/Passes of Hospitalized Patient with Health Care Worker Companion or Family Patient Precautions Hand hygiene on leaving room. No gloves required. Wear clean clothes. Wounds must be covered. Health care Worker Precautions Accompanying Patient Separate transport person to take to door of facility. Individual accompanying patient on the home visit meets patient at door of facility. Alcohol-based handrub must be available for hand hygiene of patient and health care worker during visit. Follow Manitoba Health Infection Control Guidelines for Health Care Workers in the Community. Equipment taken on visit should be bagged for return and then cleaned according to facility policy before care in the use of another patient. Family Accompanying Patient Hand hygiene prior to leaving room Equipment taken on visit should be bagged for return and then cleaned according to facility policy before care in the use of another patient. 13. Visitors Including any Hospitalized Patients Visiting a Positive Patient Visitors do not go from patient to patient giving direct care, therefore their risk of transmitting VRE is minimal. The most important measure for visitors is performing hand hygiene on entering or leaving the patient room. Visitors should ask for assistance in obtaining patient care supplies on nursing unit. 14. Positive Patient Visiting other Patients Patients restricted to room, except for necessary diagnostic or therapeutic services. In extraordinary circumstances visiting may be done for compassionate reasons following consultation with Infection Control. 15. Outpatient Service Patient Schedule patient to allow for cleaning of patient s room whenever possible, e.g. first or last appointment of the day. The patient must perform hand hygiene on arrival. Patient must have open/draining wounds covered. Place patient directly in the examination room, not to be left sitting in the waiting room. Patient should be instructed to not touch items/surfaces in examination room. Health Care Workers Health care workers must wear gown and gloves if they have direct patient contact, including transport of the patient. Place gowns in the regular laundry hamper after use. Perform hand hygiene after removal of gown and gloves. 32

42 Environment Individualize patient care equipment whenever possible. If equipment/supplies are to be shared between patients these items must be cleaned with a facility approved disinfectant before use on another patient. Minimize patient contact with items/surfaces in the exam room. Clean room surfaces that have had patient contact with facility approved disinfectant. This cleaning does not require Housekeeping Services, but can be safely performed by the clinic staff. Disposable gloves should be worn for use of facility approved disinfectant. No special precautions required for handling soiled linen or garbage. 16. Patients Requiring Physical Rehabilitation Patients requiring Physical Rehabilitation in acute care settings should receive rehabilitation therapy as appropriate by care givers. Precautions required during rehabilitation must be developed in consultation with Infection Control. Schedule therapy during a time of minimal activity in the department, e.g. end of the day. In a VRE outbreak situation, multiple VRE positive patients could be scheduled at one time. Designate therapy to one area of the department. Transport the patient according to Diagnostic Procedures/Transfer within the Facility section. Dedicated equipment is desirable. If unavailable, shared equipment must be cleaned with facility approved disinfectant after use by a VRE patient and before use in the care of another patient. Communal equipment, e.g. parallel bars must be cleaned with facility approved disinfectant after use by a VRE patient and before use in the care of another patient. If the patient requires rehabilitation on the unit outside their room, e.g. walking, this must be scheduled for a time of minimal activity on the unit. The patient must be accompanied by a health care worker or informed family. The patient must be educated and perform hand hygiene prior to leaving room. 17. Management of VRE Positive Patients on Rehabilitation Units Patients on rehabilitation units in acute care centers are to be managed according to acute care guidelines. 18. Management of VRE Positive Psychiatry Patients on Psychiatry Units Follow Routine Practices for VRE positive patients on Psychiatry Units. VRE positive psychiatry patients must perform hand hygiene prior to leaving the unit. 19. Outbreak Management Refer to Management of Contacts section #8, page 29. See Appendix A for Steps for Management of an Outbreak 20. Surveillance Each Infection Control Department in a facility should maintain a line listing of patients screened for VRE. This would enable the ICP to keep track of the screening that is being done in the facility. Each facility should maintain a standard data collection form on every identified patient who is colonized/infected with VRE in their facility. This enables the ICP to maintain a database of the VRE positive patients and prevalence in the facility. A screening line listing form and patient management form are included in Appendix F. Collection and storing of all relevant patient information must be consistent with PHIA. 33

43 C. MRSA Guidelines for Long Term Care Facilities (LTCFs), Interim Care Units and Hospice Affiliated with a Health Care Institution 1. Identification/Notification of MRSA MRSA colonized/infected individuals are not to be denied admission into LTCFs. A system and criteria must be set up with laboratory support for reporting of positive residents. Each facility should assign responsibility for the following when a resident is identified as MRSA positive: Notify unit the resident is on. Notify Infection Control Practitioner or designate. Implement Contact Precautions if required. Identify on the resident record the MRSA status and infection control precautions required. Provide the MRSA Positive resident, family members and visitors with verbal instructions regarding MRSA Positive infection control precautions as well as Resident Information Sheet. 2. Surveillance Cultures to be Performed to Identify MRSA Nares (both nares using one swab). Open wounds. Refer to Appendix C for culturing procedures. 3. Flagging/Deflagging of Resident Record A flagging system is not necessary. 4. Admission Screening Surveillance cultures for admission screening are not required. May be done as requested by acute care as part of an outbreak investigation. 5. Additional Precautions In addition to Routine Practices, Contact Precautions (refer to page 14) should be implemented for selected residents meeting the following conditions: Extensive desquamating skin disorder with known or suspected infection or significant colonization. Draining infected wounds in which drainage cannot be contained by a dressing. Colonized tracheostomy or pneumonia with uncontrolled respiratory secretions. In these situations, resident placement preference is a single room with individual toilet and hand wash facilities. 5.1 Resident Placement, Cohorting & Activities Cohorting is the preferred resident placement if there is more than one positive resident. If cohorting is not possible place the MRSA Positive resident with a low-risk roommate: No open wounds. No decubitus ulcers. No urinary catheter, feeding tubes, or other invasive devices. No debilitated or bed-bound residents requiring extensive hands on care. MRSA colonized/infected residents should not be restricted from participation in social or therapeutic group activities. Wounds must be covered with dry dressings and residents must perform hand hygiene before participating in group activities. 5.2 Hand Hygiene Routine Practices. 5.3 Gowns/Gloves/Masks/Eye Protection Gowns Routine Practices. 34

44 Gloves Routine Practices. Masks Routine Practices. Eye Protection Goggles and Face Shield Routine Practices. 5.4 Equipment Routine Practices. Priority is to have dedicated equipment, e.g. slings, sliders. 5.5 Linen/Dishes Linen Routine Practices. Dishes Routine Practices. 5.6 Needles/Syringes Routine Practices. 5.7 Lab Specimens Routine Practices. Collection of specimens as per facility procedures. 5.8 Waste Disposal Routine Practices 5.9 Environmental Control/Housekeeping Routine cleaning should be done following facility policy with particular attention to bathing and toileting facilities, recreational equipment, horizontal surfaces in the resident s room, and particular, items that are frequently touched, e.g. handrails, light cords, laundry hamper lids. When Contact Precautions are discontinued or the resident is moved/transferred, thorough terminal cleaning and changing of privacy curtains is required. Cloth or string light and call bells must be changed. Soiled equipment or furnishings must be immediately cleaned with a facility approved disinfectant. Mop heads should be laundered before reuse. In outbreaks, consideration should be given to more frequent cleaning and/or cleaning with a facility approved disinfectant. This will be determined by the outbreak investigation team Resident Health Record and Personal Documents, e.g. Wills, Voting Routine Practices Duration of Additional Precautions Infection Control Precautions must be implemented and discontinued as outlined in Additional Precautions # Post Mortem Care Routine Practices. 6. Treatment or Decolonization Treatment of infections is determined by the attending physician in consultation with an Infectious Disease Consultant as appropriate. Decolonization is not recommended. Individuals colonized with MRSA do not require decolonization before transfer to a LTCF. 7. Subsequent Cultures for Persistent Carriage Obtain cultures only when acute clinical symptoms, e.g. respiratory infection or wound drainage develop. Refer to Appendix C for culturing procedures. 8. Management of Contacts No screening of resident contacts unless there is an outbreak. 9. Diagnostic Procedures/Transfers of Residents Within the Facility If the resident is transferred, the referring ward or clinic must notify the receiving department of the necessary infection control precautions required. 35

45 Resident Precautions for Transport Perform hand hygiene on leaving room No gloves are required Wear clean clothes, housecoat or cover gown Wounds must be covered If the resident is to be transferred in a stretcher or wheelchair, it must be covered with a clean sheet prior to entering room. After returning to the room, the stretcher or wheelchair must be cleaned with facility approved disinfectant before use in the care of another resident. 10. Discharge/Transfer between Facilities Surveillance cultures are not required for patients waiting to be transferred from acute care to a LTCF. It is the responsibility of the transferring facility to identify known MRSA Positives when residents are being transferred. The MRSA status must be documented on the resident s Transfer Referral Form. The receiving ICP or designate may request the resident s MRSA status, culture and antimicrobial information from the ICP or designate at the transferring facility. This must be done by telephone or fax and recorded in the health record. Positive MRSA status does not warrant the need for an ambulance. Other transportation systems, e.g. Stretcher Car Service may be used. Transfer residents by a transportation company that has trained staff and the ability to follow proper infection control precautions. Resident Precautions for Transfers Have a clean stretcher or wheelchair covered with a clean sheet. Perform hand hygiene on leaving room. Wounds must be covered. Wear clean clothes, housecoat or cover gown. Health Care Worker Precautions for Transfers Perform hand hygiene before and after resident contact. Transferring facility notifies Transport Service resident is on Contact Precautions. Transport Service Must Follow Contact Precautions, if indicated, to collect resident in their room and when leaving resident room. During transport to other facility follow Infection Control Guidelines for Health Care Workers in the community. At receiving facility Transport Services follows Contact Precautions, if indicated, to place individual in their room and upon leaving the room. Consider the wheelchair/stretcher used to transport the individual as contaminated. Disinfect vehicle surfaces and any equipment that was in contact with the individual with facility approved disinfectant. Clean sheets must be used for the next patient. 11. Home Visits with Health Care Worker Companion or Family Routine Practices must be followed for all home visits. Refer to Section VIII. 12. Visitors Including any Residents Visiting a Positive Resident Visitors do not go from resident to resident giving direct care, therefore their risk of transmitting MRSA is minimal. The most important preventative measure for visitors is performing hand hygiene before and after visiting resident. Visitors should ask for assistance in obtaining resident care supplies on nursing unit. 36

46 13. Positive Resident Visiting other Residents Check with nurse prior to visiting. 14. Management of MRSA positive Residents on Rehabilitation Units MRSA positive residents on rehabilitation units in LTCFs are to be managed according to long term care guidelines. 15. Management of MRSA Positive Residents on Psychiatry Units MRSA Positive residents on psychiatry units in LTCFs are to be managed according to long term care guidelines. 16. Outbreak Management See Appendix A for steps for Outbreak Management. 17. Surveillance Each facility should maintain a standard data collection form on every identified resident colonized/infected with MRSA in their facility. This enables the ICP to maintain a database of MRSA positive residents and monitor the frequency in the facility. A resident management form is included in Appendix F. Collection and storing of all relevant patient information must be consistent with PHIA. 37

47 D. VRE Guidelines for Long Term Care Facilities (LTCFs), Interim Care Units and Hospice Affiliated with a Health Care Institution 1. Identification/Notification of VRE VRE colonized/infected individuals are not to be denied admission into LTCFs. A system and criteria must be set up with laboratory support for reporting of positive residents. Each facility should assign responsibility for the following when a resident is identified as VRE positive: Notify unit the resident is on. Notify Infection Control Practitioner or designate. Implement Contact Precautions if required. Identify on the resident record the VRE status and infection control precautions required. Provide the VRE Positive resident, family members and visitors with verbal instructions regarding VRE Positive infection control precautions as well as Resident Information Sheet. 2. Surveillance Cultures to be Performed to Identify VRE Rectal or ostomy swab. Refer to Appendix C for culturing procedures. 3. Flagging/Deflagging of Resident Records A flagging system is not necessary. 4. Admission Screening Surveillance cultures for admission screening are not required. May be done as requested by acute care as part of an outbreak investigation. 5. Additional Precautions In addition to Routine Practices, Contact Precautions on page 14 should be implemented for selected residents meeting the following conditions: Diarrhea or fecal incontinence not contained by incontinence briefs or diapers. Stoma not covered with a dressing or appliance to contain drainage. In these situations, resident placement preference is a single room with individual toilet and hand wash facilities. 5.1 Resident Placement, Cohorting and Activities Cohorting is the preferred resident placement if there is more than one positive resident. If cohorting is not possible place the VRE Positive resident with a low risk roommate: No open wounds. No decubitus ulcers. No urinary catheters, feeding tubes or other invasive devices. No debilitated or bed-bound residents requiring extensive hands on care. VRE colonized/infected residents should not be restricted from participation in social or therapeutic group activities. Wounds must be covered with dry dressings and residents must perform hand hygiene before participating in group activities. 5.2 Hand Hygiene Routine Practices. 5.3 Gowns/Gloves/Masks/Eye Protection Gowns Routine Practices. Gloves Routine Practices. Masks Routine Practices. Eye Protection Goggles and Face Shield Routine Practices. 38

48 5.4 Equipment Routine Practices. Priority is to have dedicated equipment, e.g. slings, sliders. 5.5 Linen/Dishes Linen Routine Practices. Dishes Routine Practices. 5.6 Needles/Syringes Routine Practices. 5.7 Lab Specimens Routine Practices. Collection of specimens following facility procedures. 5.8 Waste Disposal Routine Practices. 5.9 Resident Health Record and Personal Documents, e.g. Wills, Voting Routine Practices Environmental Control/Housekeeping Routine cleaning should be done following facility policy with particular attention to bathing and toileting facilities, recreational equipment, horizontal surfaces in the resident s room, and particular, items that are frequently touched, e.g. handrails, light cords, laundry hamper lids. When Contact Precautions are discontinued or the resident is moved/transferred, thorough cleaning and changing of privacy curtains is required. Cloth or string light and call bells must be changed. Soiled equipment or furnishings soiled with feces must be immediately cleaned with a facility approved disinfectant. Mop heads should be laundered before re-use. In outbreaks, consideration should be given to more frequent cleaning and/or cleaning with a facility approved disinfectant. This will be determined by the outbreak management team Duration of Infection Control Precautions Evidence indicates people with VRE are often colonized. Infection Control Precautions must be implemented and discontinued as outlined in Additional precautions # Post Mortem Care Routine Practices. 6. Treatment or Decolonization Treatment of infections is determined by the attending physician in consultation with an Infectious Disease Consultant. There is no effective decolonization for VRE. 7. Subsequent Cultures for Persistent Carriage Evidence indicates people with VRE are often colonized permanently. Obtain cultures only when acute clinical symptoms, e.g. respiratory infection or wound drainage develop. Refer to Appendix C for culturing procedures. 8. Management of Contacts No screening of resident contacts unless there is an outbreak. 9. Diagnostic Procedures/Transfers of Residents Within the Facility If the resident is transferred, the referring ward or clinic must notify the receiving department of the necessary infection control precautions required. Resident Precautions for Transport Perform hand hygiene on leaving room. No gloves are required. Wear clean clothes, housecoat or cover gown. Wounds must be covered. 39

49 If the resident is to be transferred in a stretcher or wheelchair, it must be covered with a clean sheet prior to entering room. After returning to the room, the stretcher or wheelchair must be cleaned with facility approved disinfectant before use in the care of another resident. 10 Discharge/Transfer Between Facilities Surveillance cultures are not required for patients waiting to be transferred from acute care to long term care. It is the responsibility of the transferring facility to identify known VRE Positives when residents are being transferred. The VRE status must be documented on the resident s Transfer Referral Form. The receiving ICP or designate may request the resident s VRE status, culture and antimicrobial information from the ICP or designate at the transferring facility. This must be done by telephone or fax and recorded in the health record. Positive VRE status does not require an ambulance for transport. Other transportation systems, e.g. Stretcher Car Service may be used. Transfer residents by a transportation company with trained staff and who can follow appropriate Infection Control precautions. Resident Precautions for Transfer Have a clean stretcher or wheelchair covered with clean sheet. Perform hand hygiene on leaving room. Wounds must be covered. Wear clean clothes, housecoat or cover gown. Health Care Worker Precautions for Transfer Hand hygiene before and after resident contact. Transferring facility notifies Transport Service patient is on Contract Precautions. Transport Service Must Follow Contact Precautions, if indicated, to collect resident in their room and when leaving resident room. During transport to other facility follow Infection Control Guidelines for Health Care Workers in the Community. At receiving facility Transport Services follows Contact Precautions, if indicated, to place individual in their room and upon leaving room. Consider the wheelchair/stretcher used to transport the individual as contaminated. Disinfect vehicle surfaces and any equipment that was in contact with the patient with facility approved disinfectant. Clean sheets must be used for the next patient. 11. Home Visits with Health Care Worker Companion or Family Routine Practices must be followed for all home visits. Refer to Community Care Guidelines. Refer to Section VIII. 12. Visitors Including any Residents Visiting a Positive Resident Visitors do not go from resident to resident giving direct care, therefore their risk of transmitting VRE is minimal. The most important measure for visitors is performing hand hygiene before and after visiting resident. Visitors should ask for assistance in obtaining resident care supplies on nursing unit. 13. Positive Resident Visiting other Residents Check with nurse prior to visiting. 14. Management of VRE Positive Residents on Rehabilitation Units VRE Positive residents on rehabilitation units in long-term care facilities are to be managed following long-term care guidelines. 40

50 15. Management of VRE Positive Residents on Psychiatry Units VRE Positive residents on psychiatry units in long-term care facilities are to be managed according to long-term care guidelines. 16. Outbreak Management See Appendix A for steps for Outbreak Management. 17. Surveillance Each facility should maintain a standard data collection form on every identified resident colonized/infected with VRE in their facility. This enables the ICP to maintain a database of VRE positive residents and monitor the frequency in the facility. A resident management form is included in Appendix F. Collection and storing all relevant patient information must be consistent with PHIA. 41

51 E. Antibiotic Resistant Gram Negative Bacilli including Extended Spectrum Beta Lactamase (ESBLs) Guidelines for Acute Care, Surgical Centres, Long Term Care Facilities (LTCFs), Interim Care Units and Hospice Affiliated with a Health Care Institution Antibiotic resistance to gram negative bacilli is evolving. Selected antibiotic resistant gram negative bacilli may require Additional Precautions while some require only Routine Practices. The following are infection control guidelines to prevent transmission of antibiotic resistant gramnegative bacilli that include: Extended spectrum Beta Lactamases (ESBLs). Gram negative bacilli that are resistant to all but one class of antimicrobial agents, e.g. strains of Acinetobacter baumanni resistant to all antimicrobial agents except imipenem. Gram negative bacilli that are intrinsically resistant to the broadest spectrum antimicrobials, e.g. Stenotrophomonas maltophilia or Burkholdia cepacia. Individuals with cystic fibrosis with antibiotic resistant gram negative bacilli follow: Infection Control Recommendations for Patients with Cystic Fibrosis: Microbiology, Important Pathogens, and Infection Control Practices to Prevent Patient-to-Patient Transmission published in the American Journal of Infection Control, May Identification and Notification of Antibiotic Resistant Gram Negative Bacilli A system and criteria must be set up with the laboratory support for reporting of the above microorganisms. Each facility should assign responsibility for the following when a patient/resident is identified as positive: Notify unit the patient is on. Notify Infection Control or designate and if applicable, the Health Information Department. Implement Contact Precautions described below. Identify on the patient/resident record the status and infection control precautions required. Provide the positive patient/resident, family members and visitors with verbal instructions regarding antibiotic resistant gram-negative bacilli and Contact Precautions. 2. Flagging and Deflagging of Patient Records is Not Required 3. Routine Admission Screening is Not Required. If an Outbreak Occurs Admission Screening May be Appropriate, as Directed by Infection Control 4. Additional Precautions Contact Precautions 4.1 Acute Care Facilities and Surgical Centres In addition to Routine Practices the patient must be placed on Contact Precautions. See page 13 for Contact Precautions. Cohorting will be the preferred placement if there is more than one positive individual. Cohort in consultation with Infection Control. There are no special precautions for the patient health record or personal documents. The patient will remain on Contact Precautions until culture negative. 4.2 Long Term Care Facilities, Interim Care Units and Hospice Affiliated with a Health Care Institution In addition to Routine Practices, Contact Precautions should only be implemented for selected residents who meet the following conditions: Draining infected wounds in which drainage cannot be contained by dressing. 42

52 Extensive disquamating skin disorder with known or suspected infection or significant colonization. Acute diarrhea of likely infectious cause if uncontrolled (incontinent) can not be contained by incontinence briefs and resident is not confined to bed. See page 14 for Contact Precautions. 4.3 Other Infection Control Management Practices Treatment should be done in consultation with an Infectious Disease Consultant. Screening cultures for persistent carriage are not recommended. Screening of contacts is not recommended. Screening may be considered during an outbreak in consultation with Infection Control. The transferring facility shall identify known positives prior to transfer. Routine Practices should be followed for all home visits. Refer to Section VIII. If an outbreak occurs follow Steps for Outbreak Management in Appendix A. 43

53 F. Vancomycin Intermediate and Resistant Staphylococcus aureus (VISA/VRSA) Guidelines for Acute Care, Surgical Centres, Long Term Care Facilities (LTCFs), Interim Care Units and Hospice Affiliated with a Health Care Institution Infection Control should be notified immediately if VISA/VRSA is isolated. Follow MRSA Guidelines for Acute Care, Surgical Centres, Long Term Care Facilities (LTCFs), Interim Care Units and Hospice Affiliated with a Health Care Institution included in Section VII with the exception of the following: 1. Surveillance cultures: Nares, open wounds, drains and other clinically relevant sites such as catheter exit sites, e.g. vascular, urinary 2. Admission screening is not recommended. If cases do occur refer to the MRSA Guidelines for Acute Care, Surgical Centres, Long Term Care Facilities (LTCFs), Interim Care Units and Hospice Affiliated with a Health Care Institution. Refer to Section VII. 3. Isolate the patient/resident in a private room with separate toilet and hand wash facilities. 4. Don gown and gloves before entry to the patient s/resident s room. 5. Minimize the number of persons caring for the patient/resident, e.g. assign dedicated staff to care for the VISA/VRSA positive patient/resident. 6. Subsequent cultures for persistent carriage and the duration of Additional Precautions will be determined in consultation with Infection Control and/or Infectious Diseases Consultant and/or Public Health authorities. 7. Contact investigation of staff would only be done in consultation with Infection Control, Occupational Health and/or Infectious Diseases Consultant and/or Public Health authorities. 8. Each facility should maintain a standard data collection form in Appendix F on every patient/resident who is colonized/infected with VISA/VRSA in their facility. This enables the ICP to maintain a database of positive patients/residents and frequency in the facility. 9. Collection and storing of all relevant patient information must be consistent with PHIA. A screening line listing form and patient/resident management form is included in Appendix F. 44

54 VIII. ARO Infection Control Guidelines for Community Care A. General Information These guidelines are supported by the existing document, Infection Control Guidelines for Health Care Workers in the Community. Manitoba Health, September There are important differences between acute care facilities and community-based health services with respect to infection control recommendations. Home Care programs need to balance infection control precautions with promoting optimal, healthy lifestyles for clients; particularly since colonization or infection with an ARO may persist indefinitely or may periodically re-emerge, despite treatment or attempts at decolonization. Clients who are colonized or infected with these microorganisms have not been shown to pose a health risk to health care providers or other household contacts, particularly if Routine Practices as outlined in the Infection Control Guidelines for Health Care Workers in the Community are followed. Routine Practices are the essential infection control measures recommended for all clients at all times. Regular hand hygiene and environmental cleaning are essential and the primary infection control measures for all Community Care clients at all times, including persons colonized or infected with an ARO. This is important as many colonized clients are not identified as such. Hand hygiene is the most important way to reduce risk of transmission AROs, as microorganisms are readily transmitted among individuals via the unwashed hands of health care providers. Special attention to handling and, where required, cleaning and disinfection of shared equipment carried to and from the home is also important, to avoid cross-contamination. B. Transfers of ARO Colonized or Infected Clients To or From Facilities Open and timely communication regarding a person s colonization or infection history of AROS is essential between the Community Care service and the facility. A receiving facility or Community Care service should inform the facility or Community Care service from where the client was transferred if, within hours of admission, the new resident/client is found to be infected or colonized with an ARO. Follow-up cultures for AROS are not usually required when an individual is transferred into Community Care services as clients who are colonized or infected do not pose a risk to health care workers or other family members. If follow-up cultures are required by Infection Control or Infectious Disease Specialists, the client should be followed by their physician. C. Home Care 1. Admission Admission to Home Care services should not be denied or delayed on the basis of colonization or infection with an ARO. Home Care Services should be notified of client s ARO status. 2. Home Arrangements There is no need to disrupt housing arrangements if a household member is colonized or infected with an ARO. Toilets and bathrooms should be kept clean. Refer to Cleaning Requirements in #9. 3. Client Activities Clients colonized or infected with an ARO may participate in all recreational and social activities. Open wounds or lesions that are colonized or infected should be covered by clean, dry dressings. 45

55 4. Hand Hygiene Hand Hygiene in accordance with Routine Practices must be followed at all times: To the extent clients are able to participate in self-care, they should be taught, encouraged and reminded of the importance of hand washing after using the toilet and before eating or preparing food. Clients who have difficulty in self-care should be assisted in washing their hands whenever their hands may be contaminated. Other persons living in the household of clients who are colonized or infected with an ARO should be taught proper hand washing technique and the importance of hand hygiene. 5. Personal Protective Equipment (PPE) PPE should be used according to Routine Practices to protect the caregiver from anticipated exposure to blood or body fluids. Gloves and gowns may be required in the exceptional situation of clients colonized or infected with VISA/VRSA; mask/eye protection may also be required if performing procedures likely to generate splash or splatter, e.g. wound manipulation, suctioning of VISA/VRSA contaminated material. Consultation with Infection Control or Infectious Diseases is recommended on a case-by-case basis. 6. Dishes, Glasses, Cups and Eating Utensils Normal household dishwashing effectively cleans dishes and utensils. Wash dishes in a regular dishwasher, or in the kitchen sink, using hot water and regular dish soap. Gloves may be worn while washing dishes, but are not absolutely necessary. Gloves are not required when handling food trays, dishes or eating utensils. The use of disposable dishes and utensils is not necessary. 7. Laundry Although soiled linen may carry large numbers of infectious organisms, the risk of disease transmission is low, provided hygienic and common sense handling of clean and soiled linen is carried out. Normal household clothes washing and drying effectively clean linen and clothing. 8. Garbage Place all disposable waste, such as dressings and bandages, in a leak-proof bag and close securely. Double bagging is not necessary. Discard with the regular household garbage. 9. Cleaning Requirements Consistent, regular cleaning assists in reducing the potential for environmental transmission of microorganisms. AROs can be effectively removed from the environment through regular housekeeping and cleaning practices, and can be inactivated by using a variety of household cleaning and disinfectant products, e.g. Lysol, Pinesol, Mr. Clean, 70% isopropyl alcohol, regular household bleach diluted one part bleach to nine parts water mixed fresh daily. Follow manufacturer s recommendations for contact time. Gloves should be worn during cleaning activities. Either disposable vinyl gloves or reusable rubber gloves can be used. Reusable rubber gloves should be washed and hung to dry after use. It may be easier to wash these gloves while still on the hands, after cleaning activities, and then hang to dry. Policies should be developed for the routine cleaning of spills of blood or other body fluids and/or secretions. 10. Clients Care Equipment and Supplies Clients should be evaluated on a case-by-case basis to determine whether dedicated equipment is indicated. 46

56 In the exceptional situation of clients who are colonized or infected with VISA/VRSA, disposable items are preferred. If reusable items that can not be easily disinfected are used, e.g., blood pressure cuffs, they must be dedicated for single client use. Clients who are colonized or infected with VISA/VRSA should have non-disposable items that cannot be easily cleaned or disinfected, e.g. adhesive tape, dedicated for them. Minimize equipment and supplies going into the home. Do not stockpile supplies such as dressings. Clean and disinfect with an appropriate disinfectant any equipment removed from the home and before use by another client. Re-useable items that are washable may be washed in the same manner as regular household laundry. Equipment that cannot be immersed in water, such as glucometers or infusion pumps, should be cleaned according to manufacturer s recommendations and wiped down with a suitable disinfectant. Refer to Cleaning Requirements in # Bathing Clients infected or colonized with an ARO should undergo the same bathing schedule that is routinely provided to other clients. A regular soap may be used as there is no evidence that AROs are more resistant to removal from the skin than regular microorganisms. Clients should have their own bath towel, which should not be shared with others. Clients who have diarrhea or fecal incontinence, with resulting extensive fecal contamination of skin, should be bathed as necessary for healthy skin care. In event of fecal contamination, the bathtub should be cleaned and disinfected with a suitable disinfectant compound. Refer to Cleaning Requirements in #9. D. Group Homes for the Physically and Mentally Challenged There is no need to disrupt housing arrangements if a household member is colonized or infected with an ARO. Hand hygiene and environmental cleaning are the essential and primary infection control measures for all residents at all times, including persons colonized or infected with an ARO. Other persons living in the household should be taught good hand washing technique and the importance of handwashing. Residents colonized or infected with an ARO may participate in all recreational and social activities. It is especially important to teach, encourage and remind the person who is colonized or infected with an ARO, and all other household members, of the importance of hand washing after using the toilet, and before eating or preparing food. Follow the above ARO Guidelines for Home Care when providing direct personal care. Refer to Infection Control Guidelines for Community Shelters and Group Homes Manitoba Health. E. Doctors Offices/Outpatient Clinics/Dental Offices/Travel Clinics Follow-up cultures for ARO s are not usually required when an individual is discharged from hospital. These individuals are not a risk to health care workers or other family members in the community. If follow-up cultures are required, the positive individual should be followed by their physician in conjunction with facility Infection Control. Hand hygiene and the consistent use of Routine Practices with all patients are considered essential infection control practices for all office/clinic settings. 47

57 Use of gloves and gowns are required for the care of patients colonized or infected with VISA/VRSA; mask/eye protection is also recommended if performing procedures likely to generate splash or splatter, e.g. wound manipulation, suctioning of VISA/VRSA contaminated material. Consultation with Infection Control or Infectious Diseases is recommended on a case-by-case basis. Clean soiled surfaces immediately with a low-level detergent disinfectant product. Clean examination tables with a low-level detergent disinfectant at the end of each clinic. Clean contact surface of any equipment used on patients, e.g. stethoscopes, between patients. The following detergent disinfectants are suggested for use in the daily cleaning and disinfection of office surfaces/equipment; phenolic, iodophor, quaternary ammonium compound, hydrogen peroxide, or a 10% fresh solution of sodium hypochlorite. Follow manufacturers recommendations for contact time. F. First Responders There is no evidence that providing services to patients with ARO s is a risk for first responders when Routine Practices are followed. Since the duration of time the ambulance crew spends in contact with the patient is limited, the amount of bacterial shedding is likely minimal. Therefore, hand hygiene and adherence to Routine Practices is sufficient to prevent transmission. Hand hygiene is the most important precautionary measure when dealing with all patients including ARO colonized or infected patients since the major emphasis is prevention of cross-contamination to other patients. PPE should be used according to Routine Practices to protect the First Responder from anticipated exposure to blood or body fluids. G. Community (Workplace, School, Daycare, Shelters, Hospice) There is no need to disclose colonization with AROs in the workplace, school or daycare setting. Admission to school, daycare and shelters should not be denied or delayed on the basis of colonization or infection with an ARO. Employment should not be denied on the basis of colonization or infection with an ARO. Refer to Infection Control Guidelines for Community Shelters and Group Homes Manitoba Health. Health care workers and food handlers must maintain excellent hygiene and hand hygiene practices at all times. H. Community-Associated MRSA (CA- MRSA) MRSA can cause illness in persons outside of hospitals and health care facilities. MRSA infections that are acquired by persons in the community who have not been recently, within the past year, hospitalized or had a medical procedure, e.g. dialysis, surgery, catheters, are known as CA-MRSA infections. CA-MRSA infections are usually manifested as skin infections, such as boils and abscesses, and occur in otherwise healthy people. CA-MRSA infections can also cause more serious infections, such as bacteremia or necrotizing pneumonia, at times resulting in toxic shock syndrome and death. Clusters of CA-MRSA skin infections have been reported among athletes including contact and noncontact sports, military recruits, children, Pacific Islanders, Alaskan Natives, Native Americans, men who have sex with men, and prisoners. Recently, a significant increase in CA-MRSA infections has been identified in First Nations communities in northern Manitoba; primarily in children and the elderly in Norman and Burntwood Regional Health Authorities. 48

58 Persons with MRSA infections that meet all of the following criteria likely have CA-MRSA infections: Diagnosis of MRSA was made in the outpatient setting or by a culture positive for MRSA in less than 48 hours after admission to a hospital. No medical history of MRSA infection or colonization. No medical history in the past year of hospitalization, admission to a personal care home or hospice, dialysis, or surgery. No permanent indwelling catheters or medical devices that pass through the skin into the body. The main mode of transmission of CA-MRSA is via hands which may become contaminated by contact with a) colonized or infected individuals, b) colonized or infected body sites of other persons, or c) devices, items, or environmental surfaces contaminated with body fluids containing MRSA. Factors that have been associated with the spread of CA-MRSA skin infections include close skin-to-skin contact, openings in the skin such as cuts or abrasions, contaminated items and surfaces, crowded living conditions, and poor hygiene. Recently recognized outbreaks of CA-MRSA have been associated with strains that have some unique microbiologic and genetic properties compared with the traditional hospital-based MRSA strains, suggesting some biologic properties, e.g. virulence factors such as Panton Valentine leukocidin, a toxin that destroys white blood cells and results in severe soft tissue damage, may allow the community strains to spread more easily or cause more skin disease. Unlike typical hospital-acquired MRSA, CA-MRSA strains are unlikely to be resistant to multiple antimicrobial classes. However, a unique feature of CA-MRSA strains in northern Manitoba appears to be significant mupiricin resistant. Preliminary investigation of the changing epidemiology of MRSA in northern Manitoba suggests that the emergence of CA-MRSA is not related to the spread of a hospital organism. It is not currently know how widespread CA-MRSA carriage might be in the community. Consideration must be given to developing treatment guidelines for skin and soft tissue infections given the increase in CA-MRSA. Health care providers should consider using treatments other than antibiotics for persons with mild skin infections. Prevention of CA-MRSA infections is an area of ongoing investigation. No single prevention approach is likely to work alone, but several measures should be considered pending further information: Careful handwashing is important for prevention of the spread of many infections, including CA-MRSA. Persons with active CA-MRSA and MSSA skin infections should cover the area if it is draining, wash their hands after dressing changes, and properly dispose of soiled dressings. Patients and families should be provided with simple instructions to prevent transmission of skin infections to family members and other contacts, including education on appropriate wound management, hand and body hygiene, and avoiding sharing of potentially contaminated items. Good hygiene practices such as showering with soap after all physical competitions, avoiding sharing of personal items like razors and towels, and establishing routine environmental cleaning schedules for shared equipment should be promoted in sports venues including gymnasiums and locker rooms. More frequent culturing of skin and soft tissue infections, such as boils and abscesses, and susceptibility testing of S. aureus isolates should be encouraged in primary care providers. In some CA-MRSA outbreaks, prior use of antibiotics has been found to be a risk factor for CA-MRSA infection. Therefore, the appropriate use of antibiotics, e.g. use only when needed to treat bacterial infections, should be reinforced especially in northern Manitoba communities at this time to prevent the development of resistant strains. 49

59 Primary care providers should be educated concerning careful selection of empirical antimicrobial therapy when treatment is indicated for severe skin and soft tissue infections. Non-beta-lactam antibiotics would be preferred such as trimethoprimsulphamethoxazole, tetracyclines, erythromycin, clindamycin or quinolones. The use of rifampin to treat MRSA infections should be discouraged in communities that have a high incidence of tuberculosis. Clindamycin should also be used with caution in settings where C. difficile is increasing. Surgical drainage of minor skin and soft tissue infections, e.g. boils and abscesses, should be the mainstay of therapy, rather than relying on antibiotics alone. There are no data to suggest that decolonization protocols for CA-MRSA for patients or their families are necessary or have long-term effectiveness; nor would decolonization therapy be recommended given mupiricin resistance strain in northern Manitoba. There is no evidence that excluding MRSAcolonized individuals from normal activities such as group child care, school, the workplace, or athletics is effective in limiting the spread of CA-MRSA; and exclusion policies are therefore not recommended. 50

60 IX. Occupational Health A. MRSA 1. Health Care Worker is Exposed to MRSA Follow Public Health Agency of Canada Guidelines for Prevention & Control of Occupational Infections in Health Care, No modifications to work practices or work restrictions for health care worker exposed to MRSA (Refer to Routine Practices section in this document on Personal Protective Equipment, page 10). Occupational Health should not routinely obtain specimens for culture from health care worker(s) exposed to MRSA. Identification by Infection Control, Infectious Diseases, Occupational Health Physician or Local Public Health Authorities of a health care worker epidemiologically linked to patient transmission may be an indication to obtain screening cultures. 2. Health Care Worker is Colonized or Infected with MRSA Occupational Health (OH) to collaborate with Infection Control, Infectious Diseases or Local Public Health authorities of a health care worker epidemiologically linked to patient transmission. Consider work restrictions and reassignments until appropriate decolonization therapy. Occupational Health should refer to Infectious Diseases or Public Health for confirmation of diagnosis and treatment. Clinical management may include lab investigations with molecular typing and/or antimicrobial treatment/therapy. Follow and refer to Public Health Agency of Canada Infection Control Guidelines for Prevention & Control of Occupational Infections in Health Care, 2002, when considering on applying: Engineering controls. Administration controls. Occupational Health work practices. 51

61 3. Occupational Management of Health Care Worker in Outbreak Situation Occupational Health liaises with Infection Control if an outbreak is suspected. Public Health would be consulted as required by Manitoba Health legislation. Occupational Health refers health care workers colonized with MRSA and epidemiologically linked to patient/resident transmission for medical assessment, lab investigation with molecular typing and for appropriate therapy. Consider and assess health care workers colonized with MRSA and epidemiologically linked to outbreak for fitness for work. Establish a plan for health care worker follow-up. Occupational Health in collaboration with Infection Control, may modify work during outbreak, e.g. assign MRSA colonized health care work to MRSA patients. Occupational Health should track statistics on: The number of health care workers with MRSA infections. Time loss due to MRSA infection. The number of health care workers with MRSA epidemiologically linked to transmission. B. VRE There is little evidence, which addresses Occupational Health recommendations and followup care management of VRE. Health care workers that are known to be exposed to, infected with and/or considered to be involved in an outbreak situation should be dealt with on a case-by-case basis. Occupational Health should liaise with Infection Control, Infectious Disease Specialists, Occupational Health Physicians and Local Public Health Authorities if faced with this situation. 1. Health Care Worker is Exposed to VRE Follow Public Health Agency of Canada, Infection Control Guidelines for Prevention and Control of Occupational Infections in Health Care, Occupational Health should not obtain specimens for culture from health care worker(s) exposed to VRE. No modifications to work practices or work restrictions for health care worker if exposed to VRE. Refer to Routine Practices section in this document on Personal Protective Equipment, page Health Care Worker is Colonized or Infected with VRE Confirm diagnosis for clinical management including, where appropriate, lab investigation with molecular typing. If colonized with VRE and have diarrhea, health care worker should not work until symptoms resolve, medical assessment is complete and appropriate control measures are in place. Follow and refer to Public Health Agency of Canada Infection Control Guidelines for Prevention & Control of Occupational Infections in Health Care, 2002, when considering and applying: Engineering controls. Administration controls. Occupational Health work practices. 3. Occupational Management of Health Care Worker in Outbreak Situation Outbreak considered if more than one health care worker epidemiologically linked meets criteria for diagnosis. Occupational Health liaises with Infection Control if outbreak is suspected. Public Health would be consulted if required by Manitoba Health legislation. 52

62 Occupational Health refers health care worker(s) colonized with VRE and epidemiologically linked to patient/resident transmission for medical assessment which may include lab investigation with molecular typing. Occupational Health to consider and assess health care worker(s) fitness for work. Establish health care worker follow-up. Occupational Health in collaboration with Infection Control may modify work practices during outbreak, e.g. assign VRE colonized health care worker to patient with VRE positive patients. Occupational Health should track statistics on: The number of health care worker with VRE infections. Time loss due to VRE infection. The number of health care workers with VRE epidemiologically linked to transmission. C. Other AROs There is little evidence, which addresses Occupational Health recommendations and followup care management of other AROs such as ESBL, VISA and VRSA. Health care workers that are known to be exposed to, infected with and or considered to be involved in an outbreak situation should be dealt with on a case by case basis. Occupational Health should liase with Infection Control, Infectious Disease Specialists, Occupational Health Physicians and Local Public Health Authorities if faced with this situation. D. Public Health Agency of Canada (PHAC) Website for Occupational Health Guidelines 53

63 X. Appendix A. Steps for Outbreak Management Regional Health Authorities and facilities must ensure they have an approved outbreak management plan to address specific epidemiological significant organisms or infectious disease, e.g. AROs. This outbreak management plan should include the following steps as well as define roles and responsibilities for the action of individuals and agencies. Individuals with specific expertise in infectious diseases and epidemiology should be part of the outbreak team. If this is not available internally, then external support should be identified. Communication and update of the progress of the outbreak must be done on a regular and timely basis. 1. Purpose 1.1 To promptly identify and control outbreaks of infection. 1.2 Minimize patient/client/resident and health care worker morbidity and effectively control and end outbreaks due to Antibiotic Resistant Organisms. 2. Components of an Outbreak Investigation 2.1 Establish the existence of an ARO outbreak. 2.2 Confirm the diagnosis. 2.3 Establish the case definition and count cases. 2.4 Relate the outbreak to time, place and person. 2.5 Determine who is at risk of becoming ill. 2.6 Formulate a tentative hypothesis. 2.7 Compare the hypothesis with the established facts. 2.8 Plan a detailed epidemiologic investigation. 2.9 Prepare a written report Implement control and prevention measures. 3. Sequence of Events in an Outbreak Investigation The sequence of events may vary, depending on the nature of outbreak and infecting organism. Always confirm an ARO outbreak exists, establish or verify diagnosis of ARO cases and identify agent before formulating a hypothesis. Steps often occur simultaneously. 3.1 Establish the Existence of an Outbreak Compare current ARO incidence with usual or base line incidence (calculate rates). If local data is not available, compare to the literature. Compare available information about new cases with a predetermined case definition. Assess the need for outside consultation, e.g. Infectious Diseases, Public Health. Report to Public Health authorities if required. Institute appropriate early measures to control the cases of AROs. 3.2 Confirm the Diagnosis Analyze histories of cases and in consultation with the laboratories, ensure the appropriate specimens are obtained and isolates of relevant organisms will be held. Analyze laboratory results to confirm or reject the suspected diagnosis and to determine the type of ARO. 54

64 3.3 Establish the Case Definition and Count Cases Develop a case definition and establish methods for identifying and counting cases. The case definition may be broad initially, refined as the outbreak progresses. The case definition may include a specific laboratory component. Using the case definition, review cases identified to describe the disease presentations. Obtain the appropriate laboratory specimens to identify the specific ARO outbreak. Seek additional ARO cases and collect critical relevant data and specimens. Encourage immediate reporting of new ARO cases by other health care workers. Search for other ARO cases that may occur retrospectively or concurrently by reviewing laboratory reports, health records, discussing with other health care workers as well as, possibly reviewing public health data. Select critical items that need to be collected on a data collection form. This could be by using a questionnaire or data abstract form. 3.4 Relate the Outbreak to Time, Place and Person Characterize the outbreak according to time, place and person. Time: What is the exact period of the ARO outbreak? Identify the first ARO case or first indication of the outbreak. What is the probable period of exposure? Record date of onset of illness for cases by drawing an epidemic curve. Is the outbreak a common source or propagated? Place: Where is the ARO outbreak occurring? Search for clustering of cases by type of service, ward, and place. This might involve the use of tables or spot maps. Person: Evaluate patient characteristics, e.g. age, sex, underlying disease Evaluate possible exposures, e.g. surgery, nursing or medical staff, infected cases Evaluate therapeutic interventions, e.g. invasive procedures, medications, antibiotics 3.5 Determine Who is at Risk of Becoming Ill Count cases and relate the number of cases to appropriate risk groups to determine who is at risk of becoming ill. Contact those who can provide information on the illness or about other circumstances that have contributed to the outbreak. Calculate rates of infection, including stratification on the basis of potential risk factors. 3.6 Formulate a Tentative Hypothesis Do an evaluation of the ARO outbreak by reviewing the epidemic curve. Record, tabulate and review common host factors and exposures. With this analysis, formulate a tentative hypothesis to explain the most likely cause, source and distribution of cases. 3.7 Compare the Hypothesis with the Established Facts The hypothesis will direct the course of the investigation and will be tested by various data gathered during the investigation. Several hypothesis may be required. The investigation may end with descriptive epidemiology, e.g. problem goes away without intervention, mode of transmission, type of appropriate interventions. 3.8 Plan a Detailed Epidemiologic Investigation Determine from the collected data what other information is needed and what resources are available to test the hypothesis. 55

65 The extent of the investigation will be determined by the personnel, severity of the problem and resource allocations. Epidemiological approaches for testing a hypothesis: Case-control study (most frequently used). Cohort study. Experimental interventions study. Analyze data derived from case investigation to determine the potential of ARO transmission and risk factors associated with the disease. Refine hypothesis and carry out additional studies, as appropriate. Summarize and interpret all of the information that has been collected and examine the results of laboratory tests that have been conducted. Construct epidemic curves, calculate rates, develop appropriate tables and charts, apply statistical tests to the data and interpret the data. On the basis of the available data and the appropriate calculations, accept or reject the hypothesis. Institution of the most appropriate control measures may be done anytime during the outbreak. 3.9 Prepare a Written Report A written report should summarize the investigation and be prepared as soon as the investigation is completed and disseminated to those who need to know. Findings can also be communicated by an oral briefing report at an appropriate forum. Describe the study methods. Laboratory, epidemiological, case definition, case finding and verification of diagnosis. Sources of data. Hypothesis testing, if any. Description of study design, description of control groups, rationale for choice and statistical tests used. Results used. Facts only with no explanations. May use table, graphs and charts. Analysis of data and statistical conclusions. Discussion. Interpretation. Description of control measures. Description of other important outcomes. Recommendations for future surveillance and control. References 3.10 Implement Control and Preventative Measure May be done anytime during the outbreak. Identify specific preventative and control measures on the basis of the nature of the ARO agent and characteristics of high risk groups and sources, e.g. eliminate contaminated products, and modify nursing procedures. Evaluate the control and preventative measures on an ongoing basis. Use the opportunity of the ARO outbreak to review and correct practices that may have contributed to the outbreak. If imminent danger exists, control and preventative measures should be initiated after the tentative hypothesis has been formed. 56

66 Methicillin-Resistant Staphylococcus aureus (MRSA) Fact Sheet for Health Care Workers What is Staphylococcus aureus? Staphylococcus aureus (S. aureus) is a bacteria or germ that normally lives on the skin or in the nose of many people. Usually, these individuals are not aware of it and are completely healthy. This is called colonization. It is normal to be colonized with bacteria in many parts of our bodies. S. aureus is capable of causing infections from mild skin and tissue to severe systemic infections such as pneumonia and bloodstream infection. S. aureus is one of the most common causes of community and hospital acquired infections, and affects individuals of all ages. What is Methicillin Resistant Staphylococcus aureus (MRSA)? The usual treatment for S. aureus infections is a group of antibiotics related to penicillin, which include methicillin, oxacillin and cloxacillin. Over the last 50 years, S. aureus has become resistant to multiple antibiotics including this specific group of antibiotics. These resistant bacteria are called Methicillin Resistant Staphylcoccus aureus, or MRSA. MRSA causes infections similar to antibiotic sensitive S. aureus strains. Infections caused by MRSA are sometimes more difficult and expensive to treat because the usual antibiotics cannot be used. What to look for (signs and symptoms of MRSA)? For most people, MRSA causes no harm. If people develop symptoms of infection, antibiotics should be used in consultation with an Infectious Disease Specialist. Infections caused by MRSA present in the same way as infections caused by non-mrsa. Symptoms will depend on the site of infection. How is MRSA transmitted (spread)? MRSA can be passed from an infected person or from a colonized person (one who is a carrier of MRSA, e.g. the presence of MRSA bacteria on their skin and nose with no symptoms). MRSA is spread by direct contact with a positive MRSA individual or by indirect contact, e.g. patient/resident/client equipment contaminated with MRSA. MRSA can be spread from one person to another by health care workers hands or by sharing contaminated equipment. How is MRSA detected? The laboratory can identify MRSA either by a screening swab of the nose or wound that is ordered by the physician or Infection Control Practitioner or by a clinical specimen obtained from an infected individual. Laboratories perform tests to determine which antibiotics will be effective (sensitive) or not effective (resistant) for treatment. If S. aureus is identified as resistant to oxacillin, additional tests are done to confirm the resistance. MRSA are often resistant to multiple commonly used antibiotics. Who is at risk? Patients: Some patients are at higher risk for acquiring MRSA. Some risk factors are: Prolonged hospital stay. Receiving intense antibiotic therapy. Hospitalization in an intensive care or burn unit. Exposure to patients with MRSA. Exposure to MRSA contaminated equipment. 57

67 Residents: Residents can be at risk of MRSA. Some risk factors are: A hospital stay greater than 24 hours. Receiving intense antibiotic therapy. Exposure to a MRSA positive person. Exposure to MRSA contaminated equipment. Community: MRSA also causes illness in persons outside hospitals. Community acquired MRSA infections are usually skin infections, but can also cause severe illness. Cases of MRSA disease in the community have been associated with: Recent antibiotic use. Sharing contaminated items. Having active skin diseases. Living in crowded settings. Health care Worker/Staff: Health care workers are not usually at risk for MRSA infection. The chances of infection with MRSA do not increase even if you have been in contact with an individual with MRSA, e.g. at work. If you are immunocompromised the risk is still very small. Pregnant women who are otherwise healthy are also not at any increased risk of acquiring MRSA. How is MRSA treated? Colonized individuals do not need treatment. Treatment of MRSA infections will be directed by the individual s doctor often in consultation with an Infectious Diseases specialist. Options for treatment may be limited and costly. What are the Infection Control considerations? Routine Practices are required for all care activities to limit the spread of microorganisms. Key points include: Hand hygiene with soap and water or alcohol-based handrub before and after contact with every patient/resident/client. Good environmental cleaning including patient/resident care equipment. If gloves are used they must be changed and hands washed between procedures performed on patients/residents/clients. To reduce the risk of MRSA transmission in a health care institution, known MRSA positive patients/ residents are placed on Contact Precautions as directed by Infection Control. Refer to facility s Infection Control Manual for details on Routine Practices and Contact Precautions. Screening of contacts if required in a health care institution will be directed by Infection Control and/or Occupational Health. Environmental culturing is not recommended unless directed by Infection Control. Health Care workers are not screened for MRSA unless a worker is linked to patient transmission. Good hand hygiene is the best way to prevent the spread of these organisms. 58

68 Vancomycin-Resistant Enterococci (VRE) Fact Sheet for Health Care Workers What are Enterococci? Enterococci are bacteria found in the bowel of healthy people and usually do not cause illness. This is called colonization. Enterococci are capable of causing wound and skin infections, and less often, more serious infections of the blood or other body sites. What are Vancomycin Resistant Enterococci (VRE)? The antibiotic Vancomycin is sometimes the only antibiotic that is effective in treating serious infections caused by enterococci. VRE is a type of enterococcus that has become resistant to the antibiotics normally used to kill it, including vancomycin. When vancomycin can no longer kill enterococci this means they have become resistant. VRE is not easier to acquire and does not cause more severe infections than other enterococci. What to look for? (signs and symptoms of VRE) Infections rarely develop, usually only seriously ill individuals get infections and will depend on the part of the body involved. VRE can cause an infection in the bladder, a wound or in the blood. How is VRE transmitted (spread)? Enterococci, including VRE, are normally found in the human bowel and are passed from the body through feces. Enterococci can be found on people s hands, or on things that are touched such as toilet seats, door handles, call bells, or patient care equipment. VRE is passed from one person to another by direct contact with feces, or indirectly through equipment or items that have become contaminated. VRE can live in the environment for days or even months. How is VRE detected? The laboratory can identify VRE either by a screening swab of the rectum that is ordered by the physician or Infection Control Practitioner or by a clinical specimen obtained from an infected individual. Who is at risk? Patients: Some patients are at higher risk for acquiring VRE, Some risk factors are: Prolonged hospital stay in a health care facility where VRE cases have been reported. Treatment with frequent doses of vancomycin in the past. Hospitalization in an intensive care unit. Suppressed immune system. Has an indwelling device, e.g. foley catheter. Has had major surgery. Exposure to patients with VRE. Exposure to VRE contaminated equipment. Residents: Residents can be at risk of VRE. Some risk factors are: A hospital stay greater than 24 hours. Exposure to a VRE positive person. Exposure to VRE contaminated equipment. Community: Healthy people living in the community are at low risk for getting VRE infections. Health care worker/staff: Health care workers are not usually at risk for VRE infection. The chances of infection with VRE do not increase even if you have been in contact with an individual with VRE, e.g. at work. If you are immunocompromised the risk is still very small. Pregnant women who are otherwise healthy are not at increased risk of acquiring VRE. 59

69 How is VRE treated? Healthy people, who are carriers (colonized) with no symptoms of infection do not need treatment. Consultation with an Infectious Disease Specialist is recommended for treatment of individuals who have infection with VRE. What are the infection control considerations? Routine Practices are required for all patient/resident/client care activities to limit the spread of microorganisms. Key points include: Hand hygiene with soap and water or alcohol-based hand rub before and after contact with every patient/resident/client. Good environmental cleaning, including patient/resident/client equipment When gloves are used, they must be changed and hands washed, between procedures and patient/residents/clients. Special attention to environmental cleaning is required as VRE can live in the environment for long periods if cleaning is not performed (days to months). To reduce the risk of VRE transmission in a health care institution, known VRE positive patients/residents are placed on Contact Precautions as directed by Infection Prevention and Control. Refer to facility s Infection Control Manual for details on Routine Practices and Contact Precautions Screening of contacts if required in a health care institution will be directed by Infection Control and/or Occupational Health. Environmental culturing is not recommended unless directed by Infection Control. Health care workers are not screened for VRE unless a worker is linked to patient transmission. Good hand hygiene is the best way to prevent the spread of these organisms. 60

70 Extended Spectrum Beta Lactamase Producing Bacteria (ESBLs) Fact Sheet for Health Care Workers What is Extended Spectrum Beta Lactamases (ESBL)? Extended spectrum beta lactamases (ESBLs) are enzymes produced by some gram negative bacteria that can inactivate a wide range of antibiotics particularly penicillins and cephalosporins. E. coli and Klebsiella are the organisms most frequently associated with ESBLs. Colonization of the gastrointestinal tract is the most common presentation and less frequently the respiratory tract. The urinary tract and wounds are the sites most frequently infected with ESBLs. ESBL have been present in Europe and the USA since Only recently have these bacteria been detected in Canada in low, but increasing numbers. What to look for (signs and symptoms of ESBLs)? Most people with ESBL have no symptoms (asymptomatic). For the few people who develop symptoms of urinary tract infection, wound infection, pneumonia or blood infection, antibiotics should be used. ESBL infections present in the same way as non-esbl producing organisms. These infections can be serious; therefore, knowing a person has ESBL is important to ensure the most appropriate treatments are prescribed. How is ESBL transmitted (spread)? Poor personal hygiene, especially after using the washroom, can spread these bacteria. The spread of ESBL in a facility occurs most commonly through direct contact with someone who has ESBL, contaminated environment, or on the hands of health care providers. Careful cleaning of areas that might be touched by hands is important to reduce the spread of these organisms in a facility. How is ESBL detected? The laboratory can identify ESBL either by a screening swab of rectum that is ordered by the physician or Infection Control Practitioner or by a clinical specimen obtained from an infected individual. Laboratories perform tests to determine which antibiotics will be effective (sensitive) or not effective (resistant) for treatment. Who is at risk? Patients: Some patients are at higher risk for acquiring ESBL. Some risk factors are: Prolonged hospital stay in a health care facility where ESBL cases have been reported. Treatment with antibiotics, especially cephalosporins. Recent surgery. Instrumentation (IV and urinary catheters). Prolonged hospitalization and/or admission to a high-risk unit. Exposure to patients with ESBL Exposure to ESBL contaminated equipment. Residents: Residents can be at risk of ESBL. Some risk factors are: A hospital stay greater than 24 hours. Exposure to an ESBL positive person. Exposure to ESBL contaminated equipment. Community: Healthy people living in the community are at low risk for getting ESBL infections. 61

71 Health care worker/staff: Health care workers are not usually at risk for ESBL infection. The chances of infection with ESBL do not increase even if you have been in contact with an individual with ESBL, e.g. at work. If you are immunocompromised the risk is still very small. Pregnant women who are otherwise healthy are not at increased risk of acquiring ESBL. How is ESBL treated? Treatment is only necessary for people with symptomatic infections. Consultation with an Infectious Disease Specialist is recommended for those with symptoms of infection with ESBL. There is no effective way to treat asymptomatic colonization with eradication therapy. Carriers can frequently clear this organism without any treatment. What are the Infection Control considerations? Routine Practices are required for all patient/resident/client care activities to limit the spread of microorganisms. Key points include: Hand hygiene with soap and water or alcohol-based hand rub before and after contact with every patient/resident/client. Good environmental cleaning, including patient/resident/client equipment. When gloves are used, they must be changed and hands washed, between procedures performed on patients/residents/clients. Special attention to environmental cleaning is required as ESBL can live in the environment for long periods if cleaning is not performed (days to months). To reduce the risk of ESBL transmission in a health care institution, known ESBL positive patients/ residents are placed on Contact Precautions as directed by Infection Prevention and Control. Refer to facility s Infection Control Manual for details on Routine Practices and Contact Precautions Screening of contacts if required in a health care institution will be directed by Infection Control and/or Occupational Health. Environmental culturing is not recommended unless directed by Infection Control. Health care workers are not screened for ESBL unless a worker is linked to patient transmission. Good hand hygiene is the best way to prevent the spread of these organisms 62

72 Vancomycin Intermediate Staphlococcus aureus (VISA) and Vancomycin-Resistant Staphlococus aureus (VRSA) Fact Sheet for Health Care Workers What is Staphylococcus aureus? Staphylococcus aureus (S. aureus) is a bacteria or germ that normally lives on the skin or in the nose of many people. Usually, these individuals are not aware of it and are completely healthy. This is called colonization. It is normal to be colonized with bacteria in many parts of our bodies. S. aureus is capable of causing infections from mild skin and tissue to severe systemic infections such as pneumonia and bloodstream infection. S. aureus is one of the most common causes of community and hospital acquired infections, and affects individuals of all ages. What are VISA and VRSA? The usual treatment for S. aureus infections is a group of antibiotics related to penicillin which include methicillin, oxacillin and cloxacillin. Over the past 50 years, S. aureus has become resistant to multiple antibiotics including this specific group of antibiotics. This led to increased use of vancomycin. While most S. aureus are susceptible to vancomycin, a few have developed resistance and cannot be successfully treated with vancomycin. These antimicrobial resistant S. aureus are classified as either VISA or VRSA based on laboratory tests which determine the degree of resistance. In the late 1990 s initial cases of VISA and VRSA were reported. VISA/VRSA cause similar infections to antibiotic sensitive S. aureus strains but infections may be difficult to treat because of limited effective antibiotics. What to look for (signs and symptoms of VISA/VRSA)? VISA and VRSA isolated to date are also Methicillin resistant. All VRSA isolates have been identified in individuals with Vancomycin Resistant Enterococcus (VRE) colonization or infection isolated in addition to MRSA. It is likely that the resistance from VRE was transferred to the MRSA strain, resulting in VRSA. The signs and symptoms of infection or colonization with VISA/VRSA are similar to other types of S. aureus infection. How is VISA and VRSA transmitted (spread)? VISA/VRSA can be passed from an infected person or from a colonized person (one who is a carrier of VISA/VRSA, e.g. the presence of VISA/VRSA bacteria on their skin and nose with no symptoms). VISA/VRSA is spread by direct contact with a positive VISA/VRSA individual or by indirect contact, e.g. patient/resident/client equipment contaminated by a person with VISA/VRSA. VISA/VRSA can be spread from one person to another by health care workers hands or by sharing contaminated equipment. How is VISA/VRSA detected? The laboratory can identify VISA/VRSA either by a screening swab of the nose or wound that is ordered by the physician or Infection Control Practitioner or by a clinical specimen obtained from an infected individual. Laboratories perform tests to determine if S. aureus bacteria are resistant to antibiotics. S. aureus with reduced susceptibility to vancomycin is called VISA while S. aureus fully resistant to vancomycin is called VRSA. The identification of VISA/VRSA constitutes a crisis and requires immediate response. 63

73 Who is at risk? At present VISA and VRSA infections are rare. Antibiotic use is a major risk factor for emergence of antibiotic resistant organisms (ARO s). Reduction of overuse and misuse of antibiotics will decrease the risk of emergence of S. aureus with reduced susceptibility to vancomycin. Patients: Some patients are at higher risk for acquiring VISA/VRSA. Some risk factors are: Underlying health conditions, e.g. diabetes, kidney disease. Previous infection with VISA/VRSA. Presence of IV catheters or other invasive devices. Recent hospitalization. Recent exposure to vancomycin or other antimicrobial agents. Exposure to patients with VISA/VRSA. Exposure to VISA/VRSA contaminated equipment. Residents: Residents can be at risk of VISA/VRSA. Some risk factors are: A hospital stay greater than 24 hours. Receiving intense antibiotic therapy. Exposure to a VISA/VRSA positive person. Exposure to VISA/VRSA contaminated equipment. Community: Healthy people living in the community are at a low risk for VISA/VRSA infections. Health care Worker/Staff: Health care workers are not at risk for VISA/VRSA infection. The chances of infection with VISA/VRSA do not increase even if you have been in contact with an individual with VISA/VRSA, e.g. at work. If you are immunocompromised the risk is still very small. Pregnant women who are otherwise healthy are also not at any increased risk of acquiring VISA/VRSA. How is VISA/VRSA treated? Colonized individuals do not need treatment. Treatment of VISA/VRSA infections will be directed by the individual s doctor in consultation with an Infectious Diseases Specialist. Options for treatment may be very limited and costly. What are the Infection Control considerations? There is significant concern about the spread of VISA and VRSA among individuals because of limited treatment options. If a VISA or VRSA is suspected, specific infection control precautions need to be initiated immediately to decrease the risk of transmission to others. Infection Control must be notified immediately when VISA or VRSA is suspected. To reduce the risk of VISA or VRSA transmission, known VISA/VRSA positive patients/residents are placed on Contact Precautions: Private room. Dedicated equipment. Personal protective equipment such as gloves and gowns when entering the room. Possibility of assigning dedicated staff may be indicated. Refer to facility s Infection Control Manual for details on Routine Practices and Contact Precautions. Screening of contacts following a confirmed case may be intense and will be directed by Infection Prevention and Control, and Occupational Health and possibly Public Health Authorities. Contact investigation of staff would only be done in consultation with Infection Control/Infectious Disease Consultant and/or Public Health Authorities. Good hand hygiene is the best way to prevent the spread of these organisms. 64

74 Methicillin-Resistant Staphylococcus aureus (MRSA) Fact Sheet for Patient, Resident Family and Visitors One of the test results shows you or your family member has a germ or bacteria called Methicillin-Resistant Staphylococcus aureus (MRSA). What is Staphylococcus aureus? Staphylococcus aureus (S. aureus) is a bacteria or germ that normally lives on the skin or in the nose of many people. Usually, they are not aware of it and are completely healthy. This is called colonization. It is normal to be colonized with bacteria in many parts of our bodies. If S. aureus gets inside the body, for example, under the skin or into the lungs, it can cause infections. When it does cause infection, it is usually treated with antibiotics. What does antibiotic resistance mean? Antibiotics are drugs used to treat infections caused by germs. Sometimes these drugs will no longer kill the germs and these germs are called antibiotic resistant. What is Methicillin Resistant Staphyloccus aureus or MRSA? The antibiotic used to treat S.aureus is a drug called methicillin. Some S.aureus are no longer killed by methicillin and they are called MRSA. When this happens a stronger antibiotic is needed to treat the infection. Individuals can have an infection caused by MRSA or they can just carry the germ on their skin or nose. How does a person get MRSA? MRSA can be found in the community and hospital, on people and objects. MRSA can be passed from a person who is either sick with MRSA or just carrying the bacteria harmlessly on their skin or in their nose by hands of health care workers. MRSA can also live on environmental surfaces, e.g. door knobs, water taps, and equipment touched by a person with MRSA. MRSA can spread from one person to another by directly or indirectly touching something the MRSA bacteria is on. Who gets MRSA? Anyone can get MRSA. However patients in hospitals who have open wounds, catheters or drainage tubes, and those who are very ill, are most likely to get MRSA. Residents in personal care homes are at a lower risk for MRSA but a long stay in hospital, receiving a lot of antibiotics, or contact with an individual or equipment that has MRSA might increase their risk of MRSA. The general public living in the community are at low risk of getting MRSA, so there is generally no need for special precautions in the home. Why are special precautions needed? Special precautions taken during a hospital stay and may be taken with a resident in a personal care home to stop MRSA from spreading to other sick patients/residents. What are the special precautions? Some of the precautions may include: Having patient/resident remain in a private room. A sign placed on the door of the room to alert everyone of the precautions needed. Everyone must wash their hands or use alcohol-based handrub (sanitizer) when leaving the room. If the patient/resident has to leave their room, their hands must be washed well or an alcohol-based handrub (sanitizer) used as well as skin wounds covered. 65

75 If the patient is in the hospital they may not be able to go to other areas of the hospital or to the cafeteria. Residents may be allowed to go to other areas of the personel care home, e.g. to participate in activities. Tests (swabs) may be done on a regular basis to see if they still carry MRSA. What about family and visitors? Family and friends can visit but they will be told to wash their hands or use an alcohol-based handrub (sanitizer) before leaving the room. Visitors may still have close contact such as hugging, kissing and handholding. Family members rarely get MRSA. If they do, it does not usually cause a problem. Patients/residents with MRSA do not pose a risk to their families or to other healthy people. How can the person with MRSA help? Remind all health care workers and visitors to wash their hands or use an alcohol-based handrub (sanitizer) before and after they touch the MRSA positive individual or are in the room. The person who has MRSA should wash their hands well or use an alcohol-based handrub (sanitizer) often. When washing their hands, turn off the taps with a paper towel to avoid getting hands dirty again. If another doctor, hospital or clinic is visited or they receive home care, it is important to tell staff that they have MRSA. Good hand washing or using alcohol-based handrub (sanitizer) is the best way to prevent the spread of these germs. What about at home? There are no special precautions at home except people should wash their hands often. Hands should be washed after going to the bathroom, touching their nose or their wound. This is always good to do to prevent the spread of germs, not just because someone has MRSA. 66

76 Vancomycin-Resistant Enterococci (VRE) Fact Sheet for Patient, Resident, Family and Visitors One of the test results shows you or your family member has a germ or bacteria called Vancomycin-Resistant Enterococci (VRE). What are Enterococci? Enterococci are bacteria or germs that are normally found in the bowel and usually do not cause illness. This is called colonization. Enterococci can cause wound and skin infections, and less often, more serious infections of the blood and other body sites. What does antibiotic resistance mean? Antibiotics are drugs used to treat infections caused by germs. Sometimes these drugs will no longer kill the germs and these germs are called antibiotic resistant. What is Vancomycin-Resistant Enterococci or VRE? An antibiotic used to treat enterococci is a drug called vancomycin. Some enterococci are no longer killed by vancomycin and they are called Vancomycin Resistant Enterococci or VRE. How does a person get VRE? VRE can be found in the hospital, on people and objects. VRE can be passed by hands of health care workers from a person who is either sick with VRE or just carrying the bacteria harmlessly in their bowel. Residents in personal care homes are at a lower risk for VRE but a long stay in hospital, receiving a lot of antibiotics, or contact with an individual or equipment that has VRE might increase their risk of VRE. VRE can also live on equipment touched by a person with VRE. VRE can spread from one person to another by directly or indirectly touching something the VRE bacteria is on. Who gets VRE? Patients in hospitals who have open wounds, catheters or drainage tubes and those who are very sick are most likely to get VRE. The general public living in the community who are in good health are at low risk of getting VRE, so there is generally no need for special precautions in their home. Why are special precautions needed? Special precautions are taken during a hospital stay and may be taken with a resident in a personal care home to stop VRE from spreading to other patients/residents. What are the special precautions? Some of the precautions may include: Having the patient/resident remain in a private room. A sign placed on the room door of the room to alert everyone of the precautions needed. Everyone must wash their hands or use alcohol-based handrub (sanitizer) when leaving the room. If the patient/resident has to leave their room, their hands must be washed well or an alcohol-based handrub (sanitizer) used as well as skin wounds covered. If a patient is in the hospital they may not be able to go to other areas of the hospital or cafeteria. Residents may be allowed to go to other areas of the personel care home, e.g. to participate in activities. 67

77 What about family and visitors? Family and friends can visit but they will be told to wash their hands or use an alcohol-based handrub (sanitizer) before leaving the room. Visitors may still have close contact such as hugging, kissing and hand holding. Family members rarely get VRE. If they do, it does not usually cause a problem. Patients/residents with VRE do not pose a risk to their families or to other healthy people. What about at home? There are no special precautions at home except people should wash their hands often. Hands should be washed after going to the bathroom, or touching their wound. This is always good to do to prevent the spread of germs and not just because someone has VRE. How can the person with VRE help? Remind all staff and visitors to wash their hands or use an alcohol-based handrub (sanitizer) before and after they touch a VRE positive individual or are in the room. The person who has VRE should wash their hands well or use an alcohol-based handrub (sanitizer) often. When washing their hands, turn off the taps with a paper towel to avoid getting hands dirty again. If another doctor, hospital, clinic is visited or they receive home care, it is important for you to tell staff that they have VRE Good handwashing or using alcohol-based handrub (sanitizer) is the best way to prevent the spread of these germs. 68

78 Extended Spectrum Beta Lactamase Producing Bacteria (ESBLs) Fact Sheet for Patient, Resident, Family and Visitors One of the test results shows you or your family member has a germ or bacteria called Extended Spectrum Beta Lactamase or ESBL. What is Extended Spectrum Beta Lactamase (ESBL)? Extended Spectrum Beta Lactamase (ESBLs) are enzymes produced by some bacteria or germs that can make them resistant to certain antibiotics. These bacteria or germs can be found in many parts of your body but are normally in your bowel. What does antibiotic resistance mean? Antibiotics are drugs used to treat infections caused by germs. Sometimes these drugs will no longer kill the germs and these germs are called antibiotic resistant. How does a person get an ESBL? ESBL can be present in patients in the hospital and residents in personel care homes. This bacteria can be spread by not washing their hands, especially after using the bathroom, can spread these bacteria. The spread of ESBL in a hospital can occur most commonly through contact with another person that has an ESBL, or on the hands of health care workers. Who Gets an ESBL? Anyone can get an ESBL. Patients in hospitals who have open wounds, catheters, or drainage tubes and those who are very ill are most likely to get an ESBL. Residents in personal care homes are at a lower risk for ESBLs but a long stay in hospital, receiving a lot of antibiotics or contact with an individual or equipment that has ESBL might increase their risk of ESBL. The general public living in the community are at low risk of getting an ESBL, so there is generally no need for special precautions in the home. Why are special precautions needed? It is important that special precautions are taken during a hospital stay and may be taken with a resident in a personal care home to stop the germ from spreading to other patients/residents. What are the special precautions? Some of the precautions may include: Having the patient/resident remain in a private room. A sign placed on the door of the room to alert everyone of the precautions needed. Everyone must wash their hands or use alcohol-based handrub (sanitizer) when leaving the room. If the patient/resident has to leave their room, their hands must be washed well or an alcohol-based handrub (sanitizer) used as well as skin wounds covered. If a patient is in the hospital they may not be able to go to other areas of the hospital or cafeteria. Residents may be allowed to go to other areas of the personal care home, e.g. to participate in activities. What about family and visitors? Family and friends can visit but they will be told to wash their hands or use an alcohol-based handrub (sanitizer) before leaving the room. Visitors may still have close contact such as hugging, kissing and hand holding. Family members rarely get an ESBL. If they do, it does not usually cause a problem. Patients with an ESBL do not pose a risk to their families or to other healthy people. 69

79 What about at home? There are no special precautions at home except people should wash their hands often. Hands should be washed after going to the bathroom, or touching their wound. This is always good to do to prevent the spread of germs and not just because someone has ESBL. How can the person with ESBL help? Remind all staff and visitors to wash their hands or use an alcohol-based handrub (sanitizer) before and after they touch the ESBL positive individual or are in the room. The person who has an ESBL should wash their hands well or use an alcohol-based handrub (sanitizer) often. When washing their hands, turn off the taps with a paper towel to avoid getting hands dirty again. If another doctor, hospital, clinic is visited or they receive home care, it is important to tell staff that they have an ESBL. Good handwashing or using alcohol-based handrub (sanitizer) is the best way to prevent the spread of these germs. 70

80 Vancomycin Intermediate Resistant Staphylococcus aureus (VISA) and Vancomycin Resistant Staphylococus aureus (VRSA) Fact Sheet for Patient, Resident, Family and Visitors One of the test results shows you or your family member has a germ or bacteria called Vancomycin Intermediate Resistant Staphylococcus aureus (VISA) or Vancomycin Resistant Staphylococcus aureus (VRSA). What is Staphylococcus aureus? Staphylococcus aureus (S. aureus) is a bacteria or germ that normally lives on the skin or in the nose of many people. Usually, they are not aware of it and are completely healthy. This is called colonization. It is normal to be colonized with bacteria in many parts of our bodies. If S. aureus gets inside the body, for example, under the skin or into the lungs, it can cause infections. When it does cause infection, it is usually treated with antibiotics. What does antibiotic resistance mean? Antibiotics are drugs used to treat infections caused by germs. Sometimes these drugs will no longer kill the germs and these germs are called antibiotic resistant. What are VISA and VRSA? The usual treatment for S. aureus infections is a group of antibiotics related to penicillin which include methicillin, oxacillin and cloxacillin. Over the past 50 years, S. aureus has become resistant to many antibiotics including this group of antibiotics. This led to increased use of another antibiotic called vancomycin. While most S. aureus are killed by vancomycin, a few have developed resistance and cannot be killed by vancomycin. This group of S. aureus is classified as either VISA or VRSA. How does a person get VISA/VRSA? VISA and VRSA are types of antibiotic resistant S. aureus bacteria. Spread occurs among people having close physical contact with VISA/VRSA infected patients or contaminated material like bandages. It is important for all patients, residents, staff and visitors to wash their hands or use an alcohol-based handrub (sanitizer) and avoid touching their noses and mouths with their hands. Who gets VISA or VRSA? Individuals most likely to get VISA or VRSA are those who are very ill and receiving a lot of antibiotics particularly vancomycin, those with previous MRSA infections who have open wounds, catheters or drainage tubes, and those who are very ill. Residents in personal care homes are at lower risk for VISA or VRSA but a long stay in hospital, receiving a lot of antibiotics or contact with an individual or equipment that has VISA or VRSA might increase their risk of VISA or VRSA. The general public living in the community are at very low risk of getting VISA or VRSA, so there is generally no need for special precautions in the home. Why are special precautions needed? Special precautions are taken during a hospital stay and may be taken with a resident in a personal care home to stop VISA/VRSA from spreading to other patients/residents. 71

81 What are the special precautions? Some of the precautions may include: Having patient/resident remain in a private room. A sign placed on the door of the room to alert everyone of the precautions needed. Everyone must wash their hands or use alcohol-based handrub (sanitizer) when leaving the room. If the patient/resident has to leave their room, their hands must be washed well or an alcohol-based handrub (sanitizer) used as well as skin wounds covered. If the patient is in the hospital they may not be able to go to other areas of the hospital or to the cafeteria. What about family and visitors? Family and friends can visit but they will be told to wash their hands or use an alcohol-based handrub (sanitizer) before leaving the room. Visitors may still have close contact such as hugging, kissing and handholding. Family members rarely get VISA/VRSA. If they do, it does not usually cause a problem. Patients with VISA/VRSA do not pose a risk to their families or to other healthy people. What about at home? There are no special precautions at home except people should wash their hands often. Hands should be washed after going to the bathroom, touching their nose or their wound. This is always good to do to prevent the spread of germs, not just because someone has VISA/VRSA. How can the person with VISA or VRSA help? Remind all health care workers and visitors to wash their hands or use an alcohol-based handrub (sanitizer) before and after they touch the VISA/VRSA positive individual or are in the room. The person who has VISA/VRSA should wash their hands well or use an alcoholbased handrub (sanitizer) often. When washing their hands, turn off the taps with a paper towel to avoid getting hands dirty again. If another doctor, hospital or clinic is visited or they receive home care, it is important to tell staff that they have VISA/VRSA. Good hand washing or using alcohol-based handrub (sanitizer) is the best way to prevent the spread of these germs. 72

82 Testing for Methicillin Resistant Staphylococcus aureus (MRSA) Fact Sheet for Patient and Family During this admission, prior admission, or a follow-up visit to a hospital, you or your family member may have been in contact with a person who was found to have an uncommon germ called Methicillin Resistant Staphylococcus aureus (MRSA). Screening for resistant germs is an important part of the Infection Control Program to reduce the risk of spread of antibiotic germs to other patients. What is Staphylococcus aureus? Staphylococcus aureus (S. aureus) is a bacteria or germ that normally lives on the skin or in the nose of many people. Usually, they are not aware of it and are completely healthy. This is called colonization. It is normal to be colonized with bacteria in many parts of our bodies. If S. aureus gets inside the body, for example, under the skin or into the lungs, it can cause infections. When it does cause infection, it is usually treated with antibiotics. What does antibiotic resistant mean? Antibiotics are drugs used to treat infections caused by germs. Sometimes these drugs will no longer kill the germs and these germs are called antibiotic resistant. What is Methicillin Resistant Staphyloccus aureus or MRSA? The antibiotic used to treat S.aureus is a drug called methicillin. Some S.aureus are no longer killed by methicillin and they are called MRSA. When this happens a stronger antibiotic is needed to treat the infection. Individuals can have an infection caused by MRSA or they can just carry the germ on their skin or nose. Why is testing needed? Hospitals are places where germs may be passed from one patient to another. Testing is required to prevent the spread of this germ to other patients. How do we test for MRSA? One way to help us find this germ is to take swabs of your nose and wounds. Results are usually available with in hours. If you test positive, you will require special precautions for MRSA. The doctor will be notified if the test is positive for MRSA. Can family and friends get MRSA? The risk is very low. Healthy family members and friends may also carry this germ but not show any signs of infection. Family members should always wash their hands or use alcohol-based handrub (sanitizers) and follow directions from hospital staff, and on signs on patient s door. If any family or visitor is concerned about MRSA, they should speak with staff or contact Infection Control. The greatest concern is in the hospital setting where it is easy to spread MRSA to many patients. How can the person with MRSA help? Remind all health care workers and visitors to wash their hands or use an alcohol-based handrub (sanitizer) often. The person with MRSA should wash their hands well or use an alcohol-based handrub (sanitizer) often. When washing their hands, turn off the taps with a paper towel to avoid getting hands dirty again. Good hand washing or using alcohol-based handrub (sanitizer) is the best way to prevent the spread of these germs. 73

83 Testing for Vancomycin Resistant Enterococci (VRE) Fact Sheet for Patient and Family During this admission, prior admission, or a follow-up visit to a hospital, you or your family member may have been in contact with a person who was found to have an uncommon germ called Vancomycin Resistant Enterococci, or VRE. Screening for resistant germs is an important part of the Infection Control Program to reduce the risk of spread of antibiotic germs to other patients. What are Enterococci? Enterococci are bacteria or germs that are normally found in the bowel and usually do not cause illness. This is called colonization. Enterococci can cause wound and skin infection, and less often, more serious infections of the blood and other body sites. What does antibiotic resistant mean? Antibiotics are drugs used to treat infections caused by germs. Sometimes these drugs will no longer kill the germs and these germs are called antibiotic resistant. What is Vancomycin Resistant Enterococci or VRE? An antibiotic used to treat enterococcus is a drug called vancomycin. Some enterococci are no longer killed by vancomycin and they are called Vancomycin Resistant Enterococci or VRE. Why is testing needed? Hospitals are places where germs may be passed from one patient to another. Testing is required to prevent the spread of this germ to other patients. How do we test for VRE? One way to help us find this germ is to take a swab of your rectum. Results are usually available within hours. If you test positive, you will require special precautions for VRE. The doctor will be notified if the test is positive for VRE. Can family and friends get VRE? There is no risk to healthy people. Family members should always wash their hands or use alcohol-based handrub (sanitizers) and follow directions from staff and on sign on patient s door. If any family or visitor is concerned about VRE, they should speak with staff or contact Infection Control. The greatest concern is in the hospital setting where it is easy to spread VRE to many patients. How can the person with VRE help? Remind all health care workers and visitors to wash their hands or use alcohol-based handrub (sanitizer) often. The person with VRE should wash their hands well or use an alcohol-based handrub (sanitizer) often. When washing their hands, turn off the taps with a paper towel to avoid getting hands dirty again. Good handwashing or using alcohol-based handrub (sanitizer) is the best way to prevent the spread of these germs. 74

84 C. Guidelines for Specimen Collection Specimen collection should be performed according to facility based policy using the following guidelines. 1. Specimen Collection from Nares Carefully insert swab into the nose and sample secretions from the rear of the nostril (before the nasopharynx) by rolling the swab five times. Transfer the same swab into the second nostril and repeat the sample collection. Place the swab in the transport container. Label the container with the site of sample collected. Specimens should be kept at room temperature and sent to the lab as soon as possible according to facility procedure. 2. Specimen Collection from Wounds Cleanse wound with sterile water or sterile normal saline prior to culture. Swab wound site. Place the swab in the transport container. Label the container with the site of each sample collected. Specimens should be kept at room temperature and sent to the lab as soon as possible according to facility procedure. 3. Specimen Collection from Rectum/Ostomy Insert the swab approximately 2.5 cm (for adults) beyond the anal sphincter/stoma and gently rotate. Contact the laboratory for specimen collection for children. Place the swab in the transport container. Label the container with the site of sample collected. Specimens should be kept at room temperature and sent to the lab as soon as possible according to facility procedure. 4. Nares and Rectal Specimen Collection Nares Carefully insert swab into the patient s nose and sample secretions from the rear of the nostril (before the nasopharynx) by rolling the swab five times. Return swab to its container and send to laboratory immediately. Rectal Insert the swab approximately 2.5 cm (for adults) beyond the anal sphincter and gently rotate. Contact the laboratory for specimen collection for children. Return swab to its container and send to laboratory immediately. 75

85 D. Routine Practices 1. Hand Hygiene Quick Reference Chart Hand washing/hand hygiene reduces the number of microorganisms on the hands and is the most important practice to prevent the spread of infection. When Before: Direct hands-on care with a patient/resident/client Performing invasive procedures Handling dressings or touching open wounds Preparing and administering medications Preparing, handling, serving, or eating food Feeding a patient/resident/client Shifts and breaks After: Contact with blood, body fluids, non-intact skin, and/or mucous membranes Contact with items known, or considered to be contaminated Removal of gloves Personal use of toilet or wiping nose Shifts and breaks Between: Procedures on the same patient/resident/client where soiling of hands is likely, to avoid crosscontamination of body sites Hand Washing/Hand Hygiene Agents Alcohol-Based Handrub: Must contain a minimum of 60% alcohol Use in all clinical situations, except when hands are visibly soiled Use as an alternate when plain or antimicrobial soap is indicated, 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/residents on infection control precautions/isolation Use in critical care areas: ICU, OR, Burn Unit, Dialysis, Intensive Care Nurseries 76

86 2. Hand Hygiene Procedure Alcohol-Based Handrub Using an alcohol-based handrub Apply 2-3 ml of product to the palm of one hand. Rub hands together covering all surfaces including fingernails, web spaces, thumbs and palms. The product generally dries within seconds. Ensure hands are completely dry before performing another task. 77

87 3. Hand Hygiene Procedure Plain or Antimicrobial Soap Using plain soap or antimicrobial soap Wet hands under warm running water. Apply soap and distribute over hands. Rub hans together vigorously for seconds to create a good lather. Using friction, cover all hand surfaces including fingernails, web spaces, thumbs and palms. Rinse under warm running water. Dry hands gently and thoroughly with a disposable towel. Turn off faucet using a clean disposable towel. 78

88 E. Additional Precautions-Contact Precautions Procedures and Signs 1. Donning Personal Protective Equipment Procedure Perform Hand Hygiene. Put on long sleeve gown if required with opening at back. Tie neck and waist ties of gown. Apply gloves. Enter room. 2. Removal of Personal Protective Equipment Procedure Remove gloves using glove-to-glove, skinto-skin technique. Discard gloves. Perform Hand Hygiene If gown used, untie neckties first, then waist ties on the gown. Place fingers of one hand under the opposite cuff and pull cuff over hand. Using the gown-covered hand, pull the gown down over the other hand. Pull the gown down off the arms, being careful that the hands do not touch the outside of the gown. Hold the gown away from your uniform and roll it up with contaminated side inside in a way that minimize air disturbance. Dispose gown into garbage or laundry hamper. Perform Hand Hygiene. 79

89 3. Donning Personal Protective Equipment Sign Donning Personal Protective Equipment Perform hand hygiene Put on long sleeve gown if required with opening of gown at back Tie neck and waist ties Apply gloves Enter room 80

90 4. Removing Personal Protective Equipment Sign Removing Personal Protective Equipment Remove gloves using glove-to-glove, skin-to-skin technique, discard Perform hand hygiene If gown used, untie neckties first, then waist ties on the gown Place fingers of one hand under the opposite cuff and pull cuff over hand Using the gown-covered hand, pull the gown down over the other hand Pull the gown down off the arms, being careful that the hands do not touch the outside of the gown Hold the gown away from your uniform and roll it up with contaminated side inside in a way that minimize air disturbance Dispose gown into garbage or laundry hamper Perform hand hygiene 81

91 5. Contact Precautions Sign (English) Contact Precautions 82

92 6. Contact Precautions Sign (Bilingual) Contact Precautions Précautions lors de contacts 83

93 F. Surveillance Forms 1. MRSA/VRE Screening Line Listing Other Other Other Other Other Other Rectal Wound #3 Wound #2 Wound #1 Nares VRE MRSA Name PHIN# Admission Date D/M/Y MRSA/VRE Screening Line Listing Facility Transferred From Date Screening D/M/Y Reason for Screening (See Legend*) Results 84

94 2. ARO Patient/Resident Management Form ARO PATIENT/RESIDENT MANAGEMENT FORM This form is documentation of initial positive result. Subsequent positive/negative results would be documented in the Notes Section. Year: Unit/Ward where discovered positive: Name: Health Record Number: PHIN: Date of Birth: Sex: (D/M/Y) Date of Admission/Medical Appt: (D/M/Y) Date of Discharge: (D/M/Y) Date of Death: Physician: Type of ARO: Infection: Colonized: (Y/N) (Y/N) Date of Positive Culture: Site(s) Positive: Diagnostic Culture: Surveillance Culture: Pulse Field Gel Strain: (Y/N) (Y/N) Date Isolated: Where acquired (See legend*): Name of Facility/Ward Acquired: Isolation Implemented: (D/M/Y) Isolation Discontinued: (D/M/Y) Date Health Record Flagged: (D/M/Y) Date Health Record Deflagged: (D/M/Y) Acquisition of ARO (See definitions on page 84): Part of an Outbreak: (Y/N) Treated: (Y/N, Record in Notes) Decolonized: (Y/N, Record in Notes) *Where Acquired Legend: (Refer to Definitions on Page 87) 1. Community 2. Nosocomial acquired in your facility 3. Nosocomial acquired in a hospital in Winnipeg 4. Nosocomial acquired in a hospital in Rural Manitoba 5. Nosocomial acquired in a hospital outside Manitoba 6. Nosocomial acquired in a LTCF in Winnipeg 7. Nosocomial acquired in LTCF in Rural Manitoba 8. Recolonized 9. Unknown 85

95 Notes (Record treatments, subsequent positive and/or follow-up cultures and other issues related to progress): Treatments: Subsequent Follow-up Cultures: Other Issues: Name of Person Completing Form: Date of Completion of Form: (D/M/Y) 86

96 3. ARO DEFINITIONS 3.1 MRSA Nosocomial acquisition current facility Diagnosis of MRSA was made by a culture positive for MRSA 48 hours after admission to current facility and: No medical history of previous MRSA infection or colonization Diagnosis of MRSA was made by a culture positive for MRSA within 48 hours after admission to current facility and: Medical history in the past year at current facility of: Hospitalization Dialysis Surgery Placement of permanent indwelling catheters or medical devices that pass through the skin into the body Diagnosis of MRSA was made post discharge from current facility by a culture positive for MRSA within 48 hours of admission to a receiving facility. Diagnosis of MRSA was made post discharge from current facility by a culture positive for MRSA 48 hours of admission to receiving facility and there is an epi link* to current facility and no epi link* to the receiving facility. Infection or colonization occurred in a newborn, even if 48 hours of age and the mother acquired colonization or infection 48 hours after admission and there is no epi link* to suspect that colonization occurred prior to transfer. Nosocomial acquisition another facility Diagnosis of MRSA was made by a culture positive for MRSA within 48 hours after admission to the hospital and: Medical history in the past year at another facility**of: Hospitalization Dialysis Surgery Placement of permanent indwelling catheters or medical devices that pass through the skin into the body. No admission screening cultures; diagnosis of MRSA was made by a culture positive 48 hours after admission and: There is no epi link* to current facility and There is an epi link* to another facility.** Infection or colonization occurred in a newborn, even if 48 hours of age and the mother s diagnosis of MRSA was made in by a culture positive for MRSA within 48 hours after admission or there is reason to suspect that colonization occurred prior to admission such as an epi link to another facility.** Unknown (unclear): It is unclear where the MRSA was acquired: Patient is not epi linked* to current facility cases and there is a history of multiple admissions to more than one facility. Unable to gather information about previous admissions to facilities therefore community acquired criteria cannot be substantiated. Community Acquired Diagnosis of MRSA was made in the outpatient setting or by a culture positive for MRSA within 48 hours after admission to the hospital and: No medical history of MRSA infection or colonization and: No medical history in the past year of: Hospitalization Admission to a LTCF or hospice Dialysis Surgery No permanent indwelling catheters or medical devices that pass through the skin into the body. 87

97 Recolonized Patient has a previous history of MRSA within the past year, received eradication treatment and has three sets of weekly negative cultures taken post eradication. Diagnosis of MRSA was made by a culture positive for MRSA within one year of receiving eradication treatment and the CMRSA strain is identical to the strain the patient was originally diagnosed with. There is no epi link* to current facility or other facilities. * Epi link: Within the past year the patient was identified as having previous contact with a MRSA case and the MRSA Pulse Field Gel Electrophoresis (PFGE) matches the contact case. Within 30 days of patient s admission, transmission of MRSA occurred and the MRSA PFGE found in the patient matches the strain transmitted in the facility **Another facility (please indicate in the data base): Outside Manitoba Winnipeg hospital Rural hospital Long Term Care facility 3.2 VRE Nosocomial acquisition current facility Diagnosis of VRE was made by a culture positive for VRE 48 hours after admission to current facility and: No medical history of previous VRE infection or colonization Diagnosis of VRE was made by a culture positive for VRE within 48 hours after admission to current facility and: Medical history in the past year at current facility of: Hospitalization Dialysis Surgery Placement of permanent indwelling catheters or medical devices that pass through the skin into the body. Diagnosis of VRE was made post discharge from current facility by a culture positive for VRE within 48 hours of admission to a receiving facility. Diagnosis of VRE was made post discharge from current facility by a culture positive for VRE 48 hours of admission to receiving facility and there is an epi link* to current facility and no epi link* to the receiving facility. Infection or colonization occurred in a newborn, even if 48 hours of age and the mother acquired colonization or infection 48 hours after admission and there is no epi link* to suspect that colonization occurred prior to transfer. Nosocomial acquisition another facility Diagnosis of VRE was made by a culture positive for VRE within 48 hours after admission to the hospital and: Medical history in the past year at another facility**of: Hospitalization Dialysis Surgery Placement of permanent indwelling catheters or medical devices that pass through the skin into the body No admission screening cultures; diagnosis of VRE was made by a culture positive 48 hours after admission and: There is no epi link* to current facility and There is an epi link* to another facility.** Infection or colonization occurred in a newborn, even if 48 hours of age and the mother s diagnosis of VRE was made by a culture positive for VRE within 48 hours after admission or there is reason to suspect that colonization occurred prior to admission such as an epi link* to another facility.** 88

98 Unknown (Unclear) It is unclear where the VRE was acquired: Patient is not epi linked* to current facility cases and there is a history of multiple admissions to more than one facility. Unable to gather information about previous admissions to facilities therefore community acquired criteria cannot be substantiated. Community Acquired Diagnosis of VRE was made in the outpatient setting or by a culture positive for VRE within 48 hours after admission to the hospital and: No medical history of VRE infection or colonization and: No medical history in the past year of: Hospitalization Admission to a LTCF or hospice Dialysis Surgery No permanent indwelling catheters or medical devices that pass through the skin into the body. * Epi link: Within the past year the patient was identified as having previous contact with a VRE case and the VRE Pulse Field Gel Electrophoresis (PFGE) matches the contact case. Within 30 days of patient s admission, transmission of VRE occurred and the VRE PFGE found in the patient matches the strain transmitted in the facility. **Another facility (please indicate in the data base): Outside Manitoba Winnipeg hospital Rural hospital Long Term Care facility 3.3 ESBL Nosocomial acquisition-current facility: Diagnosis of ESBL was made by a culture positive for ESBL 48 hours after admission to current facility and: No medical history of previous ESBL infection or colonization. Diagnosis of ESBL was made by a culture positive for ESBL within 48 hours after admission to current facility and: Medical history in the past year at current facility of: Hospitalization Dialysis Surgery Placement of permanent indwelling catheters or medical devices that pass through the skin into the body. Diagnosis of ESBL was made post discharge from current facility by a culture positive for ESBL within 48 hours of admission to a receiving facility. Diagnosis of ESBL was made post discharge from current facility by a culture positive for ESBL 48 hours of admission to receiving facility and there is an epi link* to current facility and no epi link* to the receiving facility. Infection or colonization occurred in a newborn, even if 48 hours of age and the mother acquired colonization or infection 48 hours after admission and there is no epi link* to suspect that colonization occurred prior to transfer. Nosocomial acquisition another facility Diagnosis of ESBL was made by a culture positive for ESBL within 48 hours after admission to the hospital and: Medical history in the past year at another facility**of: Hospitalization Dialysis Surgery 89

99 Placement of permanent indwelling catheters or medical devices that pass through the skin into the body. No admission screening cultures; diagnosis of ESBL was made by a culture positive 48 hours after admission and: There is no epi link* to current facility and There is an epi link* to another facility.** Infection or colonization occurred in a newborn, even if 48 hours of age and the mother s diagnosis of ESBL was made by a culture positive for ESBL within 48 hours after admission or there is reason to suspect that colonization occurred prior to admission such as an epi link to another facility.** Unknown (Unclear) It is unclear where the ESBL was acquired: Patient is not epi linked* to current facility cases and there is a history of multiple admissions to more than one facility. Unable to gather information about previous admissions to facilities therefore community acquired criteria cannot be substantiated. Community Acquired Diagnosis of ESBL was made in the outpatient setting or by a culture positive for ESBL within 48 hours after admission to the hospital and: No medical history of ESBL infection or colonization and: No medical history in the past year of: Hospitalization Admission to a LTCF or hospice Dialysis Surgery No permanent indwelling catheters or medical devices that pass through the skin into the body. Recolonized Patient has a previous history of ESBL within the past year, received treatment and is culture negative post treatment. Diagnosis of ESBL was made by a culture positive for ESBL within one year of receiving treatment and the ESBL strain is identical to the strain the patient was originally diagnosed with. There is no epi link* to current facility or other facilities. * Epi link: Within the past year the patient was identified as having previous contact with a ESBL case and the ESBL Pulse Field Gel Electrophoresis (PFGE) matches the contact case. Within 30 days of patient s admission, transmission of ESBL occurred and the ESBL PFGE found in the patient matches the strain transmitted in the facility. **Another facility (please indicate in the data base): Outside Manitoba Winnipeg hospital Rural hospital Long Term Care facility 3.4 VISA/VRSA Nosocomial acquisition current facility Diagnosis of VISA/VRSA was made by a culture positive for VISA/VRSA 48 hours after admission to current facility and: No medical history of previous VISA/VRSA infection or colonization. Diagnosis of VISA/VRSA was made by a culture positive for VISA/VRSA within 48 hours after admission to current facility and: Medical history in the past year at current facility of: Hospitalization Dialysis Surgery 90

100 Placement of permanent indwelling catheters or medical devices that pass through the skin into the body. Diagnosis of VISA/VRSA was made post discharge from current facility by a culture positive for VISA/VRSA within 48 hours of admission to a receiving facility. Diagnosis of VISA/VRSA was made post discharge from current facility by a culture positive for VISA/VRSA 48 hours of admission to receiving facility and there is an epi link* to current facility and no epi link* to the receiving facility. Infection or colonization occurred in a newborn, even if 48 hours of age and the mother acquired colonization or infection 48 hours after admission and there is no epi link* to suspect that colonization occurred prior to transfer. Nosocomial acquisition another facility Diagnosis of VISA/VRSA was made by a culture positive for VISA/VRSA within 48 hours after admission to the hospital and: Medical history in the past year at another facility**of: Hospitalization Dialysis Surgery Placement of permanent indwelling catheters or medical devices that pass through the skin into the body No admission screening cultures; diagnosis of VISA/VRSA was made by a culture positive 48 hours after admission and: There is no epi link* to current facility and There is an epi link* to another facility.** Infection or colonization occurred in a newborn, even if 48 hours of age and the mother s diagnosis of VISA/VRSA was made by a culture positive for VISA/VRSA within 48 hours after admission or there is reason to suspect that colonization occurred prior to admission such as an epi link to another facility.** Unknown (Unclear) It is unclear where the VISA/VRSA was acquired: Patient is not epi linked* to current facility cases and there is a history of multiple admissions to more than one facility. Unable to gather information about previous admissions to facilities therefore community acquired criteria cannot be substantiated. Community Acquired Diagnosis of VISA/VRSA was made in the outpatient setting or by a culture positive for VISA/VRSA within 48 hours after admission to the hospital and: No medical history of VISA/VRSA infection or colonization and: No medical history in the past year of: Hospitalization Admission to a LTCF or hospice Dialysis Surgery No permanent indwelling catheters or medical devices that pass through the skin into the body. * Epi link: Within the past year the patient was identified as having previous contact with a VISA/VRSA case and the VISA/ VRSA Pulse Field Gel Electrophoresis (PFGE) matches the contact case. Within 30 days of patient s admission, transmission of VISA/VRSA occurred and the VISA/VRSA PFGE found in the patient matches the strain transmitted in the facility. **Another facility (please indicate in the data base): Outside Manitoba Winnipeg hospital Rural hospital Long Term Care facility 91

101 G. Sample Letter Physician Notification of ARO Date Dr. Dear Dr. : You were identified as the family physician of this patient/resident. Pt/Resident: DOB: Telephone: Address: Province: Postal Code: Health Record No. # MHSC No. # PHIN No. # Recently was identified in the following culture sites. SITE DATE POSITIVE This patient/resident ( ) has been informed ( ) has not been informed they are positive for this organism. The following Manitoba Health publications are available for your guidance: Website: http// What you should know about Methicillin Resistant Staphylococcus Aureus (MRSA) What you should know about Vancomycin-Resistant Enterococci (VRE) Website: http// Infection Control Guidelines for Health care workers in the Community Should you have any further questions with regards to the above patient/resident, please do not hesitate in contacting Infection Control at. Yours sincerely, cc Health Information 92

102 H. Transfer/Referral Form 93

103 94

104 Infection Control Guidelines for Health Care Workers in the Community COMMUNICABLE DISEASE CONTROL Preamble: These infection control practice guidelines outline the standards for preventing the spread of all infective microorganisms in community settings. Precautions used in acute care settings may be more intensive depending on the microorganism (e.g., MRSA,VRE) and will generally be stopped once the individual is discharged from that facility. 1. Handwashing A second handwash with soap and running water is the most effective method of preventing the spread of infective microorganisms. Paper towels or a clean towel must be used to dry hands and turn off faucets. Use only bar soap that is well drained, or liquid soap. Clients should be encouraged to wash out liquid soap containers before refilling. Handwashing should be done before and after direct care; after removing gloves; after handling body substances, contaminated equipment, articles and surfaces, linen, garbage and dishes; and before leaving a client s home. When handwashing facilities are inaccessible use a waterless alcohol or chlorhexidenebased handwashing product and rub vigorously for seconds, e.g., towelettes, liquid, gel. Wash hands with soap and water at the next possible opportunity. 2. Gowns, Masks, Protective Eye Wear and Gloves (Personal Protective Attire) Disposable Gowns or Aprons should be used when splashing or soiling of clothes with blood or body fluids is likely to occur. Masks and Protective Eyewear should be used if splashing of blood or body fluids is likely to occur. Disposable Gloves should be used when contact with blood is likely to occur. They should also be used for handling of potentially infectious material such as feces, wound secretions, mucous membrane lesions, skin lesions, and also when the health care worker has nonintact skin on hands. 3. Nursing/Medical Equipment and Supplies Reusable equipment should be cleaned after use and then either sterilized or disinfected depending on how it will be used (e.g., footcare instruments or forceps for wound care should be sterilized; bed pans and urinals should be disinfected; and stethoscopes should be wiped with 70% alcohol). Standard procedures should be developed by health care agencies for processing all equipment and supplies. Revised September

105 Use of disposable equipment may eliminate the need for cleaning, disinfection or sterilization procedures for reusable equipment. Disposable equipment should be placed in a bag and discarded with regular waste. Needles, syringes and other sharps should be placed in a puncture-resistant container. If a commercial disposal container is not available, a plastic, thick-walled, household container (e.g., bleach, vinegar bottle) should be used. 4. Household Equipment/Articles/Supplies Equipment such as bath stools, etc. should be cleaned with a normal household cleaner before use by other individuals. After handling contaminated equipment, hands should be washed immediately with soap and running water for seconds. 5. Linen Linen and clothing should be washed by the usual methods. Health care workers should wear protective attire (i.e., disposable gloves and gown or apron) to sort or handle linen that is heavily soiled with body fluids. Wash hands for seconds with soap and running water after removing gloves. 6. Dishes Dishes should be washed by the usual methods. 7. Garbage Dispose of soiled gloves and other supplies in the regular garbage. Wash hands with soap and running water for seconds after handling garbage. 8. Environment Clean the household/environment as usual with regular household cleaner, paying special attention to items frequently handled during care. After a spill of blood or body fluids the surface should be cleaned with soap and hot water and, if possible, disinfected with a solution such as 1:10 bleach and water. Gloves should be used and hands washed after removing gloves. Infection Control Guidelines for Health Care Workers in the Community Revised September

106 Xl References AORN Standards, Recommended Practices & Guidelines, Arnold M, Dempsey J, Fishman M, McAuley P, Tibert C, Vallande N. The Best Hospital Practices for Controlling Methicillin-Resistant Staphylococcus aureus: On the Cutting Edge. Infection Control & Hospital Epidemiology, Vol. 23, No. 2, p Back to Basics, CHICA Manitoba, Canada Communicable Disease Report. Prevention & Control of Occupational Infections in Health Care. Volume 28S1, March Canada Communicable Disease Report. Surveillance for Methicillin-Resistant Staphylococcus Aureus in Canadian Hospitals. A Report Update from the Canadian Nosocomial Infection Surveillance Program. Volume 31, Number 3, February 1, Canada Communicable Disease Report Supplement. Routine Practices & Additional Precautions for Preventing the Transmission of Infection in Health Care. Volume 25S4, July Canadian Nosocomial Infection Surveillance Project (CNISP) and Canadian Epidemiology Committee (CHEC) ARO Definitions, Draft Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, Healthcare Infection Control Practices Advisory Committee, Infection Prevention & Control Guideline for MRSA in the Community, Capital Health Region, August Infection Control Guidelines for Community Shelters and Group Homes. Manitoba Health, April Infection Control Guidelines for Health Care Workers in the Community. Manitoba Health, Infection Control Guidelines for the Management of Respiratory Infections. Winnipeg Regional Health Authority, March Infection Control Recommendations for Patients with Cystic Fibrosis: Microbiology, Important Pathogens, and Infection Control Practices to Prevent Patient-to-Patient Transmission. American Journal of Infection Control, May (3 Suppl), Investigation & Control of Vancomycin-Intermediate & Resistant Staphylococcus aureus (VISA/VRSA), Centers for Disease Control & Prevention, April 21, Muto C, Jernigan J, Ostowsky B, Richet H, Jarvis W, Boyce J, Farr B. SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains of Staphylococcus aureus & Enterococcus. Infection Control & Hospital Epidemiology, May 2003, p ORNAC Recommended Standards, Guidelines & Position Statements for Perioperative Registered Nursing Practice, August Papia G, Louie M, Tralla A, Johnson C, Collins V, Simor A. Screening High-Risk Patients for Methicillin Resistant Staphylococcus aureus on Admission to the Hospital: Is It Cost Effective? Infection Control & Hospital Epidemiology, Vol. 20, No. 7, p The Management of Infection & Colonization due to Methicillin-Resistant Staphylococcus aureus: ACIDS/CAMM position paper. The Canadian Journal of Infectious Diseases. Vol. 15, Number 1, Jan/Feb 2004, p