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PIDAC Best Practices for Infection Prevention and Control of Resistant Staphylococcus aureus and Ent


... Prevention and Control of Resistant Staphylococcus aureus and Enterococci ... Topics identified through consultation with healthcare providers ... – PowerPoint PPT presentation

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Title: PIDAC Best Practices for Infection Prevention and Control of Resistant Staphylococcus aureus and Ent

PIDAC Best Practices for Infection Prevention
and Control of Resistant Staphylococcus aureus
and Enterococci
  • CIPHI Conference
  • May 4, 2007
  • Liz Van Horne
  • Infection Prevention Control Consultant

  • To provide an overview of the PIDAC best practice
  • To discuss the role of public health in
    implementing the recommendations

Best Practice Documents
  • Topics identified through consultation with
    healthcare providers
  • Search done to identify international, national,
    provincial guidelines/documents
  • Literature search conducted to identify evidence
    related to topic
  • Draft document developed and revised by Infection
    Prevention Control (IPC) subcommittee
  • Final draft sent for stakeholder review results
    reviewed by IPC subcommittee
  • Final document to PIDAC for approval then to
    Chief Medical Officer of Health (CMOH)
  • Posted on PIDAC website after approval from CMOH
  • Documents reviewed a minimum of every 2 years or
    more frequently as necessary

Best Practice Assumptions
  • Health care settings have basic infection
    prevention and control systems in place
  • Health care settings
  • Routinely implement best practices
  • Devote adequate resources to infection prevention
    and control
  • Have programs that promote good hand hygiene
    practices and ensure adherence to standards
  • Devote adequate resources to housekeeping
  • Provide a setting conducive to following and
    maintaining Routine Practices
  • Provide regular education to staff

Best Practice Assumptions
  • Health care settings
  • Promote collaboration between occupational health
    and infection prevention and control
  • Comply with Occupational Health and Safety Act
    and other legislated requirements
  • Have effective working relationship with local
    public health unit
  • Have access to ongoing infection prevention and
    control advice
  • Report back to staff on the impact of their
    surveillance efforts
  • Regularly assess the effectiveness of their
    infection prevention and control education
    programs and their impact on practices

  • Adherence to Routine Practices which includes
    hand hygiene, cannot be overemphasized.

Rationale for a comprehensive IPAC program to
prevent MRSA and VRE
  • MRSA and VRE impact patient outcomes, quality of
    care and duration of hospitalization.
  • Patients infected with MRSA have a higher
    incidence of mortality, particularly those with
    MRSA bacteremia
  • The use of Contact Precautions impacts quality of
    care and quality of life, with patients
    expressing greater dissatisfaction with treatment
    and receiving less documented care
  • The duration of stay in hospital for MRSA and VRE
    patients is often longer than those without MRSA
    and VRE

Rationale for a comprehensive IPAC program to
prevent MRSA and VRE
  • Increased cost of care to health care system
  • In 2004 dollars it is estimated it cost between
    16836-35000 to manage a patient infected with
    MRSA and 1634 to manage a colonized patient.
  • Therefore following IPAC best practices decreases
    adverse outcomes and reduces associated costs to
    the health care system.

Number of Patients Colonized/Infected with MRSA,
Ontario, 1992-2005
QMP/LS Surveys, 1996-2005
No. patients colonized/infected
Grading System for Recommendations
  • Categories for strength of each recommendation
  • A- Good evidence to support a recommendation for
  • B- Moderate evidence to support recommendation
    for use
  • C- Insufficient evidence to support a
    recommendation for or against its use
  • D- Moderate evidence to support a recommendation
    against use
  • E- Good evidence to support a recommendation
    against use.
  • Categories for quality of evidence
  • 1- Evidence from at least 1 properly randomized
    controlled trial
  • 11- Evidence from at least 1 well-designed
    clinical trial without randomization.
  • 111- Evidence from opinions of respected
    authorities on basis of clinical experience,
    descriptive studies or reports of expert

Screening to identify colonized and infected
patients with MRSA and VRE
  • Screening is not a control method in itself as
    Routine Practices must be used with every
  • Purpose is to identify patients with MRSA or VRE
    so further control measures can be put in place

Admission screening
  • Admission screening tool should be applied to all
    patients. The following patients are at increased
    risk for both MRSA and VRE so should be screened
    for both (A11 recommendation)
  • Those who have
  • Previously been colonized or infected with MRSA
    or VRE
  • Spent time in a health care facility outside of
    Canada in the last 12 months
  • Spent time in a health care facility or who have
    spent more than 12 continuous hours in any health
    care facility in the past 12 months
  • Transferred between health care facilities (e.g.
    between hospitals or between a long term care
    home and a hospital)
  • Patients recently exposed to a unit/area of
    health care facility with an MRSA or VRE outbreak
  • Other high-risk patient populations as identified
    by the Infection Prevention Control
    Professionals (ICP), Public Health or RICN

Admission screening
  • Based on local epidemiology and risk factors,
    additional individuals may be considered for MRSA
  • Those receiving home health care services in the
    past year
  • Those receiving treatment with an indwelling
    medical device
  • Those receiving care in intensive care units,
    transplant units, burn units
  • Those living in a communal setting (e.g.
    shelters, halfway home, correctional facility)
  • Those with a history of injection drug use
  • Those who are household contacts of people with
  • Those who are immunocompromised
  • Populations where Ca-MRSA is known to be a
    problem (e.g. organized sports teams)

  • Verification
  • If there is a single positive specimen from a
    single site in a newly identified case,
    consideration should be given to confirming with
    a repeat specimen (B111)
  • ? Mislabelling at unit level
  • ? Error in laboratory
  • Discrepant results could be a false-positive. If
    results do not concur, an investigation must be
    performed to identify the reasons for the

  • MRSA (A11)
  • Anterior nares AND
  • Perianal area AND
  • Skin lesions, wounds, incisions, ulcers and exit
    sites of indwelling devices
  • Newborns a swab from the umbilicus should also
    be taken
  • a perineal or groin swab is also acceptable
  • VRE
  • Must include stool or a swab from the rectum or
    anus. Stool specimens are preferred as they
    provide a higher yield. (A11)

Additional Precautions for MRSA and VRE in
addition to Routine Practices
  • Contact Precautions
  • Decisions regarding patient placement
  • Safe management of equipment and environment
  • Appropriate PPE for the organism and setting
  • Effective communication to affected departments
    and other facilities
  • Education for staff, patients and family

Contact Precautions
  • Acute Care
  • Placement single room
  • Hand hygiene staff and patients
  • Dedicate equipment
  • PPE
  • Gloves enter room/bed space
  • Gown enter room/bed space
  • Consider mask
  • Visitors
  • PPE only if contact with other patients or
    provide direct care
  • Educate on hand hygiene and use of PPE
  • Patients no PPE to leave room if assessment
  • Long-Term Care
  • Placement determine based on risk factors
  • Hand hygiene staff and residents
  • Dedicate equipment
  • Adapt to permit residents to participate in
  • PPE
  • Gloves and gown for direct care
  • Visitors
  • PPE only if moving between residents or provide
    direct care
  • Residents no PPE to leave room

Personal Protective Equipment (PPE) for MRSA or
VRE in non-acute care settings
  • Direct Care
  • Providing hands on care such as bathing, washing,
    turning patient, changing clothes/incontinence
    briefs, dressing changes, care of open
    wounds/lesions or toileting.
  • Feeding, and pushing a wheel chair are not
    classified as direct care.

Signage and Patient/visitor education
  • Signage indicating Contact Precautions should be
    posted at the entrance to room or bedspace.
    Signage should maintain privacy by indicating
    only the precautions that are required, not
    information regarding the patient's condition
  • Patients and visitors must be informed about the
    reason for implementing the Contact Precautions
    and be educated in the proper use of hand hygiene
    and Contact Precautions (C111)

Environment and equipment
  • Dedicate equipment to a single patient on Contact
    Precautions. If MRSA positive or VRE positive
    patients are cohorted, equipment may be cohorted.
  • Equipment must be cleaned and disinfected as per
    Routine Practices between patients
  • Review your cleaning and disinfection methods to
    ensure that they are adequate for disinfection of
    contaminated surfaces (C111)
  • As per Routine Practices, rooms and dedicated
    equipment used for patients with MRSA must be
    thoroughly cleaned and then disinfected using a
    hospital-grade disinfectant upon discharge of the
    patient. (B111)

Environment and equipment
  • Stringent protocols are required for the daily
    cleaning of rooms contaminated with VRE.
  • There must be a process to ensure that there has
    been adequate cleaning and disinfection of rooms
    and shared non-medical equipment contaminated
    with VRE following patient discharge.
  • Use of a checklist to ensure that all areas and
    surfaces are cleaned and disinfected and that
    post-cleaning inspection of the room has taken
    place (B111)
  • In situations with persistent VRE transmission,
    consideration may be given to post-cleaning
    environmental cultures to document that discharge
    cleaning of rooms is adequate.

  • Routine health care cleaning practices for
    laundering linens are adequate for eliminating
    MRSA and VRE. (A1)
  • All curtains should be removed and laundered when
    soiled and after discharge of a patient with
    VRE. (B111)
  • Consideration should be given to removal and
    laundering of privacy curtains after discharge of
    an MRSA patient.

Patient Transfers
  • When a patient with MRSA or VRE is transferred
    to, from, or within a health care setting,
    communication regarding the MRSA or VRE status is
  • All health care facilities in Ontario are
    expected to have the ability to care for patients
    who have MRSA or VRE.

Patient Mobility
  • In acute care settings, prior to leaving their
    room, patients with MRSA or VRE should be
    assessed on a case-by-case basis to determine
    their risk of transmission. (B111)
  • Patient understands and is able to comply with
  • Drainage is contained
  • Does not have a productive cough (applicable for
  • Is continent of stool and urine or contained by
    incontinence brief/indwelling catheter
  • Patient uses basic hygiene practices, including
    cleaning hands on leaving room
  • Is not on an outbreak unit
  • Has no other disease requiring precautions
  • Additional restrictions may be considered for
    patients with VRE

Patient Mobility
  • In non-acute care settings, residents with MRSA
    or VRE are not required to remain in their room.

Staff Considerations
  • Staff must receive education in the correct and
    consistent use of Routine Practices as a
    fundamental aspect of infection prevention and
    control in health care settings, with emphasis on
    hand hygiene and appropriate use of PPE. (B111)
  • Screening of staff for MRSA should be considered
    when an outbreak of the same strain of MRSA
    continues to spread despite adherence to control
    measures, or when an individual is strongly
    epidemiologically linked to the new acquisition
    of MRSA. (B111)

Staff Considerations
  • Decolonization of staff colonized with MRSA
    should be done when they are epidemiologically
    linked to an outbreak with the same strain and
    adherence to Additional Precautions has failed to
    contain the outbreak. (A11)
  • If staff are colonized with a strain of MRSA that
    is different from the outbreak strain,
    decolonization may be considered. (B111)

  • Visitors have not been implicated in the
    transmission of MRSA or VRE in health care
    facilities however, all persons entering and
    leaving a patients room require instruction on
    how to enter and leave the room safely when the
    patient is on Contact Precautions.
  • Written information should be available for
    patients and their families describing Contact
    Precautions and why they are important. (B111)
  • Visitors should receive education and training in
    correct hand hygiene procedures. (B111)

  • Routine decolonization therapy of MRSA patients
    is not currently recommended. (E11)
  • Decolonization therapy with topical antibiotics
    alone is not effective.
  • VRE decolonization is not effective and is not
    recommended. (E1)
  • In situations where a patient colonized with MRSA
    is implicated in an outbreak, decolonization may
    be considered in consultation with the ICP.
  • If MRSA decolonization therapy is used, attention
    must be given to scrupulously cleaning the
    environment in order to decrease the risk of
    recolonization, as the environment can play a
    role in transmission.

Role of the Laboratory
  • Labs should recognize that turnaround time is
    critical in prevention of transmission of MRSA
    and VRE. Labs and ICP should develop reporting
    systems that notify ICPs of suspected MRSA or
    VRE prior to final confirmation. (A111)
  • The lab should employ methods that allow for as
    rapid as possible turnaround time for screening
    specimens for MRSA and VRE. (A11)
  • Labs should save isolates of MRSA and VRE (one
    isolate per patient) for a minimum of 6 months
  • Lab support during outbreak investigation should
    include the ability to obtain molecular typing.

  • Education concerning the epidemiology, prevention
    and control of MRSA and VRE should be given to
    staff to ensure that they are knowledgeable
    regarding transmission and the correct use of PPE
    and to enable them to use and teach Additional
    Precautions appropriately.(B111)
  • Patients and visitors should be taught hand
    hygiene and encouraged to remind anyone entering
    the room to perform hand hygiene before and after
    leaving the room (B111)
  • Patient teaching should include basic hygiene
    practices such as not sharing personal items and
    covering their mouth when coughing. (B111)
  • Visitors should receive instruction regarding
    specific facility control measures that might be
    in place before they visit a patient. (B111)

Antibiotic Stewardship
  • Policies and procedures should be implemented to
    promote judicious antibiotic use, in order to
    limit the increase and spread of antibiotic
    resistant organisms. (A11)
  • Health care settings should institute formulary
    control of antibiotics and should conduct regular
    reviews of antibiotic utilization. (A111)

Program Evaluation
  • Multi-disciplinary audits followed by feedback
    and an action plan to improve practices
  • Screening tools are used to identify MRSA, VRE
  • Hand Hygiene, Routine Practices, Additional
  • Disinfecting of equipment that moves from patient
    to patient
  • Cleaning of rooms

Program Evaluation
  • Surveillance
  • It is important to have front line staff,
    administrators and IPAC Committee review
    surveillance data and provide feedback which may
    prompt a review of practices and prevention
  • Collate and analyze data
  • Generate facility and unit associated infection
  • Create standardized reports from the data
  • Examine trends for sources of MRSA or VRE
  • Feedback rates and trends to staff
  • There should be an ongoing plan of action to
    improve the processes and outcomes

FAQ To Wear a Surgical Mask or not?
  • The use of a surgical mask for contact with
    patients colonized/infected with MRSA is
  • evidence from 1 study showed a lower rate of
    colonization in staff wearing masks, likely due
    to avoidance of hand-to-nose contact.
  • Recommendation
  • Acute care, consideration may be given to wearing
    a surgical mask as part of precautions when
    entering the room of a patient with MRSA to
    decrease nasal acquisition by health care
  • Non acute care, consideration maybe given to
    wearing a surgical mask for the provision of
    direct care with residents with MRSA as per
    Routine Practices to decrease nasal acquisition
    by health care workers.
  • If masks are worn, ensure they are worn safely
    and correctly.

FAQ What is the MRSA benchmark per 1000 days?
  • Canadian Nosocomial Infections Surveillance
    Program (CNISP) average
  • MRSA 0.7/1000 patient days
  • VRE 0.15/1000 patient days
  • There is no provincial benchmark rate. Facilities
    are not using the same methods and definitions
    for collecting data so rates are not comparable.
  • Surveillance should be done for MRSA and VRE
    rates can be compared for the facility over time
    and between clinical areas within the facility.

FAQ Why are rooms not to be shared by MRSA
patients and VRE patients only in acute care
  • Single rooms are always preferred for both MRSA
    and VRE patients in both acute and non-acute care
  • Many facilities have insufficient single rooms to
    accommodate all MRSA and VRE patients
  • In acute care settings, because of acuity and
    frequent interventions the risk of acquisition
    and subsequent clinical infection is higher
  • In non-acute settings, the quality of life of the
    resident must be considered

FAQ Is there evidence one way or the other
regarding MRSA decolonization or is it on a
case-by-case basis?
  • Routine decolonization is not currently
    recommended. Decolonization is decided on a
    case-by-case basis. Factors to consider are
  • Presence of indwelling devices
  • Presence of wounds/skin lesions
  • Presence of multiple co-morbidities
  • Mupirocin susceptibility of the MRSA isolate
  • Linkage of the patient to ongoing transmission
  • Ability to comply with decolonization/hygiene

FAQ The document recommends that settings verify
a single positive swab with a repeat swab. If the
repeat swab is negative and no errors are found,
how many negative specimens are needed to remove
the patient from additional precautions?
  • Two

FAQ Are droplet precautions required for MRSA in
the sputum for a chronic COPD patient or would
one use Contact precautions with Routine
  • Routine Practices requires use of a mask when
    within one meter of a coughing patient
  • Plus Contact Precautions for MRSA.

FAQ Are shaking hands, playing cards or being
tablemates considered activities that allow
transmission to occur?
  • Cleaning hands correctly before and after the
    activity will remove organisms
  • Is there strategically and safely placed alcohol
    based-hand rub as they entire the OT room, Dining
    room, physio room, game room?

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