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

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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
• MOHLTC

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Objectives

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

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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

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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

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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

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

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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

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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.

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Number of Patients Colonized/Infected with MRSA,
Ontario, 1992-2005
.
QMP/LS Surveys, 1996-2005
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VRE - ONTARIO
2,161
No. patients colonized/infected
1,031
718
685
589
492
445
445
237
167
99
7
2
0
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Grading System for Recommendations

• Categories for strength of each recommendation
• A- Good evidence to support a recommendation for
  use
• 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
  committees.

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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
  patient/resident
• Purpose is to identify patients with MRSA or VRE
  so further control measures can be put in place

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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

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Admission screening

• Based on local epidemiology and risk factors,
  additional individuals may be considered for MRSA
  screening
• 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
  MRSA
• Those who are immunocompromised
• Populations where Ca-MRSA is known to be a
  problem (e.g. organized sports teams)

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Screening

• 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
  discrepancy.

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Specimens

• 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)

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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

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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
  allows

• Long-Term Care
• Placement determine based on risk factors
• Hand hygiene staff and residents
• Dedicate equipment
• Adapt to permit residents to participate in
  activities
• PPE
• Gloves and gown for direct care
• Visitors
• PPE only if moving between residents or provide
  direct care
• Residents no PPE to leave room

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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.

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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
  (C111)
• 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)

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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.
  (B111)
• 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)

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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.

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Laundering

• 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.

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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
  essential.
• All health care facilities in Ontario are
  expected to have the ability to care for patients
  who have MRSA or VRE.

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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
  precautions
• Drainage is contained
• Does not have a productive cough (applicable for
  MRSA)
• 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

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Patient Mobility

• In non-acute care settings, residents with MRSA
  or VRE are not required to remain in their room.
  (B111)

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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)

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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)

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Visitors

• 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)

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Decolonization

• 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.
  (B111)
• 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.

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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
  (A111)
• Lab support during outbreak investigation should
  include the ability to obtain molecular typing.
  (A111)

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Education

• 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)

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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)

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Program Evaluation

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

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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
  measures.
• Collate and analyze data
• Generate facility and unit associated infection
  rates
• 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

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FAQ To Wear a Surgical Mask or not?

• The use of a surgical mask for contact with
  patients colonized/infected with MRSA is
  controversial.
• 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
  workers.
• 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.

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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.

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FAQ Why are rooms not to be shared by MRSA
patients and VRE patients only in acute care
settings?

• Single rooms are always preferred for both MRSA
  and VRE patients in both acute and non-acute care
  settings
• 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

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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
  measures

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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

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FAQ Are droplet precautions required for MRSA in
the sputum for a chronic COPD patient or would
one use Contact precautions with Routine
Practices?

• Routine Practices requires use of a mask when
  within one meter of a coughing patient
• Plus Contact Precautions for MRSA.

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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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