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Management of Multi-resistant Organisms and Clostridium difficile PD2007_084:PCP 1

Version Two July 2014

Management of Multi-resistant Organisms and Clostridium difficile

This policy compliance procedure (PCP) relates to

PD2007_084: Infection Control Policy: Prevention & Management of Multi-Resistant Organisms (MRO)

PCP number PD2007_084:PCP 1

Sites where PCP applies All HNE Health Facilities

Target audience All HNE Health Managers and Staff

Description Procedures to manage MRSA and other MROs + C. difficile

Subject Multi-resistant organism + C. difficile

Keywords MRSA, MRAB, CRE, VRE, MRO, Multi-resistant organism, Healthcare-associated infection, ESBL, Clostridium difficile, infection control, infection prevention, antimicrobial stewardship, antibiotic resistance, antimicrobial resistance, vancomycin-resistant enterococcus

Replaces Existing PCP? Yes

Registration Number/s or previous documents

PD2007_084;PCP 1 Version One from 11 December 2013

Related Legislation (including OHS legislation), Australian Standards, NSW Health Policy or Circular, other HNEH Documents, Professional Guidelines, Codes of Practice or Ethics:

National Guidelines for the Prevention and Control of Infection in Healthcare

NSW Health Policy Directive PD2007_36: Infection Control Policy

ASID/AICA position statement on Infection Control Guidelines for C. difficile

Western Australia Infection Prevention & Control of VRE in Acute care, December 2011

Royal Perth Hospital, MRSA Policy October 2011

PD2007_036:PCP 3 and PD2007_084:PCP 2 Allocation of isolation rooms and use of patient cohorting for designated infectious diseases

Cleaning of Non-Critical, Reusable Medical Equipment PD2012_061:PCP 1

GNAH_0088: Management of Multi Resistant Organisms in Operating Theatres and Other Interventional Procedural Settings

Portfolio Executive Director responsible for Policy

Karen Kelly, Director Nursing and Midwifery

Policy Contact Person Dr John Ferguson, Director , Infection Prevention Service

Contact Details [email protected] Ph:4921 4444

Summary

This Policy Compliance Procedure provides guidance on specific HNE Health implementation of

PD2007_084: Infection Control Policy: Prevention & Management of Multi-Resistant Organisms (MRO).

The aim is to reduce emergence and cross-transmission of MRO and C. difficile in healthcare.

Distribution: All HNE Health managers and staff

Date PCP authorised: 13 July 2014

PCP authorised by: Karen Kelly, Director Nursing and Midwifery

Date of Issue: 16 July 2014

PCP Review Due Date: 16 July 2017

TRIM Number: 14/37-2-58

Policy Compliance Procedure

http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0013/120154/PD2007_036_PCP_3_and_PD2007_084_PCP_2_Isolation_Rooms_and_Patient_Cohorting.pdf

http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0013/120154/PD2007_036_PCP_3_and_PD2007_084_PCP_2_Isolation_Rooms_and_Patient_Cohorting.pdf

http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0005/118643/PD2012_061_PCP_1_Cleaning_of_non-critical_reusable_medical_equipment.pdf

http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0006/75606/GNAH_0088_MRO_Management_interventional_areas.pdf

http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0006/75606/GNAH_0088_MRO_Management_interventional_areas.pdf

mailto:[email protected]



Note: Over time links in this document may cease working. Where this occurs please source the document in the PPG Directory at: http://ppg.hne.health.nsw.gov.au/

RISK STATEMENT

Patients or staff colonised or infected with MROs or C. difficile represent a significant risk to patients and a range of control measures are required to reduce this risk.

Risk Category: Clinical Care & Patient Safety

Compliance

Compliance with this PCP is mandatory.

Implementation Plan and Monitoring

1. Infection prevention and control staff education.

2. Bed managers and admission clerks education.

3. HNE Health IPCU mandatory infection control education curriculum revision to reflect new requirements.

4. HNE Health medical (including GPs) and nursing staff – synopsis of changes to be distributed to all.

Feedback

Any feedback on this document should be sent to the Contact Officer listed on the front page.

Supporting materials

MRO intranet resource page: includes all relevant current supporting materials including patient information sheets, infection control care plans, standardised signage, site-specific availability of isolation accommodation.

Information sheets are also held on the HNELHD PPG database.

http://ppg.hne.health.nsw.gov.au/

http://intranet.hne.health.nsw.gov.au/hne_infection_prevention__and__control/multi-resistant_organism_control



A. Roles and responsibilities

This excerpt from the NSW MRO Policy: PD 2007_084: Roles and Responsibilities Population Health Officer must develop management and accountability approaches for infection prevention and control that align with patient safety initiatives and activities to reduce the transmission of MRO. These should be sufficiently flexible to allow rapid response to local epidemiological changes, outbreaks or changes in the understanding of the spread and consequences of patients acquiring an MRO. Chief Executive is responsible for:

ensuring that resources are available to enable implementation of this policy.

ensure service agreement and PSS complies with policy Director of Clinical Governance is responsible for:

ensuring implementation of this policy

ensuring development of local policies and procedures to support this policy Infection Control Professional (ICP) is responsible for:

tracking of MRO patients through effective screening and laboratory liaison

ensuring attending medical officer and ward clinical staff are advised of a new isolate

ensuring an Infection Control Plan is initiated for each MRO patient and patient & family education. Infectious Diseases/Clinical Microbiology specialist is responsible for:

ensuring ICP and ward clinical staff are notified of new isolates. Head of Pharmacy is responsible for:

ensuring that antibiotic utilisation data is collated and reported to relevant staff. Nurse Unit Manager is responsible for:

ensuring compliance with this policy by staff and his/her ward/unit and the patient’s individual management.

ensuring feedback to staff of compliance with the policy.

PPE equipment availability. All HCW are responsible for:

complying with hand hygiene and personal protective equipment requirements for safe practice.

complying with prevention/management strategies for MRO infected/colonised patients.

http://www0.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_084.pdf



B. Definitions and descriptions

Please see the intranet page for this policy compliance procedure to access patient fact sheets and clinician summaries for each type of MRO and C. difficile.

Acronym or term

Explanation

MRO Multi-resistant organism: for the purposes of this document refers to MRSA, VRE CRE, MRAB and meropenem-resistant Pseudomonas aeruginosa positive for a carbapenemase gene.

Standard Precautions (SP)

Standard Infection Control Precautions These represent the base level standard required for all clinical interactions, regardless of the infection status of a patient. They are designed to prevent contact spread of infection, particularly spread of blood-borne viruses via exposure to blood or body substances. They also reduce spread of MROs and C. difficile. Hand hygiene before and after care of patients, use of personal protective equipment (PPE)i.e. gloves, fluid resistant apron or long sleeved plastic aprons, fluid resistant mask (surgical), safety eye wear when necessary to avoid exposure to blood or body fluids, safe management of sharps, linen, waste & pathology specimen handling, environmental cleaning and disinfection and other measures.

Contact Precautions (CP)

Contact (additional) transmission-based precautions. Patients with active alerts for MRO organisms and C. difficile are placed under CP. In addition to standard precautions, implement contact precautions in the presence of known or suspected infectious agents that are spread by direct or indirect contact with the patient or the patient’s environment. CP involve isolation of the patient in a single closed room or designated areas and use of personal protective equipment by the healthcare worker (gloves, fluid resistant apron or long sleeved plastic apron) to prevent contamination of clothing or skin during patient care.

CDI Clostridium difficile infection. Patients with symptomatic CDI are placed under CP (contact transmission-based precautions) until more than 48 hours of normal formed stools. Clostridium difficile causes post-antibiotic diarrhoea and sometimes severe colitis. The organism transmits via direct and indirect contact spread, often via a contaminated patient environment or contaminated patient equipment or other fomites. CP and environmental cleaning and disinfection (that is effective against spores) are essential for control. Reduction in antibiotic exposure (especially cephalosporins) also has an important role in reducing transmission. Community carriage and disease are reasonably frequent. Exposure to agents that reduce stomach acidity increase the risk of CDI and make relapse more likely after treatment.

CRE

Carbapenem-resistant Enterobacteriaceae. These Gram negative bacteria are resistant to carbapenems (eg. meropenem or imipenem). The Enterobacteriaceae family includes a range of bacterial species that predominantly live in the bowel such as E. coli, Klebsiella pneumoniae , Proteus, Morganella, Enterobacter, Citrobacter, Serratia and others. CRE does NOT include Acinetobacter baumannii (see MRAB entry) or Pseudomonas species. Various other Gram negatives can be carbapenem resistant. Only MRAB colonised require routine Contact precautions. Patients with carbapenem-resistant Pseudomonas aeruginosa are managed under Standard precautions unless an outbreak or cross-transmission cluster is detected.



Acronym or term

Explanation

A majority of CRE are multi-resistant with few available treatment options. They cause sepsis in hospitalised patients, particularly those in intensive care. Mortality rates are high. Tourists and people from overseas may be colonised with such organisms for more than 6 months following travel and may develop post-procedure infections. CRE usually contain a metallobetalactamase enzyme that has a distinct name e.g. NDM1 or IMP4. New isolates of CRE are sent for genetic testing to detect these genes. ESBLs are not considered as CRE unless they are also carbapenem-resistant.

ESBL Extended-spectrum betalactamase producing enteric Gram negative bacillus from the E. coli (Enterobacteriaceae) family. Generally means resistance to third generation cephalosporins. ESBL-colonised or infected patients are managed under SP (standard infection control precautions) in HNELHD unless there is evidence of epidemic spread. NOTE: ESBL positive patients managed at Calvary Mater Newcastle are placed under Contact Precautions. Tourists and people from overseas are frequently colonised with such organisms for more than 6 months following travel and may develop post invasive procedure infections.

MRAB Meropenem-resistant Acinetobacter baumannii MRAB are Gram negative bacteria that live in soil, water and on skin and can survive in the environment for extended periods. In the past, patients most at risk of developing MRAB infections have been those with a long term admission, especially longterm intensive care patients. MRAB are categorised as similar MROs to CRE as capacity for spread and control measures are the same.

B. cepacia

Burkholderia cepacia is a multi-resistant Gram negative bacterium that causes infection in cystic fibrosis patients. It represents a cross-infection risk for CF patients. CF patients that are colonised or infected with cepacia remain so for life and are flagged on iPM. B. cepacia may also rarely cause infection in non-CF patients. Those patients are NOT flagged on iPM but are tracked by infection control on ICNET.

MSSA methicillin-susceptible Staphylococcus aureus NB. This is not a multi-resistant organism. Staphylococcus aureus is carried in the nostrils of approximately 30% of healthy adults but it can invade the body through broken skin, especially through surgical wounds. Invasive infection may cause a wide range of clinical disease, including cellulitis, bacteraemia or osteomyelitis. MSSA infection is usually endogenous- caused by the strain carried by the patient. A higher proportion of infants and children carry Staphylococcus aureus.

MRSA methicillin-resistant Staphylococcus aureus MRSA is resistant to all beta-lactam antibiotics including penicillins and



Acronym or term

Explanation

cephalosporins. MRSA are not more or less virulent than methicillin-susceptible strains but MRSA infections are more difficult to treat because the number of effective antibiotics is reduced (sometimes to only one or two). Acquisition of MRSA is a potential risk to all patients but infections with MRSA are of particular significance for patients undergoing surgery, especially the implantation of prosthetic joints, and invasive medical procedures, including coronary artery angioplasty and insertion of stents. It is important to prevent MRSA from becoming established in hospital wards where there are patients undergoing these high-risk procedures. MRSA infection is frequently exogenous- caused by a strain cross-transmitted from another person or the environment. One study indicated that 29% of patients who become colonised with MRSA in hospital developed infection over the following 18 months, with MRSA bacteraemia occurring in one third of these patients. Reduction in antibiotic exposure also has an important role in reducing transmission. Community carriage occurs and community acquired MRSA infections are becoming more frequent in HNELHD.

VRE vancomycin-resistant enterococcus VRE is an opportunistic pathogen, causing infection in intensive care patients (IV line–associated sepsis, intra-abdominal infection and urinary tract infection), neutropenic and other haematology patients (IV line-associated sepsis), bacteraemia associated with mucositis or enteritis and solid organ transplant patients. A major reservoir for VRE is unrecognised colonised patients in hospitals and proximity to a colonised patient is a major risk factor for acquisition. Certain high risk patients (see Section B2) are more prone to transmit VRE. Transmission of VRE is primarily directly via contaminated hands and clothing of health care workers and indirectly via contaminated equipment and or environment. CP (contact transmission-based precautions) and environmental cleaning and disinfection are essential for control. Reduction in antibiotic exposure (especially cephalosporins) also has an important role in reducing transmission. Community carriage occurs but community acquired VRE infections are rare. VRE is subclassified as vanA or vanB by a test of the genotype.

AMS Antimicrobial stewardship A process to ensure that all antibiotic prescriptions are appropriate – correct drug(s), dose, route of administration and duration of treatment. This involves implementation of guidelines, measurement of antimicrobial resistance and usage and periodic audits to examine appropriateness of treatment.

Carrier status (C. difficile)

Active: A person with diarrhoea who has toxigenic C. difficile detected on one occasion (CDI). Cleared: A person with CDI who has recovered and is > 48 hours of normal formed stools. These patients are at risk of relapse for at least 8 weeks following recovery. Stool remains positive for C. difficile for weeks, despite clinical recovery. Re-testing to assess clearance is NOT indicated.

Carrier status (MRSA) See iPM flags (Appendix 1)

Active: A person who has MRSA detected on one occasion. Such patients are flagged on iPM. Cleared: A person who has had two extended sets of negative MRSA swabs collected on the same or different days, more than 6 months from the last positive MRSA culture and more than 2 weeks since MRSA antibiotic therapy or antiseptic



Acronym or term

Explanation

body wash treatment. (See section F)

Carrier status (CRE)

Active: A person who has CRE detected on one occasion. Such patients are flagged on iPM. CRE patients are not cleared as there is no clearance documentation

Carrier status (VRE)

Active: A person who has VRE detected on one occasion. Such patients are flagged on iPM. Cleared: A person who has had two extended sets of negative VRE swabs collected on the same or different days, more than 6 months from the last positive VRE culture and more than 2 weeks since VRE antibiotic therapy or antiseptic body wash treatment. (See section F)

Cohorting The grouping of people together with the same pathogen-MRO strain, antibiograms or C. difficile in a designated area. After discussion with ICP or medical microbiologists

Colonisation Detection of an organism from a site that shows no sign of invasive infection, usually the nose or the perineum, and often a chronic ulcer.

HAI Healthcare-associated infection: infection that becomes evident during hospital admission or in the outpatient setting in the presence of certain healthcare associated risk factors.

ICNET HNELHD software program that tracks patient movements and infection data. This is used by IPS staff. The software provides a wide range of reports on infection data and outbreaks.

ICP Infection control professional

Infection Detection of an organism from a site where clinical signs and symptoms indicating invasion of the host such as inflammation, pus and/or bacteraemia are present.

IPS Infection Prevention Service

Residential care facility

Any long term care facility including aged care facilities, hostels, mental healthcare homes, prisons and rehabilitation group homes.



B. Patient placement, movement and cohorting

Overview Patients identified to be an infectious risk due to MROs or C. difficile are alerted on iPM and placed in isolation in most locations across Hunter New England.

B1. Requirements relevant to HNELHD staff Admission staff, Bed Managers, ED triage and Bed Allocation and (Clerical) staff are required to

take note of patient infection control alerts and allocate appropriate placement (see also

HNELHD PCP Allocation of isolation rooms and use of patient cohorting for designated

infectious diseases). For the iPM alerts in use in Hunter New England – see Appendix 1.

Patients with an MRO alert require management under Contact Precautions in a single room

or designated area with ensuite or separate toilet (i.e. commode if necessary) - this is

mandatory for all sites, including intensive care and HDUs.

All patients with diarrhoea and/or recent onset vomiting (including those with C. difficile

infection) are also managed under CP until 48 hours after the normal formed stools or

vomiting ceased.

Designated Rehabilitation and Aged Care facilities and facilities with insufficient single room

accommodation need to allocate dedicated bathroom and toilet facilities to ensure safe

cohorting of patients (if necessary use commodes) ensuring enhanced cleaning and

disinfection is undertaken after each use.

High risk (section B2 below) MRO patients and all patients with diarrhoea in Ambulatory care &

Emergency Departments must either be placed in single room with ensuite or in a designated

partitioned area with dedicated bathroom and toilet facilities.

Cystic fibrosis patient placement and clinic arrangements are described in separate HNELHD

guidelines/policy developed by Respiratory Medicine (Paediatric and Adult).

Staff must inform transporting agencies or medical imaging, operating theatre, clinics and other

locations of the patient’s MRO/gastrointestinal symptom status PRIOR to transport. Transfer/

discharge papers and patient charts are to be placed into a plastic bag during transport to

another unit/ department/OT / facility.

Patients who are MRO screened on admission or transfer are managed under Standard

Precautions unless they have a current iPM MRO alert.

Staff who are caring for MRO or C. difficile patients must not care for non-MRO

immunosuppressed patients at the same time.

For the transport of MRO patients within the facility the transporting person must wear apron

and gloves before direct contact with the patient. Change apron and gloves once outside the

room before moving off.

For an orderly having contact with the bed during transport, gloves alone are suitable.

All equipment used in transport must be cleaned & disinfected before reuse.

B2. Requirements relevant to IPS staff An “Alert” system for MRO and C. difficile patients is implemented and maintained by the

Infection Prevention Service LHD-wide.

At sites where cohorting has to occur, the antibiograms of the MRO isolates must be examined

for similarity. If different by 2 or more antibiotic class results, then assume that they are

different strains and do NOT cohort together. Consult with Medical microbiologist if necessary.



Manage MRO carriers in residential aged care, mental health inpatient or rehabilitation

settings, custodial institutions under Standard Precautions provided the patients do NOT have

any of these risk factors for transmission:

patients who are incapable of maintaining their own personal hygiene. patients with a discharging wound(s) that cannot be adequately covered patients with diarrhoea (within the previous 48 hrs) or faecal incontinence patients with enterostomies (VRE only) patient with coincident respiratory infection (MRSA only) catheterised or incontinent patients with MRO colonisation of the urinary tract

In non-acute care settings, MRO patients without any risk factors for transmission may

participate in group activities as required. Hand hygiene with alcohol based hand rub prior to

group activities or upon leaving their room location is recommended for all residents/patients

whether they are known to have MRO colonisation or not. All equipment cleaned and

disinfected after use.

MRSA-colonised patients with risk factors for transmission (above) can be considered for MRSA

load reduction or decolonisation procedures (Section F2).

C. Antimicrobial stewardship (AMS)

Overview AMS is a key preventative control for MROs and C. difficile. Refer to the HNELHD Antimicrobial Stewardship Web resource.

All Acute Networks sites submit antimicrobial utilisation surveillance data to the National Antibiotic

Utilisation Program. Reports are reviewed by the Area Antimicrobial Working party which reports

to the Area Quality Use of Medicines Committee.

District Immunology and Infectious Diseases Stream have adopted quarterly antimicrobial usage of

third and fourth generation cephalosporins and quinolones at all facilities as key performance

indicators.

Pathology North (HAPS) Medical microbiologists conduct passive surveillance for MROs (production

of cumulative antibiograms), detection of MRO clusters.

http://intranet.hne.health.nsw.gov.au/hne_infection_prevention__and__control/immunology_and_infectious_diseases_stream/antimicrobial_stewardship

http://intranet.hne.health.nsw.gov.au/hne_infection_prevention__and__control/immunology_and_infectious_diseases_stream/antimicrobial_stewardship



D. Environmental cleaning and disinfection

Overview HNELHD must comply with NSW Environmental policy and procedures in order to prevent the healthcare environment being a significant reservoir and risk for transmission of MROs or C. difficile. HNELHD staff must ensure that reusable medical items are cleaned and disinfected prior to patient use.

D1. Requirements relevant to HNELHD staff

Health Service Managers, Engineering and NUMs must take prompt corrective action arising

out of audits as required by the policy and subject this to review by the relevant IPC

Committee

Within HNELHD there are no additional cleaning requirements if MRO patient is within the

environment for less than four (4) hours, normal cleaning, of all surfaces touched by the patient

or healthcare worker must be cleaned and disinfected and spot cleaning for blood and body

substances. If greater than this time, cleaning and disinfection by an approved method and

curtain (including silver lined) change is required.

Equipment cleaning and disinfection

Adhere to the Cleaning and Disinfection of Non-critical Reusable Medical Items PCP.

Where possible, dedicated equipment is required for each patient managed under contact

precautions. Dedicated equipment will include: tourniquet, stethoscope, sphygmomanometer,

oximeter machine, temperature probe, surgical tape, wheelchair, shower chair, lifting sling,

slide sheet and commode if used.

Healthcare worker must NOT routinely use personal equipment (e.g. stethoscope) to

examine patients held under contact precautions. Mobile telephones and similar and pagers

must NOT be used in contact precaution rooms. If personal equipment is used, it MUST be

cleaned/disinfected upon leaving with large alcohol wipes. Medical charts are NOT to be

taken in to the room.

Equipment designated reusable and required for use on other patients must be cleaned and

disinfected upon leaving the room. Non-reusable equipment and stocks of unused disposable

items should be discarded upon patient discharge.

Outpatient clinics, anaesthetic bays or other high patient throughput areas, must keep

equipment, stock, medications and linen located in immediate patient environment to a

minimum.

Alcohol disinfectant wipes are recommended for disinfection of specialised medical equipment

– e.g. X-ray, ECG machines that are taken into rooms where patients are managed under

contact precautions.

The Nurse Unit Manager is responsible for ensuring daily reduction of clutter in the shared

clerical areas to enable cleaning once per shift. Cleaning must include computer keyboards,

electrical cords, computer mice and computer boxes/screen surrounds and telephones (large

alcohol wipes used) and bench tops. NB.

o Remind staff and patients to keep MRO rooms free from clutter ensuring optimal

daily cleaning.

o Do not use alcohol wipes on computer screens.

http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0005/118643/PD2012_061_PCP_1_Cleaning_of_non-critical_reusable_medical_equipment.pdf



D2. Requirements relevant to IPS staff IPS staff or other designated staff conduct MRO room separation environmental audits as per

IPS annual audit calendars to meet compliance with NSW Policy Directive 2007/84.

IPS and Nursing Managers work with HealthShare (old HSS) to conduct the environmental

audits of priority one areas (very high risk and high risk locations).

D3. Requirements of HealthShare Cleaning services will be maintained to the standards required for conformance with the NSW

Infection Control Policy and/or NSW Health Cleaning Service Standards, Guidelines and Policy

for NSW Health Facilities and other such standards which may apply from time to time together

with the agreed level of aesthetic presentation of the Hospitals as agreed between the hospital

and the Provider.

Within HNELHD there are no additional cleaning requirements if MRO patient is within the

environment for less than four (4) hours unless ICP/designate requests a clean and disinfection

clean due to circumstances. Normal cleaning of surfaces touched by patients and staff apply.If

greater than this time, cleaning and disinfection of the environment and equipment is

undertaken with an approved standard operating procedure which will include curtain

(including silver lined) changes.

The LHD via the Service Catalogue requires HealthShare to comply with this PCP, namely:

Where possible, involve IPS and Nursing Managers with HealthShare environmental audits of

priority one areas (very high and high risk locations)

Report environmental audit results to each local IPC Committee in a timely manner to ensure

reports are included in the agenda.

HealthShare, Engineering and NUMs to take prompt corrective action arising out of audits as

required by the policy and subject this to review at the IPC Committee

Provide adequate staffing and service levels as defined in the service catalogue

Provide adequate training for cleaning and audit staff. Provide additional training for cleaning

and disinfection of isolation rooms in the very high risk areas e.g. ICU, Renal Units & EDs



E. Surveillance and screening for MROs and C. difficile

Overview Targeted screening on a situational and risk basis is used to detect colonisation and infection with these organisms. Certain preoperative patients undergo MRSA screening and staphylococcal load reduction prior to surgery. MRSA positive healthcare staff require management that includes MRSA decolonisation.

E1. Requirements relevant to HNELHD staff

Adhere to these HNELHD admission screening requirements :

HNELHD Admission MRO screening requirements (MRSA, VRE, CRE, MRAB,

ESBL) Pathology test request: ‘MRO screen’ Specimens required: nose + throat + perianal or rectal swab

+/- wounds, chronic ulcers, PEG site, IDC or SPC urine

Criteria – any one of:

Any chronic (> 1 month) open wound

Presence of a percutaneous gastrostomy

Patient transfer from facility outside of HNELHD or Private hospital

Patient transfer from international facility

Admitted overnight in overseas hospital or residential care facility in previous 12 months



Sample collection procedure – brief requirements

Use bacterial NOT viral transport swab.

Ensure correct test request is made (see above and Appendix 2).

For Intensive Care Units, ensure that admission or discharge screen is indicated on the request form notes.

See HNELHD MRO sample collection fact sheet for graphical depiction of nose, throat and perianal sample collection.

Nose

Sample both nostrils with swab pre-moistened with transport medium, then place in transport medium

Throat

Sample pharyngeal wall and tonsillar fossae with dry swab, then place in transport medium

Perianal Wounds

Part buttock and sample across the intergluteal cleft ensuring contact with the anal margins by parting the buttocks with the other hand with swab pre-moistened with transport medium, then place in the transport medium Sample wound base with swab pre-moistened with transport medium, then place in transport medium

E2. Requirements relevant to IPS staff and special units

E2.1 IPS staff

IPS staff will attend newly identified MRO patients as soon as practicable to ensure that proper patient placement and precautions are in place.

Patients with an existing iPM MRO alert will be evaluated to determine if they warrant repeat screening for clearance (section F3) and ensuring correct patient placement and contact precautions are instigated.

E2.2 Microbiology laboratories Microbiology laboratories store all new blood isolates and MRSA, VRE, C. difficile or meropenem-

resistant Gram negative isolates for later typing if required. Blood isolates are stored regardless of their susceptibility or deemed significance.

All laboratories must notify the facilities’ Infection Prevention Service staff when they detect an MRO isolate or C. difficile case. Specific review lists for IPS staff on ICNET facilitate this communication process.

E2.3 Preoperative screening for methicillin-resistant Staphylococcus aureus and load reduction

procedure

Screening is required for prosthetic total joint (all HNELHD units) and infrarenal vascular, oesophagectomy and hepatectomy, (John Hunter Hospital). Patients who will require post-operative intensive care are also screened, whatever type of operation.

Screening specimen site required- nose swab only – request ‘Preoperative MRSA screening’.

Patients who are shown to be MRSA colonised: o Review laboratory results to identify whether the isolate is mupirocin resistant. If

resistant discuss with medical microbiologist




o Commence preoperative staphylococcal load reduction procedure (previously termed ‘decolonisation’) up to 5 days before surgery and continue after surgery, if required, to complete 5 full days treatment (ie, the 5 days can include preoperative and postoperative periods of treatment).

Preoperative MRSA load reduction procedure

Change bed linen daily (at home or in hospital) and clean bed rails and bedside equipment / furnishings

Apply antimicrobial body wash (triclosan or chlorhexidine as directed) during shower (including hair). See information sheet for this procedure on the MRO Intranet site1.

o leave body wash in place for at least for 3 minutes before rinsing well. o After shower, dry with fresh clean towel and put on clean clothes and wear a pair of clean

slippers.

Apply nasal 2% mupirocin three times daily:

o Disinfect hands with alcohol hand rub and allow to dry, or wash hands covering all surfaces and dry.

o Open the mupirocin 2% (Bactroban) nasal ointment. Place small amount (size of match head) of ointment onto a clean cotton bud and massage gently around the inside of the nostril on one side, making sure not to insert it too deeply (no more than 2cm inside). Use a new cotton bud for the other nostril so that you do not contaminate the mupirocin tube with staph.

o After applying the ointment, press a finger against the nose next to the nostril opening and use a circular motion to spread the ointment within the nose.

o Disinfect hands with alcohol hand rub or wash hands and dry with a clean towel after applying the ointment.

The iPM MRSA alert remains active (i.e. isolated under Contact Precautions) during the surgical admission even if the patient has undergone load reduction procedure.

MRSA colonised patients require a glycopeptide antibiotic (usually teicoplanin) for preoperative surgical prophylaxis even if they have undergone load reduction procedure. Refer to HNELHD Surgical Prophylaxis Clinical Practice Guideline on the HNELHD PPG.

Discuss patients with mupirocin-resistant MRSA isolate with the Medical Microbiologist about an alternative regimen2.

E2.4 Intensive Care and Armidale HDU MRO screening

John Hunter and Calvary Mater Intensive care units screen admissions and discharges for MRSA, VRE and MRGN (ESBL, CRE and related MRGN) (specimen sites - nose, throat, perianal swabs)

Tamworth, Manning ICU/HDU and Armidale HDU screen admissions and discharges for MRSA carriage (specimen sites - nose, throat, and perianal swabs).

Short procedure-type admissions < 4 hours are not screened. Open wounds (discharging or dehisced wound, chronic skin ulcer) are swabbed as part of

the same screening set.

1 http://intranet.hne.health.nsw.gov.au/hne_infection_prevention__and__control/multi-

resistant_organism_control 2 Alternative nasal ointment is required - options include tea tree or chlorhexidine-based nasal ointment. In view of lower likelihood of success, consider also use of systemic treatment with a rifampicin-based combination.

http://ppg.hne.health.nsw.gov.au/





Perform discharge screens for MRO or MRSA (specimen sites - nose, throat, perianal), only if admission to ICU / HDU exceeds 48 hours.

E2.5 Antenatal clinics (across HNELHD)

Routinely question pregnant women about recent (past 12 months) history of skin/soft tissue infection /or family members with a history of boils or other skin infection and/or MRSA culture positive results.

Re-screening of patients for MRSA and/or MRSA decolonisation (eradication) can be discussed with the on-call Infectious Diseases Physician or Medical microbiologist preferably during antenatal care. It is usually indicted to decolonise the entire household at the same time. For guidance see this reference (available on intranet)3

Antenatal mothers who have previously been alerted as MRSA positive on iPM or who have undergone MRSA decolonisation should have two sets of MRSA clearance screens (specimen site - nose, throat and perianal swabs) attended prior to delivery (see MRO Clearance section F).

E2.6 Neonatal Intensive Care Unit (John Hunter Hospital)

Screen all neonates transferred from another neonatal ICU (nose and/or throat, rectal/perianal) for MRSA and VRE.

Manage all MRO alerted neonates under Contact Precautions in designated area.

If an MRSA - alerted asymptomatic mother, more than 6 months since last positive culture who

has not been screened prior to delivery:

Screen mother after delivery with 2 clearance swab sets (specimen site - nose, throat, perianal swabs)

Maintain neonate and mother under Contact Precautions including having an alert until the results of the screens are available and are negative

Clearance swabs for the mother can be performed even if she has received prophylactic antibiotics (e.g. cephazolin or ampicillin etc.) during delivery that are not active against her MRSA strain or has an intravascular cannula in situ – mother and neonate.

If mother has symptomatic disease due to MRSA or is diagnosed as colonised prior to delivery, then her neonate is assumed to be colonised with MRSA (no screening indicated) and both mother and neonate are MRSA alerted. They both are managed under Contact Precautions and the neonate should not be restricted from access to his/her mother. The family should be offered advice on management of recurrent MRSA infection- refer to Infectious Diseases service or Medical Microbiologist. Note: breast feeding should not be affected by the MRSA status of either mother or baby. The mother should be designated an area for expressing breast milk and given instruction for the management of the expressed milk that will be placed in a designated fridge and the management of the equipment and hand hygiene.

3 Management of recurrent staphylococcal infection. Ferguson-J, Medicine Today 2012. Available on MRO intranet resource page.





If an MRSA -alerted neonate requires prolonged NICU stay (> 4 weeks) then rescreen the neonate (throat, axilla, perianal, +/- nose) and discuss possible load reduction procedure with the Medical microbiologist on a case by case basis. VRE colonised neonates are not rendered inactive status unless > 6 months from last positive culture and are documented to have negative clearance swabs at that time – see Section F. CRE colonised neonates are not generally rendered as ‘inactive’ carriers. Clinical follow-up of MRO- colonised neonates Neonates/mothers who are still MRO positive or have an MRO Alert at discharge should be provided with a Neonatal MRO information sheet. This information sheet recommends follow-up MRO surveillance of the neonate and referral to Infectious Diseases outpatients (Drs Ferguson, Pickles or Lai) if infections due to MROs are detected. At follow-up by neonatal service, provided that no MRO infections have occurred in neonate or their family, then do not proceed to MRSA decolonisation. Monitor carriage of the MRO and document clearance > 6 months after the last positive culture (GP can be used to attend clearance swabs); see Section F.

E2.8 Oncology / Haematology patient screening (all HNELHD units)

Perform full MRO screening swab set (specimen sites - nose, throat, perianal; MRSA, VRE, CRE) for inpatients or outpatients who are to have care transferred to external units (e.g. for Bone marrow transplant in Sydney) PRIOR to transfer.

Clinical Unit must make necessary arrangements to ensure that results are provided to the facility where the patient is to undergo treatment.

E2.9 Organ donors (HNELHD)4

Patients who are to donate organs require full MRO screening swab set (MRSA, VRE, CRE) PRIOR to transfer/death (specimen site - collect nose, throat and perianal swabs (use single head swabs).

Blood cultures should also be collected if the patient is febrile

Organ donation coordinator must ensure that results are provided to the facilities where organs are sent for transplantation. If outstanding microbiology results at the time of organ retrieval are passed onto the NSW Organ and Tissue donation service, for dissemination to transplanting hospitals.

E2.10 Screening of healthcare workers for MROs

No routine screening for Multi-Resistant Organisms (MROs) in healthcare workers currently takes place in HNELHD.

Clinical Units that are shown to have clonal spread of an MRSA strain may be subject to confidential HCW screening and decolonisation as part of outbreak control efforts via the Staff Health service (see Section F).

4 NSW Multi-resistant Organism Policy 2007/84.





Healthcare workers who are identified with colonisation / infection due to an MRO (e.g. MRSA) following screening or as an incidental finding are to self-refer or be referred by their line manager to the person with Staff Health responsibilities (staff health nurses / delegate) who will manage and discuss each case with an Infectious Diseases consultant Staff health / delegates are required to inform the ICP regarding the HCW MRO positive status to enable MRO management of the case e.g.an iPM alert activated.

MRSA positive healthcare workers

Staff Health / delegate discuss each case with the Director of IPS.

Healthcare workers infected or colonised with MRSA who provide direct clinical care should not provide clinical care prior to commencing decolonisation.

Wounds should be covered with a waterproof occlusive dressing(s). In cases where wounds cannot be effectively covered or exudate cannot be contained, exclude from the clinical environment until containment is achieved

HCWs with active exfoliative conditions (e.g. eczema, psoriasis) will require consultation with an Infectious Diseases Physician or Dermatologist. Where the HCW is working in a clinical environment the unit manager / Staff Health / delegate will need to arrange an individual risk assessment with facility ICP to determine safe work practices to be applied to prevent transmission of infection. Healthcare workers should attend a consultation with an Infectious Diseases Consultant for management as appropriate:

o Infectious Diseases Outpatients Clinics JHH or Taree sites only) (Drs Ferguson, Lai or Pickles. NB. Staff Health / delegate can write the referral which should specify ‘MRSA colonised HCW- Ferguson, Lai or Pickles’).

o Upper Hunter Valley, New England or LMNC: - staff health or delegate should discuss the case management by telephone with the IPS Director. It may be practical to commence decolonisation prior to ID review. The staff MRSA information sheet should be provided.

If not already completed within the previous 12 months, the HCW should complete the MYLINK hand hygiene training and send evidence of completion to Staff Health / delegate by email or post.

Necessary medical certification (workers compensation or sick leave) by ID consultant or GP will be provided to cover the pre-decolonisation period and may need to be managed in consultation with the Nurse Manager/ Health service manager.

HCW MRSA decolonisation and clearance (Infectious Diseases and IPS)

Decolonisation proceeds once infections have been adequately treated – see Section F, usually 5 day protocol with the addition of systemic antibiotics (oral rifampicin and fusidate) after recovery from active MRSA infection if present.

Treat all members of the HCW’s household topically as well. Topical agent supplies can be scripted by the ID consultant or GP on the same script as that for the HCW. Supply one mupirocin 2% nasal ointment tube per person. HCW’s cost centre should be specified on the script.

Arrange self-collected follow-up swabs at 1 month (nasal/throat/perianal) and 3 months. Arrange re-attendance at 6 months for 2 sets of clearance swabs– see Section F or arrange for GP to conduct these.

If any swabs are positive, then more prolonged, repeat systemic and topical decolonisation of 7-10 days needs to be arranged by discussion with an ID consultant.

MRSA -colonised HCW are not excluded from work during decolonisation unless they have an active exfoliative skin condition requiring dermatological treatment, wounds not able to be covered or wound exudate not able to be contained, hand skin lesions or an upper respiratory tract infection. Provided these conditions are not present, they are permitted to return to work immediately after commencing topical treatment.



Documentation of process, followup swab results and clearance is performed on ICNET by IPS staff in consultation with Staff Health/delegate.

HCW colonised with VRE or CRE

Staff Health / delegate / IPS discuss each case with the on-call Infectious Diseases Consultant or the Director of IPS.

In general, such HCW should not be working in a high risk clinical setting – eg. ICUs, Oncology, Dialysis or Transplant units

Clearance swabs for VRE can be collected when more than 6 months from the last positive VRE culture and more than 2 weeks since VRE antibiotic therapy or antiseptic body wash treatment.

(See section F) CRE cannot be rendered inactive

No decolonisation procedures are worthwhile. Lactobacillus rhamnosus GG-containing yogurt is an option for VRE colonised HCW – (100g/day for 4 weeks5)

Documentation of process and clearance is performed on ICNET by IPS staff in consultation with Staff Health/delegate.

5 Med J Aust. 2007 May 7;186(9):454-7. Probiotic treatment of vancomycin-resistant enterococci: a randomised controlled trial. Manley KJ, Fraenkel MB, Mayall BC, Power DA.

http://www.ncbi.nlm.nih.gov/pubmed/17484706

http://www.ncbi.nlm.nih.gov/pubmed?term=Manley%20KJ%5BAuthor%5D&cauthor=true&cauthor_uid=17484706

http://www.ncbi.nlm.nih.gov/pubmed?term=Fraenkel%20MB%5BAuthor%5D&cauthor=true&cauthor_uid=17484706

http://www.ncbi.nlm.nih.gov/pubmed?term=Mayall%20BC%5BAuthor%5D&cauthor=true&cauthor_uid=17484706

http://www.ncbi.nlm.nih.gov/pubmed?term=Power%20DA%5BAuthor%5D&cauthor=true&cauthor_uid=17484706



F. MRSA decolonisation, MRO load reduction and MRO clearance procedures

Overview Targeted decolonisation is used for some patients or HCW colonised with MRSA to reduce the incidence of infection recurrence and to reduce capacity for patient or HCW to patient transmission of MRSA. Other MRO load reduction strategies are also available for targeted use. Most MRSA patients eventually clear carriage by 6 months – ie. MRSA can no longer be demonstrated at any body site. A majority of patients with VRE and CRE also clear within a similar timeframe. Late relapse of carriage may occur.

F1 MRSA decolonisation procedures

F1.1 Requirements relevant to HNELHD HCWs To note the options available for MRSA decolonisation. See HNELHD MRSA staff information sheet.

F1.2 Requirements relevant to IPS and Staff Health Regimes in use in HNELHD are specified on the Healthcare Infection Control Special Interest Group (HICSIG)

website, specifically:

Outpatient approach (including MRSA colonised HCW):

http://hicsigwiki.asid.net.au/index.php?title=Patient_MRSA_decolonisation_instructions

Inpatient approach:

http://hicsigwiki.asid.net.au/index.php?title=Inpatient_MRSA_decolonisation_instructions

Tailoring of the approach required for specific patients with open wounds or indwelling transcutaneous or

mucosal devices- discuss with Medical microbiologist as required6.

Patients/HCW who may be subjected to MRSA decolonisation include:

Selected inpatients after discussion with Medical Microbiologist: especially consider patients under current treatment for MRSA treatment, patients who are expected to require prolonged admission.

HCW colonised or infected with MRSA (managed via Staff Health and Infectious Diseases clinic)

F2 MRO load reduction procedures

F2.1 Requirements relevant to IPS staff MRO patients with risk factors for MRO transmission7 are recommended to shower daily with

triclosan body wash to reduce skin bacterial load. No other soap should be used. Discontinue this treatment if excessive skin drying occurs.

6 Either systemic rifampicin-containing combination regimen required and/or topical antimicrobial / chlorhexidine / silver dressing required for open wounds/ulcers/device exit site. 7 Risk factors for MRO transmission include:

patients who are incapable of maintaining their own personal hygiene.

patients with a discharging wound(s) that cannot be adequately covered

patients with diarrhoea (within the previous 48 hrs) or faecal incontinence

patients with enterostomies (VRE only)

patient with coincident respiratory infection (MRSA only)


http://hicsigwiki.asid.net.au/index.php?title=Patient_MRSA_decolonisation_instructions

http://hicsigwiki.asid.net.au/index.php?title=Inpatient_MRSA_decolonisation_instructions



MRO Clearance Procedure (MRSA, VRE only)

In general, MRO clearance screening may only be performed more than 6 months after the last positive MRO culture. Presence of an indwelling devices or non-intact skin are no longer contraindications for clearance screening (however such devices or skin require culture- see below)

Clearance screening may be performed after re-admission or as an outpatient provided that the patient in the preceding 2 weeks has NOT been using either antiseptic body wash or antibiotics1 that are active against the MRO concerned.

Clearance screening requires two separately collected swab sets (can be on same or different days) that sample a range of body sites, dependent upon what sort of MRO (MRSA or VRE) is to be sought (see Appendix 2).

Pathology request form (appendix 2 for wording) should be used with a separate form for each clearance set.

If clearance screening is arranged by a secondary service – e.g. Perioperative service or General Practice, then copies of the results to the relevant Infection Control Professional should be specified on the request form.

IPS staff document clearance process on ICNET and amend iPM alert status as required.

VRE colonised patients can be considered for prescription of daily Lactobacillus rhamnosus GG-containing yogurt (100g/day for 4 weeks8) to reduce gut carriage. Arrange via Dietician.

F3 MRO Clearance Procedures for known MRO-colonised patients or HCW

F3.1 Requirements relevant to IPS staff

catheterised or incontinent patients with MRO colonisation of the urinary tract 8 Med J Aust. 2007 May 7;186(9):454-7. Probiotic treatment of vancomycin-resistant enterococci: a randomised controlled trial. Manley KJ, Fraenkel MB, Mayall BC, Power DA.

http://www.ncbi.nlm.nih.gov/pubmed/17484706

http://www.ncbi.nlm.nih.gov/pubmed?term=Manley%20KJ%5BAuthor%5D&cauthor=true&cauthor_uid=17484706

http://www.ncbi.nlm.nih.gov/pubmed?term=Fraenkel%20MB%5BAuthor%5D&cauthor=true&cauthor_uid=17484706

http://www.ncbi.nlm.nih.gov/pubmed?term=Mayall%20BC%5BAuthor%5D&cauthor=true&cauthor_uid=17484706

http://www.ncbi.nlm.nih.gov/pubmed?term=Power%20DA%5BAuthor%5D&cauthor=true&cauthor_uid=17484706



Note : Patients colonised or infected with MRGN (CRE, ESBL, MRAB, Burkholderia cepacia in association with Cystic Fibrosis) are never ‘cleared’- the patient remains alerted for life. 1 MRSA-active antibiotics include vancomycin, teicoplanin, ceftaroline, daptomycin, rifampicin, fusidic acid, linezolid, pristinamycin and dependent on susceptibility of the particular MRSA strain, clindamycin, cotrimoxazole and doxycycline. VRE-active antibiotics include teicoplanin, linezolid and daptomycin.



F4 MRO screening for patient MRO cohorts

F4.1 Requirements relevant to IPS staff

An inpatient cohorted with an MRO-alerted patient for more than 48 hrs is to be flagged on ICNET and will require screening for the relevant organism to detect MRO transmission (see Appendix 2)

If swabs cannot be collected, then that patient should be screened upon subsequent readmission – ICNET alert will facilitate this.

Contact screening swabs may be collected whilst a patient is on antibiotics.

The sensitivity of detection is poor when cohort screening is performed soon after exposure. In some circumstances (e.g. outbreaks), IPS may direct for a second sample to be collected at a later time point to provide better assurance of control.

Note

C. difficile cohorts are tagged on ICNET and not screened unless they develop diarrhoea.

Non-cystic fibrosis patient cohorts of B. cepacia do not require screening.



Appendix 1: iPM Alerts and ICNET MRO tagging

Relevant to IPS staff and Bed managers For prioritisation of single room resources, consult the HNELHD PCP: Allocation of isolation rooms and use of patient cohorting for designated infectious diseases. Organism iPM alert Acronyms ICNET Tags Definition & Management

Methicillin resistant Staphylococcus aureus Cohort

MRSA/Hospital of acquisition/ICP initials

MRSA-Alert Subtype tracked as organism XP

Requires single room with ensuite or for facilities without single rooms designated area or cohorted after discussion with ICP and contact transmission-based precautions

No entry on iPM Contact-MRSA Contact of an active MRSA patient; tag cleared once the patient has had clearance screen

Meropenem resistant Gram negative bacillus (eg. CRE, MRAB) Cohort

CRE / Hospital of acquisition/ICP initials MRAB/Hospital of acquisition/ICP initials

CRE –Alert Subtype tracked as organism XP

Requires single room with ensuite or for facilities without single rooms designated area or cohorted after discussion with ICP and contact transmission-based precautions

No entry on iPM Contact-CRE / MRGN Contact of an CRE/MRAB patient; tag cleared once the patient has had clearance screen

Vancomycin-resistant enterococcus Cohort

VRE /Hospital of acquisition/ICP initials

VRE – Alert Requires single room with ensuite or for facilities without single rooms designated area or cohorted after discussion with ICP and contact transmission-based precautions

No entry on iPM Contact-VRE Contact of an active VRE patient; tag cleared once the patient has had clearance screen

Clostridium difficile

C. difficile/Temp alert /Hospital of acquisition/ICP initials

C. difficile – Alert C. difficile patient with diarrhoea requires single room with ensuite and contact transmission-based precautions until 48 hrs. after first normal formed stool following recovery

Alert ended at patient discharge

Close Case at discharge

B cepacia Cepacia-CF/Hospital of acquisition/ICP initials Cepacia –Non CF/Hospital of acquisition/ICP initials

Cepacia-CF-Active Cepacia-Non CF also tagged

CF patients with cepacia remain with an active alert forever



Organism iPM alert Acronyms ICNET Tags Definition & Management

ESBLs Not tagged on iPM generally unless clonal outbreak identified or with patients managed at the Calvary Mater Hospital- see their protocol fact sheet. ESBL/Mater only/Hospital of acquisition/ICP initials

ESBL-Alert Subtype tracked as organism XP (ICNET will open new case for readmitted ESBL-alerted patients at CMH)

Genotype proven ESBL Used for epidemiological tracking in ICNET



Appendix 2: MRO pathology requests and specimens (all HNELHD Labs) Appendix 2.1 Admission MRO screening request

Reason for multi-resistant organism screen

Request form test request

Specimens Required

HNELHD admission screen additional criteria:

Any chronic (> 1 month) open wound

Presence of a percutaneous gastrostomy

Patient transfer from facility outside of HNELHD or Private hospital

Patient transfer from international facility

Admitted overnight in overseas hospital or residential care facility in previous 12 months

MRO screen Nose, throat, perianal, +/-wound(s), ulcer(s), PEG site, IDC or SPC urine

MRSA methicillin-resistant Staphylococcus aureus CRE meropenem-resistant Gram negative bacillus VRE MRGN MRAB

vancomycin-resistant Enterococcus multi-resistant Gram negative bacillus meropenem-resistant Acinetobacter baumannii

ESBL Extended-spectrum betalactamase producing Enterobacteriaceae

Appendix 2.2 MRO cohort and clearance screening request Reason for multi-resistant organism screen

Request form test request

Specimens Required

MRSA clearance or cohort screen

MRSA screen

Nose, throat, perianal +/- wound(s), ulcer(s), IDC or SPC urine, PEG site

VRE clearance or cohort screen

VRE screen

perianal +/- IDC or SPC urine

MRGN cohort screen (CRE, MRAB, other) (no clearance documentation possible)

MRGN screen Throat, perianal +/- wound(s), ulcer(s), IDC or SPC urine, PEG site

Preoperative MRSA screen

MRSA screen

Nose only

Definition of significant cohort exposure is residence > 48 hours in same shared area with index case. Cohort screens are performed once only unless otherwise directed. For clearance screens, collect 2 sets same or different days and submit each set with a separate request forms in a separate specimen bag.