Prevention Strategies

For this guidance, the term ‘healthcare facility’ refers to all acute care hospitals and post-acute care facilities that care for patients or residents who remain overnight and require medical care, skilled nursing care, or rehabilitation services.

These facilities have staff that provide non-skilled personal care (i.e., assistance with activities of daily living like bathing, dressing, and cooking) to people with disabilities or older adults, similar to that provided by family members in the home. This includes settings like group homes, assisted living, and personal care homes. On-site healthcare services at high-risk congregate care sites are often provided by visiting or shared healthcare personnel (e.g., physical therapy, wound care, intravenous injections, or catheter care provided by home health agency nurses).

An organism with a resistance phenotype (i.e., pattern of resistance to different antimicrobial agents) or a resistance mechanism that has never or very rarely been identified in the United States. Often, experience with these organisms is limited and a more extensive evaluation is needed to define the risk for transmission. In the Interim Guidance for a Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs), these are classified as Tier 1 organisms and mechanisms. Tier 1 organisms and mechanisms are uniform across the U.S.

Although most prevention strategies are anticipated to reduce spread of all MDROs, health departments should select focus MDROs to inform selection of MDRO Prevention Plan activities, and process and outcome measures. Health departments should include multiple focus MDROs, aiming to include as many targeted MDROs as their resources allow. If resources initially allow for only one focus MDRO, jurisdictions should consider phased inclusion of additional focus MDROs in subsequent years. Health departments may wish to evaluate, on a yearly basis, whether additional focus MDROs should be added, based on the epidemiology or MDROs within their region and in surrounding regions. Focus MDROs may differ across areas in a single public health jurisdiction to reflect differences in local epidemiology.

Health departments should begin selection of focus MDROs by using available data to determine the epidemiologic stage(s) of targeted MDROs across their jurisdiction. Prevention strategies are most effective at slowing spread when started in early epidemiologic stages, including prior to an MDRO’s introduction to the region.¹ Therefore if there are targeted MDROs in early epidemic stages (i.e., no cases identified or limited spread) in the jurisdiction, these should be included in the jurisdiction’s focus MDROs, especially if they are at later epidemiologic stages in a neighboring jurisdiction. Additional considerations for choosing focus MDROs include leveraging preexisting prevention efforts, healthcare facility interest, and the ability to monitor impacts of the MDRO Prevention Plan on incidence or prevalence in the jurisdiction.

Certain healthcare facility characteristics (e.g., length of patient stay, acuity of care provided, admission and discharge patterns, and IPC program and practices) predict a healthcare facility’s likely role in regional MDRO spread. Targeting prevention activities (described in Section II) to facilities based on their predicted role enables health departments to tailor interventions for greatest impact and efficiency. Therefore, one preparatory step, prior to making a prevention plan, is to risk stratify facilities based on their characteristics. Facilities may change categories as the local epidemiology changes or as more information about the local epidemiology becomes available.

Suggested Approach for Facility Risk Stratification (see Table 1)

1. Inventory: Create an inventory of healthcare facilities in the jurisdiction, labeled by facility type (i.e., long-term acute care hospitals [LTACHs], ventilator-capable skilled nursing facilities [vSNFs], skilled nursing facilities that do not care for ventilated residents [SNFs], inpatient rehabilitation facilities [IRF], acute care hospitals [ACHs]). Use the inventory for subsequent risk stratification steps.
2. Identify influential facilities: These are the facilities at highest risk of MDRO importation and transmission, usually due to their care of high-acuity patients/residents with long lengths of stay. Categorize these as “influential” facilities. These facilities have a large overall influence on regional MDRO prevalence, which can be positive or negative based on their efforts to prevent and respond to MDRO threats.^1,5,6
   • At minimum, influential facilities include all LTACHs and vSNFs, which are at higher risk of importation and sustained transmission because they provide care to high-acuity patients/residents and have long average lengths of stay.
   • Facilities that are not vSNFs or LTACHs may also be influential; these are facilities that generally have had substantial transmission of a focus MDRO and are believed to impact regional prevalence. Because these do not have all the characteristics (i.e., long average length of stay and high-acuity population) of typical influential facilities, they are most frequently identified through response to novel and targeted MDROs, investigation of epidemiologically linked cases, and/or ad hoc point prevalence surveys (PPS).
3. Identify facilities that are highly connected to influential facilities through patient sharing: These facilities are the acute care hospitals and skilled nursing facilities that most frequently receive patients from influential facilities and are therefore likely to admit patients/residents with MDROs. Categorize these facilities as “highly connected.

Among highly connected facilities, additional characteristics can further predict their potential role in MDRO spread:

• • Dispersal: Healthcare facilities with shorter lengths of stay, like ACH, can play a substantial role in MDRO dispersal–the spread of MDROs among facilities in a region–because relative to other facility types, they discharge patients at a higher rate and to many different facilities, including influential facilities.
  • Collection: Healthcare facilities with longer lengths of stay, such as skilled nursing facilities, are at risk of sustained MDRO transmission due to a higher risk of admitting MDRO colonized patients/residents, long average lengths of stay, and generally less resourced infection control programs compared to higher acuity settings. Compared to influential facilities, the transmission rates are typically lower due to the lower acuity of care provided; therefore, the overall influence on regional prevalence is less.

When selecting prevention activities for facilities that have characteristics of both influential and highly connected facilities, such as vSNFs, follow recommendations for influential facilities.

To identify highly connected facilities, informal methods (e.g., asking influential facilities about their transfer patterns) are likely sufficient, although formal network analysis based on patient sharing data could also be used. Additionally, examining transfer patterns across jurisdictional boundaries can help identify facilities that frequently receive patients/residents from influential facilities in other public health jurisdictions.

4. Categorize all remaining facilities as “other”: “Other” can include a variety of healthcare facility types. These facilities generally have less influence on regional MDRO prevalence and are therefore not the focus of the most resource-intensive prevention interventions (i.e., proactive infection prevention assessments and colonization screening). However, they can benefit from prevention interventions such as education and communication. Additionally, like facilities in influential or highly connected categories, when cases of novel and targeted MDROs are identified in “other” facilities, a public health investigation should be performed in accordance with the Interim Guidance for a Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs).

Prevention activities will be most impactful when they are implemented in all influential and highly connected facilities. Operationally, most health departments will implement prevention plans in phases, generally by piloting implementation in a subset of facilities and then expanding as experience and capacity grow. Selection of facilities for initial implementation should take into consideration local capacity, current epidemiology of focus MDROs, number and type of facilities in the jurisdiction, and health equity (i.e., ensuring the inclusion of facilities that serve populations experiencing health inequities or disparities in health outcomes in the jurisdiction’s MDRO prevention initiatives).

Example approaches for initial implementation of prevention activities include selection by:

• Geographic region: Begin implementation in facilities in a geographic region within a public health jurisdiction. Factors to consider when prioritizing regions for intervention include: the number of influential facilities, the local epidemiology of novel or targeted MDROs (e.g., prioritizing areas where the MDROs of interest are in early stages of emergence), and the presence of factors favorable to implementation (e.g., existing partnerships between facility and public health, ease of logistics).
• Patient/resident-sharing network: Begin implementation in a subset of facilities that frequently share patients/residents.
• Facility category: Begin implementation in influential facilities, then expand to highly connected facilities. This strategy can be applied for an entire jurisdiction, or in combination with the geographic or patient-sharing network strategies above.

Approaches that maximize participation of influential facilities in highly impactful prevention activities (e.g., colonization screening and initiatives to improve infection control) are predicted to have the greatest and most rapid impact in the region.¹

MDRO Prevention Plans should include at least one activity from each of the four strategies described in this section: conduct education, improve IPC practices, detect colonized individuals, and facilitate communication. Activities can be implemented using a phased approach. The following overarching principles¹ may inform selection and prioritization of different prevention activities:

• Starting MDRO prevention activities early is expected to avert the greatest number of transmissions relative to delayed intervention. However, even after endemicity is reached, prevention can still decrease transmission.

• The relative impact of different prevention activities varies by facility risk category and the epidemiologic stage of an MDRO. Jurisdictions should prioritize activities expected to have the biggest regional impact on MDRO transmission. This may require limiting some resource-intensive activities (e.g., public health supported colonization screening) to influential facilities rather than pursuing broader implementation.

• In non-endemic settings, MDRO prevalence is expected to continue to rise despite the use of prevention strategies, but at a slower rate compared to if these strategies are not implemented.

This section describes each prevention strategy and provides example prevention activities aligned with the strategy. The strength of the recommendations (Table 2) in this section are informed by the published literature, public health agency field experiences, and CDC mathematical modeling. A more detailed description of the CDC mathematical model inputs and results can be found in the FAQ.

Table 2. Activity recommendation levels

Highly recommended: Activities expected to have greatest relative impact in reducing MDRO prevalence. These should be the highest priority for implementation.

Well-directed education can increase healthcare personnel and facility administration engagement and adherence to recommended interventions. Heath departments should educate healthcare personnel about strategies to detect and prevent the spread of novel and targeted MDROs, MDRO transmission fundamentals, IPC principles, and the characteristics of novel or targeted MDROs in their jurisdiction.

Education can be conducted using different approaches (e.g., webinars, in-person workshops, onsite visits, email communication) and include both broad-based, general education efforts and more individualized efforts tailored to facility-specific needs. Educational subject matter and audience can also be tailored based on the characteristics of the focus organism; for example, a region focusing on carbapenem-resistant Acinetobacter baumannii or Candida auris, organisms for which the healthcare environment plays an important role in transmission, may choose to develop educational materials for environmental services workers. Whenever feasible, opportunities for active engagement (e.g., practicing learned skills followed by return demonstration of competency) should be incorporated into educational offerings.

Education should include expectations for facilities to promote staff education about MDROs and IPC.

Intensive, customized educational activities, such as onsite education, should be prioritized for influential facilities because of the potential for education to enhance the impact of other prevention interventions (i.e., colonization screening and infection control assessments) targeted to this facility type (Table 3).

Table 3. Recommended educational activities by facility category

Core IPC practices are designed to reduce pathogen transmission and infections among patients and residents at healthcare facilities across the continuum of care.⁷ Good adherence to these practices is predicted to limit transmission of novel and targeted MDROs overall, not just the focus MDROs.

Health departments can improve facility IPC through prevention-driven (i.e., conducted independently of identification of new targeted MDRO colonization or infection or infection control concerns) assessment of IPC practices, coupled with recommendations and coaching to mitigate identified gaps. Prevention-driven IPC activities are listed in Table 4 and complement response-driven infection control assessments described in the Interim Guidance for a Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs).

• In prevention-driven IPC assessments, practices should be assessed using a standardized tool that reviews facility policies and practices and includes direct observations of, at minimum, hand hygiene, personal protective equipment (PPE) use, environmental cleaning and disinfection practices, and measures to prevent transmission from sinks, drains, and plumbing. CDC infection control assessment and response (ICAR) tools are available for different healthcare settings and include these key areas for MDRO prevention-focused assessments.

After an initial assessment, follow-up with the facility’s leadership and infection control program is crucial to review progress towards implementing recommendations, provide additional implementation assistance, if needed, and identify additional educational opportunities. Instituting IPC improvements prior to MDRO introduction at healthcare facilities is anticipated to prevent transmission once introduction occurs.

• Prevention-driven IPC assessments can be performed on a recurring or ad hoc
  • Prioritize recurring IPC assessments for influential facilities, as IPC improvements in these facilities are expected to result in larger regional reductions in MDRO prevalence relative to these activities in highly connected and other facility types.
    • Perform recurring IPC assessments at least yearly, regardless of the presence or absence of targeted MDRO(s). This provides opportunity for ongoing conversation between the facility and health department to improve IPC practices and identify and address issues as they arise.
    • If there is also capacity for recurring assessments at highly connected facility types, select these facilities based on identified need or characteristics, such as prior MDRO outbreaks, prior IPC gaps, regulatory survey findings, health equity considerations, or ad hoc assessment results.
  • Ad hoc or as-needed IPC assessments are generally one-time IPC assessments that, for prevention, should be used to identify and correct infection control gaps in highly connected facilities that have not had a recent assessment or have a suspected high MDRO prevalence (as defined by the health department). Prioritize facilities with substantial IPC gaps identified on ad hoc IPC assessments for follow up and/or recurring visits, as determined by the local public health authority. 

To improve IPC practices in skilled nursing facilities, MDRO Prevention Plans should include implementation of Enhanced Barrier Precautions (EBP). As EBP requires gown and glove use for certain residents during specific high-contact resident care activities that have been found to increase risk for MDRO transmission, it is a key intervention to prevent transmission of MDROs in skilled nursing facilities.

Table 4. Recommended infection prevention and control (IPC) activities by facility category. The prevention-driven IPC activities listed in this table complement and do not replace response-driven infection control assessments described in the Interim Guidance for a Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs).

Individuals with clinical MDRO infections represent only a small fraction of total individuals with a targeted MDRO as many more are colonized. Colonized individuals can be a source of transmission to others within healthcare settings, particularly when their colonization status is unknown and, as a result, recommended IPC interventions are not applied. Even under enhanced detection efforts, MDROs may spread substantially in a facility or region before the first clinical culture is detected.⁸ Combining colonization screening with good adherence to core IPC practices will have a larger impact on limiting novel and targeted MDRO transmission than either of these strategies alone. Prevention-driven (i.e., not in response to a case) point prevalence surveys (PPSs) and admission screening are two strategies that can be used to detect colonized individuals.

Prevention-driven PPSs are colonization screenings performed unit- or facility-wide based on the healthcare facility (or unit-level) risk for MDRO importation and transmission (Table 5). These are pre-planned, and therefore distinct from the response-driven PPSs performed following identification of patient/resident with a novel or targeted MDRO and described in the Interim Guidance for a Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs). The goal of these surveys is to identify colonized individuals so recommended interventions can be applied and to regularly assess facility MDRO epidemiology. These surveys are distinct from colonization screening performed in response to case detection or an outbreak.

• Prevention-driven, recurring PPSs are performed at a predetermined frequency (e.g., every four to six months). These are resource-intensive and should therefore be prioritized for influential facilities (or units), where they are expected to have the greatest impact on regional MDRO prevalence.

       Implementation considerations:

• • In facilities that care for patients/residents with a wide range of risk levels for MDRO acquisition, recurring PPSs should be limited to high-risk patients/residents or units (e.g., the ventilator unit in a vSNF), unless there is concern for high colonization pressure among other patients/residents. In a facility where all patients/residents are at high-risk for MDROs (e.g., LTACH), the PPS should generally be performed facility-wide.

       Maximizing efficacy:

• • CDC mathematical models suggest the more frequently PPSs are performed in influential facilities, the greater the predicted reductions in regional MDRO prevalence. However, the benefit of more timely detection must be balanced with available laboratory, public health, and facility resources and may also be informed by the MDRO’s epidemiologic stage.
    • Increasing the frequency of PPS from twice yearly to quarterly is predicted to have greater benefits in regions with higher prevalence compared to those with limited spread of the MDRO. Screening less frequently than every six months is only predicted to be impactful in regions where the MDRO is pre-introduction.
    • In areas that are pre-introduction or have limited spread of the targeted MDRO, the decreased impact of less frequent PPSs may be moderated by other activities, such as admission screening (described below) or enhanced laboratory surveillance of clinical cultures.
    • The frequency of prevention-driven, recurring PPSs may change over time based on local epidemiology. Since even with effective prevention strategies the prevalence will slowly increase, in some areas an increase in PPS frequency may be necessary, for example, from twice yearly to quarterly as prevalence rises.
    • Reductions in regional MDRO prevalence are not predicted to result from prevention-driven, recurring PPSs performed at non-influential facility types.

• Prevention-driven, ad hoc PPSs are performed once or intermittently to help define the regional epidemiology. These may identify facilities that lack typical characteristics of influential facilities but have high MDRO prevalence and/or unidentified MDRO transmission where additional IPC and/or screening efforts may be beneficial.

Recommended actions when cases are identified on prevention-driven PPS:

• If the number of cases identified is at or below the facility’s baseline (i.e., prevalence is the same or lower than on previous PPS), then performing screening or IPC assessments beyond those already scheduled is not indicated.
• If the number of cases detected on prevention-driven PPS is above the baseline established by prior PPS, or otherwise suggestive of increased transmission in the facility, take actions to mitigate further spread:
  • Assess infection control practices.
  • Consider performing at least one additional PPS approximately 2-4 weeks after the prevention PPS, on the unit(s) where transmission is suspected.
    • The extent of screening (e.g., scope of individuals screened during follow up and number of follow up PPSs) depends on the stage of MDRO emergence, facility prevalence, facility infection control infrastructure, and jurisdictional capacity. Screening guidance in the Interim Guidance for a Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs), can additionally inform the extent of screening for MDROs falling within the response tiers. For example,
      • Identification of a cluster of a targeted MDRO that has never or very rarely been identified in the region should prompt follow up screening and infection control support with the goal of eliminating, or at least greatly reducing, spread in the index facility and preventing spread at connected facilities.
      • An increase over baseline of an MDRO (e.g., potential outbreak) that is in stages of advanced spread in a region, in a facility with baseline low to moderate prevalence, may prompt one to two additional PPSs after gaps in infection control are addressed, to assess whether transmission is controlled (i.e., returned to or below baseline).
    • Screening performed in response to findings from a prevention-driven PPS should be performed with a clear goal, such as to assess whether infection control measures have reduced transmission. Outside of acute outbreaks, this goal should generally be able to be accomplished with 1-2 follow-up PPSs.
    • If the facility is engaged in recurring PPSs (see below), these should continue on the planned schedule (e.g., quarterly).

Admission Screening is the use of colonization screening to identify an MDRO at the time of admission to a new healthcare facility or unit within the same facility to ensure timely implementation of recommended interventions (e.g., use of Contact Precautions, placement in a cohort unit). In addition, admission screening can be useful to measure IPC effectiveness at a facility (i.e., parsing MDRO importation from intra-facility transmission when coupled with repeat PPSs) and identify other facilities in the region with a high MDRO prevalence. Admission screening requires the facility to develop procedures to ensure screening is performed promptly for all intended patients/residents, with coordination between facilities and laboratories performing testing.

Implementation considerations:

• Facilities may perform universal or targeted admission screening. Targeting may be based on patient MDRO acquisition risk factors (e.g., those who are bedbound, require high levels of care, are receiving antibiotics, current mechanical ventilation, etc.), transfer from certain facilities (e.g., influential facilities, facilities with outbreaks), and/or admission into certain units (e.g., intensive care units). The approach to admission screening will depend on facility type and available resources; please see FAQs for additional admission screening considerations.

Maximizing efficacy:

• The benefit of admission screening is predicated on good adherence to IPC practices in the facility in which it is implemented. In the absence of good adherence to IPC practices, admission screening is not expected to reduce facility and regional transmission.
• CDC mathematical modeling indicates that the impact of admission screening on regional prevalence depends on facility risk category and epidemiologic stage of an MDRO.
  • At early epidemiologic stages, implementing admission screening in influential facilities (e.g., LTACH, vSNF) where the focus MDROs have not been identified or are low prevalence is predicted to have the greatest impact on regional prevalence. At this epidemiologic stage, admission screening in highly connected facilities that discharge to many different facilities (i.e. those identified as dispersal facilities in the risk stratification), such as ACHs, is also predicted to be impactful, but less so than in influential facilities.
  • At later epidemiologic stages, implementing admission screening in highly connected facilities that discharge to many different facilities (e.g., ACHs) is predicted to have the greatest impact on regional prevalence. At these stages, admission screening is predicted to have substantially less benefit in other settings, but could be beneficial for facilities with certain characteristics:
    • Influential facilities with demonstrated strong IPC programs and low rates of intra-facility transmission, for which admission screening results can be used to enhance certain IPC practices. For example, admission screening in such facilities could enhance timely placement of patients/residents in a cohorted unit or facilitate implementation of other measures that substantially disrupt transmission.
    • Highly connected facilities that regularly receive patients/residents from an influential facility that is experiencing unmitigated transmission or cares for many individuals with focus MDRO(s) (e.g., SNFs that do not provide care for mechanically ventilated patients/residents). In this scenario, admission screening should be implemented after a proactive, ad hoc
• In general, implement admission screening only after conducting a baseline PPS, particularly in long-term care settings; admission screening does not replace ongoing, recurring PPSs in influential facilities.
• In lieu of admission screening, ACHs and LTACHs in areas of high prevalence may implement empiric Contact Precautions based on a patient’s/resident’s individual MDRO risk factors and/or the characteristics of the transferring facility (e.g., high MDRO prevalence, characteristics of an influential facility).
• CDC continues to recommend admission screening for individuals with recent history of overnight stays or invasive procedures in healthcare facilities outside the United States.^9-11 

Table 5. Recommended prevention-driven colonization screening activities by healthcare facility category. Additional screening may be recommended for purposes of public health response to identification of novel or targeted MDROs.

Communication between healthcare facilities and public health, and between facilities that share patients, is critical for maximizing the impact of other prevention strategies.

Communication between public health and healthcare facilities ensures situational awareness of MDRO epidemiology in the region and recommended measures to detect MDROs and prevent spread.

Effective communication whenever a patient/resident infected or colonized with an MDRO is transferred within or between healthcare facilities, increases the likelihood appropriate IPC actions will be implemented continuously through transitions of care, decreasing the likelihood of MDROs spreading to others. At a minimum, the type of MDRO and the necessary infection control actions to be taken (e.g., implementation of Transmission-Based Precautions) should be communicated. An example CDC interfacility transfer form is available here.

Prior to selecting communication-based activities to include in the MDRO Prevention Plan, health departments may wish to evaluate current communication practices between healthcare facilities and health departments, as well as between healthcare facilities, and between health departments (e.g., interjurisdictional health department communication or state and local health department communication) to identify gaps in practices. Interventions to improve interfacility communication and health department notification should engage facilities across all risk categories (Table 6).

CDC mathematical modeling indicates that the population-level impact of improved interfacility communication is modest relative to infection control improvements and active colonization screening within influential facilities. When allocating resources, priority should be given to these activities over large investments in interfacility communication, such as antibiotic resistance information exchanges.

Table 6. Recommended communication activities by facility category

Below are tables providing an overview of the elements described in the Public Health Strategies to Prevent the Spread of Novel and Targeted Multidrug-resistant Organisms (MDROs). Please see the full document for important definitions and for detailed descriptions.

Section I. Preparing to Implement an MDRO Prevention Plan

Section II. Elements of an MDRO Prevention Plan