VI. Prevention of Transmission of Multidrug Resistant Organisms
Management of Multidrug-Resistant Organisms in Healthcare Settings (2006)
The CDC/HICPAC system for categorizing recommendations is as follows:
Category IA Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
Category IB Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale.
Category IC Required for implementation, as mandated by federal and/or state regulation or standard.
Category II Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.
No recommendation Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.
V.A. General recommendations for all healthcare settings independent of the prevalence of multidrug resistant organism (MDRO) infections or the population served. (See Table 3, Tier 1.)
V.A.1. Administrative Measures
V.A.1.a. Make MDRO prevention and control an organizational patient safety priority.3, 146, 151, 154, 182, 185, 194, 205, 208, 210, 242, 327, 328 Category IB
V.A.1.b. Provide administrative support, and both fiscal and human resources, to prevent and control MDRO transmission within the healthcare organization. 3, 9, 146, 152, 182-184, 208, 328, 329 Category IB
V.A.1.c. In healthcare facilities without expertise for analyzing epidemiologic data, recognizing MDRO problems, or devising effective control strategies (e.g., small or rural hospitals, rehabilitation centers, long-term care facilities [LTCFs], freestanding ambulatory centers), identify experts who can provide consultation as needed.151, 188 Category II
V.A.1.d. Implement systems to communicate information about reportable MDROs [e.g., VRSA, VISA, MRSA, Penicillin resistant S. pneumoniae (PRSP)] to administrative personnel and as required by state and local health authorities ([This link is no longer active: www.cdc.gov/epo/dphsi/nndsshis.htm. Information may be available on National Notifiable Diseases Surveillance System (NNDSS) website accessed May 4, 2016]).Refer to websites for updated requirements of local and state health departments. Category II/IC
V.A.1.e. Implement a multidisciplinary process to monitor and improve healthcare personnel (HCP) adherence to recommended practices for Standard and Contact Precautions3, 105, 182, 184, 189, 242, 273, 312, 330 Category IB
V.A.1.f. Implement systems to designate patients known to be colonized or infected with a targeted MDRO and to notify receiving healthcare facilities and personnel prior to transfer of such patients within or between facilities.87, 151 Category IB
V.A.1.g. Support participation of the facility or healthcare system in local, regional, and national coalitions to combat emerging or growing MDRO problems.41, 146, 151, 167, 188, 206, 207, 211, 331 Category IB
V.A.1.h. Provide updated feedback at least annually to healthcare providers and administrators on facility and patient-care-unit trends in MDRO infections. Include information on changes in prevalence or incidence of infection, results of assessments for system failures, and action plans to improve adherence to and effectiveness of recommended infection control practices to prevent MDRO transmission.152, 154, 159, 184, 204, 205, 242, 312, 332 Category IB
V.A.2. Education and Training of Healthcare Personnel
V.A.2.a. Provide education and training on risks and prevention of MDRO transmission during orientation and periodic educational updates for healthcare personnel; include information on organizational experience with MDROs and prevention strategies.38, 152, 154, 173, 176, 189, 190, 203, 204, 217, 242, 330, 333, 334 Category IB
Edit: An ~ indicates text that was edited for clarity. The edit does not constitute change to the intent of the recommendations.
V.A.3. Judicious Use of Antimicrobial Agents ~ (i.e., systems to promote optimal treatment of infections and appropriate antimicrobial use).
V.A.3.a. In hospitals and LTCFs, ensure that a multidisciplinary process is in place to review antimicrobial utilization, local susceptibility patterns (antibiograms), and antimicrobial agents included in the formulary to foster appropriate antimicrobial use.209, 212, 214, 215, 217, 242, 254, 334-339 Category IB
V.A.3.b. Implement systems (e.g., computerized physician order entry, comment in microbiology susceptibility report, notification from a clinical pharmacist or unit director) to prompt clinicians to use the appropriate antimicrobial agent and regimen for the given clinical situation.156, 157, 161, 166, 174, 175, 212, 214, 218, 254, 334, 335, 337, 340-346 Category IB
V.A.3.b.i. Provide clinicians with antimicrobial susceptibility reports and analysis of current trends, updated at least annually, to guide antimicrobial prescribing practices.342, 347 Category IB
V.A.3.b.ii. In settings that administer antimicrobial agents but have limited electronic communication system infrastructures to implement physician prompts (e.g., LTCFs, home care and infusion companies), implement a process for appropriate review of prescribed antimicrobials. Prepare and distribute reports to prescribers that summarize findings and provide suggestions for improving antimicrobial use.342, 348, 349 Category II
V.A.4. Surveillance
V.A.4.a. In microbiology laboratories, use standardized laboratory methods and follow published guidance for determining antimicrobial susceptibility of targeted (e.g., MRSA, VRE, MDR-ESBLs) and emerging (e.g., VRSA, MDR-Acinetobacter baumannii) MDROs.8, 154, 177, 190, 193, 209, 254, 347, 350-353 Category IB
V.A.4.b. In all healthcare organizations, establish systems to ensure that clinical microbiology laboratories (in-house and out-sourced) promptly notify infection control staff or a medical director/ designee when a novel resistance pattern for that facility is detected.9, 22, 154, 162, 169 Category IB
V.A.4.c. In hospitals and LTCFs, develop and implement laboratory protocols for storing isolates of selected MDROs for molecular typing when needed to confirm transmission or delineate the epidemiology of the MDRO within the healthcare setting.7, 8, 38, 140, 153, 154, 187, 190, 208, 217, 354, 355 Category IB
V.A.4.d. Prepare facility-specific antimicrobial susceptibility reports as recommended by the Clinical and Laboratory Standards Institute (CLSI) ([This link is no longer active: www.phppo.cdc.gov/dls/master/default.aspx.]); monitor these reports for evidence of changing resistance patterns that may indicate the emergence or transmission of MDROs.347, 351, 356, 357 Category IB/IC
V.A.4.d.i. In hospitals and LTCFs with special-care units (e.g., ventilator-dependent, ICU, or oncology units), develop and monitor unit-specific antimicrobial susceptibility reports.358-361 Category IB
V.A.4.d.ii. Establish a frequency for preparing summary reports based on volume of clinical isolates, with updates at least annually.347, 362 Category II/IC
V.A.4.d.iii.In healthcare organizations that outsource microbiology laboratory services (e.g., ambulatory care, home care, LTCFs, smaller acute care hospitals), specify by contract that the laboratory provide either facility-specific susceptibility data or local or regional aggregate susceptibility data in order to identify prevalent MDROs and trends in the geographic area served.363 Category II
V.A.4.e. Monitor trends in the incidence of target MDROs in the facility over time using appropriate statistical methods to determine whether MDRO rates are decreasing and whether additional interventions are needed.152, 154, 183, 193, 205, 209, 217, 242, 300, 325, 326, 364, 365 Category IA
V.A.4.e.i. Specify isolate origin (i.e., location and clinical service) in MDRO monitoring protocols in hospitals and other large multi-unit facilities with high-risk patients.8, 38, 152-154, 217, 358, 361 Category IB
V.A.4.e.ii. Establish a baseline (e.g., incidence) for targeted MDRO isolates by reviewing results of clinical cultures; if more timely or localized information is needed, perform baseline point prevalence studies of colonization in high-risk units. When possible, distinguish colonization from infection in analysis of these data.152, 153, 183, 184, 189, 190, 193, 205, 242, 365 Category IB
Edit: An * indicates recommendations that were renumbered for clarity. The renumbering does not constitute change to the intent of the recommendations.V.A.5. Infection Control Precautions to Prevent Transmission of MDROs
V.A.5.a. Follow Standard Precautions during all patient encounters in all settings in which healthcare is delivered.119, 164, 255, 315, 316 Category IB
V.A.5.b. Use masks according to Standard Precautions when performing splash-generating procedures (e.g., wound irrigation, oral suctioning, intubation); when caring for patients with open tracheostomies and the potential for projectile secretions; and in circumstances where there is evidence of transmission from heavily colonized sources (e.g., burn wounds). Masks are not otherwise recommended for prevention of MDRO transmission from patients to healthcare personnel during routine care (e.g., upon room entry).8, 22, 151, 152, 154, 189, 190, 193, 208, 240, 366 Category IB
V.A.5.c. Use of Contact Precautions
V.A.5.c.i. In acute-care hospitals
Implement Contact Precautions routinely for all patients infected with target MDROs and for patients that have been previously identified as being colonized with target MDROs (e.g., patients transferred from other units or facilities who are known to be colonized).11, 38, 68, 114, 151, 183, 188, 204, 217, 242, 304 Category IB
V.A.5.c.ii. In LTCFs
- * Consider the individual patient’s clinical situation and prevalence or incidence of MDRO in the facility when deciding whether to implement or modify Contact Precautions in addition to Standard Precautions for a patient infected or colonized with a target MDRO. Category II
- * For relatively healthy residents (e.g., mainly independent) follow Standard Precautions, making sure that gloves and gowns are used for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence, and ostomy tubes/bags.78-80, 85, 151, 367, 368 Category II
- * For ill residents (e.g., those totally dependent upon healthcare personnel for healthcare and activities of daily living, ventilator-dependent) and for those residents whose infected secretions or drainage cannot be contained, use Contact Precautions in addition to Standard Precautions.316, 369, 370 Category II
- * For MDRO colonized or infected patients without draining wounds, diarrhea, or uncontrolled secretions, establish ranges of permitted ambulation, socialization, and use of common areas based on their risk to other patients and on the ability of the colonized or infected patients to observe proper hand hygiene and other recommended precautions to contain secretions and excretions.151, 163, 371 Category II
V.A.5.d. In ambulatory settings
Use Standard Precautions for patients known to be infected or colonized with target MDROs, making sure that gloves and gowns are used for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence, and ostomy tubes and bags. Category II
V.A.5.e. In home care settings
- * Follow Standard Precautions making sure to use gowns and gloves for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence, and ostomy tubes and bags. Category II
- * Limit the amount of reusable patient-care equipment that is brought into the home of patients infected or colonized with MDROs. When possible, leave patient-care equipment in the home until the patient is discharged from home care services. Category II
- * If noncritical patient-care equipment (e.g., stethoscopes) cannot remain in the home, clean and disinfect items before removing them from the home, using a low to intermediate level disinfectant, or place reusable items in a plastic bag for transport to another site for subsequent cleaning and disinfection. Category II
V.A.5.f. * In ambulatory or home care settings
No recommendation is made for routine use of gloves, gowns, or both to prevent MDRO transmission in ambulatory or home care settings. Unresolved issue
V.A.5.g. * In hemodialysis units
Follow the “Recommendations to Prevent Transmission of Infections in Chronic Hemodialysis Patients”372 ([This link is no longer active: www.cms.hhs.gov/home/regsguidance.asp]). Category IC
V.A.5.h. * Discontinuation of Contact Precautions.
No recommendation can be made regarding when to discontinue Contact Precautions. Unresolved issue (See Background for discussion of options.)
V.A.5.i. * Patient placement in hospitals and LTCFs
V.A.5.i.1. * When single-patient rooms are available, assign priority for these rooms to patients with known or suspected MDRO colonization or infection. Give highest priority to those patients who have conditions that may facilitate transmission, e.g., uncontained secretions or excretions.8, 38, 110, 151, 188, 208, 240, 304 Category IB
V.A.5.i.2. * When single-patient rooms are not available, cohort patients with the same MDRO in the same room or patient-care area.8, 38, 92, 151-153, 162, 183, 184, 188, 217, 242, 304 Category IB
V.A.5.i.3. * When cohorting patients with the same MDRO is not possible, place MDRO patients in rooms with patients who are at low risk for acquisition of MDROs and associated adverse outcomes from infection and are likely to have short lengths of stay. Category II
V.A.6. Environmental Measures
V.A.6.a. Clean and disinfect surfaces and equipment that may be contaminated with pathogens, including those that are in close proximity to the patient (e.g., bed rails, over bed tables) and frequently-touched surfaces in the patient care environment (e.g., door knobs, surfaces in and surrounding toilets in patients’ rooms) on a more frequent schedule compared to that for minimal touch surfaces (e.g., horizontal surfaces in waiting rooms).111, 297, 373 Category IB
V.A.6.b. Dedicate noncritical medical items to use on individual patients known to be infected or colonized with MDROs.38, 217, 323, 374, 375 Category IB
V.A.6.c. Prioritize room cleaning of patients on Contact Precautions. Focus on cleaning and disinfecting frequently touched surfaces (e.g., bedrails, bedside commodes, bathroom fixtures in the patient’s room, doorknobs) and equipment in the immediate vicinity of the patient.109, 110, 114-117, 297, 301, 373, 376, 377 Category IB
V.B. Intensified interventions to prevent MDRO transmission (See Table 3, Tier 2.)
The interventions presented below have been utilized in various combinations to reduce transmission of MDROs in healthcare facilities. Neither the effectiveness of individual components nor that of specific combinations of control measures has been assessed in controlled trials. Nevertheless, various combinations of control elements selected under the guidance of knowledgeable content experts have repeatedly reduced MDRO transmission rates in a variety of healthcare settings.
V.B.1. Indications and Approach
V.B.1.a. Indications for intensified MDRO control efforts (VII.B.1.a.i and VII.B.1.a.ii) should result in selection and implementation of one or more of the interventions described in VII.B.2 to VII.B.8 below. Individualize the selection of control measures according to local considerations.8, 11, 38, 68, 114, 152-154, 183-185, 189, 190, 193, 194, 209, 217, 242, 312, 364, 365 Category IB
V.B.1.a.i. When incidence or prevalence of MDROs are not decreasing despite implementation of and correct adherence to the routine control measures described above, intensify MDRO control efforts by adopting one or more of the interventions described below.92, 152, 183, 184, 193, 365 Category IB
V.B.1.a.ii. When the first case or outbreak of an epidemiologically important MDRO (e.g., VRE, MRSA, VISA, VRSA, MDR-GNB) is identified within a healthcare facility or unit.22, 23, 25, 68, 170, 172, 184, 240, 242, 378 Category IB
V.B.1.b. Continue to monitor the incidence of target MDRO infection and colonization after additional interventions are implemented. If rates do not decrease, implement more interventions as needed to reduce MDRO transmission.11, 38, 68, 92, 152, 175, 184, 365 Category IB
V.B.2. Administrative Measures
V.B.2.a. Identify persons with experience in infection control and the epidemiology of MDRO, either in house or through outside consultation, for assessment of the local MDRO problem and for the design, implementation, and evaluation of appropriate control measures.3, 68, 146, 151-154, 167, 184, 190, 193, 242, 328, 377 Category IB
V.B.2.b. Provide necessary leadership, funding, and day-to-day oversight to implement interventions selected. Involve the governing body and leadership of the healthcare facility or system that have organizational responsibility for this and other infection control efforts.8, 38, 152, 154, 184, 189, 190, 208 Category IB
V.B.2.c. Evaluate healthcare system factors for their role in creating or perpetuating transmission of MDROs, including: staffing levels, education and training, availability of consumable and durable resources, communication processes, policies and procedures, and adherence to recommended infection control measures (e.g., hand hygiene and Standard or Contact Precautions). Develop, implement, and monitor action plans to correct system failures.3, 8, 38, 152, 154, 172, 173, 175, 188, 196, 198, 199, 208, 217, 280, 323, 379, 380 Category IB
V.B.2.d. During the process, update healthcare providers and administrators on the progress and effectiveness of the intensified interventions. Include information on changes in prevalence, rates of infection and colonization; results of assessments and corrective actions for system failures; degrees of adherence to recommended practices; and action plans to improve adherence to recommended infection control practices to prevent MDRO transmission.152, 154, 159, 184, 204, 205, 312, 332, 381 Category IB
V.B.3. Educational Interventions
Intensify the frequency of MDRO educational programs for healthcare personnel, especially those who work in areas in which MDRO rates are not decreasing. Provide individual or unit-specific feedback when available.3, 38, 152, 154, 159, 170, 182, 183, 189, 190, 193, 194, 204, 205, 209, 215, 218, 312 Category IB
V.B.4. Judicious Use of Antimicrobial Agents
Review the role of antimicrobial use in perpetuating the MDRO problem targeted for intensified intervention. Control and improve antimicrobial use as indicated. Antimicrobial agents that may be targeted include vancomycin, third-generation cephalosporins, and anti-anaerobic agents for VRE (217); third-generation cephalosporins for ESBLs; 212, 214, 215 and quinolones and carbapenems.80, 156, 166, 174, 175, 209, 218, 242, 254, 329, 334, 335, 337, 341 Category IB
V.B.5. Surveillance
V.B.5.a. Calculate and analyze prevalence and incidence rates of targeted MDRO infection and colonization in populations at risk; when possible, distinguish colonization from infection152, 153, 183, 184, 189, 190, 193, 205, 215, 242, 365 Category IB
V.B.5.a.i. Include only one isolate per patient, not multiple isolates from the same patient, when calculating rates.347, 382 Category II
V.B.5.a.ii. Increase the frequency of compiling and monitoring antimicrobial susceptibility summary reports for a targeted MDRO as indicated by an increase in incidence of infection or colonization with that MDRO. Category II
V.B.5.b. Develop and implement protocols to obtain active surveillance cultures (ASC) for targeted MDROs from patients in populations at risk (e.g., patients in intensive care, burn, bone marrow/stem cell transplant, and oncology units; patients transferred from facilities known to have high MDRO prevalence rates; roommates of colonized or infected persons; and patients known to have been previously infected or colonized with an MDRO).8, 38, 68, 114, 151-154, 167, 168, 183, 184, 187-190, 192, 193, 217, 242 Category IB
V.B.5.b.i. Obtain ASC from areas of skin breakdown and draining wounds. In addition, include the following sites according to target MDROs:
V.B.5.b.i.1. For MRSA: Sampling the anterior nares is usually sufficient; throat, endotracheal tube aspirate, percutaneous gastrostomy sites, and perirectal or perineal cultures may be added to increase the yield. Swabs from several sites may be placed in the same selective broth tube prior to transport.117, 383, 384 Category IB
V.B.5.b.i.2. For VRE: Stool, rectal, or perirectal samples should be collected.154, 193, 217, 242 Category IB
V.B.5.b.i.3. For MDR-GNB: Endotracheal tube aspirates or sputum should be cultured if a respiratory tract reservoir is suspected, (e.g., Acinetobacter spp., Burkholderia spp.).385, 386 Category IB
V.B.5.b.ii. Obtain surveillance cultures for the target MDRO from patients at the time of admission to high-risk areas, e.g., ICUs, and at periodic intervals as needed to assess MDRO transmission.8, 151, 154, 159, 184, 208, 215, 242, 387 Category IB
V.B.5.c. Conduct culture surveys to assess the efficacy of the enhanced MDRO control interventions.
V.B.5.c.i. Conduct serial (e.g., weekly, until transmission has ceased and then decreasing frequency) unit-specific point prevalence culture surveys of the target MDRO to determine if transmission has decreased or ceased.107, 167, 175, 184, 188, 218, 339 Category IB
V.B.5.c.ii. Repeat point-prevalence culture surveys at routine intervals or at time of patient discharge or transfer until transmission has ceased.8, 152-154, 168, 178, 190, 215, 218, 242, 388 Category IB
V.B.5.c.iii. If indicated by assessment of the MDRO problem, collect cultures to assess the colonization status of roommates and other patients with substantial exposure to patients with known MDRO infection or colonization.25, 68, 167, 193 Category IB
V.B.5.d. Obtain cultures of healthcare personnel for target MDRO when there is epidemiologic evidence implicating the healthcare staff member as a source of ongoing transmission.153, 365 Category IB
V.B.6. Enhanced Infection Control Precautions
V.B.6.a. * Use of Contact Precautions
V.B.6.a.i. Implement Contact Precautions routinely for all patients colonized or infected with a target MDRO.8, 11, 38, 68, 114, 151, 154, 183, 188, 189, 217, 242, 304 Category IA
V.B.6.a.ii. Because environmental surfaces and medical equipment, especially those in close proximity to the patient, may be contaminated, don gowns and gloves before or upon entry to the patient’s room or cubicle.38, 68, 154, 187, 189, 242 Category IB
V.B.6.a.iii. In LTCFs, modify Contact Precautions to allow MDRO colonized/infected patients whose site of colonization or infection can be appropriately contained and who can observe good hand hygiene practices to enter common areas and participate in group activities.78, 86, 151, 367 Category IB
V.B.6.b. When ASC are obtained as part of an intensified MDRO control program, implement Contact Precautions until the surveillance culture is reported negative for the target MDRO.8, 30, 153, 389, 390 Category IB
V.B.6.c. No recommendation is made regarding universal use of gloves, gowns, or both in high-risk units in acute-care hospitals.153, 273, 312, 320, 391 Unresolved issue
V.B.7. Patient Admission and Placement
V.B.7. Implement policies for patient admission and placement as needed to prevent transmission of a problem MDRO.183, 184, 189, 193, 242, 339, 392 Category IB
V.B.7.a.i. Place MDRO patients in single-patient rooms.6, 151, 158, 160, 166, 170, 187, 208, 240, 282, 393-395 Category IB
V.B.7.a.ii. Cohort patients with the same MDRO in designated areas (e.g., rooms, bays, patient care areas.8, 151, 152, 159, 161, 176, 181, 183, 184, 188, 208, 217, 242, 280, 339, 344 Category IB
V.B.7.a.iii. When transmission continues despite adherence to Standard and Contact Precautions and cohorting patients, assign dedicated nursing and ancillary service staff to the care of MDRO patients only. Some facilities may consider this option when intensified measures are first implemented.184, 217, 242, 278 Category IB
V.B.7.a.iv. Stop new admissions to the unit of facility if transmission continues despite the implementation of the enhanced control measures described above. (Refer to state or local regulations that may apply upon closure of hospital units or services.)9, 38, 146, 159, 161, 168, 175, 205, 279, 280, 332, 339, 396 Category IB
V.B.8. Enhanced Environmental Measures
V.B.8.a. Implement patient-dedicated or single-use disposable noncritical equipment (e.g., blood pressure cuff, stethoscope) and instruments and devices.38, 104, 151, 156, 159, 163, 181, 217, 323, 329, 367, 389, 390, 394 Category IB
V.B.8.b. Intensify and reinforce training of environmental staff who work in areas targeted for intensified MDRO control and monitor adherence to environmental cleaning policies. Some facilities may choose to assign dedicated staff to targeted patient care areas to enhance consistency of proper environmental cleaning and disinfection services.38, 154, 159, 165, 172, 173, 175, 178-181, 193, 205, 208, 217, 279, 301, 327, 339, 397 Category IB
V.B.8.c. Monitor (i.e., supervise and inspect) cleaning performance to ensure consistent cleaning and disinfection of surfaces in close proximity to the patient and those likely to be touched by the patient and HCP (e.g., bedrails, carts, bedside commodes, doorknobs, faucet handles).8, 38, 109, 111, 154, 169, 180, 208, 217, 301, 333, 398 Category IB
V.B.8.d. Obtain environmental cultures (e.g., surfaces, shared medical equipment) when there is epidemiologic evidence that an environmental source is associated with ongoing transmission of the targeted MDRO.399-402 Category IB
V.B.8.e. Vacate units for environmental assessment and intensive cleaning when previous efforts to eliminate environmental reservoirs have failed.175, 205, 279, 339, 403 Category II
V.B.9. Decolonization
V.B.9.a. Consult with physicians with expertise in infectious diseases and/or healthcare epidemiology on a case-by-case basis regarding the appropriate use of decolonization therapy for patients or staff during limited periods of time, as a component of an intensified MRSA control program.152, 168, 170, 172, 183, 194, 304 Category II
V.B.9.b. When decolonization for MRSA is used, perform susceptibility testing for the decolonizing agent against the target organism in the individual being treated or the MDRO strain that is epidemiologically implicated in transmission. Monitor susceptibility to detect emergence of resistance to the decolonizing agent. Consult with a microbiologist for appropriate testing for mupirocin resistance, since standards have not been established.289, 290, 304, 308 Category IB
V.B.9.b.i. Because mupirocin-resistant strains may emerge and because it is unusual to eradicate MRSA when multiple body sites are colonized, do not use topical mupirocin routinely for MRSA decolonization of patients as a component of MRSA control programs in any healthcare setting.289, 404 Category IB
V.B.9.b.ii. Limit decolonization of HCP found to be colonized with MRSA to persons who have been epidemiologically linked as a likely source of ongoing transmission to patients. Consider reassignment of HCP if decolonization is not successful and ongoing transmission to patients persists.120, 122, 168 Category IB
V.B.9.c. No recommendation can be made for decolonizing patients with VRE or MDR-GNB. Regimens and efficacy of decolonization protocols for VRE and MDR-GNB have not been established.284, 286, 288, 307, 387, 405 Unresolved issue