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Strategies to Prevent Hospital-onset Staphylococcus aureus Bloodstream Infections in Acute Care Facilities

Introduction

Purpose:

This document provides information about interventions for prevention of hospital-onset Staphylococcus aureus Bloodstream Infections (HO SA BSIs) in acute care facilities. The strategies are intended to facilitate implementation of HO SA BSI prevention efforts by state and local health departments, quality improvement organizations, hospital associations, and healthcare facilities. The interventions are not intended for use in response to an outbreak.

All acute care facilities should reinforce core infection control practices on an ongoing basis.  This includes ongoing competency-based training and monitoring adherence with feedback of results for hand hygiene, environmental cleaning and disinfection, and use of personal protective equipment. Hospitals should work to implement the CDC Core Elements of Hospital Antibiotic Stewardship Programs

Core and supplemental strategies for prevention of HO SA BSIs in acute care facilities are listed below. Core strategies are strongly supported by published evidence and should form the foundation of HO SA BSI prevention.  Supplemental strategies are generally supported by less evidence and should be considered for use when reduction goals are not met after implementation of core interventions or when facilities wish to implement a more aggressive prevention strategy.

To develop a HO SA BSI prevention strategy, facilities should first review recent episodes of HO SA BSI to identify common risk factors and underlying syndromes that might help identify the populations and interventions which might be most important to target.  Elements that should be reviewed include associated syndromes (e.g., wound infections or pneumonia) that may have led to the BSI, unit types, presence of indwelling devices such as central venous catheters (CVCs), and prior invasive procedures or surgeries. Based on this review of facility-level data, each facility should select core and supplemental strategies for implementation that are most likely to have an impact on facility rates.

1. IMPLEMENT INTERVENTIONS TO REDUCE DEVICE AND PROCEDURE RELATED HEALTHCARE-ASSOCIATED INFECTIONS

  • Surgical site infection (SSI) prevention practices
    • Core Strategies:
      • Follow evidence-based guidance for the prevention of SSIs
      • For all patients undergoing high risk surgeries (e.g. cardiothoracic (CT), orthopedic, and neurosurgery), unless known to be S. aureus negative, use an intranasal antistaphyloccal antibiotic/antiseptic (e.g. mupirocin or iodophor) and chlorhexidine wash or wipes prior to surgery.
        • Possible Regimens
          • Intranasal antistaphyloccal antibiotic/antiseptic
            • Mupirocin twice daily to each nare for the 5 days prior to day of surgery
            • 2 applications of nasal Iodophor (at least 5%) to each nare within 2 hours prior to surgery
          • Chlorhexidine
            • Daily chlorhexidine wash or wipes for up to 5 days prior to surgery
    • Supplement Strategy
      • Consider chlorhexidine bathing or wipes for up to 5 days prior to surgery for all surgical patients, not just those undergoing high risk surgeries, unless known to be S. aureus negative
  • Hemodialysis bloodstream infection prevention practices
  • Ventilator-associated Pneumonia (VAP) prevention practices

2. IMPLEMENT SOURCE CONTROL STRATEGIES FOR HIGH RISK PATIENTS DURING HIGH RISK PERIODS

  • Core Strategy:
    • Pursue a strategy to reduce carriage of S. aureus among all patients admitted to intensive care units (ICUs) (see table for summary of source control strategies) including:
      • Apply intranasal mupirocin twice a day to each nare for 5 days in conjunction with  daily chlorhexidine bathing for duration of ICU admission
  • Supplemental Strategy
    • Pursue a strategy to reduce carriage of S. aureus for patients hospitalized with CVCs or midline catheters outside the ICU
      • Apply intranasal mupirocin twice a day to each nare for 5 days in conjunction with daily chlorhexidine bathing while CVC or midline catheter is present
        • Intranasal iodophor could be considered as an alternative to intranasal mupriocin

3. IMPLEMENT INTERVENTIONS TO PREVENT TRANSMISSION OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) IN ACUTE CARE

  • Core Strategies
    • The Centers for Disease Control and Prevention (CDC) continues to recommend placing patients colonized or infected with MRSA in private rooms and on Contact Precautions in inpatient acute care settings
    • Use dedicated patient-care equipment (e.g. blood pressure cuffs, stethoscopes), and single use disposable items (e.g. single patient digital thermometer) whenever possible
    • If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient
    • Provide regular competency-based training on use of PPE and monitor adherence
    • Place patients with excessive wound drainage (i.e. suggests an increased potential for extensive environmental contamination and risk of transmission) on Contact Precautions and in a private room regardless of Multi-drug resistant organisms (MDRO) carriage status
  • Supplemental Strategy
    • Consider active surveillance testing (screening) for MRSA on admission to acute care facilities. Screening could be limited to high risk patients (e.g., prior healthcare exposure) or admission to high risk settings (e.g., intensive care unit)
      • Those found to be colonized with MRSA should be placed in private rooms and on Contact Precautions
      • Active surveillance testing could be combined with source control strategies as described above for high risk patients (i.e. ICU patients and those outside the ICU with CVCs or Midline Catheters)

4. DEVELOP INFRASTRUCTURE TO SUPPORT HO SA BSI PREVENTION

  • Core Strategies
    • Incorporate reduction of HO SA BSIs into the facility healthcare-associated infection prevention program
      • Develop a multidisciplinary workgroup, including nursing, environmental services, and infection prevention to identify and implement strategies and to follow results of interventions
    • Monitor facility HO SA BSI counts, and target units with highest number of HO SA BSIs for evaluation and intervention
      • Provide HO SA BSI rates to senior leadership, clinical staff, and other stakeholders
      • Notify appropriate individuals and facility departments about changes in the incidence (or frequency), complications (including recurrences), or severity of HO SA BSIs
    • Review individual HO SA BSI episodes to assess modifiable risk factors including clinical management decisions and the use of infection control measures to identify gaps
    • Educate and train all healthcare personnel on prevention practices for HO SA BSI and core infection control practices such as hand hygiene, PPE use, Standard Precautions, Contact Precautions, and environmental cleaning and disinfection
    • Routinely audit and conduct competency-based assessments for core infection control practices
      • Adherence to hand hygiene, Standard Precautions, and Contact Precautions
      • Adequacy of room cleaning and environmental services

Table 1: Summary of Source Control Strategies by Central Venous Catheter (CVC) or Midline Catheter Presence and Unit Type

Table 1: Summary of Source Control Strategies by Central Venous Catheter (CVC) or Midline Catheter Presence and Unit Type 
Patient Type Intensive Care Unit non-Intensive Care Unit
CVC or Midline Catheter Present Topical chlorhexidine gluconate (at least 2%) + Intranasal antistaphyloccal antibiotic/antiseptic (e.g. mupirocin or iodophor) (core strategy) Topical chlorhexidine gluconate (at least 2%) + Intranasal antistaphyloccal antibiotic/antiseptic (e.g. mupirocin or iodophor) (supplemental strategy)
No CVC or Midline Catheter present Topical chlorhexidine gluconate (at least 2%) + Intranasal antistaphyloccal antibiotic/antiseptic (i.e. mupirocin or iodophor) (core strategy) None (note that source control strategies may apply to pre-operative surgical patients outside the intensive care unit- see section 1on SSI prevention)

References

  1. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J and the Healthcare Infection Control Practices Advisory Committee (HICPAC).  Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 [PDF – 83 pages].
  2. Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, et al.  Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update by the Infectious Disease Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).  Infection Control and Hospital Epidemiology, Volume 35 (S2), July 2014, S89-S107.
  3. Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, et al.  Centers for Disease Control and Prevention Guidelines for the Prevention of Surgical Site Infection, 2017.  JAMA Surgery, special web publication, May 2017.
  4. Anderson DJ, Podgorny K, Berrios-Torres SI, Bratzler DW, Dellinger EP, et al.  Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update by the Infectious Disease Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).  Infection Control and Hospital Epidemiology, Volume 35 (S2), June 2014, S66-S88.
  5. Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, Vandenbroucke-Grauls CM, et al.  Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus.  New England Journal of Medicine, Volume 362 (1), January 2010, 9-17.
  6. Perl TM, Cullen JJ, Wenzel RP, Zimmermean MB, Pfaller MA, et al.  Intranasal Mupirocin to Prevent Postoperative Staphylococcus aureus Infections.  New England Journal of Medicine, Volume 346 (24), June 2002, 1871-1877.
  7. Schweizer ML, Chang HY, Septimus E, Moody J, Braun B, et al.  Association of a Bundled Intervention With Surgical Site Infections Among Patients Undergoing Cardiac, Hip, or Knee Surgery.  JAMA, Volume 313 (21), June 2015, 2162-2171.
  8. Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, et al.  Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update by the Infectious Disease Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).  Infection Control and Hospital Epidemiology, Volume 35 (8), August 2014, 915-936.
  9. Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, et al.  Targeted Versus Universal Decolonization to Prevent ICU Infection.  NEJM, Volume 368 (24), June 2014, 2255-2265.
  10. Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, et al. Chlorhexidine versus Routine Bathing to Prevent Multi Drug-Resistant Organisms and All-Cause Bloodstream Infection in General Medical and Surgical Units: The ABATE Infection Cluster Randomized Trial.  Lancet, in press.
  11. Universal ICU Decolonization: An Enhanced Protocol.  Agency for Healthcare Research and Quality (AHRQ).
  12. Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings – Recommendations of the Healthcare Infection Control Practices Advisory Committee. 2017. [PDF – 15 pages].
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