Management of Multidrug-Resistant Organisms in Healthcare Settings (2006)

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Ambulatory care settings.

Facilities that provide health care to patients who do not remain overnight (e.g., hospital-based outpatient clinics, nonhospital-based clinics and physician offices, urgent care centers, surgicenters, free-standing dialysis centers, public health clinics, imaging centers, ambulatory behavioral health and substance abuse clinics, physical therapy and rehabilitation centers, and dental practices.

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In the context of this guideline, this term applies to the practice of grouping patients infected or colonized with the same infectious agent together to confine their care to one area and prevent contact with susceptible patients (cohorting patients). During outbreaks, healthcare personnel may be assigned to a cohort of patients to further limit opportunities for transmission (cohorting staff).

Contact Precautions.

Contact Precautions are a set of practices used to prevent transmission of infectious agents that are spread by direct or indirect contact with the patient or the patient’s environment. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased transmission risk. A single patient room is preferred for patients who require Contact Precautions. When a single patient room is not available, consultation with infection control is helpful to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). In multi-patient rooms, ≥3 feet spatial separation of between beds is advised to reduce the opportunities for inadvertent sharing of items between the infected/colonized patient and other patients. Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient’s environment. Donning of gown and gloves upon room entry, removal before exiting the patient room and performance of hand hygiene immediately upon exiting are done to contain pathogens.

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Epidemiologically important pathogens.

Infectious agents that have one or more of the following characteristics:

  1. A propensity for transmission within healthcare facilities based on published reports and the occurrence of temporal or geographic clusters of ≥2 patients, (e.g., VRE, MRSA and MSSA, Clostridium difficile, norovirus, RSV, influenza, rotavirus, Enterobacter spp; Serratia spp., group A streptococcus). However, for group A streptococcus, most experts consider a single case of healthcare-associated disease a trigger for investigation and enhanced control measures because of the devastating outcomes associated with HAI group A streptococcus infections. For susceptible bacteria that are known to be associated with asymptomatic colonization, isolation from normally sterile body fluids in patients with significant clinical disease would be the trigger to consider the organism as epidemiologically important.
  2. Antimicrobial resistance implications:
    • Resistance to first-line therapies (e.g., MRSA, VRE, VISA, VRSA, ESBL-producing organisms).
    • Unusual or usual agents with unusual patterns of resistance within a facility, (e.g., the first isolate of Burkholderia cepacia complex or Ralstonia spp. in non-CF patients or a quinolone-resistant strain of Pseudomonas in a facility.
    • Difficult to treat because of innate or acquired resistance to multiple classes of antimicrobial agents (e.g., Stenotrophomonas maltophilia, Acinetobacter spp.).
  3. Associated with serious clinical disease, increased morbidity and mortality (e.g., MRSA and MSSA, group A streptococcus); or
  4. A newly discovered or reemerging pathogen. The strategies described for MDROs may be applied for control of epidemiologically important organisms other than MDROs.

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Hand hygiene.

A general term that applies to any one of the following:

  1. handwashing with plain (nonantimicrobial) soap and water);
  2. antiseptic hand wash (soap containing antiseptic agents and water);
  3. antiseptic hand rub (waterless antiseptic product, most often alcohol-based, rubbed on all surfaces of hands); or
  4. surgical hand antisepsis (antiseptic hand wash or antiseptic hand rub performed preoperatively by surgical personnel to eliminate transient hand flora and reduce resident hand flora).

Healthcare-associated infection (HAI).

An infection that develops in a patient who is cared for in any setting where healthcare is delivered (e.g., acute care hospital, chronic care facility, ambulatory clinic, dialysis center, surgicenter, home) and is related to receiving health care (i.e., was not incubating or present at the time healthcare was provided). In ambulatory and home settings, HAI would apply to any infection that is associated with a medical or surgical intervention performed in those settings.

Healthcare epidemiologist.

A person whose primary training is medical (M.D., D.O.) and/or masters or doctorate-level epidemiology who has received advanced training in healthcare epidemiology. Typically these professionals direct or provide consultation to an infection prevention and control program in a hospital, long term care facility (LTCF), or healthcare delivery system (also see infection prevention and control professional).

Healthcare personnel (HCP).

All paid and unpaid persons who work in a healthcare setting, also known as healthcare workers (e.g. any person who has professional or technical training in a healthcare-related field and provides patient care in a healthcare setting or any person who provides services that support the delivery of healthcare such as dietary, housekeeping, engineering, maintenance personnel).

Home care.

A wide-range of medical, nursing, rehabilitation, hospice, and social services delivered to patients in their place of residence (e.g., private residence, senior living center, assisted living facility). Home health-care services include care provided by home health aides and skilled nurses, respiratory therapists, dieticians, physicians, chaplains, and volunteers; provision of durable medical equipment; home infusion therapy; and physical, speech, and occupational therapy.

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Infection prevention and control (ICP) professional.

Infection prevention and control (ICP) professionals can come from a wide variety of backgrounds. An ICP is a health professional whose primary training includes, but it not limited to, clinical, nursing, medical technology, microbiology, public health, or epidemiology and who has acquired specialized training in infection control. Responsibilities may include collection, analysis, and feedback of infection data and trends to healthcare providers; consultation on infection risk assessment, prevention and control strategies; performance of education and training activities; implementation of evidence-based infection control practices or those mandated by regulatory and licensing agencies; application of epidemiologic principles to improve patient outcomes; participation in planning renovation and construction projects (e.g., to ensure appropriate containment of construction dust); evaluation of new products or procedures on patient outcomes; oversight of employee health services related to infection prevention; implementation of preparedness plans; communication within the healthcare setting, with local and state health departments, and with the community at large concerning infection control issues; and participation in research.

Infection prevention and control program.

A multidisciplinary program that includes a group of activities to ensure that recommended practices for the prevention of healthcare-associated infections are implemented and followed by healthcare personnel, making the healthcare setting safe from infection for patients and healthcare personnel. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires the following five components of an infection prevention and control program for accreditation:

  1. surveillance: monitoring patients and healthcare personnel for acquisition of infection and/or colonization;
  2. investigation: identification and analysis of infection problems or undesirable trends;
  3. prevention: implementation of measures to prevent transmission of infectious agents and to reduce risks for device- and procedure-related infections;
  4. control: evaluation and management of outbreaks; and
  5. reporting: provision of information to external agencies as required by state and federal law and regulation ([This link is no longer active:]). The infection prevention and control program staff has the ultimate authority to determine infection control policies for a healthcare organization with the approval of the organization’s governing body.

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Long-term care facilities (LTCFs).

An array of residential and outpatient facilities designed to meet the bio-psychosocial needs of persons with sustained self-care deficits. These include skilled nursing facilities, chronic disease hospitals, nursing homes, foster and group homes, institutions for the developmentally disabled, residential care facilities, assisted living facilities, retirement homes, adult day health care facilities, rehabilitation centers, and long-term psychiatric hospitals.

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A term that applies collectively to items used to cover the nose and mouth and includes both procedure masks and surgical masks ([This link is no longer active:]).

Multidrug-resistant organisms (MDROs).

In general, bacteria (excluding M. tuberculosis) that are resistant to one or more classes of antimicrobial agents and usually are resistant to all but one or two commercially available antimicrobial agents (e.g., MRSA, VRE, extended spectrum beta-lactamase [ESBL]-producing or intrinsically resistant gram-negative bacilli).

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Nosocomial infection.

Derived from two Greek words “nosos” (disease) and “komeion” (to take care of). Refers to any infection that develops during or as a result of an admission to an acute care facility (hospital) and was not incubating at the time of admission.

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Standard Precautions.

A group of infection prevention practices that apply to all patients, regardless of suspected or confirmed diagnosis or presumed infection status. Standard Precautions are a combination and expansion of Universal Precautions and Body Substance Isolation. Standard Precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions includes hand hygiene, and depending on the anticipated exposure, use of gloves, gown, mask, eye protection, or face shield. Also, equipment or items in the patient environment likely to have been contaminated with infectious fluids must be handled in a manner to prevent transmission of infectious agents, (e.g. wear gloves for handling, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient).

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