Guidelines for Prevention and Control of Infection Due to Antibiotic Resistant Organisms Updated December 2020 Florida Department of Health Division of Disease Control & Health Protection Bureau of Epidemiology 850-245-4401 (24/7) FLHealth.gov Table of Contents I. Statement of Purpose ................................................................................................... 1 II. Definitions ................................................................................................................... 2 III. Introduction ................................................................................................................ 8 IV. Background ................................................................................................................ 9 A. Methicillin•Resistant Staphylococcus aureus (MRSA) .......................................... 9 B. Vancomycin•Resistant Enterococci (VRE) ......................................................... 10 C. Clostridioides difficile .......................................................................................... 10 D. Multidrug•Resistant Gram•Negative Bacilli (MDR•GNB) .................................... 11 1. Acinetobacter baumannii ........................................................................... 11 2. Carbapenem•Resistant Enterobacteriaceae (CRE) ................................... 12 E. Candida auris (C. auris) ..................................................................................... 13 V. Colonization vs. Infection .......................................................................................... 13 A. Colonization ....................................................................................................... 13 1. C. difficile ................................................................................................... 13 2. Enterococci ................................................................................................ 13 3. Methicillin•Resistant Staphylococcus aureus (MRSA) ............................... 14 4. Multidrug•Resistant Gram•Negative Bacilli (MDR•GNB)............................ 14 5. Candida auris (C. auris)............................................................................. 14 B. Infection ............................................................................................................. 14 VI. Epidemiology ........................................................................................................... 15 A. Health Care•Associated MethiciIIin-Resistant Staphylococcus aureus (HA•MRSA) ............................................................................................................. 15 B. Community•Associated Methicillin•Resistant Staphylococcus aureus (CA•MRSA) ............................................................................................................. 15 C. Vancomycin•Resistant Enterococci .................................................................... 16 D. Clostridioides difficile .......................................................................................... 17 E. Multidrug•Resistant Gram-Negative Bacilli (MDR•GNB) .................................... 18 F. Carbapenem-Resistant Enterobacteriaceae ....................................................... 18 G. Candida auris (C. auris) ..................................................................................... 19 VII. Control Measures .................................................................................................... 20 A. General Control Measures ................................................................................. 20 1. Infection Control Plan ................................................................................ 20 2. Hand Hygiene ............................................................................................ 20 3. Communications to Maintain Appropriate Patient-Based Infection Control Precautions Between and Within Facilities .................................................... 21 4. Standard Precautions ................................................................................ 22 5. Contact Precautions .................................................................................. 22 6. Enhanced Barrier Precautions ................................................................... 22 7. Education .................................................................................................. 23 8. Visitors....................................................................................................... 23 9. Surveillance ............................................................................................... 23 10. Environmental Measures ......................................................................... 24 11. Administrative Support ............................................................................ 25 12. Antimicrobial Stewardship ....................................................................... 25 VIII. Decolonization Therapy ......................................................................................... 26 IX. Prevention ................................................................................................................ 28 A. Institution Specific Control Measures ................................................................. 28 1. Acute Care Facilities ................................................................................. 28 2. Long-Term Care Facilities ......................................................................... 29 3. Home Health Care/Hospice ....................................................................... 35 4. Doctors’ Offices/Outpatient Clinics ............................................................ 35 5. Dialysis Settings ........................................................................................ 35 6. Schools for the Physically and Mentally Challenged ................................. 36 7. Assisted Living Facilities/Rest Homes/Retirement Centers ....................... 36 8. Rehabilitation Facilities .............................................................................. 37 9. Psychiatric Hospitals ................................................................................. 37 10. Correctional Facilities .............................................................................. 37 11. Patients Discharged to Their Homes ....................................................... 37 12. Emergency Medical Services (EMS) and Non•Emergent Transport ........ 38 X. Outbreak Control ....................................................................................................... 39 XI. The Infected or Colonized Health Care Worker ....................................................... 41 XII. Antibiotic Resistance in Animals ............................................................................. 41 XIII. Control of MRSA in Community Settings ............................................................... 42 A. Personal Hygiene ............................................................................................... 43 B. Control Measures for Health Care Practitioners ................................................. 43 C. Households ........................................................................................................ 44 D. Schools .............................................................................................................. 44 E. Day Care Settings .............................................................................................. 45 F. Athletic Settings .................................................................................................. 46 G. Workplace .......................................................................................................... 46 H. Correctional Facilities ......................................................................................... 47 XIV. Vancomycin Non•Susceptible Staphylococcus—An Emerging Pathogen ............. 47 XV. References ............................................................................................................. 49 XVI. Resources ............................................................................................................. 56 XVII. Reportable Diseases in Florida ............................................................................. 59 Appendix A .................................................................................................................... 60 III.A. Standard Precautions ..................................................................................... 60 III.A.1. New Elements of Standard Precautions ...................................................... 61 III.A.1.a. Respiratory Hygiene/Cough Etiquette ...................................................... 61 IV. Standard Precautions ........................................................................................ 62 IV.A. Hand Hygiene ................................................................................................ 63 IV.B. Personal Protective Equipment (PPE) ........................................................... 63 IV.C. Respiratory Hygiene/Cough Etiquette ............................................................ 65 IV.D. Patient Placement .......................................................................................... 65 IV.E. Patient Care Equipment and Instruments/Devices