Best Practice Guidelines for Reducing Transmission of Antibiotic Resistant Organisms (AROS) In Acute and Long Term Care Settings, Home Care, and Prehospital Care Best Practice Guidelines for Reducing Transmission of Antibiotic Resistant Organisms (AROs) In Acute & Long Term Care Settings, Home Care & Prehospital Care March 2012 For Healthcare Professionals Infection Prevention and Control Nova Scotia (IPCNS), Department of Health and Wellness March 2012 Best Practice Guidelines for Reducing Transmission of Antibiotic Resistant Organisms (AROS) In Acute and Long Term Care Settings, Home Care, and Prehospital Care Acknowledgements Guideline Development Working Group Patsy Rawding RN BScN CIC Provincial Infection Control Consultant, IPCNS Nova Scotia Department of Health and Wellness Halifax, Nova Scotia Suzanne Rhodenizer Rose RN BScN CIC Director, IPCNS and Quality and Patient Safety Nova Scotia Department of Health and Wellness Halifax, Nova Scotia IPCNS would like to recognize the significant contributions that a small provincial ad hoc working group made to the genesis of this current document. In addition to IPCNS staff, working group members were infection control practitioners from around the province including: Elizabeth Watson (South Shore Health) Debbie Goulding (Pictou County Health Authority) Jan Dearing (Colchester- East Hants Health Authority Josie Ryan (Northwood Care Inc). IPCNS would like to acknowledge the contribution and expertise of the following individuals in the reviewing of this policy. Dr. Lynn Johnston M.D. FRCPC Hospital Epidemiologist and Professor of Medicine QEII Health Sciences Centre Dr. David Haldane M.B. Ch.B. FRCPC Director Provincial Public Health Laboratory Network Director of Special Pathogens (CDHA) Division of Microbiology, Dept of Pathology and Laboratory Medicine Dr. Maureen Baikie Deputy Chief Medical Officer of Health Department of Health and Wellness Dee Mombourquette Communicable Disease Prevention and Control District Health Authority/IWK Infection Control Practitioners Western Service Provider Networks IPCNS would like to acknowledge Karla Williams, Administrative Assistant, IPCNS for the administrative support in the writing of this best practice guideline. 2 Best Practice Guidelines for Reducing Transmission of Antibiotic Resistant Organisms (AROS) In Acute and Long Term Care Settings, Home Care, and Prehospital Care Table of Contents Abbreviations .................................................................................................................. 6 Introduction .................................................................................................................... 7 Assumptions for Infection Prevention and Control ......................................................... 7 Best Practices for Infection Prevention and Control of Resistant Staphylococcus Aureus and Enterococci in Acute Care and Long Term Care Settings I. Background ...................................................................................................... 10 1. What is Staphylococcus aureus? ............................................................ 10 2. What is MRSA? ...................................................................................... 10 3. MRSA Epidemology ................................................................................ 10 4. Community-Associated MRSA ................................................................ 11 5. Healthcare-Associated MRSA (as well as VRE and other AROs) .......... 11 6. Resistance Patterns ................................................................................ 11 7. How is MRSA Acquired and Spread? ..................................................... 12 8. What is Enterococci? .............................................................................. 12 9. What is VRE? ......................................................................................... 13 10. How is VRE Acquired and Spread? ........................................................ 13 11. Extended Spectrum Beta Lactamase (ESBL) ......................................... 13 12. Carbapenem resistant Gram-negative Bacilli ......................................... 14 13. Colonization versus Infection ................................................................... 14 14. General Principles for Infection Prevention and Control .......................... 15 15. Routine Practices ..................................................................................... 15 II. Additional Precautions for ARO ..................................................................... 16 1. Initiation of Additional Precautions .......................................................... 16 2. Contact Precautions ................................................................................ 17 3. Screening for AROs ................................................................................ 18 4. Role of the Laboratory ............................................................................ 18 5. Notification/Flagging ............................................................................... 19 6. De-Flagging ............................................................................................ 20 7. Accommodations ..................................................................................... 20 8. Environment and Equipment .................................................................... 20 9. Patient Care Equipment ........................................................................... 21 10. ESBL and Environment Surfaces ............................................................ 21 11. Cleaning During Outbreaks ...................................................................... 21 12. Linen and Garbage Disposal ................................................................... 22 13. Dishes and Utensils ................................................................................. 22 14. Decolonization Therapy ........................................................................... 22 14.1 MRSA .............................................................................................. 22 14.2 VRE, ESBLs, CRGNB ...................................................................... 23 15. Occupational Health Considerations ........................................................ 23 16. Screening Healthcare Workers ................................................................ 23 3 Best Practice Guidelines for Reducing Transmission of Antibiotic Resistant Organisms (AROS) In Acute and Long Term Care Settings, Home Care, and Prehospital Care 17. Employment ............................................................................................. 23 18. Routine Pre-employment Screening ........................................................ 23 III. Education ......................................................................................................... 23 1. Education for Healthcare Workers ........................................................... 23 2. Patient Education ..................................................................................... 24 3. Visitors ..................................................................................................... 24 4. Antibiotic Stewardship.............................................................................. 24 5. Program Evaluation ................................................................................. 24 6. Pets.......................................................................................................... 25 7. Hydrotherapy Pools ................................................................................. 25 8. Outbreak Control ..................................................................................... 26 Care Settings .................................................................................................... 26 IV. Prehospital Care ................................................................................................ 26 V. Acute Care Hospitals ........................................................................................ 27 1. Screening ................................................................................................ 27 2. Screening Admitted Patients for ARO Risk Factors ................................. 28 3. Re-culture of Previously Positive Patients ............................................... 28 4. Screening Patients After Exposure .......................................................... 29 5. Swab Sites ............................................................................................... 29 6. Precautions for Patients Colonized/Infected with an ARO ....................... 29 7. Activity Restrictions for Patients who are Colonized/Infected .................. 29 8. Patients Leaving the Room for Diagnostic Testing or Other Procedures .............................................................................................. 30 9. Decolonization and Treatment ................................................................. 30 10. Supplies ................................................................................................... 30 11. Bathing/Personal Items ............................................................................ 30 12. Discontinuing Precautions ....................................................................... 30 13. Visitors ....................................................................................................