Download Management of the Patient with a Multi-resistant Organism - nc

Department & Location
Infection Control
Cooperative Wide
PURPOSE:
Protocol
Management of the Patient with a
Multi-resistant Organism (MRO)
Number
Page 1 of 9
To prevent transmission of multi-resistant organisms by identifying colonized and infected
patients in order to implement appropriate precautions (Standard and Contact).
RESPONSIBILITY STATEMENT:
1.
Physician order required for culture and treatment of multi-resistant organism.
2.
Health care workers are responsible for initiating appropriate precautions.
SUPPORTIVE DATA
Bacteria resistant to multiple antibiotics may become established as endemic pathogens in health-care
institutions. Resistant organisms of particular epidemiological significance are Methicillin Resistant
Staphylococcus aureus (MRSA) and Vancomycin Resistant Enterococcus (VRE).

Staph aureus is a gram positive, coagulase positive cocci, commonly resistant to only penicillins,
which resides on the skin; Enterococcus is a gram positive cocco-bacilli that inhabits the
gastrointestinal tract. These bacteria can become multi-drug resistant making treatment options
more difficult.

MRSA and VRE are primarily nosocomial pathogens, however, community acquisition of MRSA
is increasing.

Transmission occurs most commonly via the hands of health care workers and can also occur
through contaminated equipment or environment.

These resistant bacteria can colonize or infect any body site and can live for long periods of time
(days, weeks, months) on inanimate surfaces that have not been cleaned after use with a
disinfectant or improperly cleaned.

VRE may transfer Vancomycin-resistance to other microorganisms, namely Staphylococcus
aureus, Staphylococcus epidermidis, and Streptococci.
DEFINITIONS
MRSA is a Staph aureus resistant to oxacillin (methicillin and nafcillin). May also be called ORSA (oxacillin
resistant Staph aureus).
Respiratory MRSA refers to MRSA isolated from sputum or a bronchial or tracheal specimen. It does not
include persons who have MRSA in the nares only.
VISA is a Staph aureus with intermediate resistance to Vancomycin (not common in USA).
VRSA is a Staph aureus resistant to Vancomycin (not common in USA).
VRE is Enterococcus resistant to Vancomycin.
Colonization or “carrier” state is defined as the isolation of the organism from a site without signs or
symptoms of infection.

MRSA carriage occurs in the nares, skin, mucous membrane, and other body sites.

VRE carriage occurs in the stool, perianal area and other body sites.
Infection is present when the organism is isolated from a body site with accompanying signs and symptoms of
infection.
Infection Control
Cooperative Wide
Management of the Patient
with Multi-resistant Organism (MRO)
Page 2 of 9
PATIENTS AT RISK for multi-resistant organisms include those with:
Prolonged stay in the hospital or a LTC facility,
Prolonged or multiple use of antibiotics,
The elderly
Presence of serious underlying disease,
Open skin wounds,
Invasive devices (especially recent endotracheal
intubation or indwelling urethral catheter).
RESOURCES:
 Patient Education Handout: Antibiotic Resistant Bacteria
http://incontext.ghc.org/clinical/infection_control/protocol/mro-pted.pdf

Vancomycin Usage Recommendations
http://incontext.ghc.org/clinical/infection_control/quick_ref/hicpac95.html

Policy D-07-009 Standard and Transmission Based Precautions
http://incontext.ghc.org/about/org-pol/d-07/d-07-009.html

Appendix1 Inpatient Transmission Based Precautions

Appendix 2 Ambulatory Transmission Based Precautions

Appendix 3 Home Care Transmission Based Precautions

Isolation Precaution Transmission Based Reference Table
http://incontext.ghc.org/clinical/infection_control/quick_ref/isolation.html

Hospital Policy HN-770: Roommate Selection Guideline
http://incontext.ghc.org/nursing_ops/nsg_stds/hospnursing/hn-770.pdf

Special Precautions Stop Sign (copy center)

Wound Care Procedures (Nursing Operations)
http://incontext.ghc.org/nursing_ops/woundcare/woundtoc.html

Refer to specific Departmental Polices (Surgical Services and Admitting)

MRO Screening Checklist for the Inpatient and Surgical Services Setting
http://incontext.ghc.org/clinical/infection_control/protocol/mro screen cklst.pdf

DOH Interim Guidelines for the Evaluation and Management of MRSA Skin and Soft Tissue
Infections in Outpatient Settings
http://incontext.ghc.org/clinical/infection_control/protocol/doh mrsa interim guidelines.pdf

DOH Interim Guideline Algorithm
http://incontext.ghc.org/clinical/infection_control/protocol/doh mrsa guideline algorithim.pdf

DOH CA-MRSA Instruction for MA’s and Nursing Staff
http://incontext.ghc.org/clinical/infection_control/protocol/doh mrsa-nursing.pdf
Infection Control
Cooperative Wide
CONTENTS:
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.
XIII.
Management of the Patient
with Multi-resistant Organism (MRO)
Page 3 of 9
Culture Specimen Collection and Ordering
Re-culturing of Previously Colonized or Infected Patients
Removal of Patients from Contact Precautions
Family Member Follow-Up of a Patient with MRSA
Treatment of MRO Infection
Decolonization of MRSA Patients and Staff
Patient Education
GHC Communication and Record-Keeping
Periodic Prevalence Studies
Outbreak Surveillance
Surgical Services
Inpatient Setting
Ambulatory Care Setting
XIV. Home and Community Services
I.
CULTURE SPECIMEN COLLECTION AND ORDERING
A. CULTURE SPECIMEN COLLECTION
 Refer to the Nursing Operations Standards: Wound Culturing Procedure
http://incontext.ghc.org/nursing_ops/woundcare/woundtoc.html

Use blue top culturette for skin, nares, wounds aerobic cultures
B. CULTURE ORDERING
MRSA Colonization Surveillance Screening (no clinical symptoms of infection)
 Refer to Clinical Lab Test Directory:
http://incontext.ghc.org/clinical/clin_lab/list/labdir.html
 Type in MRSA Screen in the lab search window.
 When screening for MRSA colonization only, order lab test code




(LIS) paper code 7062
EPIC (CIS) 87081.005
Eastern WA uses PAML Lab codes
Diagnosis code: V75.9 (Screening for infectious diseases)
 Identify specific body site cultured (when performing a nares culture, one swab may be
used for both nares; otherwise use a separate swab per other body sites)
Culturing for Evidence of Infection (clinical symptoms of infection present)
 Refer to Clinical Lab Test Directory:
http://incontext.ghc.org/clinical/clin_lab/list/labdir.html
 Type in Culture in the lab search window
 Identify what culture you want performed. If you have questions contact the microbiology
laboratory for clarification.
 A regular aerobic or anerobic culture will identify all aerobic organisms, including MRSA
II.
RE-CULTURING OF PREVIOUSLY COLONIZED OR INFECTED PATIENTS
Infection Control
Cooperative Wide
Management of the Patient
with Multi-resistant Organism (MRO)
Page 4 of 9
Repeatedly negative cultures are required to assure resolution of active colonization.
III.

MRSA: Two consecutive negative cultures of nares and 2 consecutive negative cultures of
previously positive sites (if possible) obtained no sooner than 48 hrs after completion of
antibiotic therapy, and should be collected at least 5 days apart.

VRE: Two consecutive negative cultures of perirectal and 2 consecutive negative cultures of
previously positive sites (if possible) obtained no sooner than 48 hrs after completion of
antibiotic therapy, and should be collected at least 5 days apart.
REMOVAL OF PATIENTS FROM CONTACT PRECAUTIONS
Must meet the same criteria of II. Re-culturing of Previously Colonized or Infected Patients
IV.
FAMILY MEMBER FOLLOW-UP OF A PATIENT WITH MRSA
Culturing and decolonization of family members of a patient with MRSA is not usually indicated, but
may be considered for household contacts of patients with recurrent infections or family members who
have close, frequent skin to skin contact with the colonized or infected patient. Consult Infectious
Disease for evaluation and recommendations regarding specific family situation.
V.
TREATMENT OF MRO INFECTION
A. Infectious Disease clinical consultation [Central 206-326-3055 (8-330-3055)] is suggested for
specific recommendations for antibiotic treatment.
B. Refer to Vancomycin Usage Guidelines on InContext:
http://incontext.ghc.org/clinical/infection_control/quick_ref/hicpac95.html
C. Surgical prophylaxis: the use of Vancomycin as a surgical antibiotic prophylaxis may be
appropriate in patients with MRSA colonization
D. Refer to the DOH

Interim Guidelines for the Evaluation and Management of MRSA Skin and Soft Tissue
http://incontext.ghc.org/clinical/infection_control/protocol/doh mrsa interim
guidelines.pdf

Quick Reference Evaluation and Management Algorithm
http://incontext.ghc.org/clinical/infection_control/protocol/doh mrsa guideline
algorithim.pdf
Infection Control
Cooperative Wide
VI.
Management of the Patient
with Multi-resistant Organism (MRO)
Page 5 of 9
DECOLONIZATION OF MRSA PATIENTS AND STAFF
A. Contact Infectious Disease at Central 206-326-3055 (8-330-3055) for clinical consultation for
staff or patients who may be candidates for decolonization or for use as a surgical antibiotic
prophylaxis.
B.
Decolonizaton is not indicated in individuals with a new first isolate or first clinical infection.
C.
Decolonization is usually not recommended, but may be considered in:

Patients with recurrent infections at different sites

Patients with MRSA colonization who have no wounds or tubes, especially those in
institutions who are potential sources of nosocomial transmission
D. Decolonization may include several approaches or combination of approaches (skin antiseptics,
topical ointment, or systemic treatment). Consult Infectious Disease to define specific approach
appropriate for individual patient and situation.
VII.
PATIENT EDUCATION
Patient Education Handout is available on the web, resource line, and patient summary.
Review with the patient and family the following handouts:


Patient Family Education Sheet: “Precautions for Antibiotic Resistant Bacteria (for patients
with MRSA and/or VRE)
http://incontext.ghc.org/clinical/infection_control/protocol/mro-pted.pdf
“Living With MRSA”, DOH pamphlet
http://incontext.ghc.org/clinical/infection_control/protocol/doh living with mrsa.pdf

VIII. GHC COMMUNICATION AND RECORD-KEEPING
A. Lastword Demographics Screen Infectious Disease Alert Flags (IFD)
IFD Alert identifies patients who have a known VRE or MRSA culture
(M=MRSA History; V=VRE History; B=Both MRSA and VRE History)
B.
EPIC
The Problem List in Chart Review will list the code V09.91 drug resistance nos multiple drugs
for VRE and/or MRSA. The patient toolbar will be orange colored for MRO diagnosis. Provider
will insert diagnosis code in problem list, which initiates EPIC toolbar highlight.
C. Infection Control
1. Maintains a log of all MRSA/VRE cultures obtained within the GHC and VMMC Lab
Systems and as notified by providers and other resources.
2. Assures labeling of the Problem List in the Outpatient Chart
3. Available for consultation
4. Completes a MRO Screening Checklist on referred surgery patients with history of MRO
colonization/infection.
5. Liaisons with local health departments
Infection Control
Cooperative Wide
IX.
Management of the Patient
with Multi-resistant Organism (MRO)
Page 6 of 9
PERIODIC PREVALENCE STUDIES
A. To identify previously unknown human reservoirs of infection prospective microbiological
surveillance can assist in identifying the prevalence of MROs.
B.
X.
Prevalence studies will be determined and initiated by the Infection Control Committee.
OUTBREAK MANAGEMENT
A. Based on passive forms of microbiological surveillance Infection Control will identify source and
transmission mode related to an outbreak situation.
B.
Staff will notify Infection Control when outbreak/transmission is suspected in a department.
Infection Control will determine surveillance need, strategy, and control plan, as well as,
interventions required to identify and stop outbreak.
C. Detection of Secondary Nosocomial Transmission (inpatient setting)
1. The Infection Control Department or Infectious Disease will initiate screening cultures for
suspected secondary transmission.
2. If a patient, who was in the hospital greater than or equal to 24 hours without being isolated,
is found to have MRSA or VRE, culture the following persons.
Situation
Current roommate, if s/he shared a room
with the index patient for 24 hours or
more.
Action
Culture nares for MRSA.
Culture perirectal for VRE.
Former roommates if possible.
Same as above.
Other exposed patients who are identified.
Consult with the Infection Control Dept.
3. Precautions: none until culture resulted.
XI.
SURGICAL SERVICES
A. Refer to Management of the Surgical Patient with an MRO Protocol
http://incontext.ghc.org/clinical/infection_control/protocol/or mro protocol.pdf
B.
Refer to Addendum: Anesthesia MRO Protocol
http://incontext.ghc.org/clinical/infection_control/protocol/anesth add-or mro
protocol.pdf
C.
MRO Screening Checklist
http://incontext.ghc.org/clinical/infection_control/protocol/mro screen cklst.pdf
Infection Control
Cooperative Wide
XII.
Management of the Patient
with Multi-resistant Organism (MRO)
Page 7 of 9
INPATIENT SETTING
A. Inpatient Admission MRSA Surveillance Screening
1. Precautions:

Standard precautions until the culture screening results are obtained for those with no
known MRSA history.

Contact precautions for those with prior MRSA history and have no record of two
negative culture(s) within 60 days of admission.
2. Patients with new or known history of a MRO: follow Section III: Removing Patient From
Contact Precautions.
3. Inform patient that culture screening of wound sites and urine (if Foley catheter is present) is
part of the admission process to help identify antibiotic resistant organisms. Patient may refuse
culture.
4. Screen the following patients for MRSA:
WHO
Patients admitted to the hospital (any) who
have

Cutaneous wounds

Foley catheters

Invasive devices (i.e., pegs,
trach, central lines)
Patients with a prior history of MRSA
B.
WHEN
Upon admission
Upon admission
1.
Body Site
Draining/moist wounds,
open skin lesions (include
pegs, trach, central line
wound sites)
2.
Urine, if Foley catheter
1.
Nares and,
2.
Draining or moist wounds,
if present
Inpatient Documentation: Hospital/Surgical Services
a. Admitting will follow dept specific procedure.
b. Surgical services will follow OR/Anesthesia dept specific MRO protocol.
c. Discharge/Transfer: Document multi-resistant organism colonization or infection on
transfer summary for both internal and external transfers.
C. Inpatient Precautions
Refer to Policy D-07-009 Standard and Transmission Based Precautions: Appendix 1: Inpatient
Setting
http://incontext.ghc.org/clinical/infection_control/infect_cont/ic_apdx/d7009apdx1.pdf
XIII. AMBULATORY CARE SETTING
A. Ambulatory Care MRSA Surveillance Screening
1. Patients with known history of a MRO: follow Section II. Re-culturing of Previously
Colonized or Infected Patients
2. Inform patient that screening cultures to identify antibiotic resistant organisms are performed
at the first visit when ongoing wound care is requested by the provider.
3. Screen the following patients for MRSA:
WHO
WHEN
Body Site
Infection Control
Cooperative Wide
Management of the Patient
with Multi-resistant Organism (MRO)
Page 8 of 9
Patients receiving ongoing cutaneous wound
care
First wound
care visit
Draining or moist wounds,
open skin lesions
Patients scheduled for outpatient surgery
with known history of a MRO
By PCP,
surgeon, preanesthesia
provider prior
to surgery date,
if feasible.
1.
Nares and,
2.
Draining or moist wounds,
if present (open skin
lesions, and surgical sites,
percutaneous tube sites)
B. Ambulatory Care Precautions
Refer to Policy D-07-009 Appendix 2: Transmission Based Precautions for Ambulatory Care.
http://incontext.ghc.org/clinical/infection_control/infect_cont/ic_apdx/d7009apdx2.pdf
C. Ambulatory Care Documentation
1. Document in Problem List Code V09.91 drug resistance nos multiple drugs for VRE and/or
MRSA
2. Document MRO on admission notes or order form when admitting patient to an inpatient
facility.
XIV. HOME HEALTH & HOSPICE (HH &HP) SERVICES
A. Home Health & Hospice Precautions
1. Refer to Departmental Policies
2. Refer to Policy D-07-009 appendix 3: Transmission Based Precautions for Home Care
B. Home Health Hospice MRSA screening
1. Patients with known history of presence of MRO do not require surveillance screen
2. Inform patient that screening cultures to identify antibiotic resistant organisms are performed
at first or second visit when ongoing wound care is requested by the provider
3. Hospice patients are only screened for MRSA following consultation with hospice MD.
Educate patient and family regarding precautions if no screening.
4. Screen the following patients for MRSA:
When
Program Who
Hospice
Home
Health
HH
Culture only with
consultation with
hospice MD
Patients receiving
ongoing cutaneous
wound care
Patients scheduled
for outpatient surgery
with known history
of a MRO
Body Site
prn
1st or 2nd visit
If ordered by PCP,
surgeon or
anesthesia prior to
surgery
Draining or moist wounds,
skin lesions, also all other
invasive sites
Nares and,
Draining or moist wounds if
present (open skin lesions,
and surgical sites,
percutaneous tube sites)
C. Home Health and Hospice Documentation
1. MRO will be documented in Horizon as a Non-Clinical Note and in the visit documentation
2. HH & Hospice will notify Infection Control of identified MRO case by completion of Unusual
Occurrence
Infection Control
Cooperative Wide
Management of the Patient
with Multi-resistant Organism (MRO)
Page 9 of 9
REFERENCES:
CDC. Hospital Infections Program (HIP). Methicillin-resistant staphylococcus aureus. 1997
(Jan).
CDC.MMWR. Interim guidelines for prevention and control of staph infection associated with
reduced susceptibility to vancomycin. 1997 (July 11).
CDC. MMWR. Recommendations for Preventing the spread of vancomycin resistance:
Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC).
September 22, 1995/44(RR12); 1-13.
CDC. MMWR. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the
Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA
Hand Hygiene Task Force. October 25, 2002/51 (RR-16).
Muto, C., et al. SHEA Guideline for preventing nosocomial transmission of multi-drug-resistant
strains of staphylococcus aureus and Enterococcus. Journal of the Society for Infection Control and
Hospital Epidemiology: Infection Control and Hospital Epidemiology. May 2003; 24:362-386.
Murrany, B. E. Diversity among multi-resistant Enterococcus. Emerging Infectious Diseases. 1998, 4
(1).
Washington State Dept of Health. Washington State VRE Task Force. Vancomycin resistant
Enterococcus: Information and recommendations. 1996 (Feb).
Written by:
Jean Nahan, RN, Infection Control
Revised by:
Gwenda Felizardo, RN, Infection Control
Original date:
4/94
Reviewed by:
Cooperative-wide Infection Control Practitioners
GHC Infection Control Committee
Home and Community Services
Hospital Nursing
Surgical Services
Reviewed/Revised date(s):
6/95, 2/97, 3/99, 5/2000, 5/2004, 5/05
Administrative Approval:
GHC Infection Control Committee