* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Management of the Patient with a Multi-resistant Organism - nc
Sexually transmitted infection wikipedia , lookup
Middle East respiratory syndrome wikipedia , lookup
Onchocerciasis wikipedia , lookup
Clostridium difficile infection wikipedia , lookup
Dirofilaria immitis wikipedia , lookup
Trichinosis wikipedia , lookup
Schistosomiasis wikipedia , lookup
Hepatitis C wikipedia , lookup
Staphylococcus aureus wikipedia , lookup
Sarcocystis wikipedia , lookup
Marburg virus disease wikipedia , lookup
Human cytomegalovirus wikipedia , lookup
Carbapenem-resistant enterobacteriaceae wikipedia , lookup
Hepatitis B wikipedia , lookup
Coccidioidomycosis wikipedia , lookup
Neonatal infection wikipedia , lookup
Fasciolosis wikipedia , lookup
Methicillin-resistant Staphylococcus aureus wikipedia , lookup
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