PIDAC – Best Practices for Infection Prevention and Control of Resistant Staphylococcus aureus and Enterococci

1. PIDAC – Best Practices for Infection Prevention and Control of Resistant Staphylococcus aureus and Enterococci CIPHI Conference May 4, 2007 Liz Van Horne Infection Prevention & Control Consultant MOHLTC

2. Objectives • To provide an overview of the PIDAC best practice document • To discuss the role of public health in implementing the recommendations

3. Best Practice Documents • Topics identified through consultation with healthcare providers • Search done to identify international, national, provincial guidelines/documents • Literature search conducted to identify evidence related to topic • Draft document developed and revised by Infection Prevention & Control (IP&C) subcommittee • Final draft sent for stakeholder review – results reviewed by IP&C subcommittee • Final document to PIDAC for approval then to Chief Medical Officer of Health (CMOH) • Posted on PIDAC website after approval from CMOH • Documents reviewed a minimum of every 2 years or more frequently as necessary

4. Best Practice Assumptions • Health care settings have basic infection prevention and control systems in place • Health care settings: • Routinely implement best practices • Devote adequate resources to infection prevention and control • Have programs that promote good hand hygiene practices and ensure adherence to standards • Devote adequate resources to housekeeping • Provide a setting conducive to following and maintaining Routine Practices • Provide regular education to staff

5. Best Practice Assumptions • Health care settings: • Promote collaboration between occupational health and infection prevention and control • Comply with Occupational Health and Safety Act and other legislated requirements • Have effective working relationship with local public health unit • Have access to ongoing infection prevention and control advice • Report back to staff on the impact of their surveillance efforts • Regularly assess the effectiveness of their infection prevention and control education programs and their impact on practices

6. Adherence to Routine Practices which includes hand hygiene, cannot be overemphasized.

7. Rationale for a comprehensive IPAC program to prevent MRSA and VRE • MRSA and VRE impact patient outcomes, quality of care and duration of hospitalization. • Patients infected with MRSA have a higher incidence of mortality, particularly those with MRSA bacteremia • The use of Contact Precautions impacts quality of care and quality of life, with patients expressing greater dissatisfaction with treatment and receiving less documented care • The duration of stay in hospital for MRSA and VRE patients is often longer than those without MRSA and VRE

8. Rationale for a comprehensive IPAC program to prevent MRSA and VRE • Increased cost of care to health care system • In 2004 dollars it is estimated it cost between $16836-$35000 to manage a patient infected with MRSA and $1634 to manage a colonized patient. • Therefore following IPAC best practices decreases adverse outcomes and reduces associated costs to the health care system.

9. Number of Patients Colonized/Infected with MRSA, Ontario, 1992-2005 . QMP/LS Surveys, 1996-2005

10. VRE - ONTARIO 2,161 No. patients colonized/infected 1,031 718 685 589 492 445 445 237 167 99 7 2 0

11. Grading System for Recommendations Categories for strength of each recommendation A- Good evidence to support a recommendation for use B- Moderate evidence to support recommendation for use C- Insufficient evidence to support a recommendation for or against its use D- Moderate evidence to support a recommendation against use E- Good evidence to support a recommendation against use. Categories for quality of evidence 1- Evidence from at least 1 properly randomized controlled trial 11- Evidence from at least 1 well-designed clinical trial without randomization. 111- Evidence from opinions of respected authorities on basis of clinical experience, descriptive studies or reports of expert committees.

12. Screening to identify colonized and infected patients with MRSA and VRE • Screening is not a control method in itself as Routine Practices must be used with every patient/resident • Purpose is to identify patients with MRSA or VRE so further control measures can be put in place

13. Admission screening • Admission screening tool should be applied to all patients. The following patients are at increased risk for both MRSA and VRE so should be screened for both (A11 recommendation) Those who have: • Previously been colonized or infected with MRSA or VRE • Spent time in a health care facility outside of Canada in the last 12 months • Spent time in a health care facility or who have spent more than 12 continuous hours in any health care facility in the past 12 months • Transferred between health care facilities (e.g. between hospitals or between a long term care home and a hospital) • Patients recently exposed to a unit/area of health care facility with an MRSA or VRE outbreak • Other high-risk patient populations as identified by the Infection Prevention & Control Professionals (ICP), Public Health or RICN

14. Admission screening • Based on local epidemiology and risk factors, additional individuals may be considered for MRSA screening: • Those receiving home health care services in the past year • Those receiving treatment with an indwelling medical device • Those receiving care in intensive care units, transplant units, burn units • Those living in a communal setting (e.g. shelters, halfway home, correctional facility) • Those with a history of injection drug use • Those who are household contacts of people with MRSA • Those who are immunocompromised • Populations where Ca-MRSA is known to be a problem (e.g. organized sports teams)

15. Screening… • Verification: • If there is a single positive specimen from a single site in a newly identified case, consideration should be given to confirming with a repeat specimen (B111) • ? Mislabelling at unit level • ? Error in laboratory • Discrepant results could be a false-positive. If results do not concur, an investigation must be performed to identify the reasons for the discrepancy.

16. Specimens • MRSA (A11) • Anterior nares AND • Perianal* area AND • Skin lesions, wounds, incisions, ulcers and exit sites of indwelling devices • Newborns: a swab from the umbilicus should also be taken * a perineal or groin swab is also acceptable • VRE • Must include stool or a swab from the rectum or anus. Stool specimens are preferred as they provide a higher yield. (A11)

17. Additional Precautions for MRSA and VRE in addition to Routine Practices • Contact Precautions • Decisions regarding patient placement • Safe management of equipment and environment • Appropriate PPE for the organism and setting • Effective communication to affected departments and other facilities • Education for staff, patients and family

18. Acute Care Placement – single room Hand hygiene – staff and patients Dedicate equipment PPE Gloves – enter room/bed space Gown – enter room/bed space Consider mask Visitors PPE only if contact with other patients or provide direct care Educate on hand hygiene and use of PPE Patients – no PPE to leave room if assessment allows Long-Term Care Placement – determine based on risk factors Hand hygiene – staff and residents Dedicate equipment Adapt to permit residents to participate in activities PPE Gloves and gown for direct care Visitors PPE only if moving between residents or provide direct care Residents – no PPE to leave room Contact Precautions

19. Personal Protective Equipment (PPE) for MRSA or VRE in non-acute care settings • Direct Care: • Providing hands on care such as bathing, washing, turning patient, changing clothes/incontinence briefs, dressing changes, care of open wounds/lesions or toileting. • Feeding, and pushing a wheel chair are not classified as direct care.

20. Signage and Patient/visitor education • Signage indicating Contact Precautions should be posted at the entrance to room or bedspace. Signage should maintain privacy by indicating only the precautions that are required, not information regarding the patient's condition (C111) • Patients and visitors must be informed about the reason for implementing the Contact Precautions and be educated in the proper use of hand hygiene and Contact Precautions (C111)

21. Environment and equipment • Dedicate equipment to a single patient on Contact Precautions. If MRSA positive or VRE positive patients are cohorted, equipment may be cohorted. (B111) • Equipment must be cleaned and disinfected as per Routine Practices between patients • Review your cleaning and disinfection methods to ensure that they are adequate for disinfection of contaminated surfaces (C111) • As per Routine Practices, rooms and dedicated equipment used for patients with MRSA must be thoroughly cleaned and then disinfected using a hospital-grade disinfectant upon discharge of the patient. (B111)

22. Environment and equipment • Stringent protocols are required for the daily cleaning of rooms contaminated with VRE. • There must be a process to ensure that there has been adequate cleaning and disinfection of rooms and shared non-medical equipment contaminated with VRE following patient discharge. • Use of a checklist to ensure that all areas and surfaces are cleaned and disinfected and that post-cleaning inspection of the room has taken place (B111) • In situations with persistent VRE transmission, consideration may be given to post-cleaning environmental cultures to document that discharge cleaning of rooms is adequate.

23. Laundering • Routine health care cleaning practices for laundering linens are adequate for eliminating MRSA and VRE. (A1) • All curtains should be removed and laundered when soiled and after discharge of a patient with VRE. (B111) • Consideration should be given to removal and laundering of privacy curtains after discharge of an MRSA patient.

24. Patient Transfers • When a patient with MRSA or VRE is transferred to, from, or within a health care setting, communication regarding the MRSA or VRE status is essential. • All health care facilities in Ontario are expected to have the ability to care for patients who have MRSA or VRE.

25. Patient Mobility • In acute care settings, prior to leaving their room, patients with MRSA or VRE should be assessed on a case-by-case basis to determine their risk of transmission. (B111) • Patient understands and is able to comply with precautions • Drainage is contained • Does not have a productive cough (applicable for MRSA) • Is continent of stool and urine or contained by incontinence brief/indwelling catheter • Patient uses basic hygiene practices, including cleaning hands on leaving room • Is not on an outbreak unit • Has no other disease requiring precautions • Additional restrictions may be considered for patients with VRE

26. Patient Mobility • In non-acute care settings, residents with MRSA or VRE are not required to remain in their room. (B111)

27. Staff Considerations • Staff must receive education in the correct and consistent use of Routine Practices as a fundamental aspect of infection prevention and control in health care settings, with emphasis on hand hygiene and appropriate use of PPE. (B111) • Screening of staff for MRSA should be considered when an outbreak of the same strain of MRSA continues to spread despite adherence to control measures, or when an individual is strongly epidemiologically linked to the new acquisition of MRSA. (B111)

28. Staff Considerations • Decolonization of staff colonized with MRSA should be done when they are epidemiologically linked to an outbreak with the same strain and adherence to Additional Precautions has failed to contain the outbreak. (A11) • If staff are colonized with a strain of MRSA that is different from the outbreak strain, decolonization may be considered. (B111)

29. Visitors • Visitors have not been implicated in the transmission of MRSA or VRE in health care facilities; however, all persons entering and leaving a patient’s room require instruction on how to enter and leave the room safely when the patient is on Contact Precautions. • Written information should be available for patients and their families describing Contact Precautions and why they are important. (B111) • Visitors should receive education and training in correct hand hygiene procedures. (B111)

30. Decolonization • Routine decolonization therapy of MRSA patients is not currently recommended. (E11) • Decolonization therapy with topical antibiotics alone is not effective. • VRE decolonization is not effective and is not recommended. (E1) • In situations where a patient colonized with MRSA is implicated in an outbreak, decolonization may be considered in consultation with the ICP. (B111) • If MRSA decolonization therapy is used, attention must be given to scrupulously cleaning the environment in order to decrease the risk of recolonization, as the environment can play a role in transmission.

31. Role of the Laboratory • Labs should recognize that turnaround time is critical in prevention of transmission of MRSA and VRE. Labs and ICP should develop reporting systems that notify ICP’s of suspected MRSA or VRE prior to final confirmation. (A111) • The lab should employ methods that allow for as rapid as possible turnaround time for screening specimens for MRSA and VRE. (A11) • Labs should save isolates of MRSA and VRE (one isolate per patient) for a minimum of 6 months (A111) • Lab support during outbreak investigation should include the ability to obtain molecular typing. (A111)

32. Education • Education concerning the epidemiology, prevention and control of MRSA and VRE should be given to staff to ensure that they are knowledgeable regarding transmission and the correct use of PPE and to enable them to use and teach Additional Precautions appropriately.(B111) • Patients and visitors should be taught hand hygiene and encouraged to remind anyone entering the room to perform hand hygiene before and after leaving the room (B111) • Patient teaching should include basic hygiene practices such as not sharing personal items and covering their mouth when coughing. (B111) • Visitors should receive instruction regarding specific facility control measures that might be in place before they visit a patient. (B111)

33. Antibiotic Stewardship • Policies and procedures should be implemented to promote judicious antibiotic use, in order to limit the increase and spread of antibiotic resistant organisms. (A11) • Health care settings should institute formulary control of antibiotics and should conduct regular reviews of antibiotic utilization. (A111)

34. Program Evaluation • Multi-disciplinary audits followed by feedback and an action plan to improve practices : • Screening tools are used to identify MRSA, VRE patients • Hand Hygiene, Routine Practices, Additional Precautions • Disinfecting of equipment that moves from patient to patient • Cleaning of rooms

35. Program Evaluation Surveillance: • It is important to have front line staff, administrators and IPAC Committee review surveillance data and provide feedback which may prompt a review of practices and prevention measures. • Collate and analyze data • Generate facility and unit associated infection rates • Create standardized reports from the data • Examine trends for sources of MRSA or VRE • Feedback rates and trends to staff • There should be an ongoing plan of action to improve the processes and outcomes

36. FAQ: To Wear a Surgical Mask or not? The use of a surgical mask for contact with patients colonized/infected with MRSA is controversial. • evidence from 1 study showed a lower rate of colonization in staff wearing masks, likely due to avoidance of hand-to-nose contact. Recommendation: • Acute care, consideration may be given to wearing a surgical mask as part of precautions when entering the room of a patient with MRSA to decrease nasal acquisition by health care workers. • Non acute care, consideration maybe given to wearing a surgical mask for the provision of direct care with residents with MRSA as per Routine Practices to decrease nasal acquisition by health care workers. If masks are worn, ensure they are worn safely and correctly.

37. FAQ: What is the MRSA benchmark per 1000 days? Canadian Nosocomial Infections Surveillance Program (CNISP) average: • MRSA: 0.7/1000 patient days • VRE: 0.15/1000 patient days • There is no provincial benchmark rate. Facilities are not using the same methods and definitions for collecting data so rates are not comparable. • Surveillance should be done for MRSA and VRE; rates can be compared for the facility over time and between clinical areas within the facility.

38. FAQ: Why are rooms not to be shared by MRSA patients and VRE patients only in acute care settings? • Single rooms are always preferred for both MRSA and VRE patients in both acute and non-acute care settings • Many facilities have insufficient single rooms to accommodate all MRSA and VRE patients • In acute care settings, because of acuity and frequent interventions the risk of acquisition and subsequent clinical infection is higher • In non-acute settings, the quality of life of the resident must be considered

39. FAQ:Is there evidence one way or the other regarding MRSA decolonization or is it on a case-by-case basis? • Routine decolonization is not currently recommended. Decolonization is decided on a case-by-case basis. Factors to consider are: • Presence of indwelling devices • Presence of wounds/skin lesions • Presence of multiple co-morbidities • Mupirocin susceptibility of the MRSA isolate • Linkage of the patient to ongoing transmission • Ability to comply with decolonization/hygiene measures

40. FAQ: The document recommends that settings verify a single positive swab with a repeat swab. If the repeat swab is negative and no errors are found, how many negative specimens are needed to remove the patient from additional precautions? • Two

41. FAQ: Are droplet precautions required for MRSA in the sputum for a chronic COPD patient or would one use Contact precautions with Routine Practices? • Routine Practices requires use of a mask when within one meter of a coughing patient • Plus Contact Precautions for MRSA.

42. FAQ: Are shaking hands, playing cards or being tablemates considered activities that allow transmission to occur? • Cleaning hands correctly before and after the activity will remove organisms • Is there strategically and safely placed alcohol based-hand rub as they entire the OT room, Dining room, physio room, game room?