Table 3. Tier 2. Recommendations for Intensified MDRO Control Efforts

Institute one or more of the interventions described below when

1. incidence or prevalence of MDROs are not decreasing despite the use of routine control measures; or
2. the first case or outbreak of an epidemiologically important MDRO (e.g., VRE, MRSA, VISA, VRSA, MDR-GNB) is identified within a healthcare facility or unit (IB)

Continue to monitor the incidence of target MDRO infection and colonization; if rates do not decrease, implement additional interventions as needed to reduce MDRO transmission.

Administrative Measures/Adherence Monitoring

• Obtain expert consultation from persons with experience in infection control and the epidemiology of MDROs, either in- house or through outside consultation, for assessment of the local MDRO problem and guidance in the design, implementation and evaluation of appropriate control measures. (IB)
• Provide necessary leadership, funding and day-to-day oversight to implement interventions selected. (IB)
• Evaluate healthcare system factors for role in creating or perpetuating MDRO transmission, including staffing levels, education and training, availability of consumable and durable resources; communication processes, and adherence to infection control measures. (IB)
• Update healthcare providers and administrators on the progress and effectiveness of the intensified interventions. (IB)

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MDRO Education

• Intensify the frequency of educational programs for healthcare personnel, especially for those who work in areas where MDRO rates are not decreasing. Provide individual or unit-specific feedback when available. (IB)

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Judicious Antimicrobial Use

• Review the role of antimicrobial use in perpetuating the MDRO problem targeted for intensified intervention. Control and improve antimicrobial use as indicated. Antimicrobial agents that may be targeted include vancomycin, third generation cephalosporins, anti- anaerobic agents for VRE; third generation cephalosporins for ESBLs; and quinolones and carbapenems. (IB)

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Surveillance

• Calculate and analyze incidence rates of target MDROs (single isolates/patient; location-, service- specific) (IB)
• Increase frequency of compiling, monitoring antimicrobial susceptibility summary reports (II)
• Implement laboratory protocols for storing isolates of selected MDROs for molecular typing; perform typing if needed (IB)
• Develop and implement protocols to obtain active surveillance cultures from patients in populations at risk. (IB)(See recommendations for appropriate body sites and culturing methods.)
• Conduct culture surveys to assess efficacy of intensified MDRO control interventions. Conduct serial (e.g., weekly) unit- specific point prevalence culture surveys of the target MDRO to determine if transmission has decreased or ceased. (IB)
• Repeat point-prevalence culture- surveys at routine intervals and at time of patient discharge or transfer until transmission has ceased. (IB)
• If indicated by assessment of the MDRO problem, collect cultures to assess the colonization status of roommates and other patients with substantial exposure to patients with known MDRO infection or colonization. (IB)
• Obtain cultures from HCP for target MDROs when there is epidemiologic evidence implicating the staff member as a source of ongoing transmission. (IB)

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Infection Control Precautions to Prevent Transmission

Use of Contact Precautions:

• Implement Contact Precautions (CP) routinely for all patients colonized or infected with a target MDRO. (IA)
• Don gowns and gloves before or upon entry to the patient’s room or cubicle. (IB)
• In LTCFs, modify CP to allow MDRO- colonized/infected patients whose site of colonization or infection can be appropriately contained and who can observe good hand hygiene practices to enter common areas and participate in group activities
• When active surveillance cultures are obtained as part of an intensified MDRO control program, implement CP until the surveillance culture is reported negative for the target MDRO (IB)
• No recommendation is made for universal use of gloves and/or gowns. (Unresolved issue)
• Implement policies for patient admission and placement as needed to prevent transmission of the problem MDRO. (IB)
• When single-patient rooms are available, assign priority for these rooms to patients with known or suspected MDRO colonization or infection. Give highest priority to those patients who have conditions that may facilitate transmission, e.g., uncontained secretions or excretions. When single-patient rooms are not available, cohort patients with the same MDRO in the same room or patient-care area. (IB)
• When cohorting patients with the same MDRO is not possible, place MDRO patients in rooms with patients who are at low risk for acquisition of MDROs and associated adverse outcomes from infection and are likely to have short lengths of stay. (II)
• Stop new admissions to the unit or facility if transmission continues despite the implementation of the intensified control measures. (IB)

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Environmental Measures

• Implement patient.-dedicated use of non-critical equipment (IB)
• Intensify and reinforce training of environmental staff who work in areas targeted for intensified MDRO control.
• Some facilities may choose to assign dedicated staff to targeted patient care areas to enhance consistency of proper environmental cleaning and disinfection services (IB)
• Monitor cleaning performance to ensure consistent cleaning and disinfection of surfaces in close proximity to the patient and those likely to be touched by the patient and HCWs (e.g., bedrails, carts, bedside commodes, doorknobs, faucet handles) (IB).
• Obtain environmental cultures (e.g., surfaces, shared equipment) only when epidemiologically implicated in transmission (IB)
• Vacate units for environmental assessment and intensive cleaning when previous efforts to control environmental transmission have failed (II)

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Decolonization

• Consult with experts on a case-by-case basis regarding the appropriate use of decolonization therapy for patients or staff during limited period of time as a component of an intensified MRSA control program (II)
• When decolonization for MRSA is used, perform susceptibility testing for the decolonizing agent against the target organism or the MDRO strain epidemiologically implicated in transmission. Monitor susceptibility to detect emergence of resistance to the decolonizing agent. Consult with microbiologists for appropriate testing for mupirocin resistance, since standards have not been established.
• Do not use topical mupirocin routinely for MRSA decolonization of patients as a component of MRSA control programs in any healthcare setting. (IB)
• Limit decolonization to HCP found to be colonized with MRSA who have been epidemiologically implicated in ongoing transmission of MRSA to patients. (IB)
• No recommendation can be made for decolonization of patients who carry VRE or MDR- GNB.

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