Enhanced Barrier Precautions For MDRO Final
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Preventing the Spread of Novel or Targeted Multidrug-resistantOrganisms (MDROs) in Nursing Homes throughEnhanced Barrier PrecautionsClinician Outreach and Communication Activity (COCA) Webinaremergency.cdc.gov/cocaOctober 24, 2019
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At the conclusion of the session, participantswill be able to accomplish the following:1. Describe the burden of multidrug-resistant organisms (MDROs).2. Describe challenges to preventing MDRO transmission in nursing homes.3. Define Standard Precautions, Enhanced Barrier Precautions, and ContactPrecautions.4. Identify which residents and activities meet criteria for Enhanced BarrierPrecautions.5. Discuss best practices for implementing Enhanced Barrier Precautions.
Today’s First PresenterNimalie Stone, MD, MSTeam Lead, Long-term Care TeamPrevention and Response BranchDivision of Healthcare Quality PromotionCenters for Disease Control and Prevention
Today’s Second PresenterKara Jacobs-Slifka, MD, MPHLCDR United States Public Health ServiceLong-term Care Team, Prevention and Response BranchDivision of Healthcare Quality PromotionCenters for Disease Control and Prevention
National Center for Emerging and Zoonotic Infectious DiseasesEnhanced Barrier Precautions in Nursing Homes to Prevent theSpread of Novel or Targeted Multidrug-Resistant OrganismsNimalie D. Stone, MD, MSKara Jacobs-Slifka, MD, MPHMSLong-term Care Team, Prevention and Response BranchDivision of Healthcare Quality PromotionCDC Clinician Outreach and Communication Activity (COCA)October 24, 2019
Today’s Outline Burden of multidrug-resistant organisms (MDRO) Challenges with preventing MDRO transmission Define Standard Precautions, Enhanced Barrier Precautions, and ContactPrecautions Identify which residents and activities meet criteria for Enhanced BarrierPrecautions Discuss best practices for implementing Enhanced Barrier Precautions
Threat of Antibiotic Resistance (AR) 2013 CDC Antibiotic Resistance Threats in the UnitedStates– Estimated more than 2 million antibiotic-resistant infectionsand at least 23,000 deaths in US hospitals each year Infections from antibiotic resistant organisms are morecostly and difficult to treat Capacity to detect new antibiotic resistance is constantlyexpandingAntibiotic Resistance (AR) Biggest Threats and reats.html)
Carbapenemase-Producing Organisms (CPOs):Emerging Resistance Threat Produce enzymes that breakdown carbapenems Carry resistance genes on mobile genetic elements, called plasmids, that can be easilyspread Cause invasive infections associated with high mortality rates due to challengesfinding effective antibiotic treatment Emerging throughout the United States and around the globe
Carbapenemases found in CPOs Multiple different mechanisms can cause high level resistance– Examples of Carbapenemase-producing genes found in CRE (CP-CRE) KPC - Klebsiella pneumoniae carbapenemase (most common in U.S.) NDM – New Delhi Metallo-β-lactamase VIM – Verona Integron-encoded Metallo- β -lactamase OXA – Oxacillinase-48-type carbapenemases IMP – Imipenemase Metallo- β –lactamase These genes have been reported in Enterobacteriaceae, Pseudomonasaeruginosa and Acinetobacter baumannii Public health laboratories offer carbapenemase testing
Candida auris Emerging fungal pathogen Tends to be drug-resistant Colonized individuals have risk of invasiveinfection– 5-10% develop C. auris bloodstreaminfection within a year Yeast that spreads easily in healthcare settings,similar to resistant bacteria
Snapshot of Multidrug-Resistant Organism (MDRO)Carriage in Nursing HomesFacilitieswith skilledunits(n 14)Facilities withventilatorunits(n 4)Median:58% MDROcarriageMedian:76% MDROcarriageMcKinnell JA et al. Clin InfectDis. 2019. 69(9):1566-1573
Risks for MDRO Colonization and Acquisition in NursingHomes Indwelling medical devices (e.g.,urinary catheter, PEG tube,tracheostomy/vents, central line) Presence of wounds or decubitusulcers Antibiotic use in prior 3 months,particularly fluoroquinolones Recent hospitalization Comorbid medical conditions Increased functional dependenceProlonged length of stay also increasesopportunities for spread
Healthcare Networks Drive MDRO Spread Patient movements amplify the regionalburden of MDROs, especially in centerswith:––––Longer length of stayIncreasing acuity of careDecreased staff: patient ratiosGaps in infection prevention practicesWon SY et al. Clin Infect Dis. 2011;53(6):532-540.
Unrecognized MDRO Carriage in Nursing HomesFacilitieswith skilledunits (n 14)58% MDROcarriageDocumentedMDRO: 17%Facilities withventilatorunits(n 4)76% MDROcarriageDocumentedMDRO: 20%McKinnell JA et al.Clin Infect Dis. 2019.69(9):1566-1573
Challenges with Detection of MDROs Clinical cultures underestimate trueprevalence of MDROs Most centers are not performing activesurveillance to identify asymptomatic,colonized residents– Contribute to the reservoir fortransmission Inadequate communication about individualMDRO history or risk factors betweenhealthcare facilities during care transitions
Characteristics of Novel/Targeted MDROs in HealthcareResistanceDetectionTransmissionSpread
Containment StrategySystematic public health response to slow the spread of emerging ARDetectionInfection ControlContact ScreeningOften responding to asingle caseOnsite assessment usingstandardized toolsAvailable through ARLNRegular infection control assessments and screening(point prevalence surveys) until transmission stops.
AR Containment Response Experience in Post-acute CareReview of 113 CDC supported responses to emerging AR pathogens from Jan2017-Dec 2018 Over 60% (72) involved post-acute care facilities (i.e., long-term acute carehospitals, nursing homes, inpatient rehabilitation facilities)– 70% of these post-acute care responses occurred in high-acuity facilities,LTACHs or nursing homes with ventilator units Although ventilator services in nursing homes remain relatively rare, ( 5%),25% of AR containment responses involved nursing homes with this capability
Ventilator Floor March 2017 C. auris PrevalenceC. auris Prevalence 1.5% (1/69)C. auris positive (1)Screened negative for C. auris (64)Not tested for C. auris (refused or not in room) (4)Slide courtesy of Chicago Department of Public Health.
Ventilator Floor January 2018 C. auris PrevalenceC. auris Prevalence 43% (29/67)C. auris positive (29)Screened negative for C. auris (33)Not tested for C. auris (refused or not in room) (5)Slide courtesy of Chicago Department of Public Health.
Ventilator Floor October 2018 C. auris and CPO PrevalenceC. auris Prevalence 71% (49/69)CPO Prevalence 61% (42/69)C. auris positive (16)C. auris, KPC-CPO, NDM-CPO (1)C. auris, and KPC-CPO (28)C. auris, KPC-CPO, VIM-CPO (4)KPC-CPO (9)No known CPO or C. auris (11)Slide courtesy of Chicago Department of Public Health.
Common Infection Control Challenges Identified duringAR Containment Responses Gaps in adherence to hand hygiene, limited access to alcohol-based handrubs inside and outside of resident rooms Limited access to personal protective equipment (PPE) and minimal use ofContact Precautions Improper product selection, use and frequency to reduce environmentalsurface contamination within shared rooms Inadequate cleaning/disinfection of equipment shared between residents Incomplete communication of MDRO history or risk factors during facilitytransfers
MDRO Prevention: Novel and Core Strategies
Implementing PPE and Precautions in Nursing Homes
Personal Protective Equipment (PPE) & cautions
Standard PrecautionsPPERespiratory Hygiene &Cough EtiquetteHand HygieneEnvironmental Cleaning &DisinfectionInjection &Medication SafetyReprocessing of ReusableMedical Equipment
Transmission-Based PrecautionsTransmission-Based asics/transmission-based-precautions.html)
Contact Precautions for MDROs Perform hand hygiene Gown and gloves upon room entry Dedicated equipment Private room Room restriction
Difficulty in Applying Transmission-Based Precautionsfor MDROs in Nursing Homes “Transmission-Based Precautions must be used when a residentdevelops signs and symptoms of a transmissible infection” “Facility policies must identify type and duration of Transmission-BasedPrecautions” “Transmission-Based Precautions should be the least restrictivepossible for the resident based on his/her clinical situation and used forthe least amount of time” “Once the resident is no longer a risk for transmitting the infection removing Transmission-Based Precautions is required”Department of Health and Human Services. Centers for Medicare and Medicaid Services. Rev. 173, 11-22-17.State Operations Manual Appendix PP: Guidance to Surveyors for Long Term Care Facilities [PDF – 749 /Guidance/Manuals/downloads/som107ap pp guidelines ltcf.pdf
Difficulty in Applying Transmission-Based Precautionsfor MDROs in Nursing Homes “Transmission-Based Precautions must be used when a residentColonization Infection infection”develops signs and symptomsof a transmissible “Facility policies must identify type and duration of Transmission-BasedPrecautions” “Transmission-Based Precautions should be the least restrictivepossible for the resident based on his/her clinical situation and used forthe least amount of time” “Once the resident is no longer a risk for transmitting the infection removing Transmission-Based Precautions is required”Department of Health and Human Services. Centers for Medicare and Medicaid Services. Rev. 173, 11-22-17.State Operations Manual Appendix PP: Guidance to Surveyors for Long Term Care Facilities [PDF – 749 /Guidance/Manuals/downloads/som107ap pp guidelines ltcf.pdf
Difficulty in Applying Transmission-Based Precautionsfor MDROs in Nursing Homes “Transmission-Based Precautions must be used when a residentColonization Infection infection”develops signs and symptomsof a transmissible “Facility policies must identify type and duration of Transmission-BasedPrecautions”Durationof MDROshouldcolonizationcanrestrictivebe “Transmission-BasedPrecautionsbe the leastpossible for the residentbased on his/herclinical situation and used forprolonged( 6 months)the least amount of time” “Once the resident is no longer a risk for transmitting the infection removing Transmission-Based Precautions is required”Department of Health and Human Services. Centers for Medicare and Medicaid Services. Rev. 173, 11-22-17.State Operations Manual Appendix PP: Guidance to Surveyors for Long Term Care Facilities [PDF – 749 /Guidance/Manuals/downloads/som107ap pp guidelines ltcf.pdf
Difficulty in Applying Transmission-Based Precautionsfor MDROs in Nursing Homes “Transmission-Based Precautions must be used when a residentColonization Infection infection”develops signs and symptomsof a transmissible “Facility policies must identify type and duration of Transmission-BasedPrecautions”Durationof MDROshouldcolonizationcanrestrictivebe “Transmission-BasedPrecautionsbe the leastpossible for the residentbased on his/herclinical situation and used forprolonged( 6 months)the least amount of time” “Once the resident is no longer a risk for transmitting the infection remains at Precautionsrisk for transmittingthe MDROremovingResidentTransmission-Basedis required”even when not actively infectedDepartment of Health and Human Services. Centers for Medicare and Medicaid Services. Rev. 173, 11-22-17.State Operations Manual Appendix PP: Guidance to Surveyors for Long Term Care Facilities [PDF – 749 /Guidance/Manuals/downloads/som107ap pp guidelines ltcf.pdf
Focusing only on residents with active infection failsto address the continued risk of transmission fromresidents with MDRO colonization,which can persist for long periods of time (e.g.,months), and result in the silent spread of MDROs.
Resident Quality of LifeResident SafetyPreventing spread ofMDROs
“Home-like”environmentResident Quality of sident SafetyPreventing spread ofMDROs
Lack of Private roomsDifficulty ��environmentResident Quality of sident SafetyPreventing spread ofMDROs
The Need for a New Approach Clarification of how and when to use PPE and room restriction to preventthe spread of MDROs Balanced approach to managing the prolonged colonization andpreventing the silent spread of MDROs Consider at-risk nursing home residents
Enhanced Barrier Precautions (EBP):Guidance for Nursing Homes to Prevent MDRO SpreadImplementation of PPE in Nursing Homes to Prevent Spread of Novel or Targeted ng-Homes.html
“Enhanced Barrier Precautions expand theuse of PPE beyond situations in which exposure toblood and body fluids is anticipatedand refer to the use of gown and gloves duringhigh-contact resident care activities that provideopportunities for transfer of MDROs to staff handsand clothing.”
High-contact Resident Care Activities Dressing Bathing/showering Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use of a device: central line, urinary catheter, feeding tube,tracheostomy/ventilator Wound care: any skin opening requiring a dressing
MRSA Transmission to Gowns and Gloves of HCW duringCare of Colonized Residents Highest Risk:̶ Dressing̶ Transferring̶ Providing hygiene̶ Changing linens̶ Toileting Lowest Risk:̶ Giving Meds̶ Glucose monitoringRoghmann et al. Infect Control Hosp Epidemiol.2015 September; 36(9): 1050-1057
Resistant Gram-negative Bacteria (RGNB) Transmissionto Gowns and Gloves of HCW during Care of ColonizedResidents Highest Risk:̶ Showering̶ Hygiene̶ Toileting̶ Wound dressing changes Lowest Risk:̶ Assist feeding̶ Giving meds̶ Glucose monitoringBlanco et al. Infect Control Hosp Epidemiol (2018), 39,1425-1430
Enhanced Barrier Precautions should be usedfor all residents with any of the following: Infection or colonization with a novel or targeted MDRO (as of July 2019)defined as:̶ Pan-resistant organisms,̶ Carbapenemase-producing Enterobacteriaceae,̶ Carbapenemase-producing Pseudomonas spp.,̶ Carbapenemase-producing Acinetobacter baumanii,̶ Candida auris Wounds and/or indwelling medical devices (e.g. central line, urinary catheter,feeding tube, tracheostomy/ventilator) regardless of MDRO colonizationstatus residing in an at-risk area When Contact Precautions do not apply
Contact Precautions should be used: All residents infected or colonized with a novel or targeted multidrugresistant organism in specific situations:̶ Presence of acute diarrhea, draining wounds or other sites of secretions orexcretions that are unable to be kept covered or contained̶ On units or in facilities where ongoing transmission is documented orsuspected For infections (e.g., C. difficile, norovirus, scabies) and other conditionswhere Contact Precautions is recommended̶ See Appendix A – Type and duration of Precautions Recommended forSelected Infections and Conditions of the CDC Guideline for IsolationPrecautions
Why was the EBP Guidance Needed for Containment?Focusing only on residents with active infection fails to address the continued riskof transmission from residents with MDRO colonization, which can persist for longperiods of time (e.g., months) and result in the silent spread of MDROS. Contact screening detects additionalcolonized residents not previouslyrecognized Facilities needed an approach togown/glove use that was less restrictivethan Contact Precautions and could besustained for prolonged period of time EBP also addresses care of residents at riskfor acquiring colonizationAs of July 2019, Novel or TargetedMDROs are defined as: Pan-resistant organisms, Carbapenemase-producingEnterobacteriaceae, Carbapenemase-producingPseudomonas spp., Carbapenemase-producingAcinetobacter baumannii, and Candida auris
Personal Protective Equipment (PPE) & utionsContactPrecautions
Standard PrecautionsPPE used for thesePrecautions Applies to: situations:StandardPrecautionsAll residentsAny potential exposure to: BloodBody fluidsMucous membranesNon-intact skinPotentially contaminatedenvironmental surfaces orequipmentRequired PPEDepending onanticipated exposure:gloves, gown, or faceprotection(PPE always changedand hand hygieneperformed before careof another resident)
Application ofEnhanced Barrier Precautions vs. Contact PrecautionsEnhanced Barrier PrecautionsContact PrecautionsApplies to:Applies to:All residents with any of the following: Infection or colonization with a novel or targetedMDRO when Contact Precautions do not apply. Wounds and/or indwelling medical devices (e.g.,central line, urinary catheter, feeding tube,tracheostomy/ventilator) regardless of MDROcolonization statusAll residents infected or colonized with a novel ortargeted multidrug-resistant in specific situations: Presence of acute diarrhea, draining wounds orother sites of secretions or excretions that areunable to be covered or contained On units or in facilities where ongoingtransmission is documented or suspectedFacilities may consider applying Enhanced BarrierPrecautions to residents infected or colonized withother epidemiologically-important MDROs based onfacility policy.For infections (e.g., C. difficile, norovirus, scabies)and other conditions where Contact Precautions isrecommendedSee Appendix A – Type and Duration of PrecautionsRecommended for Selected Infections and Conditionsof the CDC Guideline for Isolation Precautions
PPE Use inEnhanced Barrier Precautions vs. Contact PrecautionsEnhanced Barrier PrecautionsContact PrecautionsPPE used for these situations:PPE used for these situations:During high-contact resident careactivities:Any room entry Dressing Bathing/showeringTransferringProviding hygieneChanging linensChanging briefs or assisting with toiletingDevice care or use: central line, urinarycatheter, feeding tube, tracheostomy/ventilator Wound care: any skin opening requiring adressing
Required PPE forEnhanced Barrier Precautions vs. Contact PrecautionsEnhanced Barrier PrecautionsContact PrecautionsApplies to:Applies to:Gloves and gown prior to the high-contact careactivityGloves and gownNote:Note: Does not require single-room Includes consideration for single room orcohorting Does not require restrictions ofmovement/participation within facilitypolicy. Includes restriction of movement andparticipation in group activities within thefacility
Implementing Enhanced Barrier Precautionsor Contact Precautions
Post Clear Signage outside of the Resident Room Indicate type of Precautions andrequired PPE For EBP, indicate high-contact residentcare activities
The Set-Up: Personal Protective Equipment PPE, including gowns and gloves,should be available immediatelyoutside of resident room Plan for restocking Position a trash can insideresident room and near exit fordiscarding PPE
The Set-Up: Hand Hygiene Ensure access to alcohol-basedhand rub at every resident room Ideally located both inside andoutside of room Make performing hand hygieneeasy!
Cleaning & Disinfection of Shared Equipment Ensure access to cleaningsupplies/wipes Contact Precautions: dedicatedequipment
Auditing Practices and Education Incorporate periodic monitoring andassessment of adherence to determine needfor additional training and education
Ongoing Activities and Future Steps Development of additional resources to promote EBP (e.g., FAQs) Collaborating with nursing home organizations to evaluate staff education andtraining, PPE utilization, and other resource needs for successfulimplementation Will include assessments of acceptability and costs Funding projects to evaluate strategies to prevent MDRO transmission Efficacy of targeted gown/glove use; role of Chlorhexidine bathing anddecolonization; Impact of improved environmental cleaning/disinfection Establishing a Working Group to convene nursing home, academic and publichealth partners to discuss broader implementation of EBP outside of acontainment response
Resources Interim Guidance to Contain Novel MDROs l CDC Candida auris webpage ndida-auris.html Find your state HAI Coordinator and AR expert https://www.cdc.gov/hai/state-based/index.html Enhanced Barrier Precautions Guidance es.html
Thank you!Questions?Nursing Homes and Assisted Living (Long-term Care Facilities l
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3.Define Standard Precautions, Enhanced Barrier Precautions, and Contact Precautions. 4.Identify which residents and activities meet criteria for Enhanced Barrier Precautions. 5. Discuss best practices for implementing Enhanced Barrier Precautions. At the conclusion of the session, participants will be able to accomplish the following:
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