Guidelines for Prevention and Control of Infections Due to ...

Guidelines for Prevention and Control

of Infection Due to Antibiotic Resistant

Organisms

Updated December 2020

Florida Department of Health Division of Disease Control & Health Protection

Bureau of Epidemiology 850-245-4401 (24/7)

Table of Contents

I. Statement of Purpose................................................................................................... 1

II. Definitions ................................................................................................................... 2

III. Introduction ................................................................................................................ 8

IV. Background................................................................................................................ 9

A. Methicillin-Resistant Staphylococcus aureus (MRSA) .......................................... 9 B. Vancomycin-Resistant Enterococci (VRE) ......................................................... 10 C. Clostridioides difficile.......................................................................................... 10 D. Multidrug-Resistant Gram-Negative Bacilli (MDR-GNB) .................................... 11

1. Acinetobacter baumannii ........................................................................... 11 2. Carbapenem-Resistant Enterobacteriaceae (CRE) ................................... 12 E. Candida auris (C. auris) ..................................................................................... 13 V. Colonization vs. Infection .......................................................................................... 13

A. Colonization....................................................................................................... 13 1. C. difficile................................................................................................... 13 2. Enterococci................................................................................................ 13 3. Methicillin-Resistant Staphylococcus aureus (MRSA) ............................... 14 4. Multidrug-Resistant Gram-Negative Bacilli (MDR-GNB)............................ 14 5. Candida auris (C. auris)............................................................................. 14

B. Infection ............................................................................................................. 14 VI. Epidemiology ........................................................................................................... 15

A. Health Care-Associated MethiciIIin-Resistant Staphylococcus aureus (HA-MRSA)............................................................................................................. 15 B. Community-Associated Methicillin-Resistant Staphylococcus aureus (CA-MRSA)............................................................................................................. 15 C. Vancomycin-Resistant Enterococci .................................................................... 16 D. Clostridioides difficile.......................................................................................... 17 E. Multidrug-Resistant Gram-Negative Bacilli (MDR-GNB) .................................... 18 F. Carbapenem-Resistant Enterobacteriaceae....................................................... 18 G. Candida auris (C. auris) ..................................................................................... 19 VII. Control Measures.................................................................................................... 20

A. General Control Measures ................................................................................. 20 1. Infection Control Plan ................................................................................ 20 2. Hand Hygiene............................................................................................ 20

3. Communications to Maintain Appropriate Patient-Based Infection Control Precautions Between and Within Facilities.................................................... 21 4. Standard Precautions ................................................................................ 22 5. Contact Precautions .................................................................................. 22 6. Enhanced Barrier Precautions................................................................... 22 7. Education .................................................................................................. 23 8. Visitors....................................................................................................... 23 9. Surveillance............................................................................................... 23 10. Environmental Measures......................................................................... 24 11. Administrative Support ............................................................................ 25 12. Antimicrobial Stewardship ....................................................................... 25 VIII. Decolonization Therapy ......................................................................................... 26

IX. Prevention................................................................................................................ 28

A. Institution Specific Control Measures ................................................................. 28

1. Acute Care Facilities ................................................................................. 28 2. Long-Term Care Facilities ......................................................................... 29 3. Home Health Care/Hospice....................................................................... 35 4. Doctors' Offices/Outpatient Clinics ............................................................ 35 5. Dialysis Settings ........................................................................................ 35 6. Schools for the Physically and Mentally Challenged ................................. 36 7. Assisted Living Facilities/Rest Homes/Retirement Centers ....................... 36 8. Rehabilitation Facilities.............................................................................. 37 9. Psychiatric Hospitals ................................................................................. 37 10. Correctional Facilities .............................................................................. 37 11. Patients Discharged to Their Homes ....................................................... 37 12. Emergency Medical Services (EMS) and Non-Emergent Transport........ 38 X. Outbreak Control....................................................................................................... 39

XI. The Infected or Colonized Health Care Worker ....................................................... 41

XII. Antibiotic Resistance in Animals ............................................................................. 41

XIII. Control of MRSA in Community Settings ............................................................... 42

A. Personal Hygiene ............................................................................................... 43

B. Control Measures for Health Care Practitioners ................................................. 43

C. Households ........................................................................................................ 44

D. Schools .............................................................................................................. 44

E. Day Care Settings .............................................................................................. 45

F. Athletic Settings.................................................................................................. 46

G. Workplace .......................................................................................................... 46

H. Correctional Facilities ......................................................................................... 47

XIV. Vancomycin Non-Susceptible Staphylococcus--An Emerging Pathogen ............. 47

XV. References ............................................................................................................. 49

XVI. Resources ............................................................................................................. 56

XVII. Reportable Diseases in Florida............................................................................. 59

Appendix A .................................................................................................................... 60

III.A. Standard Precautions ..................................................................................... 60 III.A.1. New Elements of Standard Precautions ...................................................... 61 III.A.1.a. Respiratory Hygiene/Cough Etiquette ...................................................... 61 IV. Standard Precautions ........................................................................................ 62 IV.A. Hand Hygiene ................................................................................................ 63 IV.B. Personal Protective Equipment (PPE) ........................................................... 63 IV.C. Respiratory Hygiene/Cough Etiquette............................................................ 65 IV.D. Patient Placement.......................................................................................... 65 IV.E. Patient Care Equipment and Instruments/Devices......................................... 66 IV.F. Care of the Environment ................................................................................ 66 IV.G. Textiles and Laundry ..................................................................................... 67 IV.H. Safe Injection Practices ................................................................................. 67 IV.I. Infection Control Practices for Special Lumbar Puncture Procedures ............. 67 IV.J. Worker Safety ................................................................................................. 67 Appendix B .................................................................................................................... 68

III.B. Transmission-Based Precautions................................................................... 68 III.B.1. Contact Precautions .................................................................................... 68 V. Transmission-Based Precautions....................................................................... 69 V.A. General Principles........................................................................................... 69 V.B. Contact Precautions........................................................................................ 69 Appendix C--Use of Personal Protective Equipment (Gowning) .................................. 71

Donning PPE .......................................................................................................... 72 Donning a Gown ..................................................................................................... 72 Removal of PPE ..................................................................................................... 72 De-Gowning............................................................................................................ 73 Appendix D--Be Antibiotics Aware ............................................................................... 73

Summary of Core Elements of Hospital Antibiotic Stewardship Programs ............. 74 Appendix E--Florida Department of Health, Health Care-Associated ........................... 74

Infection Prevention Program Contact ...................... Error! Bookmark not defined.

Appendix F--Florida Infection Control Organizations.................................................... 75

Guidelines for Prevention and Control of Infections Due to Antibiotic-Resistant Organisms

I. Statement of Purpose

This document is an update of the Florida Department of Health (FDOH) Guidelines for the Control of Antibiotic Resistant Organisms 2017. While much of the information on the epidemiology of the organisms, control measures, contact precautions, and institutionspecific control measures mentioned in the previous version remain unchanged, many advances in the prevention and control of drug-resistant organisms have been made, largely in response to increasing antimicrobial resistance and reduction of the available options for treatment. However, much of the basic infection prevention and control practices were adopted from the Healthcare Infection Control Practices Advisory Committee (HICPAC) national guidelines, which have not been updated since the 2010 version of this guide.

These expanded guidelines include new information on prevention and infection control measures in the management of antibiotic-resistant organisms, including MRSA, vancomycin-resistant enterococci (VRE), Clostridioides difficile (C. difficile), and multidrug-resistant gram-negative organisms such as Acinetobacter baumannii (A. baumannii), Klebsiella pneumoniae (K. pneumoniae), and carbapenem-resistant Enterobacteriaceae (CRE).

This update will address an emerging drug-resistant fungus, Candida auris (C. auris), that has become an urgent global health threat since the 2017 update of this document. In addition, this update will address a new type of Transmission-Based Precaution that can be implemented in long-term care facilities, known as Enhanced Barrier Precautions (EBP).

Since no single approach to the control of antimicrobial-resistant organisms is appropriate for all health care facilities, these guidelines will review standard control measures appropriate for all settings and specific measures for many of the health care settings that frequently encounter these organisms.

This document is not a guide to the medical treatment of persons colonized or infected with C. auris, MRSA, VRE, or other multidrug-resistant organisms (MDRO), which is the responsibility of the patient's health care team. These guidelines also do not encompass the whole body of knowledge on this subject. Several resources from the Centers for Disease Control and Prevention (CDC) and other professional infection control organizations are provided for review and supplemental information.

The audience for these guidelines includes physicians and their office staff, schools, infection control practitioners, and others in the continuum of care involved in the control of antimicrobial-resistant organisms in non-acute health care facilities, including county health departments (CHDs).

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