Toolkitforacuteandlong-Termcaresettings

GuidanceforControlofCarbapenemResistantEnterobacteriaceae

(CRE)

ToolkitforAcuteandLong-TermCareSettings

DivisionofEpidemiologyandImmunizationMassachusettsDepartmentofPublicHealthPhone: 617-983-6800

Fax: 617-983-6813

December 8, 2017_ver 1.0

Table ofContents

ToolkitOverview / 3
Surveillance
-MassachusettsDepartmentofPublicHealth(MDPH)CREreporting
requirements / 4
LaboratoryTesting
-MassachusettsStatePublicHealthLaboratory(MASPHL)CREisolate
submissionrequirements / 5
-Clinical andLaboratoryStandards Institute (CLSI) breakpoints for
antibioticsusceptibilitytesting(AST) / 6
-Carbapenemasetesting / 7
InfectionPreventionandControl
-Acutecarehospitals(ACHs) andlong-termacute carehospitals
(LTACHs) / 9
-Skillednursingfacilities(SNFs)andrehabilitationfacilities / 14
-Ambulatorycare,outpatientclinics,hemodialysiscenters,ambulatory
surgerycenters,homehealth,hospice / 22
-Community-basedcaresettingsincludingassistedlivingfacilities,
residentialcarefacilities,adultfosterhomes,memorycare / 24
-Individuals colonizedorinfectedwithCRElivingat home / 26
References / 28
Appendix
-MASPHLtestingalgorithm / 30
-AntibioticResistanceLaboratoryNetwork(ARLN) / 31
-CRErectalscreeningspecimencollectionprotocol / 32
-Sampleinter-facilitytransferform / 34
-LTCFgeneralroomenvironmentalcleaningchecklist / 35
-LTCFcommonareasenvironmentalcleaningchecklist / 36
-Handhygiene observationtool / 37
-CREfactsheet / 38

Acknowledgement

MDPHwouldliketothanktheOregonHealthAuthority.ThecontentofthisdocumentwasadaptedfromtheBureauofInfectiousDiseaseandLaboratorySciences,2016OregonCREToolkit.

ToolkitOverview

The MassachusettsCREToolkit is designedto aidhealthcare workers involvedwithcarbapenem-resistantEnterobacteriaceaeprevention,detection,andtreatmentacrossthecontinuum ofhealthcare. Thisgroupwouldinclude infectiousdisease physicians,epidemiologists,infectionpreventionists,directorsofnursinginskillednursingfacilities,nurses,pharmacistsandmicrobiologists.

Carbapenem-resistantEnterobacteriaceae(CRE)areanemergingthreattoglobalhealth.The potentialforrapidspreadandthedifficultiesconfronted whentreatingCREinfectionsmakeitcriticallyimportantforpublichealthtopromoteaggressiveinfectioncontrolmeasures.

Ashighlightedin theCDCVitalSigns,August2015issuetitled,“Makinghealthcaresafer:Stopspreadofantibioticresistance,”acoordinated,regionalapproachtopreventthespreadofCREiscriticaltoreducetheimpactofCRE onallofMassachusetts’healthcarefacilities.Inappropriateantibioticuseandlackofinfectionpreventionsafe-guardsinonefacilityaffectothersbecauseofpatientandresidenttransfersandsharedhealthcareproviders.(1)

Routinehandhygieneandongoingmonitoringofstaffadherence tohandhygieneremainsthesinglemostimportantaspect of preventingCRE transmissionandothermulti-drug-resistantorganisms(MDROs)!However,additionalpracticesincludingappropriateantibioticuse,inter-facilitycommunications,andcontactprecautionsareneeded.

The2017MassachusettsCREToolkitisadaptedfromthe2016OregonCREToolkitwithMassachusetts-specificdefinitionsandprotocols.TheoriginaldraftofthistoolkitwrittenbytheOregonDrug-ResistantOrganismPreventionandCoordinatedRegionalEpidemiology(DROP-CRE)workgroupwasmodeledafterCDC’s 2012CREToolkit, whichisavailableontheCDCwebsite(

Thecreationofthistoolkitwassupportedbyfunding fromthe Centers forDiseaseControl andPrevention(CDC)Epidemiologyand LaboratoryCapacity(ELC)Grant.

Surveillance

MDPHCREReportingRequirements

Reportanyofthe followingEnterobacteriaceae(isolatedfromanysource)*:

Klebsiellapneumoniae
Klebsiellaoxytoca
Enterobactercloacae
Enterobacteraerogenes
Escherichia coli

Withresistancetooneormoreofthe followingcarbapenems:

-Imipenem(MIC>=4µg/ml)-Doripenem(MIC>=4µg/ml)

-Meropenem(MIC>=4µg/ml)

OR,thatdemonstratecarbapenemaseproduction(CP-CRE)

Ideally,reportingshouldbe doneautomaticallythroughelectroniclaboratoryreportingtoMDPH. Questionsaboutreportingshouldbe directedto 617-983-6801.

*105CMR300.000ReportableDiseases,Surveillance,andIsolationandQuarantineRequirements.(UpdatedJanuary2017):

LaboratoryTesting

MASPHLCREisolatesubmissionrequirements

The105CMR300.000ReportableDiseases,Surveillance,andIsolationandQuarantineRequirements ( labs.pdf)wereupdatedinJanuary2017to include arequirement that selectCREisolatesare tobe forwardedtotheMassachusetts State Public HealthLaboratory(MASPHL)foradditionalcharacterizationpurposes.

All CREwiththefollowingprofilearetobesenttothe MASPHL:

1.Klebsiellapneumoniae;Klebsiellaoxytoca;Escherichiacoli;Enterobacteraerogenes;andEnterobacter cloacae(isolatedfromanysource)withresistancetooneormore ofthefollowingcarbapenems:imipenem;meropenem;and/ordoripenem(atMIC>=4mcg/ml).Note:ertapenemresistancealoneisnota criterionforisolate submission.

2.OR, anyoftheabovefiveorganismsdemonstratingcarbapenemaseproduction, byphenotypic screeningusingthemCIM-ModifiedCarbapenemInactivationMethod;orCarba-NP;orbymechanism-specifictestingbyPCRdetectionofthefollowinggenetargets:KPC;NDM;OXA;VIM;IMP;orMCR.

3.Submit thefirstisolateofcarbapenem-resistantPseudomonasaeruginosa(CRPA)eachmonth.

4.Wewillnotbeacceptingcarbapenem-resistantAcinetobacterbaumanii(CRAB)isolates.

Isolatesaretobe submittedtotheMASPHLClinical MicrobiologyLabusingthe generalrequisitionform( submission-form.pdf).Pleaseinclude allsusceptibility results generatedatyour lab.

Pleasesendonlyoneisolateperpatientperadmission.

CLSIbreakpointsforantibioticsusceptibilitytesting(AST)

Table:CLSIbreakpoints,2015(3)

CurrentMICbreakpoints(µg/mL)
MICinterpretation1
Carbapenems / Susceptible / Intermediate / Resistant
Doripenem / ≤1 / 2 / ≥4
Ertapenem / ≤0.5 / 1 / ≥2
Imipenem / ≤1 / 2 / ≥4
Meropenem / ≤1 / 2 / ≥4
Currentdiskdiffusionzonediameters(mm)
Interpretation
Carbapenems / Susceptible / Intermediate / Resistant
Doripenem / ≥23 / 20-22 / ≤19
Ertapenem / ≥22 / 19-21 / ≤18
Imipenem / ≥23 / 20-22 / ≤19
Meropenem≥2320-22≤19

1

LaboratoriesstillusingbreakpointsbeforetheJune2010CLSIupdateshouldusetheupdatedCLSI

MICcutoffstodeterminereportingtopublichealth,independentofthesusceptibilityinterpretation(e.g.,anisolatewithanMICof8tomeropenem[“intermediate”bypre-2010CLSIinterpretation,but“resistant”byCLSIguidelinesstartingin2011]shouldstillbereportedtoMDPHandsubmittedforfurtherevaluation).

Many,if notmost,ertapenemmono-resistantEnterobacteriaceaedonotactuallyrule-inas CRE.

Carbapenemasetesting

We believetheCREresistancemechanismshouldguidethepreventionandcontrolresponseforthereasonscitedbelow.Microbiologylaboratorysusceptibilitytestingdoesnotreliablydifferentiateresistancemechanisms. As aresult, the MASPHLhasimplementedarapidmethodfortestingCREisolates(seeabove:MA SPHLCREisolatesubmissioncriteriafrom clinicallaboratories).

Carbapenemase-producingCRE(CP-CRE)

CP-CREareprimarilyresponsible for therapidworldwidespreadofCRE.Potentialforrapidspread,treatmentdifficulties,andpooroutcomesmakeitcriticallyimportanttomaintainaggressiveinfectioncontrolmeasures.Resistance amongCP-CREisconferred byenzymesthatdirectlybreakapartthe carbapenemring,inactivatingtheantibiotic.

Whenthesecarbapenemaseenzymesarelocatedonplasmids,thiscanfacilitatetransmissioninandamongbacterialspecies,andcontributetorapiddissemination.PlasmidmediatedcarbapenemasesareareasonfortherapidworldwidespreadofCP-CRE.(4,5)CarbapenemasesofglobalimportanceincludeKlebsiellapneumoniaecarbapenemase(KPC),NewDelhimetallo-β-lactamase(NDM),Veronaintegronencodedmetallo-β-lactamase(VIM),imipenemasemetallo-β-lactamase (IMP),andoxacillinase-48(OXA-48).KPChasbeenthe mostwidespreadcarbapenemase intheUnitedStates.(6)

WedefineCP-CREasEnterobacteriaceae thatcanbe showntoproduceenzymesthatinactivatecarbapenemsor thatarenucleicacidamplificationtesting (NAAT)-positiveforcarbapenemasegenes(e.g.,KPC,NDM,VIM,IMP,OXA-48).

•Serratiamarcescensmayproduceachromosomally-encodedcarbapenemasecalledtheS.marcescensenzyme(SME).Becauseitislocated onthechromosomeandnotonaplasmid,itappearstohavealimited potentialforrapidspread.

DetectionmethodsforCP-CRE

•CarbaNPTest:Arapid,accuratetechniqueforcarbapenemasedetection.(7-9)Thetestidentifiesthehydrolysisoftheβ-lactamringofacarbapenem.Abufferedsuspensionoftheorganismiscombinedwithasolutionofimipenemandphenolred; apositivetestisdefinedasacolorchangefromredtoyellowwithachangeinpH.

•ModifiedCarbapenemInactivationMethod(mCIM):Atestinwhichapaper diskwithaparticularconcentrationof meropenemis exposedtoasuspensionof the organismfor adefiniteperiodoftime,andthenusedtotestastandard,meropenem-susceptibleorganismformeropenemsusceptibility.Ifthereis nozoneof inhibition,thenthemeropenemhas beeninactivated.

•Nucleicacidamplificationtesting(NAAT):NAATistypicallyperformedonpurecoloniesofabacteriaobtained byculture,whichinvolvesgrowing,isolatingandidentifyinganorganismfromclinicalsamples.NAATtestingforresistancemarkersdirectlyfrompositivebloodculturebottlesisalsopossible.ExamplesofNAATincludePCRandtranscription-mediatedamplification(TMA).

NAAT:Isolatedcolonies.Testing CREisolatesforthepresenceofacarbapenemasegeneisthemostaccuratewaytodetect CP-CRE.WhilecarbapenemasePCRtestingofbacterial isolatesiscurrentlynotperformedbymostclinicallabs,theMASPHLhasthecapacitytoperformPCRtestingfor themostcommonlyencounteredglobalcarbapenemasesincludingKPC, NDM,VIM,IMPandOXA-48.

NAAT:Positivebloodcultures.

Severalmolecularplatforms areFDA-clearedforidentifyingorganismsanddetectingantibioticresistancemarkers,includingcarbapenemasesdirectlyfrompositivebloodculturebottles.

ExampleplatformsincludetheFilmArray®BloodCultureIdentification(BCID)Panel(BioFire,SaltLakeCity,UT)andtheVerigene®Gram-NegativeBloodCultureTest(Nanosphere,Northbrood,IL).(10,11)

InfectionPreventionandControlin:

Insummary,act“NICE”topreventthespreadofCRE:

NotifyMDPH andpertinent cliniciangroups whenanyCREareidentified.Additionally,forcarbapenemase-producingCRE(CP-CRE),notifyhospitaladministration.

Interveneonallcaseswithcoreinfectionpreventionandcontrolstrategies,includinghandhygiene,contactprecautions,privateroomsandoptimizedenvironmentalcleaning.Reduceunnecessaryantibioticsandinvasivedevices.

Additionally,forCP-CRE:

•Cohortpatients–monitoradherencetohandhygiene,contact precautions;

•Conductthoroughenvironmentalcleaningand;

•Screenhigh-riskpatientcontacts.

CommunicateCREinfectionorcolonizationstatustothereceivingfacilityuponpatienttransfer.

Educatepatients,staff,andvisitorsaboutCRE.

Part1:GeneralCREpreventionmeasuresforACHsandLTACHs

1.EnsureadequateprocessestofacilitaterapidnotificationofclinicalandinfectionpreventionandcontrolstaffwhenCREareidentifiedinthemicrobiologylaboratory.

2.“Flag”thepatient’schartforMultidrug-ResistantOrganismsandnotifythereceivingfacilityatpatienttransfer,if applicable.

3.Educate thestaffaboutCRE. Considergivinganin-servicetostaffaboutCREandotherMDROs.SampleCREeducationalmaterialsare attached asappendices.

4.Reviewmicrobiologylaboratoryrecordsforthepast12monthsto identifyanypreviouslyunrecognizedCRE casesinconsultationwithlaboratorypersonnel.ReportanynewcasesdiscoveredtoMDPH.

5.Considerimplementingactivesurveillanceculturesforpatientswhoareathigh-riskforCREcolonizationuponhospitaladmission.

Giventhecurrentepidemiology ofCP-CRE,onesuggestedapproachistoscreennewlyadmittedpatientswhohavebeenhospitalizedovernightinternationallywithinthepastsixmonths withrectalorperi-rectalswabcultures.Forbasicassistanceondeterminingglobal,nationalandlocalCP-CREepidemiology,werecommendthefollowinglinks:

i.

ii.wwwnc.cdc.gov/eid/article/17/10/pdfs/11-0655.pdf

iii.

iv.Massachusettsstateantibiogramdata: demiology/providers/mrsa/statewide-antibiogram-data.html

Part2:What todo whenCREareidentifiedatyourACHorLTACH

Initialrecommendationsbeforecarbapenemasetesting

1.NotifyMDPH ofapatient isolatemeetingtheCREcasedefinition.Reportanynewcasesorknowncasestransferredfromout-of-state.Laboratoriesarerequiredtoreportisolates.

2.Upon patienttransfer toanotherhealthcarefacility,notifythereceivingfacilitythepatienthasCREinareadilyavailablewrittenmannerinadditiontoverbalcommunication.Anexampletransferformisprovidedintheappendix.Besuretheindividualsdirectlycaringforthepatientandthoseresponsibleforinfectionpreventionatthe receivingfacilityareawareofthepatient’sCREstatus.

3.PlaceCRE-infectedandCRE-colonizedpatients oncontactprecautions.Empowerstafftomonitorandenforcecontactprecautions.

Continuecontactprecautionsfordurationofhospitalization.

“Flag”thechartofaCRE-positivepatientsotheycanbeidentifiedandplacedoncontactprecautionsimmediatelyifre-admitted.

4.PlaceCRE-infectedandCRE-colonizedpatientsinprivaterooms. Ifthenumberofsinglepatientroomsislimited,prioritizesingleroomsforCRE-positivepatientswithhighertransmissionrisksuchasdrainingwoundorstoolincontinence.CohortCRE-positivepatientsifprivate roomsareunavailable.

5.Educate staff,affectedpatientsand theirvisitorsaboutCRE.Education helpstoreducethespread ofCRE.

6.Reinforcethe importanceofadherence tocoreinfectionpreventionmeasuresofhandhygiene,contactprecautionsandenvironmentalcleaningthroughperiodicauditsandobservation.ConsidermonitoringadherencetoallcoreMDROprevention measures.

7.Notifypertinentcliniciangroups(infectiousdiseases,criticalcare,pharmacy,antibioticstewardshipprogram[ASP],etc.)ofCREin thefacility.

ConsiderinitiatingaformalASPifyourfacilitydoesnothaveonealready.SeeCDCwebsite

8.DirectlyinterfacewithclinicianscaringfortheCRE-infectedorCRE-colonizedpatient.

Encouragelimitingantibioticsandinvasivedevices.

Recommendationsafter resultsofcarbapenemasetesting:

Fornon-CP-CRE:continuecontactprecautions.PerrecentCDCguidance;noadditionalmeasuresarerequired.(2,15)

For CP-CRE:implement thefollowingadditionalmeasures:

1.NotifyMDPHinadditiontoreceivingfacilityuponpatienttransfer.

2.Notifyhospitaladministration.

Preventionofspreadneedstobe an institutionalpriority,whichrequiresleadershipandresourcesupport.

3.Review microbiology recordstoidentifyanyotherCP-CREcasesatthefacilitywithinthepast12months. Reviewofmicrobiologyrecordscan detectoutbreaksofCRE,suchas thosereportedinassociationwithcontaminatedmedicalequipment.(16)

4.Educatestaff,patientsandvisitorsaboutCP-CRE.

5.Monitoradherencetohandhygieneandcontactprecautionsfortheroom(s)of CP-CRE-positivepatients.

Stronglyconsiderahand-hygienecampaignonaffectedunits.Review withandevaluatestaffonuseofcontactprecautions.

6.Alerthousekeepingandmonitorenvironmentalcleaning.Encouragefrequent

thoroughcleaningofhigh-touchsurfaces,particularlythosenearthepatient,andcommonareasoutsidetheroom.Evaluateterminalcleaningusingvisualinspectionplusquantitative strategies,such asUV fluorescencemarkeror adenosinetriphosphate

(ATP)monitorbeforeplacinganotherpatientinthatroom.Ifavailable,supplementmanualcleaningwithUVlight,hydrogenperoxidevapororanother“notouch”modality.See theCDCenvironmentalcleaningmonitoringtoolintheappendix.

7.Verifyandauditdecontamination,disinfection,reprocessing,andsterilization(whenneeded)ofreusablemedicalequipment usedbyCP-CREpatients.

8.InconsultationwithMDPH,obtainCP-CRE screeningculturesforhigh-riskhealthcarefacilitycontacts.Expandthescreening poolifinitialtestingrevealsadditionalcases.Considerationsforcontactsathighestriskincludefactorsrelatedto durationandintensityofexposureto thecasepatientincluding:

a)Proximitytocasepatient;

b)Sharednurses,physicians,and otherhealthcareproviders;

c)Theintensityofnursingrequired;

d)Stoolandurineincontinence;

e)Sharedmedicalequipmentor procedures;and

f)Lengthofstay.

Forexample,itisimportanttoscreenroommates, evenifalreadydischarged.Otherlocalfactorsmay beconsidered;eachsituationis unique,andthefinalapproachwillbe basedondiscussionsbetweenMDPHandthehospital.

Pertinentscreeningculturedetailsinclude:

Specimensforscreeningculturesmaybeobtainedbyanyonewhoisqualified(seeappendix).

Therecommendedscreeningsitesare eitherrectal orperirectalswabs.Enhancedsensitivitymaybeachievedbyscreeningbothwounds and urine, ifcathetersare inplace.Thecost-benefitratio ofscreeningadditionalsitesisuncertainandthereforenotroutinelyrecommended.

Generally,screeningculturesshouldnotbebilledtothepatient;discussbillingwiththemicrobiologylaboratoryandfacility leadership.

Keeparecordofscreeningcultureresultsand“flag”anyCRE-colonizedpatientforappropriateinfectioncontrol.

9.CohortnursingstaffthatcareforCP-CRE-positivepatientsasresourcesallow. Thisismostimportantandmorefeasibleinthesituationof≥2CP-CRE-positivepatients.Cohortednursingtoratiosas low as1:1has beenkeyto preventingfurthertransmissioninseveral outbreaks.

10.Intheevent1case isdetected,cohort patientstoonehospitalwardwhentechnicallyfeasible.Privateroomsforeachpatientarestillrecommended.

11.Intheevent ofaclusterofcases,consideractivesurveillancecultures.Unlikescreeningculturesforhigh-riskcontacts,whichisroutinelyrecommendedwithCP-CRE cases,thisapproachisthesystematicscreening ofapredefinedpatientpopulation,suchasallICUadmissions.(17)Typically,surveillanceculturesareperformedonadmissionandperiodicallyforaffectedwards or areas.Surveillance cultures areanotherstrategy successfullyusedaspartofaninterventionbundletocontroloutbreaks.(18,19)

InfectionPreventionandControlin:

Insummary,act“NICE”topreventthespreadofCRE:

Part1:GeneralCREpreventionmeasuresforSNFs

1.Ensure adequateprocessesareinplaceforrapidnotificationofpertinentstaffwhenCREandother MDROsareidentifiedonfacilitytransfer orbythemicrobiologylaboratory.Thisshouldincluderequestingthelaboratoryto callandnotifythefacilitywhenCREareidentified.

2.Ensureroutineadherencetohandhygiene:

Beforetouching aresident,evenifgloveswillbeworn;

Beforeexitingtheresident’scareareaaftertouchingtheresidentortheresident’simmediateenvironment;

Aftercontactwithblood, bodyfluidsorexcretions,orwounddressings;

Beforeperforminganaseptictask suchascapillarybloodglucose(CBG) testingorgiving asubcutaneousinjection(mustwear gloves);

Ifhandsmovefromcontaminatedbodysitestocleanbodysitesduringresidentcare;andafter gloveremoval.

3.Ensuresufficientandappropriatecontact precaution PPE(glovesandgowns)isavailableandreadilyaccessible,andcare-giversunderstandandaretrainedonwhenandhowtouseit.

4.Upon patienttransfer toanotherhealthcarefacility,notifythereceivingfacilitythepatienthasCREinareadilyavailablewrittenmannerinadditiontoverbalcommunication.Anexampletransferformisprovidedintheappendix.Besuretheindividualsdirectlycaringforthepatientandthoseresponsibleforinfectionpreventionatthereceivingfacilityareawareofthepatient’sCREstatus.

5.EducatestaffaboutCRE.Considergivinganin-servicetostaffaboutCREandotherMDROs.SampleCREeducationalmaterials areattached asappendices.

6.Reviewgeneralinfectionpreventionandcontrolpoliciesandensureappropriatetraining,competenciesandauditsareinplace.Examples of importantbasicissuesarestandardprecautions,includinghandhygiene, contactprecautions,linenreprocessingandenvironmentalcleaning.Forenvironmentalcleaning,ensurehousekeepingisproperlyusinganEPA-registereddisinfectantlabeledfor useinhealthcare.

7.Familiarizeyourstaffwithinfectioncriteriaandsurveillancedefinitionsinlongtermcaresettings.(20)

Part2:WhattodowhenCRE isidentifiedatyourSNF

1.Promotehandhygieneandmonitorstaffadherencetohandhygiene:thisisthesinglemostimportantaspectofpreventingCRE transmission!Along-termcare facilityhandhygieneobservationtooldeveloped bytheOregonPatientSafetyCommission(OPSC)canbefoundintheappendixortheOPSCwebsiteat

2.NotifyMDPHwithinonebusinessdayofidentificationofapatient isolatemeetingtheCREcasedefinition.Reportanynewcasesor knowncasestransferredfromout-of-state.

3.Consultpublichealthaboutdevelopingtheappropriateinfectionpreventionplanfortheresident,includingtheneedforcontactprecautions,basedontheresident’sclinicalstatusandothermedicalandsocialneeds.Referto“Whenandhowtoapplycontactprecautionstoresidents”below.

4.Uponresidenttransfer toanotherhealthcarefacility,informthereceivingfacility,inwriting,thattheresident hasCRE.Anexampletransferformisprovidedasanappendix.Besurepeople

directly caringforthepatientandresponsibleforinfectionpreventionareawaretheresidenthasCRE.

5.Reviewtheimportanceofmeticulousenvironmentalcleaningwiththehousekeepers.Thisincludesataminimum,dailyroomandbathroomcleaningandattentionto“high-touch”surfacessuchaslightswitches,doorknobsandbathroomhandrails.Twolong-termcarefacilityenvironmentalcleaningchecklists,oneforresidentroomsandoneforcommonareas,canbefoundintheappendixortheOPSCwebsiteat

6.IfaCRE-infectedorCRE-colonizedresidentisdischargedhome,ensure theyareawareoftheirCREcolonizationandnotifytheresident’sprimarycareproviderofthediagnosis.Thiswillpotentially help theindividualduringfuturemedicaltreatmentandassistpublichealthin trackingCREonsubsequentfacilityadmissions.

7.Educatestaff,affectedresidentsandtheirvisitorsaboutCRE.EducationhelpstoreducethespreadofCRE.

8.Notifyappropriateclinicians(medicaldirector,directorofnursing,pharmacist,etc.)ofCREinthe facility.Specificgoals:

Limituseofcatheters,tubes andotherinvasivedevices inall residents.

Stopunnecessaryantibioticuseinallresidents,especiallythosewhoareCRE-positive.

Reviewmonthlyantibioticuse,andcultureordersandsusceptibilitypatternstoevaluateappropriateantibioticuseandidentifyifunnecessaryantibiotics andcultureswereordered.

ContactMDPHfor informationonantimicrobialstewardshipprogramsinlong-termcarefacilities.

Additionalrecommendationsbasedontheresultsofcarbapenemasetesting:

Fornon-CP-CRE:noadditionalmeasuresarerequired.Refertothesectiontitled“Whenandhowtoapply contactprecautionsforCRE-positiveresidents inSNFs”foradiscussionofhow todeterminewhethercontactprecautions shouldbeused.

For CP-CRE, implement the followingadditionalmeasures:

1.NotifyMDPH,inadditiontothereceivingfacility,uponresidenttransfer.

2.Notifyfacilityadministration.Preventionofspreadneedstobeaninstitutionalpriority,whichrequiresleadershipandmonetarysupport.

3.Reviewyourfacility’smicrobiologyrecordswithinthepast12monthstoidentifyanyothersuspectCP-CREcasesandworkwithyourlaboratorytoassurethatappropriatetestingforCP-CRE

detectionwilltakeplace.

4.Educatestaff,affectedresidentsandtheirvisitorsaboutCP-CRE.

5.Monitorfacility-widehandhygieneadherence,particularlyfortheroom(s)ofCP-CRE-positiveresidents.Usethecase asanopportunitytoinitiateafacility-widehandhygienecampaign.

6.WestronglyencourageprivatesinglebedroomsforallresidentsinfectedorcolonizedwithCP-CRE.Thiswilldecrease thechanceofCP-CREtransmissionwithinthefacility.Note:thisrecommendationisseparatefromanddoesnotmean“isolation,”whichwouldtypicallybereservedforresidentswithactiveCRE infectionwithhightransmissionriskduetotheirinability tocontaintheirbodyfluidsorwounddrainage.Isolationisconsideredanadjunctmethodtocontactprecautions focusedondecreasingtransmissionfromanactivelyillpersontoothers.Seebelowfordetails.

7.Iffeasible,when1CP-CREcaseisidentifiedatthefacility,cohorttheresidentsbyhousingtheminsamewing,eveniftheyareinsingle-bedrooms.

8.Alerthousekeepingandmonitoradequacyofenvironmentalcleaning.Encouragefrequent,thoroughcleaningofhigh-touchsurfacesinandoutsidetheroom. Usethelong-termcarefacilityenvironmentalcleaningchecklists,oneforresident rooms and oneforcommonareasprovidedintheappendix.Determineand fixanygapsintheadequacyofroomcleaningondischargeortransferbeforeplacinganotherresidentintheroom.Ifavailable,useadditionalstrategiestocheckcleaningadequacy,suchasUVfluorescencemarkersor ATPmonitors.

9.Verifyandauditdecontamination,disinfection,reprocessing,andsterilization(whenneeded)ofreusablemedicalequipment usedbyCP-CREresidents.

10.InconsultationwithMDPH(available24/7at617-983-6800),obtainCREscreeningculturesforhigh-riskresident-contacts.Expandthescreening groupifinitialtestingrevealsadditionalcases.Considerationsforcontactsathighestriskincludefactorsrelated todurationandintensityofexposuretotheknownCRE-positiveresident,includingthefollowing:

a)ProximitytoCRE-positiveresident;

b)Sharedhealthcareproviders;

c)Intensityofnursingrequired;

d)Stoolorurineincontinence;

e)Sharedmedicalequipmentor procedures;and

f)Lengthofstay.

Forexample,itisimportantto screenroommates, evenifalreadydischarged.Otherlocalfactorsshouldbeconsidered;eachsituationis unique,and thefinalapproachwillbebasedondiscussionsbetweenpublic healthandthefacility.

Pertinentscreeningculturedetailsinclude:

Seethemicrobiologylaboratorysectionfortherecommendedscreeningprotocol.MDPHisavailableforconsultationandassistancethroughouttheprocess.

IfMRSA,VREorotherMDROscreeningisperformed inyourfacility,asimilarconsentprocessmaybeusedforCP-CREscreening. Eitherverbalorwrittenconsent,dependingonyourfacility’spoliciesandprocedures,couldbeappropriate. Seetheappendixfora sampleconsentform.

Specimensforscreeningculturesmaybeobtainedbyanyonewhoisqualified(seeappendix).

Therecommendedscreening sites are either rectalorperirectalswabs.Enhancedsensitivitymaybeachieved byscreeningbothwounds andurine, ifcathetersare in place.Thecost-benefitratio ofscreeningadditionalsitesisuncertainandtherefore notroutinelyrecommended.Generally,screeningculturesshouldnotbebilledtotheresident.

Keeparecordofscreeningcultureresultsand“flag”anyCRE-colonizedresidentsforappropriateinfectioncontrol. Thedecisionwhetherto enterorwithholdresultsofscreeningtestsasmicrobiology laboratoryreportsintheclinicalchartshouldbemadeatthefacilitylevel.

11.CohortstaffthatcareforCP-CRE-positiveresidentsasresourcesallow.Inlong-termcare,thisgenerally meansassigningthesamegroup ofcaregiverstotheresidentinsteadof assigningcaregiverswhomayfloatto otherwardsorwingsofthefacility.

12.Intheeventofanoutbreak,consultwithMDPH regardingtheneedforsupplementalmeasuresincludingactivesurveillancecultures.

Whenand how to applycontactprecautions*forCRE-positiveresidentsinSNFs

*Contactprecautionsareapartoftransmission-basedprecautions,wherethetypeofpersonalprotective equipment(PPE)ischosentofittheclinicalsituation.Forexample,contactprecautionsinvolveusinggownandgloveswhenadministeringcaretoaresidentorcontactingtheirroomenvironment.Dropletprecautionsmeansusingafacemaskandfaceshieldtopreventcontactwithrespiratorydroplets.“Precautions”DONOTmean“isolation.”Isolationisaselectiveadjuncttotransmission-basedprecautionswhenadditionalseparationofanillpersonisnecessarytopreventtransmissionoftheinfectious agent.Forexample,apersonwithactivesymptomsofInfluenzaornorovirusinfectionshouldbeisolatedintheirroomuntilsymptomsresolve,andcaregiversmustusecertaintransmission-basedprecautionswhenadministeringcare.

Forwhom:

•CP-CRE-infectedorcolonizedresidents;

•Residentsinfectedwithnon- CP-CREorothertargetMDROs;and

•Residentscolonizedwithnon-CP-CRE orothertargetMDROswhoare athigher-riskfortransmission.

Howtoapply:Staffmustuse gownsand glovesforallin-roomresidentcare.

Importantdetails:

1.Roomrestriction:CRE-positiveresidentsshouldnotbediscouragedfromparticipatingindailycommunitymealsandactivitiesoutsideoftheirroom,providedtheir sourceof CREis coveredandcontained.

2.DonotforgethandhygieneisKEYtopreventing CREtransmission, andtheappropriateuseofin-roomcarecontactprecautionsprovidesanadditionalmeasureofprotection. Staffshouldberemindedtoperformhandhygienebeforedonningandafterdoffingglovesandgowns.

3.Standardprecautionsshouldbeemployedforallresidents.(21)This includestheuseofgownsandglovesforanticipatedcontactwithbodyfluidorpotentialsplashesandwhen changingsoiledbedlinens.Referto the“Standardprecautions”sectioninthe“Ambulatorycare”sectionoftheCREtoolkitforadditionalinformation.

Workingdefinitionofresidentsat“higher-riskfortransmission”basedonCDCguidance(21):

•Ventilator-dependent;

•Uncontainedincontinenceofstool;

•Uncontainedincontinenceofurine;and/or

•Woundswithdifficulttocontroldrainage.

ConsultMDPHforindividualizedcaserecommendationswhentheneedforcontactprecautionsisuncertain.

WhencancontactprecautionsforresidentswithCP-CREbediscontinued?

Discontinuecontactprecautions whenthe residenthas atleastthreenegativescreeningculturesperthefollowingalgorithm:

•Threenegativescreeningculturesthatare:

Atleastthreemonthsafterthelastpositiveculture;ANDAtleastthreemonthsafter lastcourseofantibiotics;ANDEachcultureobtained≥1weekapart.

•The recommendedscreeningsitesareeitherrectalorperirectalswabs.Iftheoriginalsiteofinfectionisstillpresentsuchasawoundthathasn’thealedorurinefromachronicallycatheterizedpatient,atleastoneculturefromsuchsitesshouldbeaddedtothescreeningfromtheGItract.

SummaryofrecommendationsformanagementofSNFresidentswithCRE

Measure / CP-CRE
infection / CP-CRE
colonization / Non-CP-CRE
infection / Non-CP-CRE
colonization††
Notifyreceivingfacility* / Yes / Yes / Yes / Yes
NotifyMDPHupontransferordeath / Yes / Yes / No / No
Standardprecautions / Yes / Yes / Yes / Yes
Contactprecautions†Gown/glovesforin-roomresidentcare / Yes / Yes / Yes / For residentsathigherriskof CREtransmission
Doorsignage / Yes / Yes / Yes / For residentsathigherriskof CREtransmission
Privateroom / Yes(stronglyencouraged) / Yes(stronglyencouraged) / Yes / No
Restrictedtoroom / Yes / No** / No** / No**
Enhancedenvironmentalcleaning / Yes / Yes / Yes / No
Designatedordisposableequipment / Yes / Yes / Yes / No
If>1case,cohortstaffiffeasible / Yes / Yes / Optional / Optional
If>1case,cohortresidentsiffeasible / Yes / Yes / Optional / Optional
ConsultwithMDPHregardingscreening cultures / Yes / Yes / No / No
Visitor recommendations:
•Perform handhygieneoften,particularlyafterleavingtheresident’sroom. / Yes / Yes / Yes / Yes
•Gown/glovesifcontactwithbodyfluidsisanticipated. / Yes / Yes / Yes / Yes

• Gown/glovesifnocontactwithbodyfluidsisanticipated.

/ No / No / No / No

*ReportMDROontransfercommunicationformforoneyearfollowingthemostrecentpositiveCREtest.

†Contactprecautionsmeansusingagownandglovesforanyin-roomresidentcare.Residentscolonizedwithnon-CP-CRErequirecontactprecautionsifthey areathigherriskforCREtransmission(seetext).

**Restricted to room.Residentsshouldberestricted to their roomsiftheyarenotable to containtheir secretionsand excretions.Residentsfor whomsecretionsandexcretionscanbecontainedmayleavetheir rooms.Uponleavingtheirrooms,allresidentsshouldbeclean,fluidscontained, ableto followinstructionswith assistanceandshouldwash theirhands.

††ColonizationwithCREmeanstheorganismispresentonthebodybutisnotcausingsymptomsofdisease.ColonizingCREcangoontocauseinfectionsofvarious body sitessuchasblood,urinary tract,orlungs.(Source:Centers forDiseaseControlandPrevention.Carbapenem-resistantEnterobacteriaceae(CRE)Infection:ClinicianFAQs. clinicianFAQ.html;accessedNov17,2015)

InfectionPreventionandControlin:

Werecommendemployingstandardprecautions.

Refertothe2011CDC booklettitled the“GuidetoInfectionPrevention forOutpatient Settings:MinimumExpectationsforSafeCare,”availablehere: HAI/settings/outpatient/outpatient-care-guidelines.html.(22)Themostpertinentinfectionpreventionandcontrolmeasuresforpreventingthetransmission ofCRE,MDROs,norovirusandmanyotherinfectionsinambulatorycaresettingare adherencetohand hygieneandproperuseofpersonalprotectiveequipment(PPE).Keyrecommendationsforeachiteminthedocumentarecopiedbelow.

Keyrecommendationsforhandhygieneinambulatorycaresettings:

1.Keysituationswherehandhygieneshouldbeperformedinclude:

• Beforetouchingapatient,evenifgloveswillbeworn;

• Beforeexitingthepatient’scareareaaftertouchingthepatientorthepatient’simmediateenvironment;
• Aftercontactwithblood,bodyfluidsorexcretions,orwound dressings;

• Beforeperforminganaseptictask suchas placing anIV,preparinganinjection;

• Ifhandsmovefromcontaminated bodysitestoclean-bodysitesin patientcare;andafter gloveremoval.

2.The preferredmethodof handdecontaminationiswithanalcohol-based handrub.

Exception:usesoapandwaterwhenhands are visiblysoiledoraftercaringforpatientswithknownorsuspectedinfectious diarrheasuchasClostridium difficileornorovirus,orafterusingtherestroom.

Key recommendationsforuseofPPEinambulatorycaresettings:

1.FacilitiesshouldensuresufficientandappropriatePPEisavailableandreadilyaccessible.

2.EducateallhealthcareprovidersonproperselectionanduseofPPE.

3.RemoveanddiscardPPEbeforeleavingthepatient’sroomorarea;and

4.Wear gloves forpotential contactwithblood,bodyfluids,mucousmembranes,non-intactskinorcontaminated equipment:

• Do notwearthesamepairofglovesforthecareofmorethanonepatient;

• Donotwashglovesforthepurposeofreuse;and
• Perform handhygieneimmediately after removing gloves.

5.Wearagowntoprotectskinandclothingduringproceduresoractivities where contactwithbloodorbodyfluidsisanticipated:

Do notwearthesamegownforthecare ofmorethanonepatient.

6.Wearmouth,noseandeyeprotectionduringproceduresthatarelikelytogeneratesplashesorspraysofbloodorotherbodyfluids.

7.Wearasurgicalmaskwhenplacingacatheterintothespinalcanalorsubduralspaceandwheninjectingmaterialintothese spaces.

Westronglyrecommendoutpatientsettingsusethechecklistincludedwiththe“GuidetoInfectionPreventionfor OutpatientSettings”documenttoreviewcurrentpoliciesandpractices.Topicsincludetransmission-basedprecautions,safeinjectionpracticesandsafemedicationstorage.

InfectionPreventionandControlin:

Standardprecautionsarerecommended.

ThemostimportantinfectionpreventionandcontrolmeasuresforCREandotherMDROsinthecommunitybasedcaresettingaresimilartothoseinoutpatientandambulatorycare. Referto the2011CDC booklettitled the “Guideto InfectionPreventionforOutpatientSettings:MinimumExpectationsforSafeCare,”availablehere: guidelines.html.(21)Themostimportantinfectionprevention andcontrolmeasuresto preventtransmissionofCRE,MDROs,norovirusand manyotherinfectionsincommunity-basedcaresettingsareadherencetohandhygieneandproperuseofpersonalprotectiveequipment(PPE)whenhandlingbodilyfluids.

Keyrecommendationsforhandhygieneincommunity-basedcare settings:

1.Keysituationswherehandhygieneshouldbeperformedinclude:

• Beforetouchingthecolonizedorinfectedperson,evenifgloveswillbeworn;
• Before exitingthe careareaaftertouchingthecolonizedorinfectedpersonortheirimmediateenvironment;

• Aftercontactwithblood,bodyfluidsorexcretions,orwound dressings;
• Beforeperforminganaseptic tasksuchasplacinganIV,bloodglucosemonitoring,preparinganinjection;

• Ifhandsmovefromcontaminated bodysitestocleanbodysites duringcare;and

• Aftergloveremoval.

2.The preferred methodofhanddecontaminationiswithanalcohol-basedhandrub

Exception:usesoapandwaterwhenhandsare visiblysoiledoraftercaringforresidentswith knownorsuspectedinfectiousdiarrheasuchasClostridium difficileornorovirus,orafterusingtherestroom.

Key recommendationsforuseofPPEincommunity-basedcaresettings:

1.FacilitiesshouldensuresufficientandappropriatePPEisavailableandreadilyaccessible.

2.EducateallhealthcareprovidersonproperselectionanduseofPPE.

3.RemoveanddiscardPPEbeforeleavingtheresident’sroomorarea.

4.Wear glovesforpotential contactwithblood,bodyfluids,mucousmembranes,non-intactskinorcontaminated equipment:

• Do notwearthesamepairofglovesforthecareofmorethanoneresident;

• Donotwashglovesforthepurposeofreuse;and

• Perform handhygieneimmediately after removinggloves,

5.Wearagowntoprotectskinandclothingduringproceduresoractivities where contactwithbloodorbodyfluidsisanticipated:

• Do notwearthesame gownforthecareofmorethanoneresident.

6.Wear mouth,nose andeyeprotectionduringproceduresthatarelikelytogeneratesplashesorspraysofbloodorotherbodyfluids.

Westronglyrecommendcommunity-basedcaresettingsusethechecklistincludedwiththe“GuidetoInfection PreventionforOutpatientSettings”documenttoreviewcurrentpoliciesandpractices.Topicsincludetransmission-basedprecautions,safeinjectionpractices andsafemedicationstorage.

InfectionPreventionandControlin:

WerecommendgoodhandhygieneandCREeducation.

Themostimportantmessageforpersonslivingathomewhoarecolonizedorinfectedwith CREandotherMDROsisadherencetogood hand hygiene.CREeducation is alsoimportant;CRE-positivepersonsshouldbeinformedthatiftheyarehospitalized,additionalprecautionswillbetaken whentheyreceivecareandtheyshouldinformtheirhealthcareprovidersoftheirhistoryofCRE.

Familymembersorhealthcareemployeesprovidingpatientcareinthehome settingshouldusestandardprecautionsandadhereto handhygieneguidelines:

Keyrecommendationsforhandhygieneinhomesettings:

1.Keysituationswherehandhygieneshouldbeperformedinclude:

• Beforetouchingthecolonizedorinfectedperson,evenifgloveswillbeworn;

• Before exitingthe careareaaftertouchingthecolonizedorinfectedpersonortheirimmediateenvironment;
• Aftercontactwithblood,bodyfluidsorexcretions,orwound dressings;

• Beforeperforminganaseptic tasksuchasplacinganIV,bloodglucosemonitoring,preparinganinjection;
• Ifhandsmovefromcontaminated bodysitestocleanbodysites duringcare;and

• Aftergloveremoval.

2.The preferredmethodofhanddecontaminationiswithanalcohol-basedhandrub

Exception:usesoapandwaterwhenhands arevisiblysoiledoraftercaringforpersonswith knownorsuspectedinfectious diarrheasuchasClostridiumdifficileornorovirus,orafterusing therestroom.

Key recommendationsforuseofPPEinhomesettings:

1.HomecareagenciesshouldensuresufficientandappropriatePPEisavailableandreadilyaccessible.

2.EducateallhealthcareprovidersonproperselectionanduseofPPE.

3.Removeanddiscard PPEbeforeleavingtheroomorarea.

4.Wear glovesforpotentialcontactwithblood,bodyfluids,mucousmembranes,non-intact skin orcontaminated equipment:

▪Donotwearthesame pairofglovesforthecareofmorethan oneperson;

▪Donotwashglovesforthepurposeofreuse;and

▪Perform handhygieneimmediately after removing gloves.

5.Wear agowntoprotectskinandclothingduringproceduresoractivities where contactwith bloodorbodyfluidsisanticipated:

6.Wear mouth,nose andeyeprotectionduringproceduresthatarelikelytogeneratesplashesorspraysofbloodorotherbodyfluids

Foradditionalinformationoninfection prevention in yourhome,pleaserefertotheAssociationforProfessionalsin Infection ControlandEpidemiology (APIC)resources:

References

1.CentersforDiseaseControlandPrevention.VitalSignsAug4,2015.MakingHealthCareSafer:StopSpreadofAntibioticResistance.

2.CentersforDiseaseControlandPrevention.FacilityGuidanceforControlofCarbapenem-resistantEnterobacteriaceae(CRE)-November2015UpdateCREToolkit.Availableat:www. cdc.gov/hai/organisms/cre/cre-toolkit/index.html;accessedOctober10,2017.

3.ClinicalandLaboratoryStandardsInstitute(CLSI).Performancestandardsforantimicrobialsusceptibilitytesting.Twenty-fifthinformationalsupplement.CLSIDocumentM100-S25.Wayne,PA,2015.

4.NordmannP,NaasT,PoirelL.GlobalspreadofCarbapenemase-producing

Enterobacteriaceae.EmergInfectDis.2011;17(10):1791-8.

5.TzouvelekisLS,MarkogiannakisA,PsichogiouM,TassiosPT,DaikosGL.CarbapenemasesinKlebsiellapneumoniaeandotherEnterobacteriaceae:anevolvingcrisisofglobaldimensions.ClinMicrobiolRev.2012;25(4):682-707.

6.CentersforDiseaseControlandPrevention.TrackingCRE.

7.NordmannP,PoirelL,DortetL.Rapiddetectionofcarbapenemase-producing

Enterobacteriaceae.EmergInfectDis.2012;18(9):1503-7.

8.TijetN,BoydD,PatelSN,MulveyMR,MelanoRG.EvaluationoftheCarbaNPtestforrapiddetectionofcarbapenemase-producingEnterobacteriaceaeandPseudomonasaeruginosa.AntimicrobAgentsChemother.2013;57(9):4578-80.

9.VasooS,CunninghamSA,KohnerPC,SimnerPJ,MandrekarJN,LolansK,etal.Comparisonofanovel,rapidchromogenicbiochemicalassay,theCarbaNPtest,withthemodifiedHodgetestfordetectionofcarbapenemase-producingGram-negativebacilli.JClinMicrobiol.2013;51(9):3097-101.

10.Verigene® Gram-NegativeBloodCultureTest(BC-GN). negative-blood-culture-test; accessed October10,2017.

11.FilmArrayBloodCultureIdentificationPanel content/uploads/2016/03/IS-FLM1-PRT-0069-04-FilmArray-Blood-Culture-Identification-Panel- Information-Sheet.pdfaccessedOctober12,2017.

12.CarvalhaesCG,PicaoRC,NicolettiAG,XavierDE,GalesAC.Cloverleaftest(modifiedHodgetest)fordetectingcarbapenemaseproductioninKlebsiellapneumoniae:beawareoffalsepositiveresults.JAntimicrobChemother.2010;65(2):249-51.

13.GirlichD,PoirelL,NordmannP.ValueofthemodifiedHodgetestfordetection ofemergingcarbapenemasesinEnterobacteriaceae.JClinMicrobiol.2012;50(2):477-9.

14.MathersAJ,CarrollJ,SifriCD,HazenKC.ModifiedHodgetestversusindirectcarbapenemasetest:prospectiveevaluationofaphenotypicassayfordetectionofKlebsiellapneumoniaecarbapenemase(KPC)inEnterobacteriaceae.JClinMicrobiol.2013;51(4):1291-3.

15.CentersforDiseaseControlandPrevention.FAQsaboutChoosingandImplementingaCREDefinition.

16.EpsteinL,HunterJC,ArwadyMA,TsaiV,SteinL,GribogiannisM,etal.NewDelhimetallo-beta-lactamase-producingcarbapenem-resistantEscherichiacoli associatedwithexposuretoduodenoscopes.JAMA. 2014;312(14):1447-55.

17.BanachDB,FrancoisJ,BlashS,PatelG,JenkinsSG,LaBombardiV,etal.

Activesurveillanceforcarbapenem-resistantEnterobacteriaceaeusingstoolspecimenssubmittedfortestingforClostridiumdifficile.InfectControlHospEpidemiol.2014;35(1):82-4.

18.HaydenMK,LinMY,LolansK,WeinerS,BlomD,MooreNM,etal.PreventionofcolonizationandinfectionbyKlebsiellapneumoniaecarbapenemase-producingEnterobacteriaceaeinlong-termacute-carehospitals.ClinInfectDis.2015;60(8):1153-61.

19.Munoz-PriceLS,HaydenMK,LolansK,WonS,CalvertK,LinM,etal. SuccessfulcontrolofanoutbreakofKlebsiellapneumoniaecarbapenemase-producingK.pneumoniaeatalong-termacutecarehospital.InfectControl HospEpidemiol.2010;31(4):341-7.

20.Source:StoneND,AshrafMS,CalderJ,CrnichC,CrossleyKetal.SurveillanceDefinitionsofInfectionsinLong-TermCareFacilities:RevisitingtheMcGeer Criteria.InfectControlHospEpidemiol.2012;33(10):965–977.

21.CentersforDiseaseControlandPrevention.ManagementofMultidrug-ResistantOrganismsinHealthCareSettings,2006.

22.CentersforDiseaseControlandPrevention.GuidetoInfectionPreventionforOutpatientSettings:MinimumExpectationsforSafeCare,May2011.www. cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html;accessedOctober12,2017.

MASPHLCRETestingAlgorithm

AntibioticResistanceLaboratoryNetwork(ARLN)

Established in 2016, CDC’sAntibioticResistanceLaboratoryNetwork (AR Lab Network)supportsnationwide labcapacitytorapidlydetectantibioticresistanceinhealthcare,food,andthe community,andinformlocalresponsestopreventspreadandprotectpeople.TheARLabNetworkincludessevenregionallabs,the NationalTuberculosis Molecular Surveillance Center(NationalTBCenter),andlabs in50states,sixcities,andPuertoRico.Asawhole,thenetworktracks changesinresistanceandhelpsidentifyandrespondtooutbreaksfaster.Theregional labforMassachusettsistheWadsworthCenterattheNewYorkStateDepartmentofHealth.

Whennewresistancethreatsoroutbreaksaredetectedwithinhealthcarefacilitiesorstateandlocallabs,regionallabsprovidesupport,whereneeded,tocharacterize,supportresponse,andtrackthesediscoveries.Sinceoutbreakresponsevariesbystate,thesupportlaunchedbytheARLabNetworkmayalsovarybystateorthreatdiscovered.The regionallabswillensure moreconsistentandimprovedcommunication,coordination,andtracking atalllevels.

The regionallabsandNationalTBCenterwork togetherwithCDCandstate andlocalhealthdepartmentlabsto:

• Detectnewresistanceandprovidebetterbig-picturetrendtrackingtocreatepathogen-specificsolutions andsupport nationalpublichealthstrategies.
• InformoutbreakresponsewhenARthreats,likeCRE,arereported,workingtogetherwithstateandlocallabs.
• PreventandcombatfutureARthreatsbycreating betterdata.
• Support innovations inantibioticanddiagnosticdevelopment.Samples fromthe labswillbemadeavailable throughtheCDCandFDAARIsolateBank, whichresearchers canuse todevelopearlierdiagnosesandmoreeffectivetreatmentoptions.

Formoreinformationvisit: networks.htmlorcontactMASPHL.

CRERectalScreening:SpecimenCollectionProtocol

Background:

Followingisolationofacarbapenemase-producing Enterobacteriaceae(CRE),screeningculturesmayberecommendedinconsultationwithMDPH.Otherappendicesprovideadditionalinformationforobtaining patientconsentaswellas specimenprocessing.

Stepsto PrepareforSpecimenCollection:

(1)Work withadministrationandinfection ireventioncontrol toclarifycosts andpaymentforsurveillancecultures.

(2)Collaboratewithyour laboratoryandMDPH regardingsupplies:

(a)MDPHrecommendscultureswabsprepackagedinneutralizingbuffer(e.g.,liquidStuarts or phosphate bufferedsaline).

(3)Informandeducate staffaboutCRE.Trainstaffonrectalandperirectalscreeningspecimencollection.

(4)Informandeducate patients regardingCREandthereason for screeningcultures.Obtainpatientconsent.

(5)Collaboratewiththe laboratoryregarding:

(a)Timingof collectionfor optimaldelivery andset-up(e.g.,specimencollectiononeither Mondayor Tuesday istypicallypreferred).

(b)Appropriatetestorder entry(e.g.,screening orsurveillancetest).

(6)Collaboratewith the laboratory andinfectionprevention control tomanage testresults.

(a)Includepertinentcliniciangroups(e.g.,infectiousdiseases,criticalcare,pharmacy,etc).

(b)Determinemanner of reportinginthepatient’schartor“flagging”ofpositiveresults.

SpecimenCollectionProtocol:

This protocoliswrittenwithculture swabsidentifiedforrectalor perirectalsites,butitisapplicable tousingpremoistened“spongesticks”andotherbodysites,as well. Ifmultiple sites arecultured, useone swabpersite toallowbetterinterpretationandpreventcross-contamination.

(1)InconsultationwithMDPH,identify high-riskcontactstoundergosurveillance cultures.

(2)Premoistenthesterileswabinliquidtransportmediaintheaccompanyingculturettetube.

(3)Insert moistenedtipofswabintothe analcanaland turn2-3times.

(a)Alternatively,samplestool for culture ifvisibleon the perianalskinor inanostomybag.

(4)Replaceswabinculturette tube andsecure top.

(5)LabelspecimenwithuniquepatientID,date, siteand collector’s initials.Placeinsealedspecimenbag.

(6)Make suretonote typeof cultureas“screening.”

(7)Sendspecimentothe laboratory.Ensure laboratoryisaware ofcorrectmethodologytoprocessspecimen.

(a)Note: ideallyspecimens shouldbe platedwithin4hours ofcollection. If significantdelayoccurs beforeplating specimens, store swabsat4°Cforup to3days.

References:

CDC.GuidanceforControlofCarbapenem-resistantEnterobacteriaceae(CRE).2012.

APIC.Guidetothe EliminationofMultidrug-resistantAcinetobacterbaumanniiTransmissioninHealthcareSettings.2010.

PrabakerKetal.TransferfromHigh-acuitylong-termcare facilitiesisassociatedwithcarriageof

Klebsiellapneumoniaecarbapenemase-producingEnterobacteriaceae:Amultihospitalstudy.ICHE2012;33:1193–1198.

SampleInter-facilityInfectionControlTransferForm

SENDINGFACILITYTOCOMPLETEFORMandCOMMUNICATETOACCEPTINGFACILITY

Pleaseattachcopiesoflatestculturereportswithsusceptibilities,ifavailable

Patient/ResidentLastName / FirstName / Date ofBirth
PrintorplacePatientLabel
SendingFacilityName / SendingFacilityUnit / SendingFacilityPhone#

Isthepatient/residentcurrentlyonantibiotics?□NO □YESDX:Doesthepatient/residenthavependingcultures? □NO □YES

Isthepatient/residentcurrentlyonprecautions?□NO □YES

TypeofPrecautions(checkallthatapply) □Contact□Droplet□AirborneIsolation

□Other:

*Culturereportwithmultipleantibioticsmarkedresistant(R);sendcopyofreportwithsusceptibilities.

**Other:lice,scabies,shingles,norovirus,influenza,tuberculosis,etc.

Doesthepatient/residentcurrentlyhaveanyofthefollowing?

• Coughorrequiressuctioning
• Diarrhea
• Vomiting
• Incontinentofurineorstool
• Openwounds/requiringdressingchange
• Drainage(source)__

• Centralline/PICC
• Hemodialysiscatheter
• Urinarycatheter
• Suprapubic catheter
• Percutaneousgastronomytube
• Tracheostomy

Personcompletingthisform:Date:

LTCFGENERALROOMENVIRONMENTALCLEANINGCHECKLIST

Date:______UnitorWard:______Room:______

Initialsofenvironmentalservicesstaff(optional):1

Evaluatethefollowingprioritysitesforeach resident room:
High-touchRoomSurfaces2 / Cleaned / NotCleaned / NotPresentinRoom
Bedrails
Traytable
Call button
RemoteControls
Bedsidetable
BedsideChair
Telephone
Room light switch
Room innerdoorknob/doorpull
Closetdoorknob/doorpull
Bathroom innerdoor knob/pull
Bathroom lightswitch
Bathroomhandrails bytoilet
Bathroomsink/faucethandles
Toilet seat
Toiletflushhandle
Toiletbedpancleaner
Showerhandholds
Evaluatethefollowingadditionalsitesiftheseequipmentarepresent intheroom:
High-touchRoomSurfaces2 / Cleaned / NotCleaned / NotPresentinRoom
IV/tubefeedingpumpcontrol panel
WoundVacuum Control panel
Wheelchair-especiallyhandles
Walker/Canehandles

1Facilitiesmaychoose toincludeidentifiersofindividualenvironmentalservicesstaffforfeedbackpurposes

2Sitesmostfrequentlycontaminatedandtouchedbyresidentsand/orhealthcareworkers

LTCFCOMMONAREASENVIRONMENTALCLEANINGCHECKLIST

Date:______UnitorWard:______

Initialsofenvironmentalservices staff(optional):

Evaluatethefollowingprioritysitesforeachresident room:
High-touchCommonSurfaces2 / Cleaned / NotCleaned / NotPresentinRoom
CommonLightSwitch
Common CallButton
TV RemoteControls
CommonChair
CommonTelephone
MechanicalLift
Hall HandRails
DoorPulls
CommonClosetDoorKnobs/Pull
MicrowaveControlPanel
Refrigerator/FreezerHandles
Bathroom innerdoor knob/pull
Bathroom lightswitch
Bathroomhandrails bytoilet
Bathroomsink/faucethandles
Bathroomtoiletseat
Toiletflushhandle
Common TubFaucet Handles
Common Showerhandholds
CommonBench
Evaluatethefollowingadditionalsitesiftheseequipmentarepresent inthefacility:
High-touchSurfaces2 / Cleaned / NotCleaned / NotPresentinRoom
BeautySalonChair
PT/OTSupportBars
Washer/DryerKnobs
ActivityRoomTables

REFERENCE:Guh,A.,Carling,P.,andtheEnvironmentalEvaluationWorkgroup.(2010).OptionsforEvaluating EnvironmentalCleaning.CentersforDiseaseControlandPrevention.

DISCLAIMER:AlldataandinformationprovidedbytheOregonPatientSafetyCommissionisforinformationalpurposesonly.TheOregonPatientSafetyCommissionmakesnorepresentationsthatthepatientsafetyrecommendationswillprotectyoufromlitigationorregulatoryactioniftherecommendationsarefollowed.TheOregonPatientSafetyCommissionisnotliableforanyerrors,omissions,losses,injuries,ordamagesarisingfromtheuseoftheserecommendations.

Unit:Date:

HandHygieneObservationTool

ObserverName:

•DIRECTIONS- Ifyou believeyouobserved ‘nohand hygiene’orareunsure,pleaseconfirmwithstaffprivately;remindifapplicable.(Somestaffmemberscarrytheirownhandsanitizer.Remembertoobserve‘handsfull’processinitsentirety).

•FORMUPDATES:

o'Nursing’ isnow‘Nursing(RN)’,Nursing(CNA)’ andNursing(Tech) ‘Students’arenow‘Student(Nursing)’,‘Student(CNA)’,‘Student(Medical)’,‘Student(Other)’.The‘OTHER’sectionisalphabetizedand‘Cath Lab’(personnel)hasbeenadded.

oSurgeonsand MedicalProvidersaredividedbyspecialty–recordby#.

RoleofObserved Person / ObservedBehavior
Nursing(RN) / Nursing(CNA) / Nursing(Tech) / Surgeon
1Cardiac
2General
3Neuro
4OB/Gyn
5Orthopedic
6Plastics
7Urology
8Other
9Unknown / Prov(Medical)
1Cardiology
2Emergency
3Fam Practice
4GI
5InternalMed
6Nephrology
7Neurology
8Oncology
9Pediatrics
10Psychiatry
11Radiology
12Other
13Unknown / Provider(Hospitalist) / Provider(Anesthesia) / Provider(PA/NP) / Provider(CNM) / Provider(Resident/Fellow) / Provider (Unknown) / Student(Nursing) / Student (CNA) / Student(Medical) / Student(Other) / OTHER–use#1Admitting
2CathLab
3Clergy
4Engineering
5EVS
6Imaging
7Lab
8NutrServices
9Pharmacy
10PT-OT-ST
11RespTherapy
12SS/CaseMgmt
13Transport
14Unknown / CircleONE / Blockedview/unsure / Usedhandsanitizer / Handwashing w/soap andwater / Nohand hygiene–askremind / Comments–record nameofobserved staffmember, feedbackgiven,response,etc.
1 / INOUT
2 / INOUT
3 / INOUT
4 / INOUT
5 / INOUT
6 / INOUT
7 / INOUT
8 / INOUT
9 / INOUT
10 / INOUT
11 / INOUT
12 / INOUT
13 / INOUT
14 / INOUT
15 / INOUT
16 / INOUT

Revised4-10-12