martes, 8 de julio de 2014

CDC - Facility-level CRE Prevention measures - 2012 CRE Toolkit - HAI

CDC - Facility-level CRE Prevention measures - 2012 CRE Toolkit - HAI

2012 CRE Toolkit - Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE)

Part 1: Facility-level CRE Prevention

Supplemental Measures for Healthcare Facilities with CRE Transmission

These additional measures should be considered when baseline core prevention practices are not effective in reducing CRE incidence.

Active Surveillance Testing

This process involves culturing patients who might not be epidemiologically linked to known CRE patients but who meet certain pre-specified criteria. This could include everyone admitted to the facility, pre-specified high-risk patients (e.g., those admitted from long-term care facilities), and/or patients admitted to high-risk settings (e.g., intensive care units [ICUs]). Active surveillance testing has been used in control efforts for several MDROs including CRE; however, the exact contribution of this practice to decreases in CRE is not known.
As described above, active surveillance testing is based on the finding that clinical cultures will identify only a minority of those patients colonized with CRE; unrecognized colonized patients might not be on Contact Precautions and are a potential source for CRE transmission. If done, surveillance testing could be focused on patients admitted to certain high-risk settings (e.g., ICUs, long-term acute care) or could target specific patients (i.e., patients with risk factors, patients admitted from high-risk settings like long-term acute care or transferred from areas with high CRE prevalence). This testing is generally done at admission but can also be done periodically during admission (e.g., weekly). Patients identified as positive by this surveillance testing should be treated as colonized (i.e., placed on Contact Precautions, etc.). In some situations (e.g., patients admitted from high-risk settings) patients might be placed in preemptive Contact Precautions until surveillance testing is found to be negative.
As with screening of epidemiologically linked CRE contacts, the use of active surveillance testing to control CRE is applicable to both acute and long-term care settings.

Chlorhexidine Bathing

Chlorhexidine bathing has been used successfully to prevent certain types of healthcare-associated infections (e.g., bloodstream infections) and to decrease colonization with specific MDROs, primarily in ICUs. For CRE, it has been used as part of a multifaceted intervention to reduce the prevalence of CRE during an outbreak in a long-term acute care facility. During chlorhexidine bathing, diluted liquid chlorhexidine (2%) or 2% chlorhexidine-impregnated wipes are used to bathe patients (usually daily) while in high-risk settings (e.g., ICUs). The chlorhexidine is usually not used above the jaw line or on open wounds. When chlorhexidine bathing is used for a particular patient population or in a particular setting, it is usually applied to all patients regardless of CRE colonization status.
In long-term care settings this type of an intervention might be used on targeted high-risk residents (e.g., residents that are totally dependent upon healthcare personnel for activities of daily living, are ventilatordependent, are incontinent of stool, or have wounds whose drainage is difficult to control) or high-risk settings (e.g., ventilator unit). In addition, chlorhexidine bathing might be less frequent in long-term care depending on the facility’s usual bathing protocol.

Recommendations for Facilities with No or Rare CRE

Experience with other MDROs suggests that it might be most effective to intervene on emerging MDROs when they first are recognized in a facility before they become common. For this reason facilities that rarely (e.g., ‹ 1 per month) or never have patients admitted who are colonized or infected with CRE should be aggressive about controlling these organisms when they are identified. An example of one approach to CRE control in these settings is shown in Appendix B.
In addition, if a facility without previous CRE performs a review of archived clinical laboratory results for CRE and identifies previously unrecognized CRE-colonized or -infected patients, the facility should consider point prevalence surveys of high-risk units to further clarify the CRE prevalence. If additional CRE colonized patients are identified, facilities should also follow the approach in Appendix B. Facilities without CRE that receive patients that are transferred from facilities known to have CRE colonized or infected patients could also consider screening those patients for CRE at admission and placing them in preemptive Contact Precautions pending the result of surveillance cultures.

Summary of Prevention Strategies for Acute and Long-Term Care Facilities

Core Measures for All Acute and Long-term Care Facilities
  1. Hand Hygiene
    • Promote hand hygiene
    • Monitor hand hygiene adherence and provide feedback
    • Ensure access to hand hygiene stations
  2. Contact Precautions
    Acute care
    • Place CRE colonized or infected patients on Contact Precautions (CP)
      • Preemptive CP might be used for patients transferred from high-risk settings
    • Educate healthcare personnel about CP
    • Monitor CP adherence and provide feedback
    • No recommendation can be made for discontinuation of CP
    • Develop lab protocols for notifying clinicians and IP about potential CRE
    Long-term care
    • Place CRE colonized or infected residents that are high-risk for transmission on CP (as described in text); for patients at lower risk for transmission use Standard Precautions for most situations
  3. Patient and staff cohorting
    • When available cohort CRE colonized or infected patients and the staff that care for them even if patients are housed in single rooms
    • If the number of single patient rooms is limited, reserve these rooms for patients with highest risk for transmission (e.g., incontinence)
  4. Minimize use of invasive devices
  5. Promote antimicrobial stewardship
  6. Screening
    • Screen patient with epidemiologic links to unrecognized CRE colonized or infected patients and/or conduct point prevalence surveys of units containing unrecognized CRE patients
Supplemental Measures for Healthcare Facilities with CRE Transmission
  1. Conduct active surveillance testing
    • Screen high-risk patients at admission or at admission and periodically during their facility stay for CRE. Preemptive CP can be used while results of admission surveillance testing are pending
    • Consider screening patients transferred from facilities known to have CRE at admission
  2. Chlorhexidine bathing
    • Bathe patients with 2% chlorhexidine

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