Special Edition on Infection Prevention & Control | Page 33

surveillance have observed a reduction in new colonization with
MRSA or nosocomial MRSA infections after implementation of
active surveillance. Of note, significant planning is involved with
instituting an active surveillance program in a unit or among
high-risk populations in a hospital. Consideration is needed of
the resources that would be allocated for efficient laboratory
processing and reporting of results, notifying frontline staff of
MRSA-positive results, implementing contact precautions if in
accordance with hospital policy, and ensuring sufficient space
is available for co-horting MRSA-positive patients or placing
MRSA-positive patients in private rooms.
Tier 2, Intervention 5: Gowning and Gloving for All
ICU Patients: If MRSA in an ICU remains prevalent, implementing
a universal gown and glove policy when caring for
all patients in the ICU (not just those in contact precautions
or those known to be colonized or infected with MRSA) may
be considered. A cluster randomized trial compared universal
glove and gown use with usual care in medical and surgical
ICUs at several U.S. hospitals. The intervention did not result
in a decrease in the primary outcome of acquisition of MRSA
or vancomycin-resistant enterococci but did lead to fewer
acquisitions of MRSA alone (difference, –2.98 acquisitions
per 1000 person-days). In addition, universal gown and glove
use decreased frequency of room entry, increased room-exit
hand hygiene compliance, and did not lead to a difference in
adverse events (preventable and nonpreventable). Whether
there is an increased risk for adverse effects among patients
who are placed on contact isolation remains an unresolved
issue. Should a strategy of universal gowning and gloving for
all ICU patients be implemented, adherence to the intervention
and to hand hygiene is key.
Clostridioides difficile
Let’s review what Rohde, et al. (2019) outlined as the
interventions for Clostridium difficile.
There are 3 primary approaches to reducing CDI rates in the
acute care setting: 1) prevent exposure to C difficile spores, 2)
minimize disruption to and preserve intestinal microbiota, and
3) improve diagnostic stewardship when it comes to testing
for CDI. The first 2 measures aim to disrupt the nosocomial
spread of C difficile and progression to infection. The third aims
to balance early recognition of patients with CDI against the
need to minimize overdiagnosis in patients who are colonized,
but not infected, with this pathogen.
Tier 1 Practices
Tier 1, Intervention 1: Antimicrobial Stewardship: The
first intervention recommended for tier 1 was to implement or
reinforce existing antimicrobial stewardship programs with a
particular focus on interventions specific to CDI. With approximately
50% of patients in the acute care setting exposed to
antibiotics and studies indicating that between 30% and 50%
of those antibiotics are unnecessary or inappropriate, disruption
of the microbiota via antibiotics is the most significant risk factor
for developing CDI. Hence, antimicrobial stewardship remains
the single most important intervention for preventing CDI and
was prominently supported in all the clinical guidelines that
were reviewed. Several systematic reviews and meta-analyses
have supported the effectiveness of antimicrobial stewardship
programs (ASPs) in preventing CDI. Although meta-analyses vary
in the type of studies and ASPs included, ASP implementation
has been consistently associated with a 32 percent to 52 percent
reduction in CDI incidence. In addition, ASPs with a particular
focus on antibiotics that are considered high risk for CDI
(third-generation cephalosporins, fluoroquinolones, ampicillin
and clindamycin) are more effective in preventing CDI. In one
single-center study performed during a CDI epidemic, an ASP
focused on high-risk antibiotics was associated with a 60 percent
reduction in CDI incidence. Improving the appropriateness
of antibiotic use not only reduces an individual’s chances of
getting CDI but may also prevent collateral transmission risk
in hospital wards. The effect of antimicrobial stewardship at
the hospital or ward level is thought to stem from a decrease
in shedding of C difficile spores in asymptomatically colonized
patients who develop antibiotic-associated diarrhea while in
the acute-care setting. Stewardship may thus lead to “herd
TIER 1: STANDARDIZED SUPPLIES, PROCEEDURES, AND PROCESSES
(Complete all interventions: review and audit compliance with tier 1 measures before moving to tier 2)
Implement
antimicrobial
stewardship
interventions specific
to CDI
Conduct early,
appropriate CDI
testing and alert
staff of CDI status
Prevent transmission
of CDI through strict
glove use and hand
hygiene
Initiate contact
precautions
promptly when
patients test positive
for CDI and maintain
for duration of CDI
illness
Ensure cleaning
and disinfection
of equipment and
environment
Monitor health
care-onset CDI rates
and share with staff
and leadership
Perform CDI needs
assessment with GPS
and TAP strategy
TIER 2: ENHANCED PRACTICES
(If CDI rates remain elevated, start with the CDI GPS and TAP strategy, and then proceed with additional interventions)
Initiate contact precautions while CDI
results are pending (for symptomatic
patients) and prolong until discharge
after patient becomes asymptomatic
Implement environmental cleaning
process tools (audit checklists) and
use of an EPA sporicidal agent
Implement hand hygiene with
soap and water as preferred
method on exit of room, with
targeted training and monitoring
of staff compliance
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