______________________________ Infection Control for New York Health Care Professionals ‒ 2024 Update
workplace practice directives for each type of organism tier and warrants further study. The CDC Interim Guidance document gives specific, detailed strategies and “recommendations for the expected response, containment, and control” [16]. Key concepts include the following. Tier 1 is limited to novel organisms and/or resistance mecha- nisms that have never (or very rarely) been identified in the United States and experience is extremely limited, thus requir- ing a more extensive evaluation. Examples of Tier 1 organisms and mechanisms include the initial identifications of Candida auris and mcr-: l-carrying Enterobacterales in the United States. 1. Initial response measures prompt implementation of appropriate IPC including contact precautions for the patient, at the facility where they are admitted, to prevent transmission. • Implement Contact Precautions for the patient until the health department and healthcare facility can assess the risk for transmission. Skilled nurs- ing facilities considering use of Enhanced Barrier Precautions for a Tier 1 organism or mechanism should first consult with public health (See Ele- ment IV). • Prioritize the facility where the patient is currently admitted for a rapid infection control assessment to identify and address potential gaps in IPC. Environmental cultures can help clarify the role of the environment in transmission of a novel MDRO and may also help identify environmental reservoirs leading to ongoing transmission. Envi- ronmental sampling plans should be developed in consultation with public health and environmental microbiology experts. 2. Conduct a healthcare investigation. These steps identify and prioritize healthcare settings based on the risk for novel MDRO transmission from the index patient to others. 3. Conduct a contact investigation. Use colonization screening to assess for transmission at healthcare facili- ties where the index patient recently received care and among their close contacts and facilitate implementa- tion of appropriate precautions. 4. Clinical laboratory prospective and retrospective Sur- veillance. Perform prospective surveillance for at least three months after identification of the index patient or three months after the last case is identified. Per- form retrospective surveillance (laboratory lookbacks) of results from these clinical laboratories to identify organisms with similar resistance patterns, extending six months prior to identification of the index case. 5. Environmental cultures can help clarify the role of the environment in transmission of a novel MDRO and may also help identify reservoirs leading to ongoing transmission.
6. Implement a system to ensure adherence to infection control measures. Outline assessment and ongoing support of measures for high levels of adherence to recommended infection control practices at facilities where the patient received care. Tier 2: Organisms in this group include (1) MDROs that are primarily associated with healthcare settings and (2) for which no current treatment options exist (pan-not susceptible) and that have the potential to spread more widely within a region (e.g., have plasmid-mediated resistance mechanisms). These mechanisms and organisms are not regularly found in a region but might be more common in other areas of the U.S. Isolates that are not susceptible to any available antimicrobials, but whose transmission dynamics are well-known, are now clas- sified as Tier 2. In most of the U.S., carbapenem-resistant Enterobacterales (CRE) with OXA-48 or metallo- β -lactamase carbapenemases (e.g., New Delhi Metallo- β -lactamase (NDM), Verona-integron- mediated carbapenemase (VIM), and imipemenemase (IMP)) and carbapenemase-producing Pseudomonas spp. meet the Tier 2 criteria. In some areas of the United States, carbapenem- resistant Enterobacterales producing Klebsiella pneumoniae carbapenemase (KPC-CRE) and C. auris also meet the Tier 2 criteria because they are not commonly identified. 1. Initial response measures are intended for prompt implementation of IPC measures including contact precautions. If the patient is admitted to a healthcare facility, health departments and healthcare facilities should ensure implementation of appropriate infection control measures which may vary depending on the healthcare setting. Prioritize the facility for a rapid infection control assessment to identify and address any potential gaps in IPC. 2. Conduct a healthcare investigation to identify healthcare settings at risk of transmission from the patient. Provide more information about when and where the organism/mechanism were acquired. Review healthcare exposures from approximately 30 days prior to the initial positive culture up to the present. 3. Conduct a contact investigation. Use colonization screening to identify individuals with targeted MDROs, to implement appropriate precautions and evaluate potential transmission. Recommendations apply to all inpatient healthcare exposures of the index patient in the 30 days prior to the identification of the target organism to the present, prioritizing the facility where the patient is currently located and settings with highest risk of transmission, as determined by the healthcare investigation: • Patient screening epidemiologically to assess for transmission even if the patient was being managed with Contact Precautions or Enhanced Barrier Precautions.
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