______________________________ Infection Control for New York Health Care Professionals ‒ 2024 Update
Case Study 3: MDRO MDRO not normally seen in the New York region with any regularity but that are present in the U.S., have been identified in two nearby facilities. Initial investigation of a patient admitted to the facility noted fever, abdominal pain, and a urinary tract infection (UTI), all of which increased rapidly and did not respond to antibiotics. The physicians suspect the case could be CRE due to the similarities with cases in two nearby states. Consider the following questions. 1. What tier(s) category might this organism be? 2. What are the response recommendations for ICP indicated in this case? Discussion This would most likely be a Tier 2 based on the geographic description, and the HCP and family members must be informed. A rapid response would include a healthcare investigation, contact precautions, contact investigations, contact screenings, including colonization, with clinical lab prospective and retrospective surveillance. Recommendations apply to all inpatient healthcare exposures of the index patient in the 30 days prior to the identification of the target organisms. This case would include transmission-based precautions and EBP, if applicable, in skilled nursing facilities. Note: UTIs are a factor in the development of sepsis. See Element VII.
Screening household contacts is generally not rec- ommended; consider screening household contacts who have frequent inpatient healthcare exposure and have had extensive contact with the index patient to determine if Transmission-Based Precau- tions are necessary for subsequent admissions. In residential care settings, consider contact screening for residents if facility and situation meet the criteria for considering broader screening for healthcare contacts in Tier 3 investigations. Prioritize roommates and residents who share a bathroom with the index patient and residents with frequent inpatient exposure. If transmission is identified, consider broader screening to inform infection control measures in the facility. 4. Clinical laboratory prospective surveillance that per- form cultures from healthcare facilities should report any organisms with similar resistance profiles to public health. 5. Environmental cultures are generally not recommended unless transmission is identified or suspected and there is epidemiologic evidence implicating an environmental reservoir in ongoing transmission. 6. Implement a system to ensure adherence to infection control measures. Healthcare facilities should: • Educate and inform the HCP and visitors about the organism and precautions indicated. • Ensure supplies are available to implement precautions. • Conduct ongoing adherence monitoring of infection control practices and provide feedback to HCP.
• Flag affected patients’ medical records to initiate appropriate infection control precautions upon readmission. • Healthcare facilities, particularly long-term care facilities, should receive regular, at least yearly, infection control assessments using a standardized assessment tool. Tier 4: Organisms are endemic in a region and have been targeted by public health for their clinical significance and potential to spread rapidly to other regions or from healthcare settings into the community. Tier 4 organisms are endemic in a region but can be less com- mon in other areas of the United States. These are MDROs that have been targeted by public health for their clinical significance and potential to spread rapidly to other regions. In some areas of the U.S., KPC-CRE, Candida auris , and Aci- netobacter baumannii with certain plasmid-mediated oxacil- linases with carbapenemase activity (e.g., OXA-23-like, OXA- 24/40-like) are endemic. Health departments and healthcare facilities should: • Ensure that healthcare facilities and providers promptly receive testing results, to facilitate implementation of appropriate ICP measures for the affected patient. • Confirm measures are in place to ensure adherence to infection control and communication of patient MDRO status at transfer. • Prioritize prevention measures described in the Public Health Strategies to Prevent the Spread of Novel and Targeted Multidrug-resistant Organisms (MDROs) over a public health response to single cases, as is done for organisms in Tiers 1-3. • Remain vigilant for outbreaks and changes in regional epidemiology that may suggest additional measures.
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