In the endemic setting, active surveillance should be used as an additional measure to control the spread of MDR-GNB between facilities or units. Surveillance data from endemic settings should be used to build risk assessment protocols and implementtargeted screening policies that will catch MDR-GNB carried by transferred patients without adding unnecessary costs or burden. As far as sampling sites, rectal swabs, urine, or respiratory secretions are sufficient for almost all MDR-GNB, with rectal swabs being the most sensitive and groin being most specific. However, sensitivity of screening is low (29%) even when six body sites are included. Although rapid polymerase chain reaction-based methods to identify MDR-GNB are in development, culture-based tests remain the standard. Once an MDR-GNB pathogen is identified, weekly screening is recommended until no cases of colonization/infection or cross-transmission are observed. Several outbreak responses have noted that MDR-GNB pathogens, particularly MDR-AB, produce significant environmental contamination due to their method of shedding (shed skin cells, stool, and/or urine). However, the mean colonization time for MDR-GNB is 144 days, representing a significant length of time. The efficacy of screening is linked to the level of compliance, so screening must be maintained over time. Methicillin-resistant Staphylococcus aureus (MRSA) : Given the increasingly endemic nature of MRSA in both healthcare and community settings, questions have emerged about the clinical value of screening for MRSA, especially among asymptomatic carriers. If conducting screening for MRSA, nasal screening is most sensitive MRSA screening may be a useful tool for identifying colonization of other, nonendemic MDROs. Evidence supports some association between MRSA status at admission and later discovery of MDRO colonization. In facilities where universal MRSA screening is already in place, a positive result may be considered a risk factor for other MDROs. By knowing risk factors associated with colonization by MDROs other than MRSA, hospitals and other facilities can develop risk-based testing approaches for screening on admission, reducing costs in time and materials. Vancomycin-resistant Enterococci (VRE): Active surveillance for VRE can help detect asymptomatic carriers, but the clinical benefit of this strategy is unclear and methods for VRE surveillance can vary widely in practice. Active surveillance helps detect asymptomatic VRE colonization in patients with C. difficile infection (CDI) in facilities with a high VRE prevalence, given high correlation between colonization with the two organisms. More than 50 percent of patients with CDI were also colonized with VRE. Despite this finding, it is not clear whether surveillance for asymptomatic VRE carriers reduces VRE- related infections. Carbapenem-resistant/carbapenemase producing Enterobacteriaceae (CRE/CPE): Although the global prevalence of CRE/CPE is increasing, not all regions or all facilities in a region share the same risk for CRE outbreaks.
Active surveillance following identification of CRE can reveal additional asymptomatic cases. Rescreening of clinical samples collected for other testing is one way to efficiently screen patients who have risk factors for multiple MDROs and identify asymptomatic carriers. In light of no clear evidence for or against universal screening for CRE, active surveillance on admission for patients in any of the following elevated risk groups is recommended: • Patients transferred from a healthcare facility in any foreign country (in light of a lack of data on global CRE prevalence • Patients transferred from acute or long-term care facilities with known high CRE prevalence • Patients previously colonized or infected with CRE • Patients who have had close contact with a person with CRE. Any surveillance must have clear definitions to avoid under- or over-reporting of CRE cases. Environmental Sampling for MDRO Surveillance Active surveillance of the environment, in addition to patients, combined with monitoring staff’s adherence to infection control practices, can identify the transmission patterns and expose areas for improvement. Environmental sampling as part of active surveillance can be used to identify areas in need of intensive cleaning or where cleaning has been missed. Environmental surveillance may serve as an indicator of MDRO carriers, at least in the case of MDR-AB, where the organism is consistently shed by patients. Genotyping MDRO Cultures Genotypic testing can help determine whether MRDOs identified in active surveillance are horizontally transmitted between patients, coming from a common environmental reservoir, or are imported from other facilities. Negative unintended consequences Active surveillance is used to identify patients to be placed on contact precautions, which reduce transmission but may have unintended adverse effects on the patient. Contact precautions have been associated with less contact from healthcare workers, delays in care, adverse events (non- infection- associated), increased symptoms of depression and anxiety, and decreased patient satisfaction with care. Rapid-result genetic testing can reduce any potential adverse effects of contact isolation by limiting the time spent in preemptive isolation pendingscreening results. A potential negative consequence of public education about and coverage of outbreaks could be increased community anxiety. When sharing information on outbreaks and infection prevention responses with patients and families, one must convey the importance of preventing transmission and managing patients’ understanding of their individual morbidity and mortality risk. Publications on techniques used to control the outbreak in a facility as well as media coverage of the outbreak, for example, could be shared.
Barriers and Facilitators Adding weekly dissemination of the results of active surveillance (MDRO rates, location of acquisition) can be key to successfully controlling MDROs. Although other components (active surveillance, patient isolation) may be in place already automated systems could support enforcement of contact precautions and save considerable infection preventionist time. Horizontal transmission of MDRO strains may not need universal active surveillance, but MDRO acquisition or infection between facilities warrants communication to identify patients at elevated risk. Coordination with regional and national public health agencies can help with interfacility transmission by coordinating notification and infection prevention efforts across all facilities. Investing in active surveillance can require expenditures for laboratory and computer resources, but these investments can help reduce the cost of other infection prevention efforts. If a facility cannot absorb the costs of running a laboratory, partnering with public health agencies for surveillance may be an option. Faster results can be available using molecular testing methods such as polymerase-chain reaction, but these tests can be costly, have limited specificity in some cases, and are not available in all facilities. Surveillance and isolation precautions do not require specific patient consent, however education and clear communication about the need for and impact of active surveillance on patients are critical. In addition, the financial burden of active surveillance should be assumed by the facility, not the patient. Key Findings Targeted active surveillance performs as well as universal active surveillance for many MDROs and uses fewer resources. However, in places where universal active surveillance is already in place, screening for other MRDOs using the same sample may be cost- effective, as patients colonized with an MDRO share risk factors for others. Some consensus exists for screening high- risk patients (those with a history of MDROs or risk factors associated with MDRO colonization/ infection) on admission, but any screening approach will require compliance with infection prevention protocols when a patient’s culture result is positive. Surveillance may improve compliance with other PSPs when it is part of a multicomponent intervention, but more research is needed on the mechanismsand circumstances of this association, as it can be confounded by the co-implementation of other, bundled practices. Environmental cleaning and decontamination The CDC defines the practice of cleaning in the healthcare environment as the removal of visible soil (e.g., organic and inorganic material) from objects and surfaces. The CDC defines disinfection as the elimination of many or all pathogenic microorganisms from the environment, while sterilization refers to the elimination of all forms of microbial life.
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