What are the management strategies for patients at risk of multidrug-resistant (MDR) organism infections?

Management of Multidrug-Resistant Organism Risk

Implement a comprehensive infection control bundle combining hand hygiene with alcohol-based rubs, contact precautions with gloves and gowns, active surveillance screening at admission for high-risk patients, single-room isolation, enhanced environmental cleaning with audit and feedback, and antimicrobial stewardship programs to prevent transmission of multidrug-resistant organisms in hospitalized patients. 1

Core Infection Control Measures

Hand Hygiene (Highest Priority)

• Perform hand hygiene with alcohol-based hand rub before and after all patient contacts as the preferred method for routine hand antisepsis 2, 1
• Use soap and water hand washing only when hands are visibly soiled with body fluids or excretions 2
• Monitor hand hygiene compliance and provide feedback to healthcare workers to achieve greater adherence 2, 1, 3
• Prohibit artificial nails among healthcare workers to reduce transmission risk 2

Contact Precautions

• Implement contact precautions requiring gloves and gowns for all encounters with colonized or infected patients in all hospital settings 2, 1
• Healthcare workers must wear gloves and gowns before entering the room and remove them promptly after care, followed by immediate hand hygiene 2
• Conduct audits of adherence to contact precautions to ensure interventions are correctly performed 2, 1

Patient Isolation and Cohorting Strategies

Single-Room Isolation (Strong Recommendation)

• Isolate all colonized and infected patients in single rooms immediately upon identification to reduce acquisition risk 2, 1
• Monitor for potential adverse effects of isolation including clinical complications from reduced contact with doctors and nurses, decreased quality of life, and psychological adverse effects 2

Cohorting When Single Rooms Unavailable

• Cohort patients with the same multidrug-resistant organism in designated areas when single rooms are not available 2, 1
• Consider cohorting dedicated staff to care for colonized/infected patients to reduce transmission risk 2

Active Surveillance and Screening

High-Risk Patient Screening

• Perform active screening cultures at hospital admission for high-risk patients including those with prior ICU stays, prolonged antibiotic therapy, central venous catheters, mechanical ventilation, or recent hospitalization abroad 2, 1
• Use rectal or perirectal swabs, inguinal area swabs, and samples from manipulated sites (catheters, wounds) for screening 2, 1
• Consider admission, discharge, and weekly screening for patients remaining in high-risk units to provide feedback and assess intervention effectiveness 2

Alert Systems

• Use alert codes to promptly identify patients already known as colonized at hospital/ward admission and implement pre-emptive contact precautions 2
• Ensure communication of multidrug-resistant organism status before transferring patients to other healthcare facilities 2

Environmental Cleaning and Disinfection

Enhanced Cleaning Protocols

• Monitor cleaning performance with audit and feedback to ensure consistent environmental cleaning 2, 1
• Specify in protocols which items require disinfection, which disinfectant agents to use (including proper dilutions), and contact times 2, 1
• Dedicate non-critical patient-care equipment to single patients or cohorts of patients infected or colonized with multidrug-resistant organisms 2
• Implement specific protocols for disinfection of endoscopes and respiratory equipment locally 2

Environmental Surveillance

• Perform environmental sampling from surfaces (mattresses, beds, bedside tables, chairs, washbasins, window sills) that have contacted colonized or infected patients 2
• Consider UV light surveillance for high-risk organisms like MDR-Klebsiella pneumoniae 2
• Consider ward or unit closure to new admissions to facilitate intensive cleaning until transmission control is achieved 2

Antimicrobial Stewardship

Antibiotic Restriction Programs

• Implement aggressive antimicrobial stewardship programs to restrict carbapenem use, as prior carbapenem exposure is the strongest predictor for NDM acquisition (OR 8.4) 1
• Plan interventions to restrict broad-spectrum antibiotic usage including fluoroquinolones and third-generation cephalosporins 1
• Restrict antibiotic usage to reduce spread of MDR-Pseudomonas aeruginosa, MDR-Klebsiella pneumoniae, and MDR-Acinetobacter baumannii 2

Education and Administrative Support

Healthcare Worker Education

• Conduct educational programs ensuring healthcare workers understand why multidrug-resistant organisms are epidemiologically critical, why prevention is essential, and which control measures are effective 2, 1
• Hold multidisciplinary meetings every 2-4 weeks with physicians, nurses, respiratory technicians, pharmacists, and environmental service personnel to review adherence audits and provide feedback 2, 1

Administrative Infrastructure

• Provide administrative support including economic and human resources to prevent and control multidrug-resistant organism transmission 2, 1
• Include environmental personnel (estates, domestic, and janitorial representatives) in infection prevention and control infrastructure 3

Critical Pitfalls to Avoid

• Do not allow incontinent patients colonized with NDM-producing organisms to walk in hallways, as environmental contamination has occurred in documented outbreaks 1
• Avoid tap water contact with central venous catheters, surgical wounds, or for rinsing medical equipment, as water systems harbor NDM organisms 1
• Do not delay implementation of contact precautions while awaiting culture results for high-risk patients; use pre-emptive contact precautions 2

Organism-Specific Considerations

For MDR-Acinetobacter baumannii

• Active screening cultures at admission have moderate evidence with strong recommendation 2
• Hand hygiene programs have moderate evidence with strong recommendation 2

For MDR-Klebsiella pneumoniae

• Chlorhexidine gluconate bathing may be useful as part of a multifaceted approach (low evidence, conditional recommendation) 2

For MDR-Pseudomonas aeruginosa

• Despite very low direct evidence, strong recommendations exist based on extrapolation from other multidrug-resistant organisms 2