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Policy for the Prevention, Control and
Management of Multi-Drug Resistant
Organisms (MDRO)
[Including Gram Positive (MRSA), Gram Negative EXECUTIVE SUMMARY
Infection Prevention & Control Precautions for Multi-drug resistant
organisms (MDRO).

All Healthcare workers (HCW) caring for Multi-drug resistant organisms
(e.g. MRSA, VRE, ESBLs and Acinetobacter species) affected patients
must be aware of and adhere to the following measures;
Prevention of Spread
Hand washing, adequate cleaning and disinfection of environment are important issues;. Thorough hand washing with soap & water and drying is the most important activity in the prevention of transmission. Hands should be washed before and after patient contact, between patients and after removing the gloves. Patient infected with multi-drug resistant Gram negative bacilli can be treated in an open ward with suitable precautions against contact spread, but single room is preferable in critical areas (SICU, MICU, NICU, CCU). MDRO contact isolation card must be displayed outside the door or above the bed. Clean latex gloves should be worn for direct patient contact. Gloves must be changed between patient care in cases of gross contamination e.g. faeces, wound, exudates etc. Disposable plastic apron should be used for patient care. All staff and visitors must wear apron when in close contact with the patient. Face Mask is NOT required. Patient care equipment such as Stethoscope, thermometer and BP apparatus should stay in Isolation room. If equipment has to be shared, it must be disinfected thoroughly. Reusable items such as ventilation tubing should be sent to CSSD for appropriate processing. All soiled/wet linen must be treated as infected. Place into the yellow plastic bag for transport to the laundry. The number of staff taking care of patient with MDRO should be kept at minimal to reduce the chances of cross transmission. Visitors should wear plastic apron ONLY if involved in direct patient care. Hands should be washed with soap & water after close contact. Transfer of patient with MDRO to other wards / department must be kept to minimal. Relevant ward staff must be notified prior to transfer of such patients. General purpose detergent and warm water should be used for routine cleaning. There is no need for separate cleaning equipment for isolation room. All surfaces and non disposable should be washed with detergent and warm water. Following cleaning, all surfaces should be allowed to dry. Rooms can be used for the next patient when the surfaces are dry. The aim of this policy is to provide guidance on the prevention, management and control of multi-drug resistant organisms (MDRO) which includes gram positive, gram negative and extended spectrum beta-lactamase (ESBL) bacteria. Objectives
 To provide hospital staff with an understanding of these organisms to inform and enable appropriate management of affected patients;  To prevent the spread of infection through the application of appropriate infection prevention and control measures. Responsibilities
All Staff
 Awareness of the policy and compliance with it;  Awareness of cross infection risk associated with MDRO;  Applying appropriate infection prevention and control measures to  Using this policy in conjunction with local policies and other Managers
 Ensuring that staff are aware of and comply with the policy;  Ensuring that staff attend or undertake relevant courses related to  Providing appropriate resources are available to minimise the risk of Infection Control Team
 Providing education/training on MDRO, their prevention, management and control which includes antimicrobial stewardship;  Surveillance of alert organisms which includes MDRO.

4 Infection Prevention & Control Precautions for MDRO
All staff caring for MDRO affected patients must be aware of and adhere
to the following measures.
4.1 Prevention of Spread
Hand washing, adequate cleaning and disinfection of environment are important issues. Hand washing:
 Thorough and effective hand washing using an antiseptic agent and proper hand drying is considered to be the most important
activity in the prevention of transmission.

 Hands should be washed before and after contact with the patient, after removing the gloves and between patients  Rings should be removed to avoid contamination and to enable adequate Isolation
 Patient infected with antibiotic resistant gram negative bacilli can be treated in an open ward with suitable precautions against contact spread, but single room isolation may be preferred if available especially in critical areas (ICU, NICU, CCU) where the chances of transmitting organisms is higher.  MDRO contact isolation card must be displayed outside the door or Protective Clothing
 Clean plastic or non-sterile latex gloves should be worn for direct contact  Hands should be washed and dried after the removal of gloves  Gloves must be changed between patient care activities that may result in gross contamination example faeces, wound, exudates and etc. Gown and Apron
 Disposable plastic apron are preferred  All persons including visitors must wear apron when in close contact with Face Mask
Patient Care Equipment

 Whenever possible equipment should stay in Isolation room e.g.  Use sphygmomanometer, BP Cuff that is designated for MDRO patients  If equipment has to be shared it must be disinfected thoroughly  All soiled /wet linen must be treated as infected  Place into the red plastic bag and finally into the hamper bag  The number of staff taking care of patient with MDRO should be kept at minimal to reduce the chances of cross transmission Transferring Patient
 Transfer of patient to wards/department must be kept at a minimal  Concern staff must be notified prior to transfer  All reusable items, e.g. ventilation tubing should be double bagged and sent to laundry/CSSD for appropriate processing.  Plastic apron should be worn only if involve in direct patient care (close  They should wash their hands after the visit Routine cleaning
 General purpose detergent and warm water should be used for routine  There is no need for separate cleaning equipment for isolation room Terminal Cleaning
 All surfaces and non disposable should be washed with detergent and  Following cleaning, all surfaces should be dried.  Rooms can be sued for the next patient when the surfaces are dry. Infection Control Nurse will ensure that the above policy is in practice from admission of a known case or after the diagnosis of MDRO infection /colonization to discharge and will be documented in nursing notes regarding the practices. 4.2 Treatment
The Medical Microbiologist will provide advice on the antibiotic treatment of a MDRO infection.
4.3 Decolonisation
This may be attempted only for MRSA currently depending on the causative organism and source of infection. Advice should be sought from the Medical Microbiologist. 4.4 Routine Environmental Cleaning
During the care of a patient with MDRO, the clinical environment may become heavily contaminated. Therefore special attention should be paid to daily cleaning of the isolation environment and a full isolation clean following discharge with Sodium hypochlorite 1,000ppm. 4.5 Terminal Environmental Cleaning
Standard terminal cleaning procedure using a combined detergent and 1,000ppm available chlorine-releasing agent, paying special attention to dust collecting areas, horizontal surfaces and floors, and curtain laundering. Only visible splashes on walls need to be removed – full wall-washing is not necessary. 4.6 Surveillance
The Infection Control Team will monitor trends in relation to MDRO where these are associated with service areas under their remit. The Clinical Governance and Risk Committee will receive information on any specific concerns, escalated from the Infection Control forum relating to infection control issues. The concerns will be assessed and action taken to address the issue identified. 4.7 Antimicrobial Stewardship
The emergence and spread of MDRO is encouraged by the use of broad- spectrum antimicrobials. Units affected by MDRO should review their antibiotic policy in conjunction with Medical Microbiologist and in line with the Antibiotic Policy especially in relation to limitation of intravenous therapy and automatic stop dates for antimicrobial therapy. Antibiotics should be used appropriately as per NHS Forth Valley Antibiotic Policy based on the results of microbiological samples. 4.8 Transfer/Discharge of Patients
 Transfer of patients with MDRO to other wards should be minimized to reduce the risk of spread, but this should not compromise other aspect
of patient’s care. All transfer should be discussed with a member of the
ICT prior to transfer;
 If a patient with MDRO is transferred to another health-care institution the receiving clinical and Infection Control staff must be informed. The ambulance service may require to be notified as well depending on the type and site of infection;  In general, MDRO do not present a risk to healthy people in the community or patients in residential or nursing homes who do not have catheters, wounds or other lesions. 4.9 Discontinuation of Infection Control Precautions
Infection control precautions should be discontinued following discussion with the ICT.
Further Readings
The increasing prevalence of antibiotic resistant micro-organisms, especially those with multi drug resistance, is causing international concern and their control is vital. Controlling multi-drug resistant organisms (MDRO) is important for the
following reasons:
 MDROs are resistant to the most usual antimicrobial therapy;  Increased patient morbidity and mortality;  Add to the cost of patient treatment in terms of resources and length of  Have the potential to spread and act as reservoirs of resistant genes for the transmission to other organisms. Since the introduction of antibiotics in the treatment of human infections and in food animals, there has been ample evidence to demonstrate that bacteria mutate and adapt to survive. Bacteria develop mechanisms to resist the action of antibiotics and in this way become resistant to their use in clinical practice. Certain bacteria seem to develop resistance more readily than others. These bacteria can develop multi resistance to several antibiotics which may severely limit therapeutic choices. The number of MDROs will increase if the selective pressure of antibiotic use continues and the resistant organism is able to spread from one person to another. Therefore the control of antibiotic resistance needs to focus on both:  Rational antibiotic use to minimise selective pressure;  The practice of effective infection control measures to prevent the Definition of MDROs
Multi-drug resistant organisms can be defined in two ways; organisms that are resistant to:  Several antimicrobial agents to which they would normally be  All but one or two antimicrobial classes, regardless of the mechanism of resistance (and often only susceptible to one or two commercially available antibiotics). Such organisms include ESBL/AMPC-producing enterobacteriaceae, vancomycin resistant enterococcus (VRE) and Meticillin-resistant Staphylococcus aureus (MRSA). Organisms that are resistant to a first-line antibiotic are commonly also included in the definition of MDRO. These include organisms that are intrinsically resistant and readily acquire additional resistance mechanisms and become multi-drug resistant e.g. carbapenem-resistant Acinetobacter. Types of MDROs
Gram Positive Bacteria
The most commonly known Gram positive MDRO bacteria are meticillin resistant Staphylococcus aureus (MRSA). There is a separate policy dedicated to the prevention, management and control of MRSA and the reader is directed to that policy. It is only mentioned here to give a holistic approach to MDROs. Gram Negative Bacteria
Gram negative bacteria are commonly found in the gastro-intestinal tract, in
water and in soil. In some hospitalised patients, colonisation of the gastro-
intestinal tract and oropharynx is common. Gram negative bacteria can be
part of the transient flora on the hands of healthcare workers. Some species
of bacteria commonly found in the bowel e.g. Escherichia coli and Klebsiella
can develop multi-resistance to antibiotics where they become collectively
referred to as multi-drug resistant gram negative bacteria (MDR-GNB). They
are seen most frequently in patients who have received broad spectrum
antibiotics and where patients have diminished immunity. MDR-GNB may
cause urinary tract infections, pneumonia and surgical site infections.
Resistance to glycopeptides such as Vancomycin i.e. vancomycin resistant
enterococcus (VRE) has emerged, in particular in Enterococcus faecalis and
Enterococcus faecium.
The emergence of VRE in Europe is thought to be linked to the use of the
glycopeptide antibiotic avoparcin, used as a growth promoter in the livestock
industry. Hence, animal strains of VRE may colonise the gut of healthy
individuals via contaminated food. In the USA, where avoparcin has not been
used, glycopeptide use is commonly linked with the use of Vancomycin itself
in hospitals and especially in certain specialties, e.g. haematology,
transplantation and renal medicine. This can also happen in the UK.
Resistance to glycopeptides reduces the options for antibiotic treatment
where clinical infection is evident.
Resistance in enterococci can transfer to other organisms. For example, the first detected clinical case of Vancomycin Resistant Staphylococcus aureus (VRSA) occurred in the USA in 2002. This was caused by Vancomycin
resistant genes transferring to Meticillin Resistant Staphylococcus aureus
(MRSA). Since then further cases have been reported in the USA and
elsewhere in the world. The risk of VRSA and potentially untreatable
Staphylococcus. aureus infections is an important reason for controlling the
spread of VRE.
Other MDR-GNB include: Pseudomonas auruginosa which is associated with
infections related to invasive devices e.g. urinary catheter and Acinetobacter.
Multi-drug resistant Pseudomonas auruginosa is resistant to at least two of
the following: ceftazidime or piperacillin/tazobactam or gentamicin (or other
aminoglycoside) or ciprofloxacin. Multi-drug resistant Pseudomonas
auruginosa strains are occasionally resistant to carbapenem antibiotics.
Multi-drug resistant Acinetobacter are defined as isolates which are resistant
to any aminoglycoside and to any third generation cephalosporin. Some
multi-resistant Acinetobacter strains are also resistant to carbapenem
antibiotics.

2.3. ESBLs
Some MDR-GNB produce an extended spectrum beta-lactamase which can
destroy/inactivate even broad spectrum antibiotics including cephalosporins.
These are referred to as extended spectrum beta lactamase bacteria or
ESBLs.
ESBL-producing coliforms are resistant to intravenous cephalosporins and they are frequently resistant to many other antibiotics including ciprofloxacin and aminoglycosides. Recently Gram-negative Enterobacteriaceae with resistance to carbapenem conferred by metallo-beta-lactamase 1 (NDM-1) was reported in the UK, amongst some patients returning from India and Pakistan. All these multi-resistant gram-negative organisms are detected by isolation
from clinical specimens where they may occur as colonizers or cause true
infection. MDR-GNB have been implicated in outbreaks of infection in the
intensive care units, neonatal, haematology/oncology units. The genes that
confer antibiotic resistance can spread to other bacteria. Multi-resistance in
these organisms limits the therapeutic options available.
Risk Factors for Acquiring MDRO
The patient risk factors associated with colonisation and infection are often the same for MRSA, VRE, MDR-GNB, C. difficile and Candida spp. The following risk factors have been identified: Gram Positive Bacteria
 Previous carriage or infection with MDRO;  Antibiotic exposure within the last year e.g. fluoroquinolones, 2nd and  Stay in a department with a high MDRO rate; Gram Negative Bacteria
 Previous carriage or infection with MDRO;  Antibiotic exposure within the last year  Hospital stay within the last year e.g. fluoroquinolones, 2nd and 3rd  Length of hospital stay in hospital;  Use of central venous or arterial catheter;  Use of gastrostomy or jejunostomy tube; 4. Sources/Reservoirs of MDROs
Infected or colonised patients are the major reservoir of MDRO. The gastrointestinal tract is the major reservoir for VRE, and multi-drug resistant gram negative bacilli (MDR-GNB), including ESBL-producing bacteria. While human sources are usually responsible for transmission of micro- organisms during health care, inanimate environmental sources may also be involved. Colonisation can be prolonged and is not always recognised. Environmental contamination can lead to transmission especially when patients have diarrhoea or faecal incontinence and the reservoir of the MDRO is the gastrointestinal tract. The inanimate environment and equipment may serve as a secondary source for MRSA and VRE but are generally less likely to do so for gram-negative bacteria. MRSA or VRE can survive for weeks to several months on various surfaces and may remain viable for prolonged periods. A common environmental source of ESBLs has only occasionally been discovered (e.g. contaminated ultrasound gel, a bronchoscope and thermometers). Unlike other gram-negative bacteria, Acinetobacter can survive for many days on both moist and dry surfaces (bed linen, curtains, floor, etc), therefore environmental contamination can be difficult to control which may lead to full ward closures for deep cleaning. Consistently following the recommended procedures for cleaning and disinfecting the environment should be adequate to keep rooms of MDRO patients clean. Identification of a Patient with MDRO Infection
Patients with MDRO infection are identified from a clinical specimen sent to the Microbiology laboratory. It is most often found in blood, wound swabs or urine and sputum samples. Routine screening for these bacteria is not necessary, and there are currently no guidelines for decolonisation. Where screening is indicated, samples should be tested to identify carriage. A newly diagnosed patient should be “flagged” on the E-ward system and case notes by the ward staff. It is the responsibility of admitting staff to ensure that the clinical alerts are checked. If the patient has previously been positive for MDRO then the ICT must be informed at the earliest opportunity. Blood stream infections will be reported to the ward/clinical team by Medical Microbiologist or the Infection Control Team. VRE infections will be reported to the ward/clinical team by Medical Microbiologist or the Infection Control Team. The Infection Control Team will conduct a risk assessment in collaboration with the clinical team and provide advice on the infection prevention and control measures required. Identification of Infection or Colonisation
As colonisation is more common than infection, careful consideration is required when interpreting positive microbiology results. When MDRO is isolated from a clinical specimen the following screening of the patient is advised prior to commencing antibiotic therapy. appropriate – urine, wound and invasive device site rectal/peri-rectal swab, nose, throat, groin, axilla and as appropriate wound and urine samples When patients are screened the microbiology request form should include C&S (to exclude VRSA) and site of original infection / colonisation documented in relevant clinical details.

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