Background

Multidrug-resistant organisms (MDROs) are microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial agents.¹ These include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci species (VRE), carbapenemase-producing Enterobacteriaceae, and Gram-negative bacteria that produce extended spectrum beta-lactamases (ESBLs). These last two types of pathogens produce chemicals that allow them to resist the effect of certain antimicrobials, and this adaptation is easily passed between different species.

Other species of note include MDR Escherichia coli and Klebsiella pneumoniae, Acinetobacter baumannii (abbreviated AB; some strains are resistant to all antimicrobial agents), and organisms such as Stenotrophomonas maltophilia that are intrinsically resistant to the broadest-spectrum antimicrobial agents.¹ MDROs’ resistances limit treatment options for patients, making infection critical to preventing further harms.

Importance of Harm Area

The World Health Organization (WHO) now recognizes that MDROs are a growing threat in every geographic region of the world.² Drug-resistant bacteria pose a significant public health risk both domestically and abroad due to their ability to colonize individuals without causing symptoms, their endurance in the environment, and the clinical threat they pose.³ The growing presence of resistant microbes is of particular concern for vulnerable patients, such as those who have received organ transplantation, those with cancer, preterm infants, and immune-suppressed and other medically vulnerable individuals.²

With treatment complicated by the limited availability of antimicrobials to treat these infections, MDROs are responsible for approximately 23,000 deaths annually from antibiotic-resistant pathogens in the United States alone.⁴ The Centers for Disease Control and Prevention (CDC) (2018) states that 11 percent of individuals screened in healthcare facilities are asymptomatic carriers for a transmissible, “hard-to-treat” microorganism.⁵

Drug-resistant organisms are becoming increasingly present in all settings and geographic areas. As cited in Tacconelli et al. (2014), carbapenem resistance increased in five European countries from 2008 to 2011.⁶ In the United States, infections caused by multidrug-resistant, Gram-negative bacteria have increased over the past decade, and one out of five hospitals reporting invasive infections implicated a carbapenem-resistant K. pneumoniae, one of the most common MDROs.⁶ While rates of hospital-onset, MRSA-related bacteremia in the United States have declined, community-onset MRSA-related bacteremia has increased in recent years.⁷

The patient safety practices (PSPs) in this report have universal application for reducing the burden of colonization and infection. When differences are significant (e.g., Enterococci in the digestive tract vs. S. aureus on patient skin), we make a note in the findings. The large benefit of these practices, however, comes from this universality: whether the organism is an extremely drug resistant A. baumannii or methicillin-susceptible S. aureus, infection prevention reduces risks and prevents patient harms.

Methods for Selecting PSPs

To determine the optimal methods for controlling MDROs and preventing MDRO-related infection, we reviewed CDC guidelines⁸ and the compendium of strategies from the Society for Healthcare Epidemiology of America.^9,10 Using these systematic reviews and reports, we developed an initial list of 23 PSPs that target diagnostic errors, and the Technical Expert Panel, Advisory Group, and AHRQ reviewed it.

Based on the reviewers’ recommendations, we identified six priority PSPs:

• Chlorhexidine bathing to control MDROs
• Hand hygiene to reduce MDRO transmission
• Active surveillance strategies for MDROs
• Environmental cleaning and disinfection strategies
• Minimizing exposure to invasive devices and reducing device-associated MDRO risks
• Communication of patients’ MDRO status

What’s New/Different Since the Last Report

The previous Making Health Care Safer reports included recommendations for infection control practices, including multicomponent interventions for device-associated infections as well as general infection prevention. In this report, we focus on the evidence for those practices (and some new practices) to reduce the transmission of and infections caused by MDROs.

As noted in previous Making Health Care Safer reports, the epidemiology of MRSA, VRE, and other MDROs has continued to evolve; this report updates the literature with responses to that emerging, evolving resistance in the following ways:

• Chlorhexidine bathing is a practice that can be combined with others (such as active surveillance and contact precautions) in response to MDRO outbreaks or added to routine patient bathing to control MDROs and prevent infection. Current guidelines focus mainly on acute care populations, especially critical care. In this report, we include studies of non-critical care populations and some studies on chlorhexidine in community settings. This review also includes information on chlorhexidine resistance and important considerations when adding chlorhexidine bathing to routine patient care.
• Hand hygiene is a universal strategy for preventing transmission of MDROs and MDRO-related infection, regardless of patient care risk factors. This review also includes new findings on the role of patient hand hygiene and mathematical models to measure the impact of hand hygiene (in combination with other PSPs or alone).
• For active surveillance, this review looks at specific strategies for identify MDRO-infected and MDRO-colonized patients, particularly active surveillance cultures/testing of patients and their environment, to prevent MDRO transmission.
• Environmental cleaning is a new practice in this report, and our review focuses both on the efficacy of different cleaning products and strategies to ensure thorough cleaning.
• Many practices and resources for minimizing the risk of harm due to device use were covered in the previous version of Making Health Care Safer; this review includes updated literature and any additional resources since that publication was written.
• Finally, communicating patients’ MDRO status (also new in this report) allows facilities to take appropriate infection prevention precautions from the start of the patient encounter. This report provides evidence on the negative effects of missed communication and some examples of communication strategies.

References for Introduction

1.

Siegel JD, Rhinehart E, Jackson M, Chiarello L. Management of multidrug-resistant organisms in healthcare settings, 2006. Atlanta, GA: Centers for Disease Control and Prevention; 2006. https://www​.cdc.gov/infectioncontrol​/guidelines/mdro/index​.html.

2.

Chan M. Ten Years in Public Health, 2007–2017: A Global Health Guardian: Climate Change, Air Pollution and Antimicrobial Resistance. Geneva: World Health Organization; 2017. https://www​.who.int/publications​/10-year-review​/chapter-guardian.pdf?ua=1.

3.

Palmore TN, Henderson DK. Managing transmission of carbapenem-resistant Enterobacteriaceae in healthcare settings: A view from the trenches. Clin Infect Dis. 2013;57(11):1593–9. doi: 10.1093/cid/cit531. [PMC free article: PMC3888298] [PubMed: 23934166] [CrossRef]

4.

Trick WE, Lin MY, Cheng-Leidig R, et al. Electronic public health registry of extensively drug-resistant organisms, Illinois, USA. Emerg Infect Dis. 2015;21(10):1725–32. doi: 10.3201/eid2110.150538. [PMC free article: PMC4593443] [PubMed: 26402744] [CrossRef]

5.

Centers for Disease Control and Prevention. Containing Unusual Resistance. CDC Vital Signs. Atlanta, GA: April 2018. https://www​.cdc.gov/vitalsigns​/pdf/2018-04-vitalsigns.pdf.

6.

Tacconelli E, Cataldo MA, Dancer SJ, et al. ESCMID guidelines for the management of the infection control measures to reduce transmission of multidrug-resistant Gram-negative bacteria in hospitalized patients. Clin Microbiol Infect. 2014;20: Suppl 1:1–55. doi: 10.1111/1469-0691.12427. [PubMed: 24329732] [CrossRef]

7.

Kourtis AP, Hatfield K, Baggs J, et al. Vital signs: Epidemiology and recent trends in methicillin-resistant and in methicillin-susceptible Staphylococcus aureus bloodstream infections - United States. MMWR Morb Mortal Wkly Rep. 2019;68(9):214–9. doi: 10.15585/mmwr.mm6809e1. [PMC free article: PMC6421967] [PubMed: 30845118] [CrossRef]

8.

Centers for Disease Control and Prevention. Interim Guidance for a Public Health Response To Contain Novel or Targeted Multidrug-Resistant Organisms (MDROs) Atlanta, GA: Centers for Disease Control and Prevention; January 2019. https://www​.cdc.gov/hai​/pdfs/containment​/Health-Response-Contain-MDRO-H.pdf.

9.

Yokoe DS, Anderson DJ, Berenholtz SM, et al. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates. Infect Control Hosp Epidemiol. 2014;35(8):967–77. doi: 10.1086/677216. [PMC free article: PMC4223864] [PubMed: 25026611] [CrossRef]

10.

Calfee DP, Salgado CD, Milstone AM, et al. Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(7):772–96. doi: 10.1086/676534. [PubMed: 24915205] [CrossRef]

5.1.1. Practice Description

For the purpose of this review, we define “chlorhexidine bathing” as application of chlorhexidine to the skin or oropharyngeal surfaces to promote decolonization and to prevent infection. As described below, oropharyngeal surfaces represent a reservoir for MDROs in mechanically ventilated patients who cannot perform their own oral care. Since chlorhexidine bathing is recommended for patients at high risk for MDRO-related infections—generally intensive-care patients, many of whom may be mechanically-ventilated as part of their care—we include oral care as part of a chlorhexidine bathing routine.³

5.1.2. Methods

To investigate the current literature for chlorhexidine bathing—for which patients, in what form, how often, and with what effectiveness—we searched three databases (CINAHL, MEDLINE, and Cochrane) for a combination of the keywords “chlorhexidine bathing” and MeSH terms related to “cross infection prevention,” “drug resistance, multiple, bacterial,” and “drug resistance, microbial.” Articles from 2008 through December 31, 2018, were included. (Any relevant articles published after the original search are included in the PRISMA diagram as additional sources.)

The initial search yielded 323 results (including 6 articles from other sources); after duplicates were removed, 300 were screened for inclusion, and 124 full-text articles were retrieved. Of those, 42 were selected for inclusion in this review. Articles were excluded if they did not mention chlorhexidine’s role in preventing MDROs, mentioned a PSP other than bathing, or discussed use of chlorhexidine outside the healthcare environment. Chlorhexidine oral care was included in this review, as were in vitro studies that assessed the impact of chlorhexidine use on the selection or development of resistant organisms.

General methods for this report are described in the Methods section of the full report.

For this patient safety practice, a PRISMA flow diagram and evidence table, along with literature-search strategy and search-term details, are included in the report appendixes A through C.

5.1.3. Review of Evidence

One of the aims of this review is to better understand the nuances of chlorhexidine’s efficacy for controlling and preventing infection caused by MDROs.

The questions of interest for this review are: Which chlorhexidine applications are most effective for decolonization and for infection control, against which organisms is chlorhexidine the most effective, and what are the potential outcomes related to chlorhexidine resistance? Further, which patients benefit the most from chlorhexidine bathing?

Many of the studies included in this report and in systematic reviews focus on intensive care unit (ICU) patients, who have the most risk factors for MDRO colonization and infection. While these patient populations show benefits in terms of reduced colonization, carriage, and infection, the studies that include relatively healthy populations (both in community and hospital settings) show more nuanced results without a clear benefit.

The studies summarized in this section include several well-designed, rigorous studies, some of which have very large populations (tens or hundreds of thousands). When findings are nuanced, we note where limitations may have contributed a null finding or if mediating factors showed benefit for one subgroup but not the whole population.

This summary indicates the best-supported uses of chlorhexidine and the level of evidence for other uses. Section 5.3.4 provides a list of resources for implementing chlorhexidine bathing protocols. Where the evidence is not definitive, such as using chlorhexidine bathing to prevent infection for relatively healthy patient populations or reduce MDROs in community settings, we hope this review will help clinical staff make their own determination on implementing chlorhexidine bathing.

5.1.3.1. Efficacy for Controlling MDROs and Preventing Infection

In the sections below, we summarize the clinical results of chlorhexidine bathing for major MDROs (MRSA, VRE, CRE), HAIs, and other results. This summary is accompanied by a table that briefly describes the supporting evidence for each section. Additional information can be found in the Chlorhexidine Bathing Evidence Table (see Appendix B).

5.1.3.1.1. MRSA

Evidence suggests that chlorhexidine bathing in the hospital setting reduces MRSA acquisition and carriage but may not always result in fewer MRSA infections. Three systematic reviews found evidence that chlorhexidine bathing alone reduces MRSA acquisition and carriage.^5–7 This finding is supported by five strong studies (four experimental, one quasi-experimental) that also found chlorhexidine bathing reduced MRSA carriage and acquisition.^8–12 While most of these studies found that bathing also reduced MRSA infections, Derde and colleagues’ review (2012) included some studies that found no significant reduction in infections.⁶

One prospective cohort study found no reduction in MRSA colonization rates, specifically, but did find a significant reduction in the rates of infections caused by all MDROs (measured in aggregate, not by specific MDRO).¹³ Interpreting these results is made more difficult by the fact that chlorhexidine bathing is recommended as part of a multicomponent strategy that includes nasal mupirocin and, in a few studies, oral antibiotics, as described in general MDRO and MRSA control guidelines.^3,14

In long-term care facilities, Peterson and colleagues’ cluster-randomized study (2016) demonstrated that a thorough decolonization protocol that includes chlorhexidine bathing can reduce MRSA colonization without the need for patient isolation.¹² This is an important finding for implementation, because extended patient isolation and gown and glove use may not be feasible or desirable in long-term or residential care settings.

Table 5.1 below presents the results from each study.

Table 5.1

Summary of MRSA Results.

5.1.3.1.2. VRE

Several studies found evidence that chlorhexidine can reduce VRE acquisition and colonization. One rigorous, multicenter study found that chlorhexidine bathing can reduce VRE acquisition.⁸ Three systematic reviews found that chlorhexidine can reduce VRE carriage in hospital patients.^5–7 Finally, two quasi-experimental studies found reduced VRE colonization among patients who were bathed daily with chlorhexidine, and the Mendes and colleagues study (2016) additionally observed reduced VRE infections.^11,15 Table 5.2 below presents the results from each study.

Table 5.2

Summary of VRE Results.

5.1.3.1.3. CRE

Few studies directly addressed chlorhexidine effects on CRE specifically (a number focused on the larger category of MDR-GNB). Of those that did, two observational cohort studies found that chlorhexidine bathing could reduce CRE colonization.^13,16 Table 5.3 below presents the results from each study.

Table 5.3

Summary of CRE Results.

5.1.3.1.4. HAIs

Many studies examined the effect of chlorhexidine bathing on rates of various HAIs, such as catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP)^g, and central line-associated blood stream infection (CLABSI). Where possible, we specify whether all infections or MDRO-only infections are noted in the results, but not all studies provided that level of detail. Based on the studies included, chlorhexidine bathing is most effective at reducing colonization by and HAIs from Gram-positive MDROs in patients who have a break in the skin due to a needed medical device (e.g., central line). Table 5.3 and the paragraphs below summarize these findings.

One review and several studies, including two large studies (Huang et al., 2013, and Huang et al., 2019) with more than 10,000 patients and 400,000 patients, respectively, have found evidence that chlorhexidine bathing can reduce the risk of HAIs, especially in intensive care units.^9,10 Huang and colleagues’ 2013 REDUCE MRSA trial found universal decolonization involving daily chlorhexidine bathing throughout the patient’s entire ICU stay and twice-daily intranasal mupirocin for 5 days was more effective than targeted decolonization or screening and isolation in reducing MRSA-positive clinical cultures and all-cause bloodstream infections.¹⁰

In a subsequent study (the ABATE Infection trial, 2019), Huang et al. evaluated the impact of universal chlorhexidine bathing and targeted mupirocin use for MRSA carriers in non-ICU settings.⁹ The authors found that the intervention did not significantly reduce MRSA- or VRE-positive clinical cultures for the overall study population. In a post-hoc analysis, patients with medical devices (including central lines, midline catheters, and lumbar drains) were found to experience a significantly greater benefit from the intervention.

Similarly, Denny and Munroe’s systematic review (2017) found the strongest evidence for reducing surgical site infection (SSI) and CLABSI rates, as well as acquisition, colonization, and infection for MRSA and VRE.⁵ Among ICU patients, Climo and colleagues’ 2013 study found a significant reduction in CLABSIs (the only HAI outcome included in that study).⁸ As mentioned above, only a few studies included in this review examined chlorhexidine bathing for CRE, and only one, Abboud and colleagues’ observational cohort study (2016), looked at CRE-related HAIs. Abboud and colleagues found reductions in those HAIs in CRE-colonized patients after chlorhexidine bathing was implemented.¹⁶

While some studies did not show an effect of chlorhexidine bathing on HAIs, most of these studies were considerably smaller than the two studies by Huang and colleagues. A rigorous cluster-randomized trial by Noto and colleagues (2015) found no impact on CLABSI, CAUTI, VAP, or Clostridioides difficile infection rates among the 9,340 patients in the study.¹⁷ Ruiz et al. (2017) reduced MDRO colonization with chlorhexidine wipes, but this did not lead to a reduction in HAIs in their single-site study. Ruiz and colleagues also noted that longer ICU stays (in one Spanish hospital) were associated with overall incidence of HAIs, suggesting that chlorhexidine bathing alone was not sufficient to reduce the infection risk posed by extended stays in intensive care.¹³

Two studies directly compared the use of chlorhexidine bathing against bathing with soap and water, finding no improvement in HAI rates when chlorhexidine was used. Kengen et al.’s study of 6,634 ICU patients (2016, Australia) found no statistically significant difference in HAIs when patients received daily bathing with chlorhexidine instead of soap and water.¹⁸

Similarly, Boonyasiri and colleagues’ smaller study of 418 Thai ICU patients (2016) found no benefit to chlorhexidine bathing over soap and water bathing on HAI rates in environments where most HAIs were caused by MDR-GNB.¹⁹ However, Camus and colleagues (2014) reduced HAIs from MDR-GNB by adding mupirocin application to chlorhexidine bathing.²⁰

Most studies of chlorhexidine for HAI prevention focused on BSIs, but a few looked at VAP and SSIs. Duszynska and colleagues’ observation study (2017) also found no reduction in intubation-related pneumonia, nor in UTIs, although overall infections and catheter-related infections were significantly lower.²¹ A randomized trial of oropharyngeal decontamination using chlorhexidine found no effect on reduced BSIs from MDR-GNB in mechanically ventilated patients.²²

Although chlorhexidine is routinely used for preoperative antisepsis in surgical settings, Abboud and colleagues (2016) found no supporting literature that chlorhexidine bathing reduced SSIs (although they did observe a reduction in SSIs among CRE-colonized patients in their study).¹⁶ In their systematic review, Denny and Munroe (2017) did not find clear evidence of the efficacy of chlorhexidine bathing for preventing SSIs.⁵

Finally, Urbanic and colleagues (2018) raise an important limitation that applies to all these studies: because of other HAI prevention initiatives, the absolute number of HAIs is, in some cases, very low.²³ The number needed to treat with chlorhexidine bathing in order to significantly reduce HAIs may be, in some cases, larger than the number of patients enrolled in studies. This finding suggests that chlorhexidine bathing has limited benefit for HAI reduction in settings where HAIs are already well controlled by other means.

Table 5.4 below presents the results from each study.

Table 5.4

Summary of HAI Results.

5.1.3.1.5. Other Results

This section summarizes other relevant results that do not fall under the categories above. Most of these studies focused on MDRO generally or MDR-GNB specifically. The studies we reviewed do not support chlorhexidine use but also do not warrant a recommendation against using it for MDR-GNB, although it may not be the most effective precaution for those organisms. Table 5.5 below presents the studies and their results.

None of the systematic reviews recommended chlorhexidine bathing for preventing/reducing MDR-GNB colonization.^6,7,24 One review (Tacconelli et al., 2014) found only temporary decolonization of MDR-GNB using chlorhexidine, and one randomized, open-label controlled trial (Boonyasiri et al., 2016) found that chlorhexidine bathing offered no reduction or delay in MDR-GNB acquisition.^19,24 Kengen and colleagues’ retrospective time study (2018) found no difference in MDRO acquisition with chlorhexidine bathing compared with soap and water, whereas Ruiz and colleagues (2017) saw a reduction in MDRO acquisition, including MDR-GNB.^13,18

Musuuza and colleagues’ pre-post study (2017) found lower colonization with MDR-GNB (specifically, fluoroquinolone-resistant GNB) after chlorhexidine bathing, but Mendes and colleagues’ quasi-experimental observational study (2016) did not.^15,25 Maxwell and colleagues (2017) found no difference between chlorhexidine and soap bathing for lowering MDRO infection rates (from GNB or GPB).²⁶ Pedreira and colleagues (2009) observed no reduction in MDRO colonization rates when chlorhexidine was added to standard oral care (toothbrushing) in pediatric ICU patients.²⁷

Table 5.5

Summary of Other Results.

5.1.4. Implementation

As described above, the most common frequency of chlorhexidine bathing was daily, and the most common application was a 2% chlorhexidine gluconate solution, either in prepackaged wipes or in soaked washcloths. One important aspect of chlorhexidine use is to allow long-term contact with the skin. Ekizoğlu and colleagues (2016) recommended a contact time of at least 5 minutes, and no-rinse applications can further take advantage of chlorhexidine’s persistent antimicrobial effects on the skin.³¹ DeBaun and colleagues’ in vitro study of MRD isolates (2008) suggests that extreme dilutions (between 1:2,048 and 1:8,192) of chlorhexidine may still be effective against MRSA and A. baumanii, but such extreme dilutions may not always be sufficiently bactericidal or inhibitory for resistant organisms (as discussed above under chlorhexidine resistance).⁴⁶

Chlorhexidine can be successfully used for MRSA decontamination, when combined with mupirocin and active surveillance.⁶ However, the effectiveness of decolonization for otherwise healthy populations is unclear. While Whitman and colleagues (2010) successfully reduced skin and soft tissue infections in healthy populations by instituting daily bathing with 2% chlorhexidine-impregnated clothes, Huang and colleagues (2019) did not find benefits to introducing chlorhexidine in a non-critical care hospital setting.^9,29

Interestingly, a study by Fritz and colleagues (2012) found that a household intervention of S. aureus decolonization and personal care hygiene (i.e., relegating personal care items to a single individual and frequent, hot-water washing of linens and towels) reduced skin and soft tissue infections in household members but not the index case patients. Fritz et al. hypothesized that the acquisition of new S. aureus strains may put someone at higher risk for infection, rather than simply being colonized; 20 percent of the index patients (pediatric patients with a skin or soft tissue infection) were not colonized with S. aureus at screening, despite having an S. aureus culture from the infection site.⁴⁷

5.1.5. Gaps and Future Directions

As covered in Denny and colleagues’ systematic review (2017), additional research could include⁵:

• Studies on the frequency and duration of bathing (how many times a day, for what period);
• Evaluations of chlorhexidine bathing’s role in multicomponent programs (also suggested in commentary by Horner et al., 2012)⁴⁹; and
• Continued research on chlorhexidine resistance and related clinical outcomes, especially the role of biofilms (as noted in commentary by Grascha, 2014) and Gram-negative bacteria (also suggested in commentary from Strich & Palmore, 2017).^50,51

Although none of the studies included in this report indicated negative clinical outcomes due to chlorhexidine resistance, commentary by Kampf (2016) cautions against use of chlorhexidine for general, nonspecific applications such as hand hygiene or instrument soaking, where insufficient concentrations are more likely to occur.⁵² Further studies to prevent these vulnerabilities in chlorhexidine bathing would be valuable to establishing bathing protocols.

References for Section 5.1

1.

Edmiston CE, Jr., Bruden B, Rucinski MC, Henen C, Graham MB, Lewis BL. Reducing the risk of surgical site infections: Does chlorhexidine gluconate provide a risk reduction benefit? Am J Infect Control. 2013;41:(5 Suppl):S49–55. doi: 10.1016/j.ajic.2012.10.030. [PubMed: 23622749] [CrossRef]

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3.

Yokoe DS, Anderson DJ, Berenholtz SM, Calfee DP, Dubberke ER, Ellingson KD, et al. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates. Infect Control Hosp Epidemiol. 2014;35(8):967–77. doi: 10.1086/677216. [PMC free article: PMC4223864] [PubMed: 25026611] [CrossRef]

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Lemmen SW, Lewalter K. Antibiotic stewardship and horizontal infection control are more effective than screening, isolation and eradication. Infection. 2018;46(5):581–90. doi: 10.1007/s15010-018-1137-1. [PMC free article: PMC6182449] [PubMed: 29796739] [CrossRef]

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Denny J, Munro CL. Chlorhexidine bathing effects on health-care-associated infections. Biol Res Nurs. 2017;19(2):123–36. doi: 10.1177/1099800416654013. [PubMed: 27306279] [CrossRef]

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Derde LP, Dautzenberg MJ, Bonten MJ. Chlorhexidine body washing to control antimicrobial-resistant bacteria in intensive care units: A systematic review. Intensive Care Med. 2012;38(6):931–9. doi: 10.1007/s00134-012-2542-z. [PMC free article: PMC3351589] [PubMed: 22527065] [CrossRef]

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Sidler JA, Battegay M, Tschudin-Sutter S, Widmer AF, Weisser M. Enterococci, Clostridium difficile and EBSL-producing bacteria: Epidemiology, clinical impact and prevention in icu patients. Swiss Med Wkly. 2014;144:w14009. doi: 10.4414/smw.2014.14009. [PubMed: 25250957] [CrossRef]

8.

Climo MW, Yokoe DS, Warren DK, Perl TM, Bolon M, Herwaldt LA, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368(6):533–42. doi: 10.1056/NEJMoa1113849. [PMC free article: PMC5703051] [PubMed: 23388005] [CrossRef]

9.

Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, Heim L, et al. Chlorhexidine versus routine bathing to prevent multidrug-resistant organisms and all-cause bloodstream infections in general medical and surgical units (ABATE infection trial): A cluster-randomised trial. Lancet. 2019;393(10177):1205–15. doi: 10.1016/s0140-6736(18)32593-5. [PMC free article: PMC6650266] [PubMed: 30850112] [CrossRef]

10.

Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, Avery TR, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255–65. doi: 10.1056/NEJMoa1207290. [PubMed: 23718152] [CrossRef]

11.

Musuuza JS, Sethi AK, Roberts TJ, Safdar N. Implementation of daily chlorhexidine bathing to reduce colonization by multidrug-resistant organisms in a critical care unit. Am J Infect Control. 2017;45(9):1014–7. doi: 10.1016/j.ajic.2017.02.038. [PMC free article: PMC6800149] [PubMed: 28431846] [CrossRef]

12.

Peterson LR, Boehm S, Beaumont JL, Patel PA, Schora DM, Peterson KE, et al. Reduction of methicillin-resistant Staphylococcus aureus infection in long-term care is possible while maintaining patient socialization: A prospective randomized clinical trial. Am J Infect Control. 2016;44(12):1622–7. doi: 10.1016/j.ajic.2016.04.251. [PMC free article: PMC5149075] [PubMed: 27492790] [CrossRef]

13.

Ruiz J, Ramirez P, Villarreal E, Gordon M, Saez I, Rodriguez A, et al. Daily bathing strategies and cross-transmission of multidrug-resistant organisms: Impact of chlorhexidine-impregnated wipes in a multidrug-resistant Gram-negative bacteria endemic intensive care unit. Am J Infect Control. 2017;45(10):1069–73. doi: 10.1016/j.ajic.2017.06.029. [PubMed: 28803661] [CrossRef]

14.

Calfee DP, Salgado CD, Milstone AM, Harris AD, Kuhar DT, Moody J, et al. Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(7):772–96. doi: 10.1086/676534. [PubMed: 24915205] [CrossRef]

15.

Mendes ET, Ranzani OT, Marchi AP, Silva MT, Filho JU, Alves T, et al. Chlorhexidine bathing for the prevention of colonization and infection with multidrug-resistant microorganisms in a hematopoietic stem cell transplantation unit over a 9-year period: Impact on chlorhexidine susceptibility. Medicine (Baltimore). 2016;95(46):e5271. doi: 10.1097/md.0000000000005271. [PMC free article: PMC5120907] [PubMed: 27861350] [CrossRef]

16.

Abboud CS, de Souza EE, Zandonadi EC, Borges LS, Miglioli L, Monaco FC, et al. Carbapenem-resistant Enterobacteriaceae on a cardiac surgery intensive care unit: Successful measures for infection control. J Hosp Infect. 2016;94(1):60–4. doi: 10.1016/j.jhin.2016.06.010. [PubMed: 27451040] [CrossRef]

17.

Noto MJ, Domenico HJ, Byrne DW, Talbot T, Rice TW, Bernard GR, et al. Chlorhexidine bathing and health care-associated infections: A randomized clinical trial. Jama. 2015;313(4):369–78. doi: 10.1001/jama.2014.18400. [PMC free article: PMC4383133] [PubMed: 25602496] [CrossRef]

18.

Kengen R, Thoonen E, Daveson K, Loong B, Rodgers H, Beckingham W, et al. Chlorhexidine washing in intensive care does not reduce bloodstream infections, blood culture contamination and drug-resistant microorganism acquisition: An interrupted time series analysis. Crit Care Resusc. 2018;20(3):231–40. pmid:30153786. [PubMed: 30153786]

19.

Boonyasiri A, Thaisiam P, Permpikul C, Judaeng T, Suiwongsa B, Apiradeewajeset N, et al. Effectiveness of chlorhexidine wipes for the prevention of multidrug-resistant bacterial colonization and hospital-acquired infections in intensive care unit patients: A randomized trial in Thailand. Infect Control Hosp Epidemiol. 2016;37(3):245–53. doi: 10.1017/ice.2015.285. [PubMed: 26894621] [CrossRef]

20.

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5.2.1. Practice Description

Hand hygiene, as defined by the Centers for Disease Control and Prevention (CDC), is “cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e., alcohol-based hand sanitizer including foam or gel), or surgical hand antisepsis.”ⁱ In this review, we include evidence-supported methods for disinfecting the skin of hands by using a cleaning solution (with or without water), with or without concurrent use of medical gloves. (This chapter does not focus on glove use.)

5.2.2. Methods

To investigate the role of hand hygiene in preventing transmission of MDROs and containing MDRO outbreaks, we searched three databases (CINAHL, MEDLINE, and Cochrane) for a combination of the keywords “hand hygiene,” “hand disinfection,” “hand sanitization,” and “hand washing,” as well as MeSH terms “cross infection prevention,” “drug resistance, multiple, bacterial,” and “drug resistance, microbial.” Articles from January 1, 2008, through December 31, 2018, were included. (Any relevant articles published after the original search are included in the PRISMA diagram as additional sources.)

The initial search yielded 225 results (including 11 articles from other sources); after duplicates were removed, 207 were screened for inclusion, and 168 full-text articles were retrieved. Of those, 17 were selected for inclusion in this review. Articles were excluded if they did not mention hand hygiene’s role in preventing MDRO transmission, described gown and glove use without also mentioning handwashing or hand disinfection, or did not include implementation in a healthcare setting. Outbreak response case studies are included in this review if they describe the role of hand hygiene in ending the outbreak.

General methods for this report are described in the Methods section of the full report.

For this patient safety practice, a PRISMA flow diagram and evidence table, along with literature-search strategy and search-term details, are included in the report appendixes A through C.

5.2.3. Review of Evidence

Consistent hand hygiene at all opportunities in patient care is essential, since MDROs can be acquired from contact with a colonized patient or contaminated surface and transferred to new patients or surfaces.^6,9 In their systematic review of prevention for MDR Gram-negative bacteria (MDR-GNB), Tacconelli and colleagues (2014) strongly recommend correct hand hygiene before and after patient contact, as well as before and after contact with the patient environment, regardless of gown and glove use.⁶ Even in facilities where hand hygiene compliance rates are high (above 80%), outbreaks can be opportunities to achieve near-perfect compliance. Palmore and Henderson (2013) note, however, that compliance will eventually return to baseline levels after an outbreak ends, highlighting the challenge of sustaining universal hand hygiene.¹⁰

Of the 17 studies and reviews included in this report, 5 studies and 1 review explicitly examined the causal relationship between better hand hygiene compliance and reduced MDRO transmission. An additional four studies used mathematical models to estimate the role of hand hygiene in multicomponent MDRO prevention strategies. Two studies looked at the role of patient hand hygiene in preventing MDROs, one study reviewed hand hygiene costs and cost savings (due to infection prevention), and one review looked at hand hygiene opportunities related to cell phone use. Finally, two reviews and one study looked at factors influencing hand hygiene and best practices for increasing compliance.

5.2.3.1. Reducing MDRO Rates Through Hand Hygiene

Four studies found that improved hand hygiene reduced MDRO transmission and one found that the association between hand hygiene and reduced MDRO transmission varied by MDRO, as summarized in the table below. One review by Taconnelli et al. (2014) did not provide statistical findings but recommended hand hygiene for MDR-GNB based on the evidence of frequent hand contamination during patient care, MDRO survivability on hands, and risk of contamination due to fomites (objects or surfaces that are likely to carry infectious pathogens) in the patient environment.⁶

Table 5.6 summarizes the findings from studies evaluating the efficacy of hand hygiene for reducing MDRO transmission and infection.

Table 5.6

Summary of Clinical Outcomes of Hand Hygiene Interventions.

De la Rosa-Zamboni and colleagues (2018) studied the efficacy of a hand hygiene intervention in a pediatric teaching hospital in Mexico. Alcohol-based hand rubs were placed in every patient unit and periodic education programs were individualized for each group of healthcare workers (attending physicians, nurses, residents, students, and ancillary staff) to highlight the mortality and costs associated with healthcare-associated infections and the evidence about efficacy of hand hygiene. Monthly monitoring and feedback were provided to each group about infection rates and hand hygiene compliance.

Hand hygiene adherence increased from 34.9 percent during the baseline period to 80.6 percent in the last 3 months of the pre-post study. The overall infection rate decreased from 7.54 to 6.46 per 1,000 patient-days (p=0.004), with central line-associated bloodstream infections declining from 4.84 to 3.66 per 1,000 central line-days (p=0.05).¹¹

Sopirala and colleagues (2014) used a hand hygiene program that trained staff nurses in infection control and linked them to infection prevention staff for ongoing monthly education, achieving very high rates of hand hygiene compliance (93%) and reducing MRSA rates by almost half in the pre-post study.¹²

Pires dos Santos and colleagues (2011) studied multiple strategies to reduce CR-PA infections in a hospital in Brazil. They found that antibiotic stewardship had little impact, but improved hand hygiene (as measured by hospitalwide use of alcohol-based hand rub) was significantly associated with reduced infection rates.¹³

Vernaz and colleagues (2008) conducted an interrupted time series study of the temporal relationship between increased alcohol-based hand rub use (as part of multicomponent intervention) and reduced MRDOs. The authors established a temporal association between increased alcohol-based hand rub use and reductions in MRSA rates but not C. difficile rates. (This finding is consistent with evidence in this report and in the guidelines reviewed, that alcohol-based hand rubs are not effective for spore-forming bacteria such as C. difficile.)¹⁴

Finally, one study of nine hospitals in Australia found that results varied across facility and different MDROs. McLaws and colleagues (2009) found mixed results across the sites included in their pre-post study of hospital regions in Australia. Hand hygiene rates increased in six of the nine hospital systems in the study. For the remaining three hospitals, one had a decrease and the other two had no observed change. Although hand hygiene increased overall, two of four clinical indicators of MRSA infection remained unchanged. The authors concluded that concurrent clinical and infection control practices at different facilities possibly influenced MRSA infection rates and modified the effects of hand hygiene compliance across the different locations.¹⁵

5.2.3.1.1. Mathematical Models of Hand Hygiene’s Impact

We reviewed four studies that used mathematical models to estimate the impact of changes in hand hygiene compliance on MDRO acquisition and infection, controlling for the influence of other concurrent infection control or antibiotic stewardship interventions. To create these models, these studies used measurement from an existing facility or ICU; because these were based on single sites, the generalizability of these models may be limited. Still, these models offer examples of how to retroactively assess the effectiveness of individual components of multicomponent interventions, a common challenge given that few hand hygiene compliance programs are implemented without other concurrent practices or programs.¹⁶

Barnes and colleagues (2014) simulated scenarios of patient-to-patient transmission via the hands of transiently contaminated healthcare workers to quantify the effects of hand hygiene versus environmental cleaning on rates of MDRO acquisition. For all organisms studied (A. baumannii, MRSA, and VRE), increases in hand-hygiene compliance outperformed equal increases in thoroughness of terminal environmental cleaning. The authors estimated that a 20 percent improvement in terminal cleaning would be required to match the reduction in organism-acquisition achieved by a 10 percent improvement in hand hygiene compliance.¹⁷

D’Agata and colleagues (2012) modeled the impact of several distinct strategies for infection control. They found that improved hand hygiene compliance reduced MDRO colonization slightly more than improved compliance with contact precautions. They estimated that a 20 percent increase in hand hygiene compliance reduced colonization between 8 and 12 percent, while a similar 20 percent increase in contact precaution compliance reduced colonization between 6 and 10 percent.⁹

Harris and colleagues (2017) randomly assigned 20 ICUs to infection control interventions and used the resulting data to understand the relative contribution of the interventions. They found that approximately 44 percent of the subsequent decrease in the MRSA acquisition rate was due to universal glove and gown use, 38.1 percent of the decrease was due to improvement in hand hygiene compliance after exiting patient rooms, and 14.5 percent of the decrease was due to the reduction in physical contacts between healthcare workers and patients.¹⁸

Wares and colleagues (2016) modeled transmission in an outpatient dialysis unit and found that even with perfect compliance with hand hygiene, 13.4 percent of patients remained colonized with MDRO. They concluded that although the hands of healthcare workers are among the main vectors of MDRO spread, transmission of MDRO occurs through numerous paths, including a contaminated environment and hospital-acquired colonization.¹⁹

5.2.3.1.2. Patient Hand Hygiene

Two studies examined the role of patient hand hygiene in reducing MDROs. Cheng and colleagues conducted two studies in Hong Kong of patient hand hygiene: one pre-post study (2015) in a hospital setting and one cluster-randomized trial (2018) in nursing homes.^20,21 In the hospital study, an intervention of single room isolation, strict contact precautions, and directly observed hand hygiene in conscious patients immediately before receiving meals and medications resulted in reduced bacteremia caused by MDR-AB. The rate decreased from 14 cases in 2013 to 1 case in the first 6 months of 2014 (p<0.001).²⁰

In the second study, directly observed hand hygiene was performed in intervention nursing homes at 2-hour intervals during the daytime and before meals and medication rounds. The volume of alcohol-based hand rub used per resident per week was three times higher in the intervention nursing homes than in the controls (p=0.006), suggesting that hand hygiene education was effective in increasing use. Serial monitoring of environmental specimens revealed a significant reduction in MRSA in the intervention versus control nursing homes (13.2 percent vs. 32.8 percent; p<0.001) and a reduction in CR-AB species (9.3 percent vs. 15.7 percent; p=0.001).²¹

5.2.4. Implementation

5.2.5. Gaps and Future Directions

As described in the process outcomes section above, it is important to understand the systemic reasons that hand hygiene is not successfully completed at all opportunities. One of these is awareness that a hand hygiene opportunity is occurring, such as touching contaminated surfaces (as mentioned in Otter and colleagues’ 2013 nonsystematic review).⁴

Graveto and colleagues’ systematic review (2018) found that in addition to known fomites such as patient linens and healthcare personnel’s clothing, cell phones are frequently used in clinical settings, are often colonized with infectious organisms, and are rarely sanitized.⁸ While this finding represents a threat to successful hand hygiene, cell phones have important clinical utility, and it would be impractical to ban cell phones in all healthcare settings. The authors note that data are limited about the connection between cell phone contamination and HAIs. The authors recommend that cell phone use be incorporated into hand hygiene promotion, including handwashing before and especially after cell phone use, and routine disinfection of cell phones.

Even when hand hygiene compliance is nearly perfect, resistance to antimicrobial solutions is an increasing concern, given the widespread and rapid rise of antibiotic resistance. In Kampf’s nonsystematic review (2016), the frequency of handwashing events greatly increased the exposure of MDROs to low levels of chlorhexidine and the selective pressure for resistance.³² Although Ho and Brantley’s commentary (2012) on a pre-post study of chlorhexidine resistance genes in MRSA did not demonstrate a correlation between increased antiseptic use for hand hygiene and increased resistance gene prevalence, the authors note that other studies have shown some association and recommend further study.³³

Outside the clinical setting, alcohol-based hand rubs are also used as a hand hygiene alternative when soap and water washing is not available. At the time of this report, the Food and Drug Administration was investigating benzalkonium chloride, ethyl alcohol, and isopropyl alcohol for safety and efficacy in over-the-counter hand rubs when used in place of soap and water washing among the general population. These ingredients are deferred from further rulemaking as data are gathered on their general safety and efficacy, and future research should include considerations about which solutions to use or avoid in community settings.^k

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5.3.1. Practice Description

With the infection prevention and healthcare practitioner in mind, this report provides evidence to support strategies for “active surveillance”—the collection and culturing of samples specifically for identifying MDRO colonization and infection among patients. However, “active surveillance” is a broad practice that encompasses many activities (sample collection, lab testing, data collection, data analysis, and reporting and feedback) and occurs at many levels.¹

Considering the broad scope, we also include best practices for active surveillance that continue beyond obtaining laboratory results. Where described in the literature, we include best practices in using active surveillance results to:

• Direct infection prevention responses;
• Evaluate the effectiveness of IP practices;
• Track and communicate MDRO status, prevalence, and risk to prevent intra- and inter-facility transmission; and
• Develop local, regional, and global datasets of MDRO prevalence that inform risk-based approaches to active surveillance and infection prevention.

Epidemiologically, genotyping of active surveillance samples can help identify potential modes of transmission or assess need for patient bathing/deeper environmental cleaning by identifying related organisms from multiple sample sites.^1,2 These genotyping data can also be used to identify whether the MDROs identified in screening are endemic to the environment or are imported by asymptomatic carriers. However, this practice requires access to labs with the capacity to do quick-turnaround, real-time genotyping.¹

Integration of active surveillance programs into electronic medical records can help automate identification and analysis but requires facilities with those capacities or access to them. However, generating larger, regional and even global surveillance systems allows individual facilities to identify risk factors for incoming patients (for example, knowing what areas of the world have high prevalence of certain MDROs).¹

Many resource challenges arise in creating sophisticated laboratory and data integration systems that can identify, genotype, and share information on MDROs. At the same time, investing in these systems benefits other infection control practices by generating the data that allow facilities to take a risk-based approach to screening, isolation, and contact precautions, which represent an opportunity for cost saving.¹ Finally, facilities must make decisions about when to stop active surveillance, balancing the costs of an active surveillance program against the possibilities of failed eradication and recolonization.³ Key findings are located in the box above.

5.3.2. Methods

To investigate how active surveillance has been implemented to prevent transmission of MDROs and contain MDRO outbreaks, we searched three databases (CINAHL, MEDLINE, and Cochrane) for a combination of the keywords “monitoring,” “surveillance,” and “monitoring and surveillance,” as well as MeSH terms “cross infection prevention,” “drug resistance, multiple, bacterial,” and “drug resistance, microbial.” Articles from January 1, 2008, through December 31, 2018, were included. (Any relevant articles published after the original search are included in the PRISMA diagram as additional sources.)

The initial search yielded 392 results (including 24 articles from other sources); after duplicates were removed, 352 were screened for inclusion, and 175 full-text articles were retrieved. Of those, 23 were selected for inclusion in this review. Articles were excluded if they did not mention active surveillance’s role in preventing MDRO transmission, only described surveillance for determining treatment, or did not include implementation in a healthcare setting.

General methods for this report are described in the Methods section of the full report.

For this patient safety practice, a PRISMA flow diagram and evidence table, along with literature-search strategy and search-term details, are included in the report appendixes A through C.

5.3.3. Review of Evidence

The Key Findings box presents a high-level summary of the findings in this review. Although the ideal method for active surveillance varies by MDRO (based on how the organism is acquired and shed by patients), one common theme is using targeted, active surveillance based on MDRO risk factors, such as recent hospitalization or history of MDRO colonization. Screening results should then be used to guide other infection control practices, such as contact precautions or decolonization protocols. Without adherence to these practices, the value of active surveillance is limited.

Screening decisions for facilities should be based on the available epidemiological surveillance data on which organisms are likely to be prevalent in a facility’s patient population. Rare MDROs will result in far higher screening costs to prevent one infection/colonization event, compared with MDROs with higher prevalence. For MDROs or other pathogens frequently present on admission (such as MRSA or C. difficile), screening results may be useful in identifying a patient at risk for other MDROs. Conducting tests for multiple MDROs on one sample may reduce the materials and time needed for sample collection but may increase costs related to lab processing.

Where active surveillance may provide the most value is in improving compliance with other PSPs in multicomponent interventions. However, it is not clear how strong that association may be or why an association appears in some studies but not others. As mentioned above, identifying patients colonized or infected with an MDRO is only valuable if the correct procedures to reduce transmission (such as hand hygiene or decolonization) are followed consistently based on that knowledge. More research is needed to understand the synergistic effect of active surveillance to maximize its benefits.

5.3.4. Implementation

5.3.5. Gaps and Future Directions

The greatest challenge to active surveillance cultures/testing for MDROs is understanding which surveillance protocols are the most sensitive and specific for correctly identifying carriers while minimizing the burden for collecting samples and processing data. Although evidence-based recommendations exist for MRSA, VRE, and CRE, numerous pathogens (particularly other MDR-GNB such as K. pneumoniae and emerging MDR pathogens such as Candida auris) lack a consistent recommendation for whom and when to screen.

Duffy and colleagues (2011), in their synopsis of a working group of infection prevention professionals, recommend strengthening partnerships between healthcare facilities and public health departments to build capacity for identifying and tracking emerging MDROs.⁵⁷ Further studies that evaluate targeted surveillance protocols based on risk factor analysis would give healthcare facilities another tool for effective, lower cost surveillance.

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5.4.1. Practice Description

Environmental surfaces serve as an intermediate vector for transmitting MDROs in healthcare settings.¹ Environmental contamination can occur from contact with MDRO-infected individuals or their body fluids and can result in transmission to another individual. The “environment” includes furniture and other surfaces in patient rooms; medical equipment; personal items belonging to patients, visitors, or staff; and structural components of the facility (e.g., sinks, air vents).

To remove MDROs or disinfect the environment, healthcare facilities use specific cleaning and disinfection practices. Enhanced or standard cleaning may be implemented on a daily basis or when a patient vacates a room (called terminal cleaning). In the event of an outbreak or increased rate of transmission, facilities may perform a more thorough, one-time environmental cleaning. The latter is frequently done when other infection control practices or standard environmental cleaning does not reduce infection rates or when a specific source of contamination is suspected or identified by environmental screening. Enhanced environmental measures also include reinforcing training of environmental services staff and monitoring adherence to environmental cleaning protocols.²

Before a disinfectant is applied, cleaning is required to manually scrub and wash any visibly soiled surfaces because disinfectants cannot typically penetrate organic matter or thick substances to eradicate microbes beneath.³ After cleaning, a disinfectant is applied and left in contact with a surface for the amount of time designated by the manufacturer as necessary to kill/deactivate microorganisms. The variations and efficacy of these environmental cleaning and disinfection practices—highlighting MDROs in healthcare settings—are the focus of the following systematic literature review.

5.4.2. Methods

To determine the most effective environmental cleaning and disinfection practices for reducing the spread of MDROs, three databases (CINAHL, MEDLINE, and Cochrane) were searched for “bacterial drug resistance,” “microbial drug resistance,” and synonyms, in combination with “disinfection methods,” “environmental monitoring,” “environmental cleaning,” and associated phrases. Articles from 2008 through 2018 were included.

The initial search yielded 375 results (including 9 from other sources); after duplicates were removed, 347 were screened for inclusion, and 130 full-text articles were retrieved. Of those, 58 were selected for inclusion in this review. Articles were excluded if they were outside the scope of this review, included insufficient detail on a patient safety practice, did not describe an intervention (e.g., surveillance only), demonstrated insufficient rigor, or were included in another PSP section of this report.

General methods for this report are described in the Methods section of the full report.

For this patient safety practice, a PRISMA flow diagram and evidence table, along with literature-search strategy and search-term details, are included in the report appendixes A through C.

5.4.3. Review of Evidence

This review includes evidence from 4 systematic reviews and 54 studies. Of the studies:

• Twenty-one were before-and-after intervention studies (one of which was a mathematically modelled and simulated intervention),
• Thirteen were outbreak studies,
• Nine were laboratory studies,
• Five were cross-sectional surveys,
• Two were cluster-randomized controlled trials,
• Two were cluster-randomized crossover studies,
• One was a prospective cohort study, and
• One was a prospective controlled quasi-experimental study.

Of all included articles, 25 took place or reviewed studies that took place in the United States, 31 occurred outside the United States, and 2 included studies from both the United States and abroad. The included studies focused on cleaning and decontamination agents to reduce MDROs and infection from MDROs, as well as facilitators and barriers to cleaning and sterilization in the healthcare environment.

5.4.4. Implementation

Overall, many of the studies reviewed included environmental cleaning and disinfection as part of a multicomponent intervention. With the use of multicomponent interventions, it is difficult to attribute the success of the intervention to any one component. However, in general, multicomponent interventions have been demonstrated to be very effective when measuring reductions in a variety of MDRO-related clinical outcomes. In one systematic review, researchers found that environmental cleaning interventions were most effective when implemented in conjunction with antimicrobial stewardship, evaluation of standard care, and source control for reducing acquisition of several MDROs.⁴⁷

5.4.5. Gaps and Future Directions

Most of the evidence presented above is taken from outbreak studies and before-and-after interventions or from in vitro studies, and the evidence is weak to draw conclusions about efficacy and implementation. Randomized studies are a more rigorous approach and should ideally be designed with one or two variable changes between the study and control groups. Multicomponent interventions make it difficult to understand which specific elements are responsible for success. More single intervention studies on environmental cleaning for MDROs would be useful.

Of particular importance for future research is comparing disinfectants for use in environmental disinfection. A handful of studies have found that QACs reduce environmental contamination with MDROs and provide residual antimicrobial properties. Although they are low toxicity to humans, evidence is mixed to support their usefulness in disinfecting high-touch surfaces and textiles that are in close contact with HCWs and patients. In addition, they cannot be used for spore-forming organisms, such as C. difficile, and are not yet used or studied as commonly as sodium hypochlorite. Lastly, many of the no-touch disinfection technologies are relatively new and have not been rigorously compared with traditional cleaning methods in clinical settings to determine which are most advantageous.

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5.5.1. Practice Description

Because medical devices provide direct access for bacteria to enter the human body, they pose a significant risk for invasive MDRO infections. Although many of the studies in this review focus on infections that are not specifically MDROs, they were included for their relevance to the prevention and control of MDROs. This review identifies and discusses opportunities to reduce device-associated risks during a patient’s care in a health facility. Key findings are presented in the box above.

5.5.2. Methods

To answer the question, “What are the best device reduction and harm minimization practices?” three databases (CINAHL, MEDLINE, and Cochrane) were searched for “catheter-related infections,” “endotracheal tubes,” and synonyms in combination with “infection control,” “microbial drug resistance,” and associated phrases. Articles from 2009 to December 2018 were included.

The initial search yielded 396 results; after duplicates were removed, 342 were screened for inclusion, and 139 full-text articles were retrieved. Of those, 17 were selected for inclusion in this review. Articles were excluded if they were outside the scope of this review, included insufficient detail on a PSP, were unable to be retrieved, or were used in the review of another PSP.

General methods for this report are described in the Methods section of the full report.

For this patient safety practice, a PRISMA flow diagram and evidence table, along with literature-search strategy and search-term details, are included in the report appendixes A through C.

5.5.3. Review of Evidence

The resulting 17 studies that were selected for review include 6 systematic reviews, 4 laboratory studies, 3 before-and-after intervention studies, 3 retrospective cohort studies, and 1 randomized control trial. The six systematic reviews included studies from various international settings. Of the 11 individual studies, 5 took place in the United States or its territories, and 6 took place abroad.

The settings for these individual studies include patient homes, surgical wards, ICUs, dialysis units, tertiary care hospitals, teaching hospitals, and laboratories. The settings covered in this review span community and primary care, long-term acute care hospitals, rehabilitation centers, hospitals, and general healthcare settings.

5.5.3.1. Least Harmful Device Use—Catheters

To reduce the harms associated with catheter use (intravascular or urinary catheters), interventions can target several stages of their use:

• Avoiding unnecessary and inappropriate catheter use,
• Ensuring aseptic placement of catheters,
• Maintaining awareness and proper care of catheters in place, and
• Promptly removing unnecessary catheters.⁵

A systematic review by Patel et al. (2018) reviewed 102 studies with interventions aiming to reduce CAUTIs and CLABSIs. The review determined that the most successful interventions targeted multiple stages. For both CAUTIs and CLABSIs, successful interventions included protocols to remove by default based on certain criteria (e.g., time).⁵ Other aspects of successful interventions (e.g., monitoring, auditing, and staffing) will be addressed in section 5.5.4.

The CDC also has a published set of guidelines for reducing both intravascular catheter-related infections and CAUTIs.^1,6 These guidelines have various recommendations for reducing harm throughout the phases of the patient’s care, including:

• Timing of catheter placement,
• Selection of the appropriate catheter device,
• Use of hand hygiene,
• Aseptic technique strategies,
• Barrier precautions during device placement and care, and
• Use of systemic antibiotics (not recommended) and antibiotic lock solutions.

Several of these interventions will be addressed below, with additional information provided in section 5.5.4.4.

5.5.3.1.1. Urinary Catheters

Specific to urinary catheters, Mody et al (2017) conducted a large-scale before-and-after intervention study of 404 nursing homes that implemented a multicomponent strategy that included targeting multiple stages of device use. This study of community-based nursing homes used the Comprehensive Unit-based Safety Program (CUSP) toolkit for CAUTI, developed as part of the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. The intervention targeted urinary catheter removal, aseptic insertion, incontinence care planning, and various training programs for staff, patients, and family.

The intervention reduced UTIs, perhaps indicating success in aseptic techniques, but did not reduce overall catheter utilization. The authors theorized that catheter utilization in nursing homes across the country was already relatively low at the start of the study, leaving little room for further reductions.⁷

The low utilization of urinary catheters in nursing homes was also confirmed in a systematic review by Meddings et al. (2017). The same review found that nursing home interventions involving improving hand hygiene, reducing catheter use, and enhancing barrier precautions were all effective at reducing UTIs in nursing home residents.⁸ In an ICU setting, Patel et al. (2018) assessed that many successful interventions included a focus on removing a urinary catheter.⁵

Another systematic review compared methods of short-term (14 days or less) bladder catheterization (indwelling urethral catheterization, intermittent urethral catheterization, and suprapubic catheterization) in hospitalized adults.⁹ For the outcome of UTI, evidence was not sufficient enough to support the use of one route of catheterization over the others to reduce infections.

Meddings et al. (2015) used the RAND/UCLA Appropriateness Method, a method for evaluating the appropriateness of medical technology, to refine criteria for the use of urinary catheters (indwelling Foley catheters, intermittent straight catheters, and external condom catheters) in hospitalized medical patients. Using the literature, the authors developed a list of potential indications for each catheter type and created different scenarios illustrating their use. A multidisciplinary panel of subject matter experts ranked the scenarios as appropriate, inappropriate, or uncertain; appropriateness is defined as use for which benefits outweigh risks. The authors conclude that Foley catheters should only be used to measure urine or manage incontinence if other methods have been exhausted or if there are medical indications where nonbarrier methods would increase harm (e.g., to improve healing of sacral ulcers).¹⁰

5.5.3.1.2. Intravascular Catheters

With respect to intravascular catheters, certain patient safety practices can be used to reduce the risk of infection when vascular access cannot be avoided. The practices included in our review focus on the use of antibiotics or specialized catheters that contain antimicrobial substances. The section below discusses these practices in further detail and their implications for antimicrobial resistance and other potential patient harm.

The CDC guidelines for preventing intravascular catheter-related infections provide recommendations for antibiotic and antiseptic use.⁶ In general, for intravascular catheters, the CDC does not recommend the use of systemic antimicrobial prophylaxis. Instead, the CDC recommends the use of certain antiseptic ointments at the catheter exit site for dialysis catheters and recommends antibiotic locking solutions (discussed below) in certain situations.⁶ For details on the strength of the evidence for each of these recommendations, please view the CDC guidelines referenced in section 5.5.4.

Regarding site placement of central venous catheters (CVCs), one systematic review of published ICU infection outbreaks found strong evidence to support the use of subclavian insertion sites compared with jugular or femoral sites to reduce the risk of CLABSI.¹¹ This practice is strongly supported by the CDC guidelines to avoid use of jugular or femoral insertion sites.⁶

As with most medical procedures that are physically invasive, sanitary practices are necessary and may reduce the risk of infected wounds and invasive infections. While no study in this review specifically addressed sanitary practices as an intervention, the CDC guidelines include detailed instructions on appropriate infection control procedures for intravascular catheters.⁶ The strongest CDC recommendations include:

• Using sterile gloves when inserting arterial, central, and midline vascular catheters;
• Frequently performing hand hygiene,
• Using sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site; and
• Using chlorhexidine antisepsis for insertion sites in specific cases (see guidelines for details).⁶

One method of combating invasive infections associated with catheters is to reduce and restrict the growth of bacteria within the catheter itself. Bacteria often form biofilms within catheters that can inhibit catheter function and increase the risk of infection. In addition to preventing bacterial infections and biofilm formation, antibiotic lock (ABL) therapy reduces costs and vein damage associated with device replacement. ABL therapy is the insertion of a concentrated antibiotic solution into a catheter lumen (its internal channel or tube) to prevent the development of microbial biofilm on catheter surfaces.

In a study by Dixon et al. (2012), ABL therapy, as an adjunct to systemic antibiotic therapy, vs. systemic antibiotic therapy alone in patients with tunneled hemodialysis catheters, reduced CLABSI incidence by over 50 percent (RR 0.50 +/− 0.03; p<0.0001) and reduced treatment failure and relapses in the study group compared with the control group.¹² The CDC recommends that ABL prophylaxis only be used for hemodialysis patients with long-term catheters who have a history of multiple CLABSIs despite appropriate aseptic techniques during catheter care and insertion.⁶

In two studies identified in this review, no antibiotic resistance was found to be associated with their use in ABLs. One retrospective cohort study in the homes of patients in the Netherlands found taurolidine to be safe for up to 702 days.¹³ Another retrospective cohort study in a dialysis unit in the United Kingdom found no increased risk of drug resistance when using vancomycin and gentamicin ABL solutions paired with systemic vancomycin and gentamicin.¹² However, increased prevalence of S. aureus and antimicrobial-resistant Enterobacteriaceae was found.

5.5.3.1.3. Catheter Innovations To Reduce Risk of Infection

Various catheter materials have been studied to determine their effectiveness at reducing biofilm formation and preventing catheter-related infections. Urinary catheters can be made of hydrophilic materials—which reduce friction during insertion, thus reducing the need for lubrication and the risk of urethral damage—or impregnated with antimicrobial chemicals to prevent colonization of the catheter with bacteria or fungi. Catheters can be constructed of latex, silicone, or other components; however, antimicrobial silver alloys may bind more readily to latex than to other materials.¹⁴

Table 5.7 summarizes the evidence found in two systematic reviews and five studies regarding the use of alternative urinary and intravascular catheter materials and antimicrobial-impregnated catheters. Three technologies were found to be successful in laboratory experiments: gum arabic capped-silver nanoparticle-coated devices¹⁵; catheters impregnated with rifampicin, triclosan, and trimethoprim¹⁶; and CVCs impregnated with minocycline and rifampicin (M/R) + chlorohexidine (CHX).¹⁷ One review found gel reservoir and hydrophilic catheters to be safer than traditional sterile noncoated catheters.¹⁸

Silver-impregnated catheters were determined to have mixed evidence.¹¹ Catheters impregnated with both silver and chlorohexidine have been demonstrated to reduce colonization and CLABSIs, especially in settings with high background rates of CLABSIs¹¹ and are highly recommended by CDC if the CVC is expected to stay in place for more than 5 days.⁶

Lastly, M/R-impregnated catheters were the most well studied, cumulatively mentioned in five different abstracted articles. Use of these antimicrobial catheters was backed by one laboratory study¹⁹ and one retrospective cohort study.²⁰ One systematic review concluded that evidence was mixed to support the use of M/R catheters.¹¹ Another innovation for increasing catheter safety is the use of needleless connectors, which were mentioned in one review as having mixed evidence regarding their efficacy.¹¹

While some studies found a reduction in catheter contamination with needleless connectors, others observed an increase in infection rates temporally associated with their introduction. If needleless connectors are used, the CDC strongly recommends that an antiseptic be used to scrub the access port and that it be accessed only with sterile devices.⁶

The CDC guidelines previously referenced also include recommendations on urinary catheter materials. The CDC acknowledges the benefits of antibiotic-impregnated or antiseptic-impregnated urinary catheters in certain situations but also addresses a mix or lack of evidence demonstrating that they reduce UTI. The CDC also states that silicone and hydrophilic catheters may be preferable in certain situations (e.g., hydrophilic catheter use for intermittent catheterization).¹

Table 5.7

Studies of Alternative Materials and Antimicrobial-Impregnated Catheters.

5.5.4. Implementation

5.5.5. Gaps and Future Directions

Gaps in evidence are listed within the guidelines cited above (e.g., CDC, SHEA/IDSA), and this review identified several gaps that require further research. In addition, further research is needed on the safety and efficacy of novel technologies such as GA-AgNPs,¹⁵ the triple antibiotic combination discussed by Bayston et al. (2009),¹⁶ and the newly developed M/R + CHX impregnated catheter discussed by Raad et al. (2012).¹⁷ Further study is also needed on ABL solutions. Specifically, long-term studies on antibiotics in ABLs are needed to determine the risk of conferring drug resistance and increasing risk of infection.¹²

Kidd et al. (2015) stated larger sample sizes are needed to create adequately powered studies on alternative catheterization methods, such as suprapubic catheterization and intermittent self-catheterization compared with indwelling urinary catheters.⁹ These methods are often cited as reducing risk of infections, but further research is needed to confirm and repeat the results of preliminary studies.

References for Section 5.5

1.

Gould C, Umscheid C, Agarwal E, Kuntz G, Pegues D. Guideline for prevention of catheter-associated urinary tract infections. Atlanta, GA: Centers for Disease Control and Prevention; 2009. https://www​.cdc.gov/infectioncontrol​/pdf​/guidelines/cauti-guidelines-H.pdf.

2.

Rajdev S, Rajdev B, Mulla S. Characterization of bacterial etiologic agents of biofilm formation in medical devices in critical care setup. Crit Care Res Pract. 2012;2012:945805. doi: 10.1155/2012/945805. [PMC free article: PMC3270516] [PubMed: 22312484] [CrossRef]

3.

Burnham JP, Rojek RP, Kollef MH. Catheter removal and outcomes of multidrug-resistant central-line-associated bloodstream infection. Medicine (Baltimore). 2018;97(42):e12782. doi: 10.1097/md.0000000000012782. [PMC free article: PMC6211864] [PubMed: 30334966] [CrossRef]

4.

Weiner LM, Webb AK, Limbago B, Dudeck MA, Patel J, Kallen AJ, et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: Summary of data reported to the national healthcare safety network at the centers for disease control and prevention, 2011–2014. Infect Control Hosp Epidemiol. 2016;37(11):1288–301. doi: 10.1017/ice.2016.174. [PMC free article: PMC6857725] [PubMed: 27573805] [CrossRef]

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Patel PK, Gupta A, Vaughn VM, Mann JD, Ameling JM, Meddings J. Review of strategies to reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) in adult ICUs. J Hosp Med. 2018;13(2):105–16. doi: 10.12788/jhm.2856. [PubMed: 29154382] [CrossRef]

6.

O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011;39(4):S1–S34. doi: 10.1016/j.ajic.2011.01.003. [PubMed: 21511081] [CrossRef]

7.

Mody L, Greene MT, Meddings J, Krein SL, McNamara SE, Trautner BW, et al. A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents. JAMA Intern Med. 2017;177(8):1154–62. doi: 10.1001/jamainternmed.2017.1689. [PMC free article: PMC5710434] [PubMed: 28525923] [CrossRef]

8.

Meddings J, Saint S, Krein SL, Gaies E, Reichert H, Hickner A, et al. Systematic review of interventions to reduce urinary tract infection in nursing home residents. J Hosp Med. 2017;12(5):356–68. doi: 10.12788/jhm.2724. [PMC free article: PMC5557395] [PubMed: 28459908] [CrossRef]

9.

Kidd EA, Stewart F, Kassis NC, Hom E, Omar MI. Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults. Cochrane Database Syst Rev. 2015(12):Cd004203. doi: 10.1002/14651858.CD004203.pub3. [PMC free article: PMC8612698] [PubMed: 26661940] [CrossRef]

10.

Meddings J, Saint S, Fowler KE, Gaies E, Hickner A, Krein SL, et al. The ann arbor criteria for appropriate urinary catheter use in hospitalized medical patients: Results obtained by using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;162:(9 Suppl):S1–34. doi: 10.7326/m14-1304. [PubMed: 25938928] [CrossRef]

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Doyle JS, Buising KL, Thursky KA, Worth LJ, Richards MJ. Epidemiology of infections acquired in intensive care units. Semin Respir Crit Care Med. 2011;32(2):115–38. doi: 10.1055/s-0031-1275525. [PubMed: 21506049] [CrossRef]

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Dixon JJ, Steele M, Makanjuola AD. Anti-microbial locks increase the prevalence of Staphylococcus aureus and antibiotic-resistant Enterobacter: Observational retrospective cohort study. Nephrol Dial Transplant. 2012;27(9):3575–81. doi: 10.1093/ndt/gfs081. [PubMed: 22513704] [CrossRef]

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Olthof ED, Rentenaar RJ, Rijs AJ, Wanten GJ. Absence of microbial adaptation to taurolidine in patients on home parenteral nutrition who develop catheter related bloodstream infections and use taurolidine locks. Clin Nutr. 2013;32(4):538–42. doi: 10.1016/j.clnu.2012.11.014. [PubMed: 23267744] [CrossRef]

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Muzzi-Bjornson L, Macera L. Preventing infection in elders with long-term indwelling urinary catheters. J Am Acad Nurse Pract. 2011;23(3):127–34. doi: 10.1111/j.1745-7599.2010.00588.x. [PubMed: 21355945] [CrossRef]

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Ansari MA, Khan HM, Khan AA, Cameotra SS, Saquib Q, Musarrat J. Gum arabic capped-silver nanoparticles inhibit biofilm formation by multi-drug resistant strains of Pseudomonas aeruginosa. J Basic Microbiol. 2014;54(7):688–99. doi: 10.1002/jobm.201300748. [PubMed: 24403133] [CrossRef]

16.

Bayston R, Fisher LE, Weber K. An antimicrobial modified silicone peritoneal catheter with activity against both Gram-positive and Gram-negative bacteria. Biomaterials. 2009;30(18):3167–73. doi: 10.1016/j.biomaterials.2009.02.028. [PubMed: 19289248] [CrossRef]

17.

Raad I, Mohamed JA, Reitzel RA, Jiang Y, Raad S, Al Shuaibi M, et al. Improved antibiotic-impregnated catheters with extended-spectrum activity against resistant bacteria and fungi. Antimicrob Agents Chemother. 2012;56(2):935–41. doi: 10.1128/aac.05836-11. [PMC free article: PMC3264266] [PubMed: 22123686] [CrossRef]

18.

Bermingham S, Hodgkinson S, Wright S, Hayter E, Spinks J, Pellowe C. Intermittent self catheterisation with hydrophilic, gel reservoir, and non-coated catheters: A systematic review and cost effectiveness analysis. BMJ. 2013;346:e8639. doi: 10.1136/bmj.e8639. [PMC free article: PMC3541473] [PubMed: 23303886] [CrossRef]

19.

Raad I, Reitzel R, Jiang Y, Chemaly RF, Dvorak T, Hachem R. Anti-adherence activity and antimicrobial durability of anti-infective-coated catheters against multidrug-resistant bacteria. J Antimicrob Chemother. 2008;62(4):746–50. doi: 10.1093/jac/dkn281. [PubMed: 18653489] [CrossRef]

20.

Ramos ER, Reitzel R, Jiang Y, Hachem RY, Chaftari AM, Chemaly RF, et al. Clinical effectiveness and risk of emerging resistance associated with prolonged use of antibiotic-impregnated catheters: More than 0.5 million catheter days and 7 years of clinical experience. Crit Care Med. 2011;39(2):245–51. doi: 10.1097/CCM.0b013e3181feb83e. [PubMed: 21057308] [CrossRef]

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Damas P, Frippiat F, Ancion A, Canivet JL, Lambermont B, Layios N, et al. Prevention of ventilator-associated pneumonia and ventilator-associated conditions: A randomized controlled trial with subglottic secretion suctioning. Crit Care Med. 2015;43(1):22–30. doi: 10.1097/ccm.0000000000000674. [PubMed: 25343570] [CrossRef]

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Camus C, Salomon S, Bouchigny C, Gacouin A, Lavoue S, Donnio PY, et al. Short-term decline in all-cause acquired infections with the routine use of a decontamination regimen combining topical polymyxin, tobramycin, and amphotericin b with mupirocin and chlorhexidine in the ICU: A single-center experience. Crit Care Med. 2014;42(5):1121–30. doi: 10.1097/ccm.0000000000000140. [PubMed: 24365857] [CrossRef]

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Saint S, Greene MT, Krein SL, Rogers MA, Ratz D, Fowler KE, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374(22):2111–9. doi: 10.1056/NEJMoa1504906. [PMC free article: PMC9661888] [PubMed: 27248619] [CrossRef]

5.6.1. Practice Description

The CDC recommends that all facilities have a system in place to communicate a patient’s MDRO status to all necessary personnel before transfer of the patient.¹ Communicating a patient’s MDRO status occurs at several points during the patient’s interaction with the healthcare system. Intrafacility communication must begin when a positive laboratory test occurs or is highly suspected based on a patient’s risk or previous exposures. The information must be disseminated to all clinicians interacting with the patient, visitors, and anyone whose patient interaction increases his or her exposure risk.

When patients are transferred between facilities, interfacility communication of patient status is required. Special care and attention to patient status communication must be taken in situations where patients are immunosuppressed and vulnerable to infection and where facilities may not have preexisting relationships or communication channels. Examples of information sharing strategies from case studies include electronic communication, a highlighted or annotated medical record or patient file, a transfer form, a brightly colored leaflet, verbal communication, and an automated alert.

5.6.2. Methods

The question of interest for this review is: What are the methods of MDRO status communication in a healthcare setting?

To answer this question, we searched three databases (CINAHL, MEDLINE, and Cochrane) for “information dissemination,” “information sharing,” “patient transfer,” or “communication” in combination with “cross-infection,” “prevention and control,” “drug resistance,” and relevant synonyms or similar phrases. Articles from 2009 to December 2018 were included.

The initial search yielded 140 results (including 8 from other sources). After duplicates were removed, 128 were screened for inclusion, and 54 full-text articles were retrieved. Of those, we selected 12 for inclusion in this review. Articles were excluded if they were out of scope or had insufficient detail about the topic of status communication or if the full article was not accessible.

General methods for this report are described in the Methods section of the full report.

For this patient safety practice, a PRISMA flow diagram and evidence table, along with literature-search strategy and search-term details, are included in the report appendixes A through C.

5.6.3. Review of Evidence

Of the 12 articles were selected for review, 2 were case studies, 2 were outbreak studies, 2 were cross-sectional studies, 2 were retrospective cohort studies, 1 was a systematic review, 1 was a prospective interrupted time series study, 1 was a prospective observational study, and 1 was a randomized controlled trial. Nine of the 13 included studies that took place in the United States, 1 took place in Australia, 1 took place in Italy, and 1 took place in Denmark. The systematic literature review was a review of German studies.

5.6.4. Implementation

As several examples in this review have pointed out, having policies in place does not guarantee effective implementation of patient status communication, be it during transfers, during organ transplantation, or within a facility itself. Engaging staff in new procedures and educating them on the steps involved are all important when applying new policies.

Methods for engaging staff in implementation could include:

• Performing needs assessments before developing new procedures,¹⁵
• Hosting multidisciplinary meetings to facilitate collaborative thinking or elicit feedback,^4,5
• Distributing reports on infection rates and trends since implementation of communication procedures,⁴ and
• Informing managers and other leaders of procedural changes.⁴

A cross-sectional survey of 448 infection control professionals in the United States reiterates the findings above. The factors that were found to improve implementation included:

• Distribution of copies of the policy to providers (p=0.03),
• Use of forms (i.e., checklists) to enhance infection control adherence (p=0.0008),
• Administrator-directed infection control activities (p<0.0001),
• A culture of data-driven decision making (p<0.0001),
• Communication of antimicrobial resistance trends to physicians (p<0.0001), and
• Interdepartmental coordination of patient care (p<0.0001).¹⁶

These tools used for changes in infection control policies can just as easily be applied to interfacility or intrafacility communication of patient MDRO status. Educating providers and staff on new policies by distributing educational resources can be part of continuing education on communication protocols. Checklists can be used to facilitate more thorough information exchange when patients are transferred within a facility. Improved communication and improved coordination of patient care foster an environment more conducive to continuity of information when interfacility communication occurs. Lastly, the reporting of data to demonstrate improvements in patient outcomes can reinforce making positive changes in facility practices that are connected to patient communication.

When implementing interfacility communication protocols, facilities may benefit from reaching out to State health departments or national organizations such as UNOS. Many already have relationships with healthcare facilities, know the appropriate contacts there, and can facilitate meetings or discussions among facilities. For example, the Oregon Health Department helped create a form and process for facilities to use with newly admitted and transferred patients. State health departments should continue to encourage and facilitate interfacility discussion about MDRO communication practices, and smaller local health departments or healthcare facilities should reach out to these larger organizations to ask for assistance in improving intrafacility communications.

5.6.5. Gaps and Future Directions

More rigorous research studies in a variety of geographic areas and healthcare settings are needed to evaluate the most effective ways to communicate patient status (e.g., checklists vs. brightly colored leaflets in patient files). Facilities that often exchange patients or are part of larger health systems are encouraged to develop relationships with one another to develop strategies and policies for patient MDRO status communication, if not regulated by the government as in the case of LTCFs.

More research and innovation are needed to promote consistent use of technology-based and paper-based communication of patient MDRO status, such as laboratory results in organ transplantation. Lastly, an iterative review of status communication policies is important to ensure that policies are useful, easy to implement, and meet the needs of the ever-changing world of infection control and prevention.

References for Section 5.6

1.

Siegel JD, Rhinehart E, Jackson M, Chiarello L. Management of multidrug-resistant organisms in healthcare settings, 2006. Atlanta, GA: Centers for Disease Control and Prevention; 2006. https://www​.cdc.gov/infectioncontrol​/guidelines/mdro/index​.html.

2.

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Ong M-S, Magrabi F, Post J, Morris S, Westbrook J, Wobcke W, et al. Communication interventions to improve adherence to infection control precautions: A randomised crossover trial. BMC Infect Dis. 2013;13:72. doi: 10.1186/1471-2334-13-72. [PMC free article: PMC3599084] [PubMed: 23388051] [CrossRef]

4.

Andersen SE, Knudsen JD. A managed multidisciplinary programme on multi-resistant Klebsiella pneumoniae in a Danish university hospital. BMJ Qual Saf. 2013;22(11):907–15. doi: 10.1136/bmjqs-2012-001791. [PubMed: 23704083] [CrossRef]

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Tacconelli E, Cataldo MA, Dancer SJ, De Angelis G, Falcone M, Frank U, et al. ESCMID guidelines for the management of the infection control measures to reduce transmission of multidrug-resistant Gram-negative bacteria in hospitalized patients. Clin Microbiol Infect. 2014;20: Suppl 1:1–55. doi: 10.1111/1469-0691.12427. [PubMed: 24329732] [CrossRef]

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Runningdeer E, Kainer M, Johnston H. Interfacility communication to prevent and control healthcare-associated infections and antimicrobial resistant pathogens across healthcare settings. Council of State and Territorial Epidemiologists 2016. https://cdn​.ymaws.com/www​.cste.org/resource​/resmgr/2016ps/16_ID_09.pdf.

8.

Buser GL, Cassidy PM, Cunningham MC, Rudin S, Hujer AM, Vega R, et al. Failure to communicate: Transmission of extensively drug-resistant bla OXA-237-containing Acinetobacter baumannii-multiple facilities in Oregon, 2012–2014. Infect Control Hosp Epidemiol. 2017;38(11):1335–41. doi: 10.1017/ice.2017.189. [PMC free article: PMC5783543] [PubMed: 28870269] [CrossRef]

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Steider K. CMS requires long-term care facilities to communicate infection prevention concerns during resident transfer/discharge. https://spice​.unc.edu​/2018/cms-requires-long-term-care-facilities-to-communicate-infection-prevention-concerns-during-resident-transfer-discharge/. Accessed October 25, 2019.

10.

Ariza-Heredia EJ, Patel R, Blumberg EA, Walker RC, Lewis R, Evans J, et al. Outcomes of transplantation using organs from a donor infected with Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae. Transpl Infect Dis. 2012;14(3):229–36. doi: 10.1111/j.1399-3062.2012.00742.x. [PubMed: 22624726] [CrossRef]

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Miller R, Covington S, Taranto S, Carrico R, Ehsan A, Friedman B, et al. Communication gaps associated with donor-derived infections. Am J Transplant. 2015;15(1):259–64. doi: 10.1111/ajt.12978. [PubMed: 25376342] [CrossRef]

12.

Transmission of multidrug-resistant Escherichia coli through kidney transplantation --- California and Texas, 2009. MMWR Morb Mortal Wkly Rep. 2010;59(50):1642–6. [PubMed: 21178948]

13.

Mularoni A, Bertani A, Vizzini G, Gona F, Campanella M, Spada M, et al. Outcome of transplantation using organs from donors infected or colonized with carbapenem-resistant Gram-negative bacteria. Am J Transplant. 2015;15(10):2674–82. doi: 10.1111/ajt.13317. [PubMed: 25981339] [CrossRef]

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Trick WE, Lin MY, Cheng-Leidig R, Driscoll M, Tang AS, Gao W, et al. Electronic public health registry of extensively drug-resistant organisms, Illinois, USA. Emerg Infect Dis. 2015;21(10):1725–32. doi: 10.3201/eid2110.150538. [PMC free article: PMC4593443] [PubMed: 26402744] [CrossRef]

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Pfeiffer CD, Cunningham MC, Poissant T, Furuno JP, Townes JM, Leitz A, et al. Establishment of a statewide network for carbapenem-resistant Enterobacteriaceae prevention in a low-incidence region. Infect Control Hosp Epidemiol. 2014;35(4):356–61. doi: 10.1086/675605. [PubMed: 24602939] [CrossRef]

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Chou AF, Yano EM, McCoy KD, Willis DR, Doebbeling BN. Structural and process factors affecting the implementation of antimicrobial resistance prevention and control strategies in U.S. hospitals. Health Care Manage Rev. 2008;33(4):308–22. doi: 10.1097/01.HCM.0000318768.36901.ef. [PubMed: 18815496] [CrossRef]