The prevention and control of multidrug-resistant organisms (MDROs) is a national priority. Patients identified with MDROs are cared for using standard precautions and contact precautions to reduce the potential for these pathogens-for which there are limited treatment options-from spreading to the environment and resulting in surgical site infections (SSIs). It's known that SSIs occur at a rate of 2 per 100 procedures-approximately 500,000 each year. SSIs caused by MDROs such as methicillin-resistant Staphylococcus aureus (MRSA) are associated with worse outcomes.1-3 Contact precautions are a set of practices used to prevent the transmission of communicable and infectious agents that can be spread by direct or indirect contact with the patient or the patient's environment. Contact transmission is divided into two subgroups: direct contact and indirect contact. Direct transmission occurs when one infected person transfers microorganisms to another person without a contaminated, intermediate object or person.4 Indirect transmission occurs when an infectious agent is transferred via a contaminated, intermediate object or person.4
According to the Association of periOperative Registered Nurses (AORN), contact precautions should be used when perioperative staff are caring for patients who have a known or suspected infection or are colonized with microorganisms transmitted by direct or indirect contact.5 Implementing contact precautions in the perioperative setting when a patient is having a surgical procedure is a critical aspect of the institution's patient safety program and an effective strategy for preventing the transmission of MDROs.
Perioperative staff caring for patients on contact precautions must follow hand hygiene requirements, including washing hands with soap and water before and after each patient contact or using an alcohol-based, waterless product. Soap and water must be used if hands are visibly soiled or come in contact with a spore-forming pathogen, such as Clostridium difficile (C. difficile).6 Additionally, staff members should wear a gown and gloves for all interactions that may involve contact with the infected patient or any potentially contaminated areas in the patient's environment.4
MDROs
MDROs are bacteria that are resistant to one or more classes of antimicrobial agents and are usually resistant to all but one or two commercially available antimicrobial agents.7 MDROs include MRSA, C. difficile, extended spectrum beta-lactamase (ESBL)-producing pathogens, vancomycin-resistant enterococci (VRE), and carbapenem-resistant Enterobacteriaceae (CRE).7,8 (See MDROs.) Although it's possible for an individual to be colonized and carry MDROs including CRE without having an infection, these pathogens can still be spread to others (see Why are CREs clinically important?). Patients with any of these pathogens who need surgery should be placed in contact precautions to prevent the spread of these pathogens.
Implementing contact precautions
Facilities should have written policies and procedures that identify patients with MDROs and require that contact precautions be implemented in all practice settings. Communication is a vital component for successful implementation of contact precautions and must occur at all points in the perioperative process, including scheduling the case and transferring the patient to the postanesthesia care unit (PACU) as well as communication with the environmental services (EVS) personnel responsible for cleaning the room.
When a patient is scheduled for surgery, his or her isolation status should be known. The patient should be transported directly to a designated section in the holding area (isolation room/cubicle) or into the room for the procedure. The staff transporting the patient must wear a gown and gloves and should be adherent to hand hygiene recommendations. All preoperative procedures, including the history and physical exam, pre-anesthesia assessment, hair removal, and site marking (as applicable), should be performed in the designated area, and all staff must follow the contact precautions. The area should be promptly cleaned and disinfected when the patient is transferred to the OR. All equipment and supplies needed for the procedure should be prepared and readily available in the room where the procedure will be performed. All unnecessary equipment and supplies should be removed and/or covered to prevent contamination.5
The patient is transported to the OR where staff (who aren't scrubbed and wearing sterile gowns) assisting in the patient transfer to the OR table have donned isolation gowns and gloves. The patient is transferred, positioned, and secured onto the OR table and prepped/draped for the procedure. After the procedure is completed, the patient is recovered and transported to the PACU maintaining the contact precautions.
Environmental cleaning is the final step in contact precautions following the surgical procedure. The EVS personnel should don a gown and gloves to clean the room. An Environmental Protection Agency (EPA)-registered disinfectant effective against the MDRO should be used to clean the room using the designated isolation room cleaning procedures approved by the facility's infection control program.5 When the specific MDRO is C. difficile, an EPA-registered, hypochlorite-based disinfectant should be used to clean the patient area, according to the special environmental cleaning and disinfection procedures for MDROs.9 AORN recommends giving special attention to cleaning high-touch areas and uncovered equipment in the room.9
Monitoring and evaluation
Perioperative managers should develop and implement a monitoring and evaluation program to provide an ongoing assessment of adherence to contact precautions. Breaches should be investigated, and the appropriative, corrective actions should be implemented. The effectiveness of cleaning after the patient leaves the area should also be evaluated.
The following are MDROs frequently seen in the healthcare setting.
* MRSA
* Vancomycin-intermediate S. aureus
* Vancomycin-resistant S. aureus
* VRE
* Escherichia coli
* Klebsiella pneumoniae carbapenemase (KPC)
* Acinetobacter baumannii-resistant to all antimicrobial agents or all except imipenem
* Stenotrophomonas maltophilia, Burkholderia cepacia, and Ralstonia pickettii-resistant to broad-spectrum antimicrobial agents
Why are CREs clinically important?
* CRE can be transmitted via direct or indirect contact.
* It's associated with high mortality (up to 50% in some studies).
* CRE frequently carries genes that enable high levels of resistance to numerous antimicrobial agents, resulting in limited therapeutic options.
* "Pan-resistant" Klebsiella pneumoniae carbapenemase (KPC)-producing strains have been reported.
* CRE have spread throughout many parts of the United States and could potentially spread even more.
Source: CDC. National Center for Emerging and Zoonotic
Infectious Diseases. Division of Healthcare Quality
Promotion. Guidance for control of carbapenem-resistant Enterobacteriaceae. 2012 CRE Toolkit.
http://www.cdc.gov/hai/pdfs/cre/cre-guidance-508.pdf.
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