IPC 3.9 Multi-drug Resistant Organisms (MDRO)
Contents
1.0 Introduction
2.0 Mode of transmission
2.1 Risk factors
2.2 Signs and symptoms - clinical indications
2.3 Screening
3.0 Antimicrobial treatment guidance
4.0 Infection prevention and control principles
4.1 Isolation
4.2 Hand hygiene
4.3 Respiratory / Cough hygiene
4.4 Personal protective equipment
4.5 Equipment
4.6 Environmental cleaning
4.7 Linen
4.8 Body fluids
4.9 Waste standard
4.10 Occupational exposure
4.10a Staff carriage
5.0 Surveillance
6.0 Outbreaks
7.0 Transmission precautions and IPC when caring for the deceased
8.0 References/Source documents
Appendix 1
Appendix 2
1.0 Introduction
Organism
It is important to control the spread of MDROs, due to the limited therapeutic alternatives, the increasingly compromised in-patient population, and the potential for transfer of resistance to other pathogenic bacteria leading to the development of further resistance. The epidemiology of MDRO infections can be complex and hospitals may be affected by sporadic cases of MDROs, epidemics or endemic colonisation and infection. Each of these situations will need to be managed in different ways, depending on the risk to the patients involved.
- Multi drug resistance gram negatives:
- Extended spectrum β-lactamase producing organisms (ESBL’s)
- Usually E. coli or Klebsiella
- Amp C producers
- Usually Enterobacter, Serratia or Citrobacter
- Multi-Drug resistant Pseudomonas
- Resistant to at least 2 of the following: ceftazidime, Piperacillin/Tazobactam, gentamicin and ciprofloxacin. Can occasionally be resistant to carbapenems.
- Any gram-negative microorganisms can be a carbapenemase producer. Suspicion should be high when a patient has spent significant time in or been treated in hospitals abroad.
- When a microorganism such as Stenotrophomonas or Acinetobacter becomes established in the clinical environment, it can be difficult to eradicate.
In Healthcare settings a Multi-Drug Resistant Organism (MDRO) of concern is a bacterium that is resistant to several antibiotics, capable of causing infection and often adapted to spread easily. Organisms
- Glycopeptide-resistant Enterococci (GRE), sometimes referred to as Vancomycin Resistant enterococci (VRE)
- Extended-spectrum β-lactamase producers (ESBLs)
- Multi-resistant Acinetobacter species (MRAB)
- Multi-resistant Pseudomonas species and other antimicrobial resistant bacteria that are AmpC producers (Amp-C)
- Carbapenem-producing Enterobacteriaceae (CPE)
- Carbapenem Resistant Enterobacterales (CRE) resistant to carbapenems but not having a carbapenemase gene
Incubation period
Patients can be colonised with a MDRO without any signs or symptoms, and this may not cause any infection or harm.
Colonisation
Colonisation occurs when a microbe establishes itself in a particular environment such the gut, without producing disease or symptoms. This is sometimes referred to as asymptomatic carriage and can be identified by screening.
Period of communicability
Patients who have been identified as having an infection caused by one of the above MDROs should be isolated and the appropriate PPE and hand hygiene implemented.
Once a patient has had a MDRO infection they may become a carrier of an MDRO e.g in their bowel and remain an infection risk.
Each patient would need to be discussed with the Infection Prevention and Control Team (IPCT) to ensure the risk of transmission is minimised.
Individuals at risk
The general population.
Notifiable disease
CPE is Notifiable to UKHSA.
The laboratory has a duty to report other MDROs.
If a patient is suspected or confirmed with a MDRO staff should contact the IPC Team.
Outbreak
Two or more epidemiologically linked healthcare associated infections (HCAI) cases by the same microorganisms will result in an investigation, which will utilise the post infection review approach. Inform the IPC team, for both a new infection and a colonisation (if a patient has a history of an MDRO infection).
2.0 Mode of transmission
Mode of Transmission will depend on the site of infection.
- Direct contact via contaminated hands
- Indirect contact via contaminated equipment and the environment
- Droplet/Airborne
2.1 Risk factors
Most of the Infections have occurred in people with other underlying medical conditions.
For CPE Please follow the risk assessment for non-acute settings.
- Recent hospitalisation, particularly if abroad
- Previous colonisation or infection with a MDRO
- Recent contact with a patient colonised or infected with a MDRO
- Multiple hospital admissions
- Prolonged in-patient stay
- Admission to an Intensive Care Unit, renal or haematology units
- Admission from a Care Home (residential or nursing)
- Recent invasive procedures
- Exposure to multiple courses of broad-spectrum antibiotics
2.2 Signs and symptoms - clinical indications
Infection – Invasion by and multiplication of pathogenic microorganisms in a bodily part or tissue, which may produce subsequent tissue injury and progress to overt disease through a variety of cellular or toxic mechanisms.
- Infected Wounds
- Urinary Tract Infection
- Blood stream Infections
- Sepsis – refer to IPC Sepsis Policy
2.3 Screening
Routine screening is not conducted for MDRO’s. If infection is suspected samples that may be sent to Microbiology for a culture could include Urine, sputum, wound swabs, blood cultures, rectal swabs, fluid, and tissue samples.
Staff screening is not recommended. There is no evidence of effectiveness, and it is not recommended in international guidelines.
See collecting a specimen at operational guideline IPC 4.1 Obtaining a clinical sample
3.0 Antimicrobial treatment guidance
The patient’s previous Microbiology and MDRO history must be considered when prescribing antibiotics.
The treatment will be guided by the microbiology results in consultation with the Microbiologist.Deviations from the policy must have associated rationale documented in the patient’s medical notes. Antimicrobial prescriptions must state an approximate course length in the form of a stop or review date.
Refer to local primary careantimicrobial guidelines( The page is available from the 'Antimicrobial Stewardship and Guidelines' page on the Connect site )
4.0 Infection prevention and control principles
Discuss any suspected/confirmed infections with the Infection Prevention Control Team.
4.1 Isolation
Patient placement/assessment for infection risk must be assessed and discussed with the IPC team prior to patient placement.
IPC 4.3 Transfer of patients with a known/suspected infection
NHS England - Chapter 1: Standard infection control precautions (SICPs)
NHS England - Chapter 2: Patient placement/ assessment of infection risk
MDRO can persist in the gut so isolation may be for the duration of admission and possible future admissions, please discuss isolation and precautions with the IPCT, the patient may also need to have their own toileting facilities.
4.2 Hand hygiene
NHS England - Chapter 1: Standard infection control precautions (SICPs)
Hand Hygiene being carried out by Healthcare Professionals and Visitors is the most effective way of reducing the spread of infections.
UKHSA handwashing advice (england.nhs.uk)
nipc manual Appendix 2 handrubbing (england.nhs.uk)
4.3 Respiratory / Cough hygiene
NHS England - Chapter 1: Standard infection control precautions (SICPs)
4.4 Personal protective equipment
NHS England - Chapter 1: Standard infection control precautions (SICPs)
for suspected/confirmed infections follow transmission-based PPE:
PPE may also be required by visitors if they are carrying out personal care.
4.5 Equipment
Decontamination of reusable non-invasive care equipment must be undertaken:
IPC 4.6 Decontamination of patient equipment
If providing domiciliary care, equipment should be transported safely and decontaminated as above policy before leaving the patient’s home.
Always adhere to COSHH risk assessments and manufacturers’ guidance for use and decontamination of all care equipment.
Guidance should be sought from the IPC Team prior to procuring, trialling, or lending any reusable non-invasive equipment.
Cleaning schedules should be in place as evidence of cleaning, along with I am clean indicator tape/stickers for medical equipment.
4.6 Environmental cleaning
NHS England - Chapter 2: Transmission based precautions (TBPs)
4.7 Linen
NHS England » Chapter 1: Standard infection control precautions (SICPs)
4.8 Body fluids
NHS England » Chapter 1: Standard infection control precautions (SICPs)
4.9 Waste standard
NHS England - Chapter 1: Standard infection control precautions (SICPs)
4.10 Occupational exposure
See occupational safety: Prevention of exposure (including sharps injuries)
NHS England » Chapter 1: Standard infection control precautions (SICPs)
Appendix 10: Best practice – management of occupational exposure incidents
4.10a Staff carriage
There have been no published reports implicating staff carriage as a source of patient colonisation or infection.
Staff screening is not recommended.
5.0 Surveillance
The IPCT will carry out routine surveillance of alert organism data from microbiology reports to monitor trends to detect outbreaks and ‘hot spot’ areas of infections. All new cases of hospital acquired MDRO’s will be reported quarterly to the Care Groups. The IPCT will carry out enhanced surveillance for specific bacteraemia in line with the Department of Health requirements, and a post infection review (PIR) will be performed by the clinical teams for all hospital acquired cases.
6.0 Outbreaks
A prompt response following detection of a MDRO in health and social care settings is required to minimise onwards transmission.
Environmental samples should only be taken when epidemiologically indicated.
Two or more epidemiologically linked cases by the same microorganisms will result in an investigation, which will utilise the post infection review approach. Further actions will be determined by the IPCT; an outbreak meeting should be held to decide whether to put a temporary halt on further admissions or discharges. The IPC may escalate the actions, which may include environmental sampling and staff screening. Outbreaks may include ward or bed closures. UKHSA will be informed of events and actions taken.
7.0 Transmission precautions and IPC when caring for the deceased
NHS England » Chapter 2: Transmission based precautions (TBPs)
Appendix 12.docx (england.nhs.uk)
8.0 References/Source documents
Department of Health (2006). Essential steps to safe, clean care. Department of Health. London
Enterococcus species and glycopeptide-resistant enterococci (GRE) (GOV.UK)
NHS England - National infection prevention and control manual (NIPCM) for England
Nottinghamshire Area Prescribing Committee. (2023). Antimicrobial Guidelines for Primary Care.
Public Health England (2014). ESBL-producing Enterobacterales in Healthcare Settings.
UKHSA, (2022). Framework of actions to contain Carbapenemase-producing Enterobacterales.
Appendix 1
Carbapenemase Producing Enterobacteriaceae (CPE)( The page is available from the 'Carbapenemase Producing Enterobacteriaceae (CPE)' page on the Connect site )
Appendix 2
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At all risk levels ensure:
Risk assessments must include consideration of the care environment, for example nursing care setting, specialist or general-rehabilitation, haemodialysis unit, EMI, dementia care unit, community hospital or hospice, mental health trust, residential care, domiciliary care, or detention centre prison. If the individual is colonised (the presence of bacteria on a body surface, such as skin or gut, without causing disease in the person): single room with en-suite facilities including toilet or designated commode is recommended; where a single room is not available, it is recommended that a designated toilet or commode is made available. No curtailment of communal activities is required where standard precautions and effective environmental hygiene are being maintained and there is no risk of transmission to others. If the individual is infected: conduct a risk assessment with your IPC advisor and or UKHSA contact to discuss possible isolation (with defined end-of-isolation criteria) consider the mental and physical health and wellbeing of the individual when deciding to isolate. Always communicate the positive status of an individual when transferring the individual between care settings |
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Care needs |
Guidance for risk assessment |
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High risk For example, the individual has:
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Identify if there is an immediate risk of infecting or contaminating others and the shared environment. Discuss management with GP or clinician in charge, IPC nurse. Consider the mental and physical health and wellbeing of the individual and the level of supervision required. |
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Medium risk For example, the individual requires assistance with hygiene, mobility or physical rehabilitation. |
No immediate risk of infecting others identified:
If unsure, contact your usual IPC advisor or UKHSA via the local Health Protection Team or Consultant in Public Health Infection, or local Community IPC Team where available in Public Health Infection, or local Community IPC Team where available. |
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Low risk For example, the individual is independent and selfcaring. |
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UKHSA (2022)
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