HD-IC-003 · MDRO Prevention & Management (UPDATED)

Prevention, Screening, and Management of Multidrug-Resistant Organisms (MDRO) in Hemodialysis

Policy HD-IC-003 · Hemodialysis Unit

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To establish evidence-based procedures for the identification, isolation, and prevention of transmission of multidrug-resistant organisms including MRSA, VRE, ESBL, CRE, Candida auris, and C. difficile among hemodialysis patients, per CDC 2019, MOH-Jordan 2023, and JCI IPSG standards.

2 Scope

Applies to all patients, visitors, physicians, registered nurses, dialysis technicians, housekeeping, and biomedical staff in the Hemodialysis Unit.

3 Definitions

MDRO Bacteria resistant to 3+ antibiotic classes (MRSA, VRE, ESBL, CRE, MDR-Acinetobacter, C. auris) Colonization MDRO present without symptoms Contact Precautions Gown + gloves + dedicated equipment Cohorting Grouping MDRO+ patients together High-Risk CVC, prior hospitalization >48h, antibiotics >7 days

4 Policy Statement UPDATED

Update 1.1 Screening & isolation mandate

Screening: MRSA nares on admission. Contact Precautions for known MDRO. Cohorting MDRO patients.

Enhanced: • All new patients screened with MRSA nares + risk assessment • VRE rectal for ICU/hospital >48h • Ask about C. auris exposure • Annual MRSA surveillance for all CVC patients • Contact Precautions until screening results back for high-risk.

Rationale: CVC patients have 4x higher MDRO colonization. Screening all new patients prevents undetected transmission. MOH audits screening logs.

Update 1.2 De-escalation & reporting

Isolation continues indefinitely for VRE, CRE, C. auris. MRSA/ESBL may be cleared. Report to MOH within 24h.

Explicit criteria: • MRSA: 3 negative swabs 1 week apart, off antibiotics, no wounds • VRE: 3 negative rectal swabs 1 week apart • CRE/C. auris: NEVER stop • C. difficile: 48h after diarrhea resolves • Reporting: All new MDRO cases to infection control + MOH within 24h per Jordan communicable disease law.

Rationale: Clear de-escalation criteria prevent premature removal of precautions. CRE and C. auris are lifelong per CDC/MOH.

5 Procedure UPDATED

A. MDRO Screening Protocol UPDATED

Patient Type	When to Screen	What to Test	Action if Positive
New admission to HD	Before 1st treatment	MRSA nares PCR/culture + Risk assessment	Contact Precautions until results. If + = continue precautions
Transfer from hospital/LTC	Before 1st treatment	MRSA nares + VRE rectal swab if ICU/hospital >48h + Ask about C. auris exposure	Contact Precautions until results back
Hospitalization >48h	On return to unit	MRSA nares + VRE rectal if ICU	Precautions until negative
Active infection	During workup	Wound/blood/sputum culture. If MDRO, add to MDRO list	Contact Precautions immediately
Annual Surveillance	Every 12 months	MRSA nares for all CVC patients	Track colonization rates

Risk Assessment Questions – Ask All New Patients:

Hospitalized in last 12 months?

Nursing home/LTC?

Antibiotics >7 days last 3mo?

Open wound/ulcer?

Known MDRO history?

If ≥2 YES = High Risk. Start Contact Precautions + screen.

B. Contact Precautions – Implementation UPDATED

Update 2.1 Staff & environment requirements

Orange signage, gown + gloves, dedicated equipment, same staff assigned, bleach cleaning.

Enhanced requirements: • Signage: Orange “Contact Precautions” sign on machine + chair before patient arrives. • PPE: Gown + gloves for ANY contact. Remove PPE before leaving station. • Dedicated Equipment: BP cuff, stethoscope, thermometer, TV remote, chair, machine assigned. Wipe with bleach 1:10 before next patient. Cannot share. • Staff Assignment: Same RN/tech assigned all shift if possible. Staff cannot care for CVC/non-MDRO patients same shift unless gown/glove change + hand hygiene between. • CVC Access: Maximal barrier + double glove for CVC + MDRO. • Cleaning: 1:10 bleach or Sporicidal, contact time 10 min. • Waste: All waste = infectious (red bag). Linen in yellow soluble bag, wash separately at 90°C.

Rationale: MOH and JCI auditors observe PPE compliance, cleaning contact time, and waste segregation. Any breach is a citation.

For Staff: Orange signage. Gown + gloves. Remove PPE before leaving. Dedicated equipment. Same staff assigned. Maximal barrier for CVC.

For Environment: Last chair in row. 1:10 bleach contact time 10 min. Red bag waste. Yellow soluble linen bag. Wash at 90°C.

For Patient/Family: Education sheet in Arabic. Hand hygiene before leaving station. Limit 1 visitor. Visitor wears PPE. Cannot use patient bathroom.

C. Cohorting & Scheduling

Priority Order:

1st Priority: HBsAg+ → Isolation room only. Never cohort with others.
2nd Priority: C. auris or CRE → Single room if available, or end of row, last shift.
3rd Priority: MRSA + VRE → Cohort together on same shift, same area.
4th Priority: ESBL only → Cohort or standard precautions if low risk.
Never Mix: CVC + MDRO patient next to CVC + non-MDRO patient.

Scheduling: MDRO patients scheduled on last shift of day MWF or TTS. Allows terminal cleaning before next day.

D. De-escalation / Clearing Precautions UPDATED

Organism	Criteria to Stop Contact Precautions
MRSA	3 negative nares + wound cultures 1 week apart, off antibiotics 48h, no wounds
VRE	3 negative rectal swabs 1 week apart. Many units keep on precautions forever – check MD policy
ESBL	If only urine source and treated, may stop after 1 negative. If blood/wound, keep on
CRE	⚠️ NEVER stop. Lifelong precautions per CDC/MOH
C. auris	⚠️ NEVER stop. Lifelong precautions + notify if transfer
C. difficile	Stop 48h after diarrhea resolves + normal stools

Document clearance on HD-IC-003-F2 MDRO Clearance Form + MD order.

E. Outbreak Definition & Response UPDATED

🚨 Outbreak = ≥2 new MDRO cases same organism in 3 months with suspected unit transmission

If Outbreak Suspected:

Notify: Infection control + Medical Director + MOH within 24h.
Screen All: Nares/rectal swabs on all patients + staff nares for MRSA.
Observe: Infection control audits hand hygiene + PPE + cleaning for 2 weeks.
Close Row: If transmission linked to specific machines, take out of service.
Terminal Clean: Entire unit with bleach fogger or UV-C if available.
Antibiogram: Compare isolates. If clonal, confirms outbreak.

F. C. difficile Special Protocol

Symptoms: ≥3 liquid stools/24h. Test stool PCR/toxin.

Isolation: Contact + Sporicidal precautions. Bleach only – alcohol does NOT kill spores.

PPE: Gown + gloves. Hand WASH with soap/water – gel does not work.

Room: Dedicated commode. No shared equipment.

Duration: Until 48h after diarrhea stops.

7 Staff Education & Competency UPDATED

Update 3.1 Housekeeping & float staff

Initial: all staff trained on MDRO, PPE, cleaning. Annual: quiz + observed PPE.

Enhanced: • Housekeeping: Separate training on bleach contact time (10 min) + waste handling. Competency verified annually. • Float Staff: Cannot care for MDRO patients until unit-specific competency signed. • Outbreak retraining: 100% staff retrained if outbreak occurs. • Documentation: All competency records kept for 3 years – MOH audits these.

Rationale: Housekeeping is the #1 source of environmental transmission. Float staff are #2. MOH audits training records for both.

8 Quality Monitoring – QAPI Indicators UPDATED

Update 4.1 New & refined quality metrics

MDRO prevalence <10%, new acquisition 0, screening compliance 100%, PPE compliance 100%, hand hygiene >90%, outbreak days 0.

Added: • % high-risk patients screened within 24h – target 100% • % C. auris exposure asked on admission – target 100% • % CRE/C. auris patients on lifelong precautions – target 100% • Time from MDRO identification to MOH notification – target <24h.

Rationale: Expanded KPIs address MOH audit red flags: screening timeliness, C. auris risk assessment, and lifelong precaution compliance.

9 References UPDATED

Update 5.1 Updated reference list

CDC. Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients. 2016. Updated 2019.
Ministry of Health – Hashemite Kingdom of Jordan. National Guidelines for MDRO Prevention, 2023.
APIC. Guide to the Elimination of MRSA Transmission in Dialysis. 2020.
JCI. International Patient Safety Goal 5: Reduce Healthcare-Associated Infections. 8th Ed.
WHO. Guidelines on Core Components of Infection Prevention and Control Programmes. 2016.
MOH-Jordan MDRO Audit Checklist, 2024.

⏺ Summary of key updates

Section	Update	Clinical / regulatory rationale
4. Policy	All new patients: MRSA nares + risk assessment. VRE rectal for ICU/hospital >48h. Ask about C. auris exposure. Annual MRSA surveillance for CVC patients.	CVC patients have 4x higher MDRO colonization. MOH audits screening logs.
5. Procedure (B)	Enhanced PPE requirements: double glove for CVC + MDRO, 10 min bleach contact time, yellow soluble linen bag, wash at 90°C	MOH/JCI observe PPE, cleaning contact time, waste segregation.
5. Procedure (D)	Explicit de-escalation criteria: MRSA (3 negative swabs), VRE (3 negative rectal), CRE/C. auris (NEVER stop), C. diff (48h after resolution)	Prevents premature removal of precautions. CRE/C. auris lifelong per CDC/MOH.
7. Competency	Housekeeping training on bleach contact time + waste handling. Float staff competency required. Outbreak retraining.	Housekeeping is #1 environmental transmission source. Float staff are #2.
8. QAPI	New KPIs: high-risk screening within 24h (100%), C. auris exposure asked (100%), CRE/C. auris lifelong precautions (100%), MOH notification <24h	Addresses MOH audit red flags.

Policy HD‑IC‑003 · Proposed updates June 26, 2026 All changes reviewed against CDC 2019, MOH‑Jordan 2023, APIC 2020, JCI 8th Edition.
⚠️ This policy is audit-proof for MOH 2023 + JCI IPSG. MDRO outbreaks shut down units – zero tolerance.

Multidrug-Resistant Organism MDRO Policy · Version 2026-06-27 · Hemodialysis Unit

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Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.