Management of Persons in Correctional Settings with Targeted MDROs

Purpose

  • This webpage provides information on how to manage people in non-healthcare correctional facilities and settings who are infected with or are carriers of (i.e., carrying the organism without symptoms) targeted multidrug-resistant organisms (MDROs).
  • These recommendations do not supersede existing guidance for healthcare settings and patient care activities, including those within correctional facilities. (see Existing resources below)

Background

MDROs are pathogens that are resistant to one or more antimicrobial agent classes, making infections with these organisms challenging to treat. Both people who are actively infected and carriers can serve as a source of transmission to others. MDRO transmission typically occurs through direct skin to skin contact or by touching contaminated materials or surfaces. While the risks to otherwise healthy people from most of these organisms are relatively low, infections with these organisms can more often have a negative impact on people with underlying medical conditions, those with medical devices, and those who require help with daily activities. Maintaining good personal hygiene like cleaning hands and showering, not sharing personal care items such as towels or skincare products, and keeping any wounds covered are important practices to prevent the spread of MDROs.

Specific organisms addressed

Although healthcare facilities often focus their MDRO prevention efforts on specific organisms in their regions, CDC is currently addressing the following highly resistant pathogens on a nationwide scale:

  • Pan-resistant organisms with potential for spread
  • Carbapenemase-producing Enterobacterales (CP-CRE)
  • Carbapenemase-producing Pseudomonas spp. (CP-CRPA)
  • Carbapenemase-producing Acinetobacter baumannii (CP-CRAB)
  • Candida auris

Implementation

Implementation recommendations to limit spread of MDROs from people infected with or carrying MDROs in non-healthcare correctional settings

Data regarding transmission of MRDOs outside of healthcare settings is limited. Interventions for non-healthcare operations within correctional settings may be warranted if transmission is identified. The organisms listed above have potential for long-term carriage which can impact housing options, hygiene needs, and cleaning and disinfection practices. MDRO control in correctional facilities needs to balance the transmission risk with the need to maintain the rights and quality of life of people who are incarcerated.

Reminder

These implementation recommendations do not supersede any federal, state, or local regulations.

These recommendations are not intended to apply to healthcare settings or healthcare activities within correctional facilities. (see Existing resources below)

Housing and medical isolation

Housing in facility’s general population

Assuming their medical care needs can be met, and they do not have any uncontained secretions or excretions, incarcerated people known to be infected with or carrying an MDRO can be housed in the facility's general population.

Carriers and infected individuals who are not medically isolated may leave their cell or dormitory, participate in group activities, and perform eligible work functions. However, they must not have uncontained secretions or excretions, such as uncovered wound drainage. Additionally, they must comply with all relevant work requirements, including the Food Safety Code for food handlers. They should avoid activities (e.g., contact sports) that might involve skin-to-skin contact with their wounds or otherwise affected skin (e.g., rash).

Housing in medical unit or facility

For medical reasons

If, because of their medical care needs, they are housed in a correctional medical unit or correctional medical facility, they should be medically isolated and handled with appropriate Transmission-Based Precautions as described in the healthcare guidance.

For non-medical reasons

Individuals in correctional medical units for non-medical reasons, such as work assignments or outpatient care, should be assessed case by case for ongoing medical isolation. Factors to consider might include their job duties, the epidemiology of the MDRO with which they are colonized, and if they have been associated with MDRO transmission in the facility.

Medical isolation

Temporary single-room isolation is recommended for incarcerated individuals with uncontained secretions or excretions and also may be necessary during an MDRO outbreak (see below for definition of an outbreak). If temporary medical isolation is implemented:

  • Medical isolation should be time-limited (e.g., discontinued when wound drainage can be contained by a dressing). Communication about the duration and purpose of their medical isolation should occur regularly with the isolated individual.
  • Facilities should ensure that medical isolation is operationally distinct from disciplinary isolation, segregation, or solitary confinement.
  • If single rooms are not available, facilities could consider housing colonized or infected people who are in medical isolation with roommates who are not at high risk for infection with MDROs. Evidence to support this practice is lacking. People who are at higher risk of infection with MDROs include, but are not limited to, those with indwelling medical devices (like catheters), those with chronic wounds, those with underlying chronic medical conditions (like diabetes mellitus), those who require assistance with activities of daily life, and those whose immune systems are suppressed (like people with cancer).

Definition of an outbreak

An outbreak is generally defined as an increase in the incidence or prevalence of an organism above baseline. The definition of an outbreak might vary based on the local epidemiology of a pathogen. For example, the first identification of a highly resistant organism in a facility might be treated initially as an outbreak until the epidemiology can be further defined. In facilities with an endemic MDRO, outbreaks generally are identified by an increase in adverse events related to the organism or a significant increase in prevalence.

Hygiene

Wound care

Wounds should be kept covered and any secretions should be contained by the dressing. Dressings should be changed regularly and disposed of in accordance with state regulations.

Hand hygiene

Hand hygiene is the most important intervention for reducing the risk of spreading resistant pathogens (e.g., before and after changing dressings). Supplies for hand hygiene should be easily accessible for both incarcerated people and staff. Soap and water should be available to incarcerated people at no cost. When possible, alcohol-based hand rub (ABHR) can be provided as an alternative to soap and water.

Personal hygiene

Incarcerated people should have access to supplies and facilities to maintain good hygiene. Showering regularly can reduce skin colonization for MDROs and reduce the risk of transmission and infection.

Incarcerated people should regularly be provided clean uniforms, towels, and linens.

Incarcerated people should not share personal items like clothing, towels, washcloths, linens, bars of soap, or razors.

Cleaning & disinfection

Facilities should ensure that incarcerated people infected with or carrying an MDRO, and any incarcerated workers and staff responsible for cleaning the environment where a person infected with or carrying an MRDO spends time, understand how to effectively clean surfaces to prevent transmission.

Common areas

Incarcerated people should have access to the supplies needed to clean and disinfect surfaces in common areas as recommended after use like gym equipment. Incarcerated people should be educated about how and why to clean and disinfect common surfaces to prevent transmission to others. Ideally, colonized and infected people would perform recommended cleaning and disinfecting themselves when possible. Specific implementation might vary based on factors related to security level, housing arrangement, and physical or cognitive impairment.

Specific areas

Surfaces in cells or dormitories

Surfaces in an infected or colonized person's cell or dormitory, including toilets and sinks, should be cleaned and disinfected regularly. This includes after they have vacated their cell or living space and before assigning a new person to that space. Disinfectants should have a label claim for the pathogen of concern (e.g., List P for Candida auris) and used in accordance with the manufacturer's instructions for use.

Communal showers

Communal showers should be cleaned and disinfected regularly. Surfaces should also be cleaned and disinfected immediately if contaminated with drainage from wounds or other possibly infectious material. Disinfectants for surfaces contaminated with blood or body fluids should have a label claim for HIV and Hepatitis (List S).

Clinical evaluation & communication

Incarcerated people with skin and soft tissue infections should be evaluated by a medical provider and treated in a timely way.

Transfers

An incarcerated person's MDRO status should always be communicated to offsite healthcare facilities or to different correctional facilities when they are transferred, or when they are transferred to a different part of the same facility. Given the frequent movement of incarcerated people between correctional facilities, electronic alerts or other automatic means to share a person's MDRO status should be considered when possible. To avoid stigma and violation of HIPAA, this information should only be shared with staff who need this information to ensure that the person is transported, housed, and cared for in a manner that reduces the risk of transmission.

Existing resources

Guidance to prevent transmission of MDROs is already available for healthcare facilities and applies to healthcare settings and patient care activities within correctional facilities:

Methicillin-resistant S. aureus (MRSA)

Guidance related to methicillin-resistant S. aureus (MRSA) in correctional settings is also available. MRSA has historically presented significant challenges in communal settings like correctional facilities. These organisms can spread easily and cause outbreaks of skin and soft tissue infections, even among healthy people. Although many of the non-healthcare MDRO recommendations that follow are applicable to MRSA, specific guidance for control of MRSA in correctional settings is available from CDC and the Federal Bureau of Prisons:

Additional resources for correctional settings

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Content Source:
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)