Skilled nursing facility (SNF) residents are at increased risk for both colonization and infection by multidrug resistant organisms (MDROs.) The prevalence of S. aureus and IP colonization among residents has been estimated at higher than 50 percent, with new colonization acquisitions occurring frequently. Because standard precautions have not been effective at controlling the spread of organisms and because contact precautions are less frequently adopted in SNF settings, infection preventionists (IPs) in these settings often seek additional strategies to help stop the spread. Two such strategies are enhanced barrier precautions (EBPs) and decolonization.


Traditionally, decolonization has been used for surgical patients, especially those undergoing high-risk surgeries. As part of the Centers for Disease Control and Prevention (CDC) core strategies for preventing surgical site infections and bloodstream infections, skin antisepsis with chlorhexidine gluconate (CHG) wash or wipes and nasal decolonization with an intranasal antibiotic or antiseptic (mupirocin or at least 5 percent Iodophor) are recommended.

In more recent studies, nasal decolonization has been used as a strategy for MDRO prevention in SNF and long term care settings. The SHIELD Orange County Project recognized that patient movement between care settings was contributing to MDRO spread. They formed a regional decolonization collaborative that instituted a protocol of chlorhexidine bathing and twice-daily povidone-iodine nasal swabs in 35 facilities. At the end of the study, they found reductions of MDRO colonization of 22 percent in nursing homes and 34 percent in long term acute care hospitals (LTACHs).

In the PROTECT study, a similar protocol was used universally, but only in nursing homes. The study assessed pre- vs. post-intervention MDRO prevalence by randomly sampling 50 residents in each facility. Decolonization was associated with a 28.8 percent decrease in MDRO prevalence, and split out by pathogen, there were 24.3 percent, 61.0 percent, and 51.9 percent decreases in methicillin-resistant S. aureus (MRSA), vancomycin-resistant enterococci (VRE), and extended spectrum beta-lactamase (ESBL), respectively.

Decolonization with CHG bathing and nasal decolonization with povidone-iodine can lower MDRO transmission within SNFs, as well as MDRO spread to other health care facilities.

Enhanced Barrier Precautions

In 2021, the Healthcare Infection Control Practices Advisory Committee (HICPAC) set forth a document entitled “Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities" that outlined topics related to the care of nursing home populations and the implementation and scope of EBPs as requested by the CDC at the November 2019 HICPAC meeting. This document highlighted that MDRO transfer is common in skilled nursing facilities, and that EBPs can help stop the transfer from happening. EBPs can and should be applied in high-touch care activities regardless of MDRO status, in addition to transmission-based precautions used when residents are infected or colonized with an MDRO. To implement EBPs effectively, staff must be trained on personal protective equipment (PPE) use, and PPE and hand hygiene supplies must be readily available at the point of care. Staff should also be trained on why EBPs are important.

In studies so far, EBPs have proven to be effective in preventing acquisition, transmission, and infection by S. aureus. Although studies have not explicitly proven that EBPs are effective in preventing the spread of MDROs or other epidemiologically significant organisms, many of these organisms require contact precautions, so although not studied, EBP should certainly be an effective prevention strategy.

When recommending EBP as additional guidance for the long term and skilled nursing care settings, the CDC considered that standard precautions are not often successfully implemented in these settings. In addition, contact precautions are not strictly adhered to, in part due to the home-like environment of these care settings. Many residents in these care settings have MDROs that are not identified—all these things make it difficult to know exactly what the potential for organism transmission is in many cases, which makes a strategy like EBP more appealing.

EBP consists of adding gowns and gloves during high-touch care activities for all residents that have a wound or indwelling device, when that PPE may traditionally only have been used for residents who displayed signs and symptoms of active infection. High-risk activities specifically include care tasks where close contact is anticipated: dressing, bathing/showering, transferring, providing hygiene (showering, shaving, brushing teeth), changing linens, incontinence care/toileting, device care or use, and wound care. EBPs would not add room placement restrictions that transmission-based precautions may include.

These activities were chosen based on observations of activities in SNFs and evaluations of these observations to determine the risk of pathogen transfer on hands after the activities occurred. Although EBPs only address gown and glove use during these activities, other PPE may be used as required in adherence to standard precautions if any blood or body fluid exposure may be expected during any care activity taking place.

It is not currently recommended that all residents in a skilled nursing facility are immediately placed on EBPs. CDC recommends that EBPs are used for residents that have any wound or indwelling device, and any resident that is infected or colonized with an MDRO if transmission-based precautions would not otherwise apply. Tips to implement EBPs include clear signage indicating they are required, having PPE and hand hygiene supplies readily available, having trash receptacles in appropriate locations for proper disposal of PPE, education and PPE training for staff, and audits to monitor compliance.


Some common objections to facility-wide implementation of additional IP strategies include cost considerations and PPE supply considerations. Although costs would be incurred for PPE, training, and additional signage as well as staff time, one study looked at the implementation of EBP in a 120-bed nursing home and found that overall, there was a cost savings. The authors found that the program would cost about $20,000 but that $54,000 in disease treatment cost would be prevented, providing an overall cost savings value of $34,000 per year to the facility when considering catheter-associated urinary tract infections alone.

Supply chain and PPE availability have been an increasingly high priority since the onset of COVID-19. Currently, PPE stock and availability has largely returned to normal. Facilities should plan for contingency and crisis standards of care, so that in the event of a shortage, a plan is in place for PPE supply preservation. (For example, residents with documented MDROs would be prioritized over those with wounds or indwelling devices.)

Jenny BenderIPs across the continuum of care should be aware of the current recommendations around EBPs and how these are practically deployed. Adoption of EBPs in long term care settings has the potential to prevent infections across the continuum of care, as residents (and any potential MDROs they are harboring) are frequently transferred between care settings. EBPs are not currently recommended in settings outside SNFs, IPs in other settings like acute care or a LTACH should be able to speak to the differences in prevention strategies in different care settings to clarify any questions from patients and their family members, as well as to better understand the risk of MDRO infection and colonization when patients and residents pass between their facilities.

Jenny Bender, MPH, BSN, RN, CIC, is clinical science liaison at PDI Northeast Region and an RN with more than 10 years' experience as an infection preventionist in community hospital, ambulatory/outpatient, academic medical center, behavioral health, and public health settings.​