STAPHYLOCOCCUS AUREUS (MRSA & MSSA) MANAGEMENT POLICY

Version / 11
Name of responsible (ratifying) committee / Infection Prevention Management Committee
Date ratified / 17 March 2017
Document Manager (job title) / Infection Prevention Management Committee
Date issued / 04 April 2017
Review date / 03 April 2020
Electronic location / Infection Prevention and Control Policies
Related Procedural Documents / Trust Policies:
Hand Hygiene policy
Isolation Policy
Standard Precautions policy
Decontamination policy
Key Words (to aid with searching) / MRSA, MSSA Staphylococcus aureus, staph aureus

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
11 / 17/03/2017 / Amendment to MRSA screening for elective orthopaedic patients / IPT
10 / 28/01/2015 / Previously ‘Interim Staphylococcus Aureus Policy’
New elective pathway and renal dialysis pathway diagrams / Infection Prevention

CONTENTS

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

6.PROCESS

7.TRAINING REQUIREMENTS

8.REFERENCES AND ASSOCIATED DOCUMENTATION

9.EQUALITY IMPACT STATEMENT

10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

Appendix 1

Appendix 2

EQUALITY IMPACT SCREENING TOOL

QUICK REFERENCE GUIDE

Screening for MRSA:

Not all elective patients need to be screened for MRSA. Some elective specialties are required to screen all patients due to the prevalence and risk of MRSA in their populations. Other elective specialties only need to screen patients with specific risk factors for MRSA. See section 6.7 for relevant screening requirements and risk assessments.

All patients admitted as emergencies must be screened for MRSA at the time of admission. Patients attending the Emergency Department but not needing admission do not require screening.

Screening for S. aureusshould be performed using a dry charcoal swab (one swab per site)

Screening Sites:

  • Anterior nares (all patients) the same swab should be used for both nostrils
  • Groin (inpatients only) the same swab should be used for both groins
  • Wounds/skin lesionsif multiple lesions, swab representative sample
  • Intravenous devicesdo not disturb covered/dressed sites unless site looks infected
  • Urinary cathetersspecimen of urine should also be obtained

Allemergency admissions (and admissions to ICU) must be given topical S aureus protection until their screening results are known:

1st Line Suppression:

  • Octenisan wash once daily until screening results known

Confirmed MRSA positive patientsshould receive suppression therapy under the guidance of the Infection Prevention Team:

1st Line Suppression:

  • Mupirocin 2% applied to the inner surface of each nostril 3 times a day for 5 days
  • Chlorhexidine Gluconate 4% (Hibiscrub) or Octenisan wash once daily for 5 days

2nd Line Suppression (for Mupirocin Resistant Strains):

  • Naseptin applied to the inner surface of each nostril 4 times a day for 10 days
  • Chlorhexidine Gluconate 4% (Hibiscrub) or Octenisan wash once daily for 10 days

Once a patient is confirmed MRSA positive they should always be assumed to have a continuing positive status irrespective of current screening results. There is no requirement to obtain 3 negative screens post suppression therapy. The patient should be screened weekly after suppression therapy but assumed to remain positive

The purpose of suppression therapy is to achieve a short-term reduction in skin +/- nasal flora. Patients should not be given more than two courses of full suppression therapy in six months.

Patients with nasal or skin carriage of MSSA, or MSSA Blood Stream Infection do not routinely need to be isolated.

Where possible, all patients with MRSA positive isolates should be placed in side rooms. High Staphylococcal dispersers must, without exception, take priority for side rooms:

  • MRSA positive sputum with productive cough
  • MRSA positive tracheostomy
  • MRSA/MSSA positive with severe skin shedding (e.g. severe eczema, psoriasis)
  • MRSA positive in uncovered discharging wound

1.INTRODUCTION

Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus(MRSA) aretypes of S. aureusbacteria present in community and healthcare settings capable of causing significant healthcare associated infection (HCAI).

2.PURPOSE

This policy defines the actions taken by Portsmouth Hospitals NHS Trust to reduce the transmission of S. aureuswithin relevant acute and community environments by reducing or managing their reservoirs and preventing onwards transmission. This policy will inform all hospital workers of their individual responsibilities to effectively manage S. aureus.

This policy should be read in conjunction with the Standard Precautions, Hand Hygiene and Isolation policies.

3.SCOPE

This policy applies to all Portsmouth Hospitals NHS Truststaff, health and non-healthcare, including agency, bank and locum staff, as well as contractors and external agencies.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4.DEFINITIONS

Colonisation:Presence of S. aureus(often nose, sputum, urine, faeces, open wounds or on the skin) without the presence of symptoms or clinical manifestations of illness or infection. A colonized individual may transmit the organism to another person.

Suppression Therapy:Temporary suppression of the S. aureus carrier state through use of topical agents (e.g. Octenisan or Chlorhexidine washes +/- antimicrobial nasal cream). This decreases the risk of transmission to others.

Infection:Invasion and multiplication of S. aureus in tissue with the manifestation of clinical symptoms of infections such as increased white blood cell counts, fever, lesions, furuncles, drainage from a break in skin continuity and erythema. Infection warrants treatment.

Mode of Transmission:The method by which S. aureus is spread into the environment and to other persons. S. aureus are transmitted primarily by direct person-to-person contact (i.e. from the hands of one individual to a susceptible individual). Contaminated bed linen, surfaces, medical equipment and high levels of environmental dust also play a significant role in transmission.

Meticillin Resistant Staphylococcus aureus (MRSA):A gram-positive bacteria, found on approximately 3% of the general population and up to 7% of hospital patients that is not inhibited by meticillin or oxacillin and many other antimicrobials.

Meticillin Sensitive Staphylococcus aureus (MSSA):A gram-positive bacterial, carried by approximately 50% of the healthy adult population at any one time (20% persistent carriers, 60% intermittent carriers, 20% non carriers). Most MSSA are sensitive to meticillin, cephalosporins and oxacillin. MSSA is a common cause of localised skin and soft tissue infections or serious disease like discitis, osteomylitis, septic arthritis, endocarditis, pneumonia or systemic sepsis.

5.DUTIES AND RESPONSIBILITIES

Infection Prevention Team:

  • Review and update MRSA/MSSA policy
  • Give additional advice regarding the management of patients with MRSA/MSSA
  • Include MRSA/MSSA in all induction and update training for clinical staff
  • Promote good practice and challenge poor practice

Microbiologists:

  • Alert Infection Prevention Team and clinical teams (where appropriate) of patients with clinically significant MRSA/MSSA infections
  • Follow the antimicrobial prescribing policy for patients with or at risk of MRSA/MSSA

Patient Flow / Duty Hospital Managers:

  • Facilitate placement of patients with MRSA into appropriate isolation rooms
  • Escalate difficulties in management/placement of MRSA/MSSA patients to the Infection Prevention Team
  • Ensure effective communication of patients risk and carriage status

Matrons / Ward Managers:

  • Must establish a culture of compliance with infection prevention practice across their units
  • Ensure admission and weekly screening for MRSA occurs as per policy
  • Promote good practice and challenge poor practice

Medical Staff:

  • Ensure compliance with infection prevention and antimicrobial prescribing policies
  • Ensure prudent antimicrobial prescribing and stringent use/removal of indwelling devices
  • Follow advice of the Infection Prevention Team relating to patients with MRSA/MSSA

All Healthcare Staff:

  • Must be familiar with and adhere to the relevant infection prevention policies to reduce the risk of cross infection of patients
  • Must adhere to the full terms and conditions documented in this policy
  • Refer to the infection prevention team if unable to follow the policy guidelines
  • Must check the MRSA status of their patient prior to any invasive procedure

6.PROCESS

6.1 General Principles:

Standard precautions, including strict hand hygiene and appropriate use of personal protective equipmentshould be applied to all patients without exception, regardless of known S. aureus colonisation or infection (refer to standard precautions and hand hygiene policy).

6.2 Screening of patients:

Screening for S. aureusshould be performed using a dry charcoal swab (one swab per site)

6.2.1 Screening Sites:

  • Anterior nares (all patients) the same swab should be used for both nostrils
  • Groin (inpatients only) the same swab should be used for both groins
  • Wounds/skin lesionsif multiple lesions, swab representative sample
  • Intravenous devicesdo not disturb covered/dressed sites unless site looks infected
  • Urinary cathetersspecimen of urine should also be obtained

6.3 Suppression Therapy:

The purpose of suppression therapy is to achieve a short-term reduction in skin +/- nasal flora to protect the patient during specific events in their admission (e.g. immediately on admission for blood cultures, lines, catheterisation etc. and for certain invasive procedures thereafter). The goal is not to achieve long-term eradication and patients should not be given more than two courses of full suppression therapy in six months to try and achieve this.

6.4 Directions for Administering Suppressive Agents:

Suppression therapy should be prescribed on the patients medication chart or as an out-patient prescription and clearly limited in duration, dependant on the agent used

6.4.1 Topical Washes:

Octenisan is a gentle, non-perfumed antimicrobial wash, suitable for use in all age groups (including neonates greater than 28 weeks gestation) and those with eczema and psoriasis.

Hibiscrub (Chlorhexidine 4%) is an antimicrobial wash suitable only for adults and should not be used on patients with hibiscrub allergy or infected, dry, or flaking skin.

  • Patients should wash once daily for 5 days as follows:

-Days 1 and 5 wash the whole body, neck, face and hair

-Days 2, 3 and 4 wash the whole body, neck and face

  • Patients should use approximately 50mls of Octenisan or Hibiscrub per wash
  • Patient should wet their skin prior to application of Octenisan or Hibiscrub
  • Octenisan or Hibiscrub should not be diluted in washing water – it must be applied neat
  • Special attention should be paid to sites such as axillae, groin, perineum and buttock areas or other skin folds
  • Fresh towels and facecloths should be used each day
  • A daily change of bedding and clothing is required and should occur at the same time as the patient washes with Octenisan or Hibiscrub
  • Suppression should be discontinued immediately and the IPCT contacted if the patient experiences excessive skin irritation or allergic reaction

6.4.2 Nasal Creams:

Mupirocin and Naseptin are antimicrobial ointments for use in the nasal passages.

Repeated or prolonged courses of Mupirocin or Naseptin must be avoided due to possible development of resistance.

General Directions:

  • Using a clean finger, the patient should wipe a pea-sized amount of ointment around the inside of each nostril and squeeze their nose
  • Patients should be able to taste the ointment at the back of their throat. If they cannot, they should apply a small amount of extra cream

6.5 Ongoing S. aureus status:

Suppression therapy is designed to reduce the burden of S. aureuson a patient’s skin. It is highly unlikely to achieve long-term eradication anda large number of patients will have detectable levels of S. aureus within one year of treatment. Once a patient is MRSA positive they should always be assumed to have a continuing positive status irrespective of current screening results. Repeated courses of suppression should not be offered unless the patient is undergoing invasive procedures.

  • There is no requirement to obtain 3 negative screens post suppression therapy. The patient should be screened weekly after suppression therapy but assumed to remain positive

6.6 Continuation of suppression therapy after discharge:
Confirmed MRSA positive patients discharged before completing suppression therapy should complete the remainder of their course in the community. Suppression therapy should be clearly written on the TTO chart and documented in the discharge letter.

6.7 ELECTIVE SURGICAL PATHWAY:

All relevantpatients booked as electives should be screened for MRSA. At present, there is no requirement to risk assess or routinely screen patients for MSSA, with the exception of patients undergoing spinal surgery.

The following specialties must screenall elective cases for MRSA prior to procedures:

  • Cardiology
  • Clinical haematology
  • Gastroenterology
  • Medical oncology
/
  • Nephrology
  • Obstetrics (caesareans)
  • Pain relief
  • Plastic surgery
  • Renal surgery
/
  • Rheumatology
  • Transplant surgery
  • Trauma and orthopaedics
  • Urology
  • Vascular surgery

The following specialties only need to screen patients identified as high risk:

  • Breast surgery
  • Colorectal surgery
  • Day case dental
  • Dermatology
  • ENT
  • Elderly medicine
  • Endocrinology
/
  • Endoscopy
  • General medicine
  • General surgery
  • Gynaecology
  • Hepatobiliary
  • Neurology
  • Obstetrics (ex caesareans)
/
  • Ophthalmology
  • Oral surgery
  • Orthodontics
  • Paediatric medicine
  • Radiotherapy
  • Rehabilitation
  • Thoracic medicine
  • Upper GI surgery

6.7.1 Risk Assessment:

A patient is regarded as ‘high risk’ for the carriage or acquisition of MRSA if they fulfill one or more of the following criteria:

  • Have been MRSA positive at any point in the past
  • Had a previous admission to any healthcare facility in the last 6 months
  • Have been admitted from a residential home (inc Nursing Homes, Military Barracks, HM Prisons)
  • Have been admitted with indwelling devices(inc urinary catheters, PICC, tunneled lines)
  • Have chronic open wound(s) (skin breaks, pressure sores, ulcers)or cellulitis
  • Have any chronic skin condition (inc psoriasis, eczema, dermatitis)
  • Have been or are an IV drug user
  • Have been or are a healthcare worker
  • Are admitted for a high risk procedure (joint replacement or implant surgery)

‘High risk’ patients must be identified at the point of pre-operative assessment or clerking. Patients with none of the above risk factors are considered to be ‘low risk’ for the carriage or acquisition of MRSA.

Screening of elective patients should occur no greater than 6 weeks prior to surgery.

For elective orthopaedic patients; if the surgery is cancelled and the patient screened negative for MRSA and has no high risk factors, a further screen is not required. However, the patient should be offered suppression therapy on the day of surgery. If the patient does fall in the high rik category they will require rescreening.

For those patients seen in pre-operative assessment more than 7 days before surgery:

  • Screening should be performed and a result obtained. Confirmed positive patients should then be treated with Octenisan/Bactroban or Hibiscrub/Bactroban in the 5 days leading up to surgery, completing their suppression course on the day of surgery. No repeat screening is required prior to surgery and the patient should be treated as colonised for the purposes of theatre – appropriate intra-operative antibiotics covering MRSA should be used

Confirmed MRSA positive patients under the guidance of the Infection Prevention Team:

1st Line Suppression:

  • Mupirocin 2% applied to the inner surface of each nostril 3 times a day for 5 days
  • Chlorhexidine Gluconate 4% (Hibiscrub) or Octenisan wash once daily for 5 days (see appendix 1)

2nd Line Suppression (for Mupirocin Resistant Strains):

  • Naseptin applied to the inner surface of each nostril 4 times a day for 10 days
  • Chlorhexidine Gluconate 4% (Hibiscrub) or Octenisan wash once daily for 10 days

For those patients seen in pre-operative assessment less than 7 days before surgery:

  • Patients should be screened, risk assessed (see criteria 6.7.1), with patients deemed as high risk given antimicrobial wash to start immediately in order to complete as many days as possible prior to surgery
  • For patients that cannot be screened prior to surgery, a screen should be obtained on the day of surgery and a risk assessment (see criteria above) performed. High-risk patients should receive an antimicrobial wash prior to going to the operating theatre.

As part of Elective Pre-Operative Assessment for patients assessed as high risk of MRSA carriage:

1st Line Suppression:

  • Chlorhexidine Gluconate 4% (Hibiscrub) or Octenisan wash once daily for 5 days

6.8 EMERGENCY ADMISSION PATHWAY:

6.8.1 Screening for MRSA:

All patients admitted as emergencies must be screened for MRSA at the time of admission. Patients attending the Emergency Department but not needing admission do not require screening. For minimum screening requirements see section6.2.1

As part of the Emergency Admission Pathway for all emergency admissions prior to screening results or any admission to ICU:

1st Line Suppression:

  • Octenisan wash once daily until screening results known

Confirmed MRSA positive patients under the guidance of the Infection Prevention Team:

1st Line Suppression:

  • Mupirocin 2% applied to the inner surface of each nostril 3 times a day for 5 days
  • Octenisan wash once daily for 5 days (see appendix 2)

2nd Line Suppression (for Mupirocin Resistant Strains):

  • Naseptin applied to the inner surface of each nostril 4 times a day for 10 days
  • Octenisan wash once daily for 10 days

6.8.2 Instructions for using Octenisan Wash