MRSA Policy: Guidelines for Control of Meticillin-Resistant Staphylococcus aureus (MRSA)

Paper copies of this Document

If you are reading a printed copy of this document, you should check the Trust’s Policy website (Intranet) to ensure that you are using the most current version.

Originator / Dr Manjula Meda (Consultant Medical Microbiologist/IC Doctor) &
Amanda Walker (IPCN Consultant)
Lead Director / Ian Fry, Director of Infection Prevention & Control
Version Number / 13
Version/implementation date / November 2014
Ratified at / Hospital Infection Control Committee
November 2014
Review date / November 2015

NB: in this document ‘meticillin’ has been used in place of the established ‘methicillin’ in accordance with the new International Pharmacopoeia guidelines.


MRSA Policy: Guidelines for Control of Meticillin-Resistant Staphylococcus aureus (MRSA)

Index

Page

3Introduction

4MRSA Screening

7MRSA Suppression Therapy and Treatment

9MRSA ‘Incidents’

-MRSA Bacteraemia

-Outbreak

-New cases on Orthopaedic wards

10Patient Care

-Isolation

-Environment and Equipment

-Visitors

-Antibiotic Stewardship

-Diagnostic testing and therapy

-Theatre guidelines

12Discharge Planning

13Monitoring

14References

17APPENDIX I – MRSA Screening Algorithm

18APPENDIX II – MRSA Screening & Suppression Chart (with Integrated Care Pathway)

20APPENDIX III – Paediatric MRSA Screening Chart

21APPENDIX IV – Inpatient placement of MRSA cases

22Monitoring tool

INTRODUCTION

Staphylococcus aureus is a bacterium that has been found on skin of 30% of the population. It is a very common cause of surgical infections, boils and carbuncles. Following the introduction of Penicillin in the 1940s, some strains of Staphylococcus aureus were able to make an enzyme (penicillinase) that broke down the antibiotic and protected the bacterium, and so by 1959, 90-95% of isolates were resistant to the antibiotic (DH 2006).

There is not just one specific disease caused by Meticillin-resistant Staphylococcus aureus (MRSA). A range of tissues and body systems can be affected.

MRSA is usually carried in the nose or skin folds (such as the groin).

So far 16 epidemic strains of MRSA have been discovered (clones EMRSA-15 and 16 are thought to be more transmissible than others (RCN 2005)).

MRSA is a problem in hospitals because it can affect vulnerable individuals who are weaker, sicker or have reduced immunity when compared to the general population.

Symptoms

Symptoms can be ambiguous as they are general and are common to different infections caused by other bacteria. They can range from colonisation (when the bacteria is doing no damage but is still capable of causing clinical infection) to fatal septicaemia.

MRSA may be found in:

  • Wound infections
  • Superficial ulcers
  • IV line infections
  • Abscesses
  • Lung infections
  • Bacteraemia/septicaemia

MRSA SCREENING

The aim of screening is to identify all positive patients within the hospital to allow targeting of isolation facilities. This can minimize the risk of onward transmission to other patients (BSAC/HIS/ICNA 2006). The aim is to also ensure that antibiotic therapyis appropriate to that patient.

From January 2015, at Frimley Park Hospital we will be following the guidance in the Department of Health’s Implementation of modified admission MRSA screening guidance for NHS (DH 2014).

In line with a risk assessment of MRSA infections identified at FPH in the past 5 years staff need to screen:

1)Any Elective or Emergency in-patients admitted to/ or to be admitted for:

-Critical Care- Neonatal Unit (NNU)

-Orthopaedics- Cardiology

-Vascular Surgery- Breast Surgery

-Urology- Haematology.

(I.E. screen all patients admitted/transferred to Critical Care/MADU, NNU, F4, F5, F6, F7/F7u, F8, SADU, Cath Lab, G9, CCU, G1).

2)In addition, any patients flagged as previous MRSA positive (as highlighted by PAS, Patient Centre, Realtime ADT, Winpath, or by the patient themselves)

3)Patients admitted electively or as emergencies with chronic ulcers/wounds or medical devices (such as long term catheters, PEGs, CVCs etc in situ)

4)Paediatrics in a high risk group (previous MRSA-positive or admission from another hospital or care facility) or in SCBU/NNU.

5)All patients (adult and paediatric) admitted to FPH from another hospital in the UK or from a hospital overseas.

Roles & Responsibilities

  • It is the ward/ department nurses’ responsibility for ensuring all pertinent patients are screened for MRSA.
  • The healthcare worker providing the specimen for testing is responsible for the appropriate collection of the specimen following Trust protocol, and the timely delivery of the specimen to the laboratory.
  • The pathology laboratory and Consultant Microbiologist are responsible for the accurate and timely processing of the specimen.
  • It is the ward/ department nurses’ responsibility for checking for MRSA screening results and documenting the results.
  • It is the ward/ department nurses’ responsibility for communicating a positive result to both the patient and the patient’s clinician.
  • It is the clinician’s responsibility to act on receipt of a positive result, and for prescribing MRSA suppression therapy and review of any antibiotic treatment.
  • It is the clinician’s responsibility to inform the patient’s GP of an MRSA positive result, via the summary on the patient’s discharge letter.

Requesting an MRSA screen

Follow the ‘MRSA Screening Algorithm’ found in Appendix I.

A trained and competent healthcare worker (HCW) must take the specimens for the MRSA screen in a timely manner (at pre-admission assessment for Elective patients; within 48 hours of admission for Emergency patients; at any time during admission if repeat screen is required or infection is suspected).

The HCW must ensure the paper pathology request form is completed appropriately, and ensure the specimen arrives at Specimen Reception in a timely manner.

Screening and results should be checked by the ward/department nursing staff and be recorded on the yellow ‘MRSA Screening and Suppression Therapy chart’.

Ideally transfers from other hospitals (including transfers to F1 and SCBU) should beisolated in a single room until negative admission screening results are available.

How to Screen

The reason for the MRSA screen being carried out must be explained to the patient prior to specimens being taken. An MRSA information leaflet (available on the hospital intranet) can be provided to the patient to aid explanation.

To determine the extent of MRSA carriage swabs must be taken from the following sites:

  • Nose- 1 swab used for both nostrils (anterior nares).
  • Groin– 1 swab used in the moist skin folds.
  • Umbilicus– in neonates.
  • Wound - Any breech in the integrity of the skin (such as IV/CVC devices, any wounds, suprapubic catheters, drain sites). State the site that was swabbed on the Microbiology request form. Do not remove Central or IV dressings if intact – swab when dressing next changed.
  • Catheter urine (if patient catheterised). Do not send this in the same bag as the wound swabs.
  • Sputum(if patient has a productive cough).

Patients who have screened negative in pre-op assessment do not require admission screening.

If a patient has been screened negative for MRSA at FPH in the 12 weeks prior to their present admission to hospital, and have not been admitted to another care facility in the interim, please contact the IPCT for MRSA screening advice on an individual basis.

Identification & Sharing Information

Patients known by Frimley Park Hospital to have MRSA (or have previously had positive MRSA at his Trust) are identified as “MRSA” on the PAS/ Patient Centre system and on Realtime.Patients with positive results after July 2009, will also have ‘Known Positive MRSA’ written at the top of all Micro results on Winpath. Having reviewed the patient’s results, the IPCNs record the date that the positive swab was taken on PAS/Patient Centre.

Any identified MRSA patients admitted must have an ‘MRSA Care Pathway’ in place (Appendix II). Completing this pathway ensures that communication of the MRSA colonisation with the patient, next of kin and clinician is recorded, as is MRSA suppression treatment.

Negative results

Routine MRSA screen results will not normally be phoned, and is the responsibility of the ward/ department nurse caring for the patient, to check the WINPATH system and document negative results on the yellow ‘MRSA Screening and Suppression Therapy chart’. Doctors can presume the result of the screen is negative unless informed by the nursing team of a positive result.

Negative results should be available to view on WINPATH within 48 hours of the specimen being sent, but positive results may take longer (possibly up to 5 days).

Positive results

MRSA positive results are available to clinicians by accessing the WINPATH system.

It is the responsibility of the ward/ department nursing staff caring for the patient, to check the WINPATH system and document positive results on the yellow ‘MRSA Screening and Suppression Therapy chart’.

It is the nursing staff responsibility to ensure the patient is informed of a positive MRSA result (within 24 hours of receipt of the result), and document the communication on the ‘MRSA Care Pathway’. The patient should be provided an MRSA information leaflet, and the IPCNs can be contacted for further advice for the patient.

It is the nursing staff responsibility to inform the patient’s clinician (within 24 hours of receipt of a positive result) and to ensure any antibiotic therapy is reviewed and MRSA suppression therapy is prescribed. Ensure also, that MRSA status information is shared with any clinical staff involved in that patient’s care.

As a minimum requirement for documentation of MRSA positive results, the ‘MRSA Care Pathway’ and yellow ‘MRSA Screening and Suppression Therapy chart’ must be completed.

Patients who have been found to be MRSA positive since July 2009 will also be flagged up to clinicians on the Microbiology section of the hospital pathology system.

The previous MRSA status should be recorded in all medicalclerking records (electronic and/or paper).

MRSA SUPPRESSION THERAPY and TREATMENT

Treatment of MRSA-positive in-patients (ADULT)

MRSA suppression treatment must be prescribed without delay by the patient’s clinician, and should be commenced for adult in-patients (within 24 hours of receipt of a positive result) and pre-op elective patients found to be MRSA-positive from any site (ideally pre-op patients should receive suppression therapy that completes on their day of admission).

If there is a record of previous completeMRSA suppression therapy (i.e. completed the 5-day course of treatment detailed below) in the past 3-6 months, please contact the Infection Prevention & Control Team for advice. Suppression therapy should not be repeated more than twice, as resistance may be encouraged (BSAC/HIS/ICNA 2006).

The MRSA screening results and suppression treatment should be recorded on the yellow ‘MRSA Screening and Suppression Therapy chart’.

Patient MRSA suppression therapy packs are provided by the Pharmacy Department, and the packs contain an ‘MRSA Suppression Therapy Information Leaflet’, for instructions on how to complete the treatment.

1. Mupirocin 2% nasal ointment

  • apply to the inner surface of each nostril (do not “poke” tube into nostril)
  • rub side of nose until patient able to taste ointment
  • apply three times daily for 5 days and then stop treatment (as resistance may be encouraged by prolonged use). Do not repeat once course of treatment has finished.

(NB. MRSA screening results showing resistance of the organism to mupirocin, will require treatment with Naseptin instead of mupirocin).

2. Hibiscrub body wash/shampoo (4% chlorhexidine)

  • Wet skin and then apply body wash thoroughly to all areas (using it like soap) before rinsing
  • Pay special attention to axillae, groin and perineal area.
  • Use for hair washing also
  • Use daily in bath or shower for 5 days only (then dispose of any remaining product)
  • Use when bed bathing for 5 days (and then dispose of any remaining product)
  • Moisturising cream and hair conditioner may be applied after use.

After each bath and hair wash freshly laundered clean clothing, bedding and towels should be used.

If patient has eczema, dermatitis or other skin condition – treat the underlying skin condition (on advice of dermatologist).

Treatment of MRSA-positive Children/ Babies

Please contact the on-call medical microbiologist for advice.

1. Mupirocin 2% nasal ointment

  • Apply to inner surface of each nostril (do not “poke” tube into nostril)
  • Rub side of nose until patient able to taste ointment
  • Apply three times daily for 5 days and then stop treatment (as resistance may be encouraged by prolonged use). Do not repeat once course of treatment has finished.

2. Body wash/ shampoo

Please contact the on-call medical microbiologist for advice.

Treatment of MRSA-positive pre-admission patients (ADULT)

A positive screen should not delay surgery for elective patients. It is preferable for the elective surgery to take place on the last day of topical suppression therapy to ensure the maximum reduction of MRSA present on the patient’s skin.

Maternity cases screening positive for MRSA should commence suppression therapy at 37 weeks.

Clearance screening is not recommended prior to admission, and these patients should be isolated in single rooms on admission.

When prescribing anti-microbial treatments (such as peri-operative antimicrobial prophylaxis) for known MRSA-positive patients, the MRSA-positive protocol must be followed.

“Re-screening”

Re-screening after MRSA suppression therapy is not required, unless the patient is in Critical Care or SCBU/NNU (where admission and weekly screens are carried out), or unless the tests are required to check for successful treatment of infection (e.g. blood cultures, tissue samples).

If patient is colonised with MRSA the clinical team must keep MRSA cover in mind while starting empirical antibiotic therapy.

Guidance to empirical therapy is available from the trust antibiotic guidelines. Treatment for MRSA patients is highlighted under individual sections.

MRSA ‘INCIDENTS’

MRSA Bacteraemia

If a patient is found to have a positive blood culture with MRSA as the causative agent, a root cause analysis (RCA) will be undertaken.

A Consultant Medical Microbiologist must undertake a root cause analysis using the Strategic Health Authority’s document (based on the NPSA document) within 5-days of the positive result. The Microbiologist will discuss the blood culture result with the pertinent Consultant team and advise on treatment measures.

The IPC nursing team in conjunction with the pertinent Head of Nursing and the Infectious Diseases pharmacist will also undertake a RCA using the Trust form.

A RCA meeting will take place to discuss the findings. This meeting will involve the Chief Executive, Director of Infection Prevention and Control, Director of Nursing, Consultant Microbiologist, IPC team, the patient’s Consultant, Patient Safety Manager and pertinent Head of Nursing.

MRSA bacteraemia results will be reported onto the Health Protection Agency MESS (mandatory enhanced surveillance scheme) web-site as per DH guidance and the completed RCA document will be sent to the NHS South Cluster (previously known as ‘SouthEast Coast Strategic Health Authority’).

Outbreak

An outbreak is defined as two or more related cases of MRSA infection (with the same sensitivity/ typing pattern) in one clinical area.

The Outbreak Control Team will be established as per the Outbreak Plan.

If patients with MRSA are unable to be nursed in single rooms, the Infection Prevention & Control Team must be informed so they can then advise on placement of patients. The reason for not isolating the patient must be recorded on their MRSA care pathway.

If an MRSA-positive patient’s clinical condition allows, they should be discharged from hospital.

New cases on Orthopaedic wards

If a patient has a positive MRSA result (who is currently nursed in a ring-fencedorthopaedic ward bay):

  • Inform on-call Medical Microbiologist (via hospital switchboard)
  • Isolate patient in side room
  • Close the bay to admissions and re-screen all other patients in the bay.

PATIENT CARE

Good infection control practices, which should be in place for all patients, should reduce the risk of cross-infection. A standard approach must be used to care for MRSA patients in accordance with the general principles of infection control, rather than introducing differing standards (BSAC/HIS/ICNA 2006).

Patient care

Patients identified with MRSA infection or colonization should be informed of their condition (BSAC/HIS/ICNA 2006).Please provide patient with FrimleyParkHospital “MRSA information leaflet” (available on the hospital intranet under “Patient information”/ “Infection Control”).

It is desirable that all patients who are infected or colonised with MRSA are nursed in a single room (Appendix II – Inpatient Placement of MRSA Cases). If no single rooms are available, due to higher priority infections, the Infection Prevention & Control Team should be contacted for advice. MRSA-positive patients should not be admitted to bays with high risk patients, such as major vascular or implant surgery, or where CVCs are present.

Due to the high profile of MRSA in the Press and on TV, communication is very important. If any patient or visitors have any concerns or queries that staff feel they are unable to answer, please contact a member of the infection prevention & control team (IPCT) who will come to speak to them.

Medical, nursing and allied health personnel must raise awareness of hand washing and must lead by example. Hands must be cleaned in line with the ‘5 Moments for Hand Hygiene’.

Isolation rooms

It is desirable that all patients who are infected or colonised with MRSA are nursed in a single room.

The room will have an individual hand washing sink and a red Infection Prevention & Control ‘warning’ card on the door.

The door should be kept closed, taking into account the patient’s psychological and physical needs. If staff feel that the patient is not safe to be cared for in a room with a closed door, please discuss this with one of the IPCT who will give advice.

The door to the patient room must be kept closed during procedures likely to increase dispersal of organisms (e.g. chest physiotherapy or bed making).

Environmentand Equipment

Bedding must be changed daily and prior to transfer to operating theatre.Send bedding to the laundry as infected linen. Infected linen should be first placed into ahot water-soluble alginate bag, and then into an outer impermeable bag for transport to the laundry.