TABLE OF CONTENTS
1 / Introduction / 4
2 / Control of MRSA in the community / 5
/ 2.1 Safe Working Practice / 5
2.2 Isolation / 5
2.3 Screening / 5
2.3.1 Household contacts/ residents in care homes / 5
2.3.2 Staff / 5
3 / Treatment / Decolonisation / 6
3.1 Patients discharged form hospital / 6
3.2 Residents/ Individuals diagnosed in the community / 6
4 / Treatment of infection and decolonisation protocol / 6
4.1 Treatment of MRSA infection / 7
4.2 Treatment for infected wounds / 7
4.3 Decolonisation of MRSA / 7
4.4 Decolonisation of normal skin / 7
4.5 Decolonisation of abnormal skin / 8
4.6 Colonised wounds / 8
4.7 Decolonisation of nasal carriage / 8
4.8 Decolonisation for throat carriage in adults / 8
4.9 Decolonisation for throat carriage for children and neonates / 8
4.10 Urine / 9
5 / Transfer to hospital or other care homes / 9
5.1 Communication / 9
5.2 Ambulance transportation / 9
6 / Communication / 9
6.1 Residents / 9
6.2 Staff / 10
7 / Care of deceased residents / 10
Appendix 1 / Contact personnel / 11
Appendix 2 / Screening / 12
Appendix 3 / Swabbing Techniques / 13
Appendix 4 / Detection and testing of MRSA / 14
Appendix 5 / Discharge, Admission Information/communication / 15
Appendix 6 / Patient Information Leaflet / 17
Appendix 7 / Staff Information Leaflet / 19
Appendix 8 / Definitions / 21
AIM
This policy aims to ensure effective, appropriate management of MRSA positive individuals in community settings in Grampian.
THIS POLICY MUST NOT BE ALTERED IN ANY WAY. IF YOU HAVE ANY CONCERNS REGARDING THE SUITABILITY OR APPLICATION OF ANY OF THE FOLLOWING POLICY CONTACT YOUR LOCAL INFECTION CONTROL TEAM (LISTED IN APPENDIX 1)
INFECTION CONTROL TRAINING FOR CARE HOMES IS AVAILABLE FROM THE
PUBLIC HEALTH INFECTION CONTROL NURSES
HEALTH PROTECTION TEAM
NHS GRAMPIAN
01224 558520
1 INTRODUCTION
Approximately 30% of the population carry the organism Staphylococcus aureus (S. aureus). This is a bacterium, which is normally found in the nose and on skin. Most healthy people are unaffected by it, however it does have the potential to cause infection in those who have severely weakened immune systems.
MRSA (Methicillin Resistant Staphylococcus aureus) is a form of S. aureus. It is transmitted in the same way, and causes the same range of infections as other strains of S. aureus, however it has developed resistance to the more commonly used antibiotics. This makes infections caused by MRSA more difficult and costly to treat, which is why every effort must be made to prevent its spread.
The majority of individuals are COLONISED which is when the organism lives harmlessly on the body with no ill effects as opposed to INFECTED which is when the organism enters tissue and causes disease. Further definitions can be found in Appendix 8.
In order to control and minimise the spread of MRSA there must be compliance with the following:
· Standard Precautions (formerly known as Universal Infection Control Precautions)
· Cleaning (domestic etc) must be of an acceptable standard
· Adherence to Infection Control Policies i.e. Clinical Waste, Laundry etc
· Infection control training
· Strict adherence to antibiotic policies
· Adequate resources for compliance
Increasingly there are a number of individuals in the community who have acquired MRSA. MRSA is essentially a hospital problem. There are a number of reasons for this:
· Invasive procedures are frequently carried out in hospitals, which is an important route of infection.
· Hospitalised patients have lowered resistance to infection.
· There is widespread use of antibiotics in hospital
People affected by MRSA do not present a risk to the community at large and should continue their normal lives without restriction. Many individuals are discharged into Care Homes and this should pose no problem to their ongoing care or that of the other residents as long as a few basic precautions are taken.
2 CONTROL OF MRSA IN THE COMMUNITY
2.1 Safe working practice
NHS GRAMPIAN SAFE WORKING PRACTICE – INFECTION CONTROL DOCUMENT MUST BE USED IN CONJUNCTION WITH THIS DOCUMENT
Staff should adhere to the “NHS Grampian Safe Working Practice – Infection Control in the Community” document, which is based around the principle of Standard Precautions (previously known as Universal Infection Control Precautions). These precautions should be applied to all residents at all times irrespective of diagnosis. This document should be located with each organisation’s Infection Control documentation.
All sections of the Safe Working Practice – Infection Control guidelines should be applied.
Additional guidance for use with patients/individuals with MRSA
Laundry
Individuals with MRSA do not need to have their laundry washed separately. If possible a biological pre-wash or detergent should be used with the hottest temperature suitable for the fabric.
Cutlery and Crockery
Cutlery and crockery requires no special treatment and can be washed in the sink or dishwasher with other items.
Cleaning and Disinfection
As per the organisation’s agreed local Infection Control Policy.
2.2 Isolation
There is no need to isolate residents to their own room if they have MRSA. It is preferable although not essential for residents who have MRSA to have a single room or be cohort nursed with other affected residents.
2.3 Screening
2.3.1 Household contacts / Residents
There is normally no need to screen household contacts or other residents in care homes for MRSA. For further advice discuss with appropriate infection control team. (See screening protocol Appendix 2 and swabbing technique Appendix 3)
2.3.2 Staff
It is not necessary for work colleagues or carers to be screened for MRSA.
3 TREATMENT/ DECOLONISATION
3.1 Patients discharged from hospital
When patients are discharged from hospital back into the community (including care homes) they may still be undergoing treatment for MRSA infection. This should be continued.
When patients are discharged from hospital back into the community (including care homes) they may still be undergoing decolonisation for MRSA. This should be continued as per the protocol (see 4.3.3)
If the post discharge decolonisation is unsuccessful. The individual should be assessed and usually one further attempt to decolonise the individual should be undertaken if:
· It is known or is likely that the individual will be admitted to hospital in the foreseeable future
· The individual has no invasive devises e.g. catheter
· The individuals skin is intact
· The individual does not have a skin condition e.g. eczema
Further advice should be sought from the Infection Control Team of the discharge hospital (Appendix 1) if the individual has:
· Invasive devises e.g. catheter
· Broken skin
· Skin conditions e.g. eczema
3.2 Residents/Individuals diagnosed in the community
Individuals with clinical infection caused by MRSA should always be treated promptly as with any other infection. If the individual is receiving systemic antibiotics these should be completed before undertaking a full MRSA screen. A full MRSA screen should be undertaken 48 hours after treatment is complete, to establish which sites are still positive (see Appendix 2).
Individuals who are colonised with MRSA will not generally require decolonisation unless it is known or is likely that the individual will be admitted to hospital in the foreseeable future. Discuss with the GP/Infection Control Team.
Further advice may be sought from the appropriate Infection Control Team (Appendix 1)
4. TREATMENT OF INFECTION AND DECOLONISATION PROTOCOL
It is essential that current local policy be adhered to however in the unlikely event of any adverse reaction please stop the treatment and seek advice promptly.
4.1 Treatment of MRSA infection
Patients who demonstrate clinical signs of infection will require treatment with the appropriate antibiotics. The agent used will depend on the site of infection. If the individual is receiving systemic antibiotics these should be completed before undertaking a full MRSA screen. Once treatment is complete, a full MRSA screen should be undertaken after 48 hours to establish which sites, if any, are still positive (see Appendix 2).
Advice can always be obtained from Medical Microbiologist (Appendix1).
It is important that the treatment should be based on the current set of full MRSA screening swabs.
It is easier for both patients and staff if the treatment for the identified sites all commence at the same time
4.2 Treatment for infected wounds
· Where possible all wounds should be covered with an occlusive dressing
· Advice on appropriate systemic antibiotics should be sought from the Medical Microbiologist.
Important: Do not apply topical treatments to acute infected surgical wounds
4.3 Decolonisation of MRSA
Appropriate decolonisation should be considered when the patient’s clinical condition allows. Once decolonisation is complete, a full MRSA screen should be undertaken after 48 hours to establish which sites, if any, are still positive (see Appendix 2).
The eradication procedure used will depend upon which body sites are colonised with MRSA.
Site / Action· Nasal carriage only
· Throat carriage
· Axilla or groin carriage / · Nasal decolonisation only
· Nasal and throat decolonisation
· Nasal and body decolonisation
4.4 Decolonisation of NORMAL skin
Skin products should not be diluted. Advice can be sought from the appropriate Infection Control Team
· 1st Line – Direct application of 4% chlorhexidine (Hibiscrub) to all skin using a damp disposable cloth or freshly laundered flannel, daily for 5 days i.e. use chlorhexidine as a soap substitute and rinse off. Wash hair twice in the 5-day period with chlorhexidine.
· Alternatives include 2% triclosan (aquasept) or 7.5% povidine-iodine.
Hair conditioners and body lotions can be used after treatment if required.
4.5 Decolonisation of ABNORMAL skin
As it is difficult to eradicate MRSA from abnormal and/or chronic skin conditions, the decolonisation protocol should not be commenced until advice has been sought from a dermatologist or medical microbiologist.
4.6 Colonised wounds
Seek advice from Infection Control or Tissue Viability Team.
4.7 Decolonisation of nasal carriage
· 1st Line – Mupirocin (“Bactroban”) nasal ointment 3 times daily to inner surface of each nostril for 5 days. Apply with cotton wool bud
In the event of mupirocin resistance:
· “Naseptin” cream (0.5% neomycin plus 0.1% chlorhexidine) provided the organism is neomycin susceptible. Further advice can be sought from Infection Control Team (Appendix 1)
4.8 Decolonisation for throat carriage in adults
Oral hygiene is very important, as teeth/dentures have been known to harbour MRSA.
· 1st Line adults - Oral trimethoprim 200mg twice daily and 500mg fusidic acid tablets twice daily for 5 days. If using fusidic acid liquid, 750mg twice daily for 5 days.
In the event of fusidic acid resistance or patient intolerance:
· Oral rifampicin 600mg once daily and trimethoprim 200mg twice daily (if susceptible) for 5 days.
Patients may require an anti-emetic.
4.9 Decolonisation for throat carriage for children and neonates
Before treating children and neonates advice must be sought from the Medical Microbiologist (Appendix 1)
4.10 Urine
Elimination of MRSA from urine is not usually possible in the presence of a urinary catheter.
If treatment is required discuss with the Medical Microbiologist and the clinician managing the patient.
5 TRANSFER TO HOSPITAL OR OTHER CARE HOMES
5.1 Communication
If a resident is to be re-admitted to hospital please ensure that the receiving ward/unit are fully aware that the patient has had MRSA in the past. This will ensure that the hospital can take appropriate precautions (Appendix 5)
If a resident is being transferred please ensure the receiving care home are fully aware of the residents MRSA status if known.
5.2 Ambulance transportation
The Scottish Ambulance Service classifies patients who are MRSA positive into two categories.
Category 1
Most patients colonised by MRSA or who have infected wounds or skin lesions which are covered by an occlusive dressing may be transported with others and require no special precautions.
Category 2
· Patients, who are heavily colonised by MRSA and are considered to be heavy shedders, eg have severe psoriasis or eczema.
· Patients who have infected exposed wounds or skin lesions, eg external fixation devices, burns etc should be transported by themselves.
· Patients who are clinically infected
· Patients who are colonised in the upper respiratory tract and present with active symptoms, eg cough
Patients in category 2 should not be transported with others. The Ambulance Service will implement appropriate precautions applicable to this category.
6 COMMUNICATION
Ensuring good communication about a resident’s MRSA status is a responsibility of all staff.
6.1 Residents
Residents found to be colonised or infected with MRSA should be informed of this. The resident and their visitors should have MRSA explained to them. A patient/relative information sheet is available (Appendix 6)
6.2 Staff
A staff information leaflet is available (Appendix 7)
For further information contact the appropriate Infection Control Team.
7. CARE OF DECEASED RESIDENTS
The precautions for handling these patients are the same as when alive (i.e. Standard Precautions (formerly known as Universal Infection Control Precautions)
· Lesions should be covered with an impermeable dressing
· Body (cadaver) bags are not necessary since there is no risk to healthy contacts unless the deceased patient has extensive burns, skin loss and/or extensive discharging wounds
· There are no contraindications for Last Offices including viewing
Appendix 1
CONTACT PERSONNEL
Organisation / Name & Title / NumberNURSING
Grampian University Hospitals Trust
ARI, Foresterhill
Woodend Hospital
Grampian University Hospital Trust (Dr Grays) & Grampian Primary Care Trust (Moray)
Grampian Primary Care Trust
NHS Grampian,
Health Protection
Summerfield House
2 Eday Road
Aberdeen AB15 6RE / Anne Smith, Infection Control Nurse
Diane Pacitti, Infection Control Nurse
Frances Murray, Infection Control Nurse
Hilarie Fryer, Infection Control Nurse
Roy Browning Infection Control Nurse
Louise McBeath Infection Control Nurse
Fiona Browning, Public Health Infection Control Nurse
Jayne Leith, Public Health Infection Control Nurse / 01224 552118 Ext 52118 Bleep 2313
01224 559431 Ext 59431
Bleep 3443
01343 543131 Ext 67571
Bleep 07623 810848
01224 663131 Switchboard
01224 556747 Ext 56747
Bleep: 01399 616196
01224 558639 Ext 58639
01224 558636 Ext 58636
MEDICAL
(Microbiology)
Grampian University Hospitals Trust & Grampian Primary Care Trust (Aberdeen & Elgin) Foresterhill, Aberdeen
(Public Health)
Health Protection Team
Summerfield House
2 Eday Road
Aberdeen AB15 6RE / Dr T M S Reid, Consultant Microbiologist
Dr I M Gould, Consultant Microbiologist
Dr Helen Howie, Consultant in Public Health Medicine (CD&EH)
Dr Arun Mukerjee, Consultant in Public Health Medicine (CD&EH) / 01224 681818 Switchboard
01224 553507 Ext 53507
01224 554952 Ext 54952
01224 558520 Ext 58520
01224 558520 Ext 58520
Appendix 2
SCREENING
· TECHNIQUE: Swabs should be moistened with sterile saline and rubbed firmly over the area to be screened. Send promptly to the Microbiology Laboratory.