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Chesterfield Royal Hospital NHS Foundation Trust METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) POLICY

1 INTRODUCTION

1.1
Staphylococcus aureus is a pathogenic micro-organism which readily grows on human skin and mucous membranes. MRSA is a strain of Staphylococcus aureus which is resistant to treatment by all beta lactam antibiotics, including penicillins and cephalosporins. MRSA is also often resistant to other classes of antibiotics and so appropriate prescribing is essential in the prevention and control of this pathogen. MRSA is neither more infectious nor virulent than methicillin sensitive Staphylococcus aureus, however it is more difficult to treat. STATEMENT
MRSA was first identified in 1961 and has become a major cause of nosocomial infections. Every effort must be made to control MRSA. It is the responsibility of every member of Trust staff to be aware of and adhere to all infection control policies and procedures which are key to minimising the spread of this pathogen. These include antibiotic prescribing guidelines, handwashing, decontamination of equipment and strict adherence to the principles laid out in this policy. COLONISATION AND INFECTION
Colonisation occurs when a patient has MRSA in or on a body site but has no clinical signs or symptoms of disease. A person colonised with MRSA may be a temporary or long term carrier of the organism. Infection occurs when MRSA enters a body site and multiplies in tissue causing clinical manifestation of disease. This is usually evident by fever, a rise in the white blood cell count or purulent drainage from a wound or body cavity. Colonised and infected patients are the major reservoirs of MRSA. Colonisation often occurs in the nares (nose), groin, chronic wounds or around invasive medical devices, i.e. gastrostomy and tracheostomy sites. Patients at risk of MRSA colonisation are generally debilitated patients who may have prolonged hospitalisations, chronic wounds or received multiple antibiotics.
4 PATIENT
SCREENING
REQUIREMENTS
Active screening of patients for MRSA carriage should be carried out to allow a targeted approach for the correct use of limited isolation rooms and cohort nursing. MUST be screened for MRSA on admission include those: -
known to be previously infected or colonised with MRSA who are frequently re-admitted to ANY healthcare facility who have been a recent inpatient in any hospital (within the last 4 weeks) All emergency patients who require admission to an inpatient ward from Emergency management unit, Emergency department, Out Patient Departments or General Practioners C:\temp\XPgrpwise\MRSA Policy updated emergency patients.doc 2.8
All patients admitted to the Clinical Decisions Unit, Birth Centres (CRHFT and Darley) that will require admission for greater than 6 hours IE those patient on a DVT pathway Patients who require screening pre-operatively include those: - All elective daycase patients except exclusions shown below) All patients who will be admitted for an Elective procedure at point of booking surgery. From Nursing or residential homes DO NOT require screening pre-operatively include:
All minor procedures undertaken in an outpatient department All other maternity and obstetric patients all admissions and discharges to and from Intensive Therapy Unit and High Dependency Unit (nose and groin only) all patients who have central lines, pre insertion or within 24 hours and weekly thereafter whilst an inpatient. MRSA SCREENING REQUIREMENTS
Emergency Admissions
Screening swabs must always be obtained from the patient’s nose, groin and ALL breaks in
skin see below. On admission and ALL subsequent screens whilst an inpatient (see appendix
1 & 2). Patients who are readmitted with 7 working days of their last screen will not be routinely
screened, they Must be referred to the IP&CT who will advise on screening requirements.
Sites for Screening Include: -
catheter specimen of urine if catheterised or sputum if patient has productive cough or throat specimen if chest infection is suspected and patient is not able to produce a specimen of sputum sites of eczema, psoriasis and dermatitis If the patient shows signs of sepsis, a blood culture must be obtained.
For planned elective inpatients See Appendix 4 & 7 For Planned daycase patients see appendix 5 & 7 All medical and Pain Service patients who attend Lister and Holywell on a regular basis are to be sent to the MRSA screening service annually by the relevant department (Appendix 7) For elective caesarean sections see Appendix 6 & 7 C:\temp\XPgrpwise\MRSA Policy updated emergency patients.doc 2.8
All screening swabs must be moistened in sterile water, and rotated to enhance pickup
of carriage
PLACEMENT OF PATIENTS KNOWN OR PREVIOUS MRSA POSITIVE
MUST be nursed in a side room with full isolation precautions (yellow door poster): -
if the patient has or is suspected of having an infection multiple breaks in skin which cannot be occluded patients screened from a high risk environment as in 4.1 above, not known to be previously positive who fit criteria i-iv following risk assessment / advice of a member of the Infection Prevention and Control Team (IP&CT). If isolation is not possible this must be reported via the Trust incident reporting
system and Matron informed
Those who can be nursed in an end bed with standard precautions: - patients not known to be previously positive who are screened but have no signs of infection or breaks in skin which can be occluded known MRSA positive patients who do not fit criteria in 6.1 i–v above. 7 DECOLONISATION
TREATMENT
PROTOCOLS
MRSA decolonisation refers mainly to the use of topical agents such as nasal ointments and body wash/shampoo to eradicate/reduce nasal and skin carriage (see Appendix 1 and 2). Complete eradication is not always possible but a decrease of carriage can reduce the risk of transmission in Healthcare settings and will also reduce the risk of inoculation to the patient’s own surgical wounds, or invasive lines. The efficacy of decolonisation regimens depends on the presence of wounds, skin lesions and invasive devices. All regimens will be carried out under the advice and supervision of the IP&CT. The IP&CT will notify wards for inpatient and departments of all positive results and initiate decolonisation protocol accordingly The MRSA screening service will action all MRSA positive results from all elective and day case patients (see appendix 4, 5 and 7). The admitting nurse will be responsible for confirming and documenting patient compliance with the decolonisation protocol (see appendix 6). Ongoing decolonisation will be recommended by the IP&CT for patients who remain in hospital following their procedure longer than 48 hours. Day case patients do NOT require follow up screens. The IP&CT will inform GP’s via post of all MRSA positive results from elective and daycase screens. Ante natal clinic will action all MRSA positive results for patients undergoing LSCS (elective) – see appendix 6 Nasal Decolonisation (appendix 1)
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This should be using mupirocin 2% in a paraffin base to the inner surface of each nostril (anterior nares) 3 times a day for 5 days. The patient should be able to taste mupirocin at the back of the throat after
application.
Mupirocin must not be used for prolonged periods or used repeatedly. Not for more than 2 x 5 day courses as resistance may be encouraged. Nasal treatment must be used with other forms of decolonisation such as povidone iodine wash 7.5%. Nasal treatment must not be recommended routinely, only when nasal colonisation has been confirmed. Skin Decolonisation (See Appendix 1 and 2)
Skin decolonisation should be carried out using povidone iodine 7.5% or octenisan as recommended by the IP&CT. Patients should wash daily for 5 days with the recommended antiseptic treatment The skin should be moistened and the skin wash applied thoroughly to all areas directly before being rinsed off. The hair should be washed twice during the 5 day cycle with the skin wash. Patients with skin conditions must be discussed with the IP&CT prior to commencing any skin decolonisation treatments. Throat Colonisation
must be discussed with the Consultant Microbiologist.
Surgical Antibiotic Chemoprophylxsis
Refer to Antibiotic formulary in the intranet under medicines management GENERAL PRINCIPLES TO MRSA MANAGEMENT
Infection Prevention and Control is the responsibility of all staff associated with patient care. A high standard of infection control is required in all wards and units although the level of risk may vary; it is an important concept of total patient care. Every effort must be made to minimise cross infection by ensuring standards of personal and environmental hygiene are maintained. The patient’s direct environment (sideroom / bed space) should be cleaned twice daily, once using neutral detergent and hot water and once using chlorclean, by domestic service staff. All equipment used on the patient should be designated for their sole use or decontaminated prior to use on another patient. i.e. B/P monitoring equipment, stethoscopes. Patient linen and nightclothes must be changed daily. Do not use fans on patients known to have MRSA colonisation or infection. When discharged the room must be decontaminated as per the room cleaning policy 3.2 in the Infection Control Manual. All waste must be categorised as clinical waste and disposed of accordingly. C:\temp\XPgrpwise\MRSA Policy updated emergency patients.doc 2.8
All linen must be classed as contaminated/infected and disposed of as in the soiled and infected linen policy 4.1 in the Infection Control Manual. TRANSFER AND DISCHARGE OF COLONISED OR INFECTED PATIENTS
Transfer of MRSA affected patients to other wards must be minimised to reduce the risk of spread, but must not compromise other aspects of care. All transfers must be reported to the IP&CT.

Out Patient Department Visits
9.2
Visit to out patient departments should be kept to a minimum. If the visit is essential prior
arrangement must be made with staff in the receiving department to enable appropriate
precautions to be applied.
Every effort must be made to eliminate MRSA before surgery (see Appendix 4). If this is not possible specific advice must be sought from the IP&CT and the Infection Control Doctor regarding Decolonisation Treatments and antibiotic chemoprophylaxis. Theatre personnel must be made aware of MRSA status prior to the patient attending for surgery, see appendix 3. MRSA should not be a barrier to good clinical care. Consequently inter-hospital transfer should not be prevented or delayed if deemed essential. The receiving hospital should be made aware of MRSA status when requesting transfer. Full clinical details regarding current MRSA status and treatments must be forwarded to the receiving Hospitals on transfer of the patient. Deceased Patients The Infection Control precautions for handling deceased patients is the same as in life, hence standard precautions must be employed. A cadaver bag is NOT required.
10 OUTBREAK
MANAGEMENT
All cases of MRSA will be monitored by the IP&CT surveillance activity. 10.2 Suspected outbreaks will be managed as outlined in the policy for Communicable Disease Control and for Major Outbreak (No. 6.1 in the Infection Control Manual).
11 ANTIBIOTIC
STEWARDSHIP
Excessive use of antibiotics promotes the emergence and spread of antibiotic resistance. Attention must be given to appropriate use of antibiotics, this includes: - i) Avoidance of inappropriate or excessive antibiotic therapy and prophylaxis. Ensuring antibiotics are given at correct dosage and duration. C:\temp\XPgrpwise\MRSA Policy updated emergency patients.doc 2.8
Limiting the use of glycopeptide antibiotics to situations where use has been shown to be appropriate (see Trust antibiotic prescribing guidelines). Ensuring the use of broad-spectrum antibiotics is clinically appropriate – see Trust antibiotic prescribing guidelines.
12 REFERENCES

Ayliffe, G., Cookson, B.D., Ducel, G., Goldmann, D., Kereselidze, T.S., Heuck, C-C. Tikhomirov, E., Thuriaux, M.C., World Health Scientific Working Group Report on the Global Control of MRSA, WHO, Geneva, Switzerland, 1995 WHO/EMC/KTS/96.1 CRHFT Policy for Obtaining Wound Swabs, Policy and Procedures Manual CRHFT Policy for dealing with High-Risk Cadavers, No. 2.5, Infection-Control Policy Manual CRHFT Disinfection Policy, No. 3.1, Infection-Control Policy Manual CRHFT Terminal-Cleaning Policy, No. 3.2, Infection-Control Policy Manual CRHFT Policy for Safety in the Transmission of Pathology Specimens, No. 1.3, Infection-Control Policy Manual CRHFT Isolation Policy, No. 1.2, Infection-Control Policy CRHFT Standard Precautions Policy, No. 1.8, Infection-Control Policy Manual Guidelines for the control and prevention of Meticillin-resistant Staphylococcus aureus (MRSA) in health care facilities by the joint BSAC/HIS/ICNA Working Party on MRSA 2006 Saving Lives: a delivery programme to reduce Healthcare Associated Infection including MRSA Director of Infection and Prevention Control C:\temp\XPgrpwise\MRSA Policy updated emergency patients.doc 2.8
Appendix 1
Policy for the control of Methicillin-resistant Staphylococcus aureus (MRSA)
Decolonisation Protocol 1 for Inpatients with Nasal Carriage
If a patient is found to be colonised with MRSA in their nose, begin nasal treatments.
No more than two courses of Mupirocin should be prescribed per admission, in order to
prevent the development of Mupirocin resistance. The patient should be able to taste the
ointment at the back of their throat if applied correctly

Treatment Programme
Days 1 – 5
2% Mupirocin nasal ointment (paraffin base) three times a day Daily shower / bath / wash with 7.5% Povidone iodine surgical scrub (Betadine) (inpatient). Daily shower / bath / wash with Octenisan skin washes (elective/daycase patients). Wash hair twice with Povidone iodine or Octenisan (day 1 and 3) (Shampoo) The skin should be moistened and the Povidone iodine applied undiluted. Use as a
soap.
Apply dressing as recommended by the IP&CT / Tissue Viability Nurse
Do not use Povidone iodine or Octenisan by adding to water.

Days 6 – 7
Obtain screening swabs from nose, groin, all breaks in skin and all recommended sites, including: (if catheterised)
(if productive cough)
throat swab (if recommended by Infection Prevention and Control Specialists) umbilicus in neonates sites of eczema, psoriasis and dermatitis pressure sores cuts and abrasions IV cannula site/s tracheostomy site all invasive device entry sites SWABS MUST BE MOISTENED WITH STERILE WATER BEFORE USE.

Do not recommence Mupirocin until culture results are available.

ONCE COMMENCED ON TREATMENT PATIENTS MUST COMPLETE A COURSE OF MUPIROCIN
(TOTAL OF FIVE DAYS) TO PREVENT THE DEVELOPMENT OF RESISTANCE.
N.B. See appendix 2 for contraindication for Betadine use
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Appendix 2
Policy for the Control of Methicillin-resistant Staphylococcus aureus (MRSA)
Decolonisation Protocol 2 for Inpatients with Skin Carriage and / or Lesions
If a patient is found to be colonised with MRSA on one or more skin sites, topical anti-staphylococcal
agents are indicated. Dressings containing Povidone iodine may reduce bacterial load. A detailed
clinical assessment must be carried out by the clinicians responsible for the patient’s care. Advice can
be sought from the IP&CT or from the Tissue Viability Nurse. The dressing must provide optimum
wound healing.
Treatment Programme
Days 1 – 5
Daily shower / bath / wash with 7.5% Povidone iodine surgical scrub (Betadine) (inpatient). Daily shower / bath / wash with Octenisan skin washes (elective/daycase patients). Wash hair twice with Povidone iodine (day 1 and 3) (Shampoo) The skin should be moistened and the Povidone iodine or Octenisan applied undiluted.
Use as a soap.
Apply dressing as recommended by the IP&CT / Tissue Viability Nurse Do not use Povidone iodine by adding to water.
Obtain screening swabs from nose, groin, all breaks in skin and all recommended sites, see appendix 1 Recommence washes until results are available and reviewed with a member the
Infection Prevention and Control Specialists.
Patients with thyroid-function problems or skin conditions (eczema/dermatitis) must undergo a risk assessment by a member of the IP&CT prior to the treatment of skin carriage. The use of Povidone iodine must be avoided for patients on long-term Lithium therapy. The use of Povidone iodine must be avoided in patients with iodine allergies. If the patient falls into the categories, the clinicians responsible for the patient’s care must contact the Infection Prevention and Control Team. • Discontinue washes once a full negative screen has been obtained.
• Screen weekly all sites until 3 negatives are obtained.
• Screen monthly whilst patient remains an inpatient or if condition
deteriorates / broad spectrum antibiotics are prescribed.
• Discontinue washes on discharge from hospital.
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Appendix 3
Policy for the Control of Methicillin-resistant Staphylococcus aureus (MRSA)
Health-Care Professionals Colonised/Infected With MRSA
1 INTRODUCTION
There is no evidence that MRSA poses a risk to healthy people, e.g. healthcare staff and their families. However, it is important to ensure that colonised staff are treated promptly to minimise risk of cross infection ROUTINE STAFF SCREENING
This should be performed only following a risk assessment by the IP&CT, where MRSA remains a problem in clinical areas despite control measures. When staff screening is indicated, swabs from the nose, groin and any breaks in the skin must be obtained prior to the commencement of the spell of duty; this will ensure no transient carriage of MRSA and prevent inappropriate treatment. DECOLONISATION OF COLONISED STAFF
Staff found to be colonised / infected with MRSA will be counselled by the Occupational Health Department and will be excluded from duty until the appropriate screening and treatment have been performed. Nasal Carriage Only - treatment will start in accordance with Appendix 1; following forty-eight
hours of nasal treatment the member of staff may return to work.
Skin Site Carriage – treatment will start in accordance with Appendix 2. The staff member
will return to work following a risk assessment performed by the Occupational Health
Department and the IP&CT. Monitoring will continue until three consecutive sets of negative
swabs have been obtained at weekly intervals.
The Occupational Health Department will liaise with the General Practitioner of any staff member found to be colonised/infected with MRSA.
3.5 Throat
Colonisation
must be discussed with the Consultant Microbiologist
Following three sets of negative screening swabs without treatment staff will be informed of the results by telephone or by letter by the Occupational Health Department who will also advise on future management and control.
4 CONTINUED
COLONISATION
Staff who are not responding to treatment will be seen by the Occupational Health Physician for advice and continued treatment and referral to the appropriate Consultant Dermatologist. Appropriate specialists, i.e. the Occupational Health physician, an independent specialist in Dermatology, the Human Resources Manager, the union representative, the manager and the Infection Prevention and Control Team will meet to discuss future management. In complicated /difficult cases with the staff member involved At all times the member of staff will be kept informed of any action taken and will receive support from the Occupational Health Department, their manager and the Trust. C:\temp\XPgrpwise\MRSA Policy updated emergency patients.doc 2.8
MRSA Screening for Elective inpatients
Patient attends new outpatient appointment and decision to book elective inpatient procedure Patient has wound(s) which require swabbing Wound(s) to be swabbed prior to leaving Patient given booking slip and advised to OPD and swabs sent with patient to Suite 9 Patient attends Outpatient Suite 9. Swabs obtained from nose and groin and recorded on LOG record. Patient issued MRSA screening information leaflet and informed they will be contacted and asked to attend Outpatient Suite 9 to obtain treatments if results are positive. Contact telephone number Results will be filed when patient returns to Pre-Assessment. If not returning results to be forwarded to C:\temp\XPgrpwise\MRSA Policy updated emergency patients.doc 2.8
MRSA Screening for Day Case Patients
Patient attends new outpatient appointment and decision to book elective inpatient procedure Patient has wound(s) which require swabbing Wound(s) to be swabbed prior to leaving Patient given booking slip and advised to OPD and swabs sent with patient to Suite 9 Patient attends Outpatient Suite 9. Swabs obtained from nose and recorded on LOG record. Patient issued MRSA screening information leaflet and informed they will be contacted and asked to attend Outpatient Suite 9 to obtain treatments if results are positive. Contact telephone number confirmed with patient. Results will be filed when patient returns to Pre-Assessment. If not returning results to be forwarded to C:\temp\XPgrpwise\MRSA Policy updated emergency patients.doc 2.8
MRSA Screening Pathway for Elective Caesarean Sections
N.B. Swabs must be moistened with sterile water prior to swabbing and rotated during swabbing procedure. Patient issued with MRSA screening information leaflet and informed they will be contacted and asked to attend ANC to obtain treatments if results positive. Contact telephone number confirmed. ANC staff to record swabbing in LOG book by use of pre-designed sticker. One sticker to be placed in the LOG book and the other sticker to be placedon the MRSA form. For swabs obtained in the community, the midwife must ensure the sticker for the LOG is brought to ANC at the earliest opportunity. community midwife to deliver to home.
Patient positive result from groin only. C:\temp\XPgrpwise\MRSA Policy updated emergency patients.doc 2.8
Elective Patient MRSA Pre-Admission Decolonisation Protocol
Pre-Assessment confirm patient able to undertake decolonisation treatments independently or with C:\temp\XPgrpwise\MRSA Policy updated emergency patients.doc 2.8

Source: http://www.crh.zcode.net/dl/6942_4341329098.pdf/as/MRSA%20Screening%20Policy.pdf