MRSA INFECTION PREVENTION AND CONTROL

MRSA INFECTION PREVENTION AND CONTROL

#International MRSA Testing Week April 1 to 7 is observed to raise awareness for detection of MRSA to surgical and high risk patients before admission to healthcare facility. 

#MRSA is formidable, versatile and unpredictable. Its capacity for genetic adaptation and the serial emergence of successful epidemic strains cause it to remain a major threat to human health.

While development of new anti-MRSA agents should be encouraged, the importance of #antimicrobial stewardship in the battle to stay ahead of the curve with regards to the ongoing control of the MRSA epidemic should be emphasised.

It is our duty to deliver patient centered care of the highest quality and until we know a practice, or an inaction is safe, we must error on the side of patient and healthcare worker safety.

MRSA SCREENING FOR INPATIENT:

• PREAMBLE:

One major mechanism for the introduction of Methicillin resistant Staphylococcus aureus (MRSA) into a facility can be the admission of a MRSA colonized patient. Determining the prevalence of these organisms will assist in defining the risk from admitted colonized patients. Timely identification will allow for prompt implementing of precautions, which should reduce risk of transmission.

• POLICY:

     1.All patients with the following risk factors will be screened for MRSA on admission:

a)      Any patient directly transferred from another facility.

b)     Any patient with a history of previous overnight admission to any health care facility in the last six months.

c)      Any patient known to be colonized or infected with MRSA.

d)     Any patient who has been on isolation precautions from an antibiotic resistant organisms.

e)     Patients for Implants/Devices/ Surgery are to be screened for MRSA.

• Cultures will be taken from the nares , open wounds and exit tube sites.

• Consent:

   Verbal consent is adequate.

• Quality Monitoring :

   The number and types of cultures, culture results and correlation of admission to

   culture should  be monitored prospectively by the infection control officer. The

   final results should be reviewed by the infection control committee.

• Collection of MRSA swab :

1. Equipment

• Swab culture kit
• Sterile gloves

1. Follow Universal Precautions.

1. Assess patient for open wounds, and/ or tube exit sites.

1. MRSA swab collection from open wounds: Wash the wound with normal saline and rotate the swab through the centre of the wound.

1. MRSA nasal swab collection for screening purpose: 
2. Take swab out of the package and insert it approximately 1 inch (2.56 cm ) into one nostril and roll gently 4-5 times.
3. Rotate the swab so that all surfaces of the mucosa or tissue are touched.
4. Insert the same swab for nasal swabbing in the other nostril and repeat the same step.

1. Insert the swab into the sterile tube. 

1. Label the specimens with the patient’s identification.

1. Label requisitions for “MRSA Screen” . Do not tick off culture and sensitivity .

2.2 Control the spread of MRSA in hospital through in patient

·        All MRSA culture positive patients should be considered for eradication therapy under the care of their attending physician.

·        When a culture is MRSA positive, the infection control coordinator should notify the unit and the attending physician as soon as possible.

·        Contact isolation precautions to be followed for known carriers or patients found MRSA positive

·        Patient isolation with designated staff is preferable.

·        Infection control team should ensure that all health personnel on duty being exposed to the patient should be made aware of the high-risk case.

·        Gowning and gloving are mandatory for any personnel entering patient’s room.

·        Provide protective eye wear in case of splashes.

·        Separate slippers should be placed at the entrance of the room ,but inside the room

·        Dusters, mops and brush used to clean patient’s room should be marked separate

·        Do not mix these cleaning items / clothing with other items

·        Disinfectant solution should be prepared and kept in patient’s room.

·        All items used for the patient should be disinfected in disinfectant solution before carrying it out of the patient’s room.

·        All items should be double- packed in red and yellow bag for biomedical wastes, and biohazard labels put if required to send to CSSD or laundry department.

·        Thorough cleaning of the room should be done on daily basis as per the housekeeping protocol.

·        On discharge / death of the patient, the room should be deep terminal cleaned and disinfected.

·        Post deep cleaning air sampling and swabs are done

·        All assigned staff to be screened for MRSA.

·        All medications should be ordered by the attending physician.

Nasal carrier (A)

Rectally colonized (B)

Clinically infected ( C )

 Mupirocin ointment

Before beginning treatment, blow your nose gently and then wash your hands.

Place a small amount of ointment (about the size of a match-head) onto your little finger/ a cotton swab and apply to the inside of a nostril. Repeat for the other nostril.

Apply gentle pressure to the outside of the nose to spread the ointment around the inside of the nostrils.

TIDx7 days to  nares and all positive wounds

1. Mupirocin oinment TIDx7

   days to nares &all positive  

   wounds.

  (NOTE : if rectum is

   positive for MRSA, 

   application of mupirocin

   to this area is of no benefit &

   Hence not recommended.

   A positive rectal culture

   indicates more systemic

   involvement & would require

   systemic antibiotics.)

2. PLUS: Rifampin

   300mg 12hX7days

3. PLUS one of the following :

  Cotrimoxazole (400mg/80mg)  

   2tablets 12hX7days OR 

  Doxycycline 100mg POq12h

   For 7 days.

1. Mupirocin ointment TID x7days

   to nares all positive wounds

2. PLUS one of the following:For

   severe infection (i.e.sepsis)

   Vancomycin I V or For minor

   infection (e.g.UTI) fusidic acid

   500 mg PO 8 hrsx7days(or

   another sensitive antibiotic as

   indicated on culture)

If culture remain positive, go to treatment B

If cultures remain positive maintain precautions, consult Infectious Disease Specialist

If cultures remain positive maintain precautions, consult Infectious Disease Specialist

Daily Triclosan (antimicrobial soap)bath for duration of mupirocin therapy.

2%Chlorhexidine gluconate can be used for daily cleaning of any wounds and insertion sites.

• Guidelines for eradication of MRSA

Table 1-Guidelines for eradication of MRSA

NOTES: Vancomycin is ineffective in clearing MRSA from the nares and should not be used for eradicating colonization in patients.

If patient is MRSA positive in open wound sites, eradication therapy may not be effective with large wounds, these may become recolonized, and therefore individual assessment is recommended.

• Continued Screening / Eradication Therapy

To determine the effectiveness of eradication therapy, collect the following cultures.

Table 2- Frequency of Screening and Continued Eradication Therapy

Culture Results

A. Nasal carrier.

B. Rectally colonized,

C. Clinical Infection

If negative 48 hrs after therapy

Maintain precautions

If positive 48 hrs after therapy

Maintain precautions add additional therapy (see table above)

Maintain precautions, consult with a Infectious Diseases Specialist for additional antibiotic

If negative 7 days after therapy

Reculture again in one week, keep on precautions unless consultation with infection control modification.

If negative in 14 days after eradication therapy

Remove from precautions.

Culture frequency

a) 48 hours after

   Treatment

b) repeat 7 days

c) Weekly x 2

When culture results are positive patient must remain or be placed again on precautions. Modification may be considered with Infection Control Consultation.

2.3 Control the spared of MRSA in hospital through Outpatient  :

In case of out patient wound dressing /or any procedure should be scheduled as last case.

2.4 Control the spared of MRSA in hospital through Employees:

·     All the medical and paramedical staff specifically working in critical areas like OT, Cath lab and ICU should be screened for MRSA through the nasal swab every six months.  If positive, treatment and follow up is carried out.

·     Any employee detected as MRSA positive should be notified to infection Control officer, nurse manager, team leaders  

·      Healthcare staff must not be allowed to work in critical care area

·      Should follow treatment plan A

If following category of high risk patients is posted for any procedure then the assigned staff or the Team Leader should inform Primary consultant/infection control doctor / nurse.

1.      Wound with or without an oozing

2.      Skin infection with or without infection

3.      MRSA

4.      HIV

5.      HbsAg

6.      HCV

7.      Tuberculosis

8.      Patient with Colostomy

9.      Infected Prosthesis

10.  Abscess

11.  Diabetic Foot

12.  Decubitus Ulcer/ Bed sore

13.  Osteomyelitis

14.  Psoriasis

15.  Patients with drain

16.  Gangrene

The Infection control Doctor/ Executive/ Nurse should assess the infection and should decide for Scheduling/ rescheduling the case. The case should be posted last in the OT or Cathlab.

In case of emergency like PAMI/ Hemodynamic instability, do deep terminal cleaning after the procedure.

Assigned nurse should inform procedure room staff regarding infection status and rescheduling status.

Follow standard precaution during procedure.

Post procedure do terminal cleaning of the procedure room.

Used instrument should be disinfected before sending to the CSSD.

Biomedical waste handling to be done as per protocol.

After terminal cleaning do the fogging of procedure room.

Posting of patients with MRSA positive:

·        MRSA positive patients are to be operated at the end of the list.

·        All non-essential equipments should be removed to prevent contamination for subsequent patients.

·        Minimal staff should be present in the OR/Cath lab to prevent cross-contamination between staff and patient.

·        The operation theatre and associated equipments are to be thoroughly cleaned and disinfect anted with standard high level disinfectant.

·        Post cleaning the area OR/Room is subjected to deep terminal cleaning.

·        Post fogging microbiological surveillance is conducted before opening the room for the other patient.

#MRSA# antimicrobial stewardship

Dr Rahul S Kamble

MBBS, MD Microbiology

Diploma Infectious Diseases (UNSW, Australia)

Infection Control course (Harvard Medical School, USA)

International Clinical Tropical Medicine course

(CMC Vellore| Haukeland university |McGill university)

International Vaccinology course (CMC Vellore)

Six Sigma Black Belt (Govt of India certified)

Auditor: JCI |NABH |NABL |CSSD |RBNQA |Texila university

PGDBA|PGDHM|PGDCR|PGDMR|PGDOM|

PGDMLS|PGDIM|PGDHI|PGDBI|PGDHA|CCDHHO

Consultant Clinical Microbiologist & Infectious Diseases

Project Lead - Antimicrobial Stewardship