GUIDELINES FOR THE CONTROL OF MRSA

TABLE OF CONTENTS

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GLOSSARY . . . . . . . . .� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ��

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .��

ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .��

BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ��

DIAGNOSIS/TREATMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .��

ADMISSIONS/DISCHARGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ��

INFECTION CONTROL/PREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . .��

MRSA CULTURING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .��

MANAGEMENT OF AN OUTBREAK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ��

CONTINUING HEALTH EDUCATION/COMMUNICATION . . . . . . . . . .��

APPENDIXS

I.�� MRSA FACT SHEET FOR EMPLOYEES . . . . . . . . . . . . . . . . . . . . ��

II.�� INFECTION CONTROL GUIDELINES . . . . . . . . . . . . . . . . . . . . . .��

- Minimum Precautions for all Patients

III.�� INFECTION CONTROL GUIDELINES . . . . . . . . . . . . . . . . . . . . . . ��

- Precautions for MRSA Colonized Patients

SUGGESTED READING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .��

GLOSSARY

BODY SUBSTANCE INSOLATION (BSI):

A system of barrier techniques and practices used by health care workers to prevent contact with all moist, wet body substances, non-intact skin and mucous membranes.� This is practiced for all patients at all times.� One category of isolation, Respiratory Precautions, is also utilized as indicated.

CARRIER:

A person who is colonized with methicillin-resistant Staphylococcus aureus (MRSA).� The organism may be present in the nares (nose), sputum, urine, an open wound, in the stool or on the skin without clinical manifestations of disease.� A carrier may transmit the organism to another person through direct contact, usually by contact with hands.

COHORT:

A group of MRSA positive patients (infected or colonized) who are physically separated, but grouped together and cared for by staff who do not care for MRSA negative patients.

COLONIZATION:

Presence of MRSA on tissue without the presence of symptoms of clinical manifestations of illness or infection.� A carrier is colonized with MRSA.

DECOLONIZATION:

Elimination of MRSA carrier state through use of infection control measures and/or antibiotics.� This decreases the risk of transmission to high-risk individuals (immunocompromised or otherwise highly susceptible persons) or to others in an outbreak situation.

ENDEMIC:

The usual rate or prevalence of persons infected and/or colonized with MRSA in a facility.� Endemic rate in each facility will be unique.

EPIDEMIC:

The common definition of an MRSA epidemic is: 1) several (e.g. three or more nosocomially-acquired) cases which are epidemiologically associated by person, time, or place, or 2) a substantial increase in number of cases in a facility endemic for MRSA.� Each facility must decide the criterion to define an outbreak.

ERADICATION:

Elimination of infections and/or colonization of MRSA in a facility through implementation of infection control and hygiene measures and/or antibiotics.

INFECTION:

Invasion and multiplication of MRSA 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 does warrant treatment.

INVASIVE DISEASE:

Clinical manifestation of symptoms caused by MRSA such as furuncles, cellulitis, pneumonia, carbuncles, septicemia, osteomyelitis or vascular line infection.

IN VIVO:

Within the living body.

IN VITRO:

Observable in a test tube, in an artificial environment.

MODE OF TRANSMISSION:

The method by which MRSA is spread into the environment and to other persons.� MRSA is transmitted primarily by direct person-to-person contract (i.e. from the hands of one individual to a susceptible individual).� It is not thought that bed linens or environmental surfaces play a significant role in MRSA transmission.� However, proper techniques for cleaning of linens and disinfection of environmental surfaces are appropriate to reduce the bacterial load.

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA):

A gram-positive bacteria that grow in clusters like grapes; growth of MRSA is not inhibited by methicillin or oxacillin and many other antibiotics.� Antibiotic therapy of choice for infection caused by MRSA in vancomycin, given intravenously.� Oral vancomycin is not effective against MRSA.

NON-ACUTE CARE:

Includes home health care, hospice, extended care, respite, rehabilitation, nursing facility, residential care, long-term care, geriatric care, adult day care, etc.

OUTBREAK:

STAPHYLOCOCCUS AUREUS (S. aureus):

A gram-positive bacterial which grows in colonies that look like grapes; most S. aureus are sensitive to methicillin, cephalosporins, nafcillin and oxacillin.

SURVEILLANCE:

Monitoring of patient data to determine incidence and prevalence of infections and distribution in a facility.

SUSCEPTIBILITY TESTING:

A laboratory test to determine if an organism can be effectively treated with a particular antibiotic.

UNIVERSAL PRECAUTIONS:

A system of barrier techniques and practices used by health care workers for contact with body fluids and blood.� Universal precautions is used when providing care for all patients to prevent the transmission of bloodborne pathogens.

VECTOR:

A carrier, for example an animal or arthropod, which transfers an infective agent from one host to another.

INTRODUCTION

The association for Professionals in Infection Control & Epidemiology, Inc. � Greater Omaha Area identified an opportunity for quality improvement and formed an advisory committee with the purpose of addressing key issues regarding MRSA.� The committee included representatives from acute care and non-acute care institutions.� The goal of the committee was to improve communication among agencies, health care facilities, and health care provides for controlling the spread of MRSA.� This goal was accomplished by the development of a document standardizing terminology and providing education on issues related to MRSA.

With the increasing number of patients in Nebraska, health care facilities affected by resistant strains of bacterial {(including methicillin-resistant Staphylococcus aureus (MRSA)}, concern regarding treatment, control and transfer of the patients between institutions is growing.� This document is provided as an education resource for facilities in developing/revising their own institutional policies.� This document provides minimum basic measures for the care of patients with MRSA.� Institutions may implement more stringent isolation precautions as directed by their Infection Control Committee.

Although this document addresses MRSA and its perceived and real problems, the control measures also are applicable to other antibiotic-resistant bacterial such as Pseudomonas aeruginosa.� It is extremely important that the concern about MRSA and antibiotic resistant organisms not be exaggerated.� Attention and precaution/cohorting practices must be paid to basic infection control principles, including handwashing.� Measures such as exclusion from admission to health care facilities are neither necessary nor reasonable.

Health care professionals are facing increasing numbers of patients with MRSA colonization and infection from both acute care and non-acute care facilities.� The need for open and frank communication about patient MRSA colonization and infection in and between acute and on-acute care facilities is vital in the effort to control and contain the spread of MRSA.� Effective communication is essential early treatment, the identification of risk factors, and the promotion of infection control precautions in both the transferring and receiving institution.� It is not acceptable practice to transfer a known MRSA infected or colonized patient without notifying the receiving facility.

To effectively improve communication we recognize that education regarding the epidemiology, transmission, control and treatment of MRSA colonization and infection is critical.� For this reason, we have addressed these issues in the following sections of this documents.�

QUESTIONS THIS DOCUMENT ATTEMPTS TO ANSWER?

A. What is MRSA?

B. What is the difference between MRSA colonization and MRSA infection?

C. What needs to be included in an institution�s policies regarding admissions and discharge of patients with MRSA-positive cultures?

D. What infection control measures need to be followed when a patient has an infection or is colonized?

E. What are the indications for culturing patients/personnel?

F. What is an outbreak?� How is it controlled?

ACKNOWLEGDEMENTS

Many sources were used to develop this document, including currently available medical literature.� A list of suggested readings is provided if additional material or support is desired.� Special recognition should go to the Kentucky State Health Department, Oklahoma State Health Department, Iowa State Health Department, and the Austin Area Infection Control Council, Austin, Texas for their excellent models on MRSA.

This document was written by the MRSA Task Force of the Greater Omaha Area Chapter of the Association for Professionals in Infection Control & Epidemiology, Inc. With review and input from infectious disease specialists in the Omaha/Lincoln area.

These members represented Infections Control practitioners from skilled care facilities and hospitals, both rural and urban.� Members of the task force were:

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Betty Brown, BSN, RN

�� Peggy Christ, RN, ET, CIC

�� Carol Clemons, RN

�� Nedra Jones-Ladd, BSN, RN

�� Ann Lorenzen, MSN, RN, CIC

�� Vince Oczki, RN, CIC

�� Jerrilynn Petznik, BS, RN

�� Karen Spenner, RN

�� Carol Stumpf, BSN, RN

�� Nancy Noda, BSN, RN, CIC, Chairperson

We gratefully acknowledge the support and input from the following physicians:

�� Philip W. Smith, MD

�� Jane S. Roccaforte, MD

�� Edward A. Horowitz, MD

�� Laurel C. Preheim, MD

�� Louis L. Safranek, MD

�� Marvin J. Bittner, MD

�� Richard Morin, MD

�� David L. Dworzack, MD

�� Robert Penn, MD

�� Gary L. Gorby, MD

�� Christopher Harrison, MD

�� Daniel Boken, MD

�� Mark E. Rupp, MD

The Task Force continues to welcome comments on these guidelines realizing that until there is more consensus in the scientific literature regarding management of MRSA, unanimity on policy is unlikely to occur.

BACKGROUND

S. aureus is a gram positive coccus distinguished by its tendency to cluster under microscopic examination and its positive result on coagulase testing.

It thrives on human skin and mucous membranes, grows rapidly under either aerobic or anaerobic conditions, and can be carried by its host for a long period of time without causing clinical consequences.

Infection caused by S. aureus are cellulitis, pustules, furuncles, carbuncles, impetigo, bacteremia, endocarditis, wound infections, and less commonly, pneumonia.� It also produces toxins which can cause gastroenteritis (following ingestion of contaminated foods) and in rare instances, toxic shock syndrome.

S. aureus is transmitted primarily through direct person-to-person contact, especially through the hands of health care workers.� Nasal carriage of S. aureus is very common and may be due to hand to nose transmission.� A nasal carrier often contaminates his/her own hands by hand to nose contact, then transmits the organism in the course of routine activities.� Since skin to skin contract is the most significant mode of transmission, handwashing is of primary importance in preventing its spread.

It can remain viable in the environment for long periods of time in linen, clothing, and dust.� However, it is not thought that inanimate objects or environmental surfaces represent significant sources for transmission infection, if appropriately handled.

Airborne spread usually plays little role in the transmission of S. aureus with the exception of burn wound infections in a burn unit, patients with S. aureus pneumonia, or patients with tracheotomies.

This organism was first identified in 1880 by a surgeon, Alexander Ogston, who noted that the majority of abscesses he studied which were inflamed and warm to touch were caused by the same organism.� In 1928, penicillin was discovered and was found effective in treating S. aureus.

In 1959, the first semi-synthetic penicillin, methicillin, was produces by altering the chemical composition of penicillin.� Two years later, the first methicillin resistant strains of S. aureus were reported.

S. aureus that is resistant to the synthetic penicillins (methicillin, oxacillin, nafcillin) is referred to as methicillin-resistant S. aureus (MRSA).� It is also resistant to cephalosporins and sometimes to other antibiotics (erythromycin, clindamycin, aminoglycosides, quinolone).

The first documented nosocomial outbreak of MRSA in the United States occurred at Boston City Hospital in 1968.� The investigation of this outbreak supported transmission by the direct contact of hands of personnel to patients in the ward.� Since this outbreak, numerous units, intensive care unites, hospital ward, and in the community at large.

MRSA colonization and infection in acute and non-acute care facilities have increased dramatically over the past two decades, evidenced by the increasing number of reported outbreaks in the medical literature.� Because of its resistance to antibiotics, management of MRSA infections requires more complicated, toxic, and expensive treatment.� MRSA colonization and infections have a significant impact on individual patients and institutions.� Many patients with MRSA remain colonized indefinitely, and the majority of hospital and nursing homes that have endemic MRSA never eradicates MRSA from the institution.

Methicillin-Resistant S. Aureus is not a �super bug� and is not more likely to cause serious infection than antibiotic susceptible S. aureus.� It is simply resistant to more antibiotics.� The mechanisms of transmission of MRSA are virtually identical to those of the usual S. aureus, which is sensitive to methicillin.

DIAGNOSIS/TREATMENT

Identification:

S. aureus colonization of the nares, rectum, or skin can be detected by culture of these areas.� Clinical infection caused by S. aureus can be identified by cultures of blood, sputum, urine, percutaneous aspiration, or surgically obtained specimens as appropriate for the particular site.

After S. aureus is identified, antibiotic susceptibilities should be performed.� Oxacillin susceptibility testing by the Kirby Bauer technique is the preferred method of identifying MRSA.� Resistance to oxacillin also defines resistance to all penicillins.� cephalosporins susceptibilities should not be reported on MRSA isolates since all isolated are considered to be resistant in vivo, regardless of in vitro susceptibilities.� Reference laboratories should be consulted when questions arise.

Colonization:

It is important for the health care professional to understand the difference between colonization and infection.� Colonization indicates the presence of the organism without symptoms of illness.� Colonization can occur in the nares, trachea, skin folds, rectum, or in an open wound such as decubitus ulcer.� The patient does not symptoms when colonized.� 70 % to 90% of all individuals are intermittently colonized with S. aureus (methicillin susceptible or resistant) in the anterior nares.� S. aureus permanently colonized the anterior nares of about 20% to 30% of the general population.� Hospital workers are more likely to be colonized than persons in the general population, presumably because of increased exposure.� Thus, a higher colonization rate with S. aureus is responsibility of the physician to determine if a patient is colonized or infected.� Colonization with MRSA is not an indication for hospital admission or for prolonged hospitalization provided appropriate arrangements for disposition can be made (e.g. discharge to home or extended care facility).

Infection:

Infection is defined as tissue invasion by S. aureus with subsequent clinical symptoms.� Clinical manifestations of infections caused by S. aureus can range from superficial skin lesions such as boils to deeper infections such as pneumonia which can progress to death.� In addition to local symptoms and signs of infection, systemic manifestation of disease such as fever, malaise, and leukocytosis are often present.

Treatment of Infections:

Treatment for an infection due to MRSA may be indication for hospital admission.� The standard antibiotic therapy for infections caused by MRSA is intravenous Vancomycin.� Vancomycin can have serious side effects, especially in elderly persons.� These side effects could include ototoxicity (loss of hearing or other auditory damage), nephrotoxicity (damage to the kidneys or renal system), and allergic reactions such as fever and rash.� Infusion of vancomycin, especially when to rapid, can result in flushing, hypotension, and tachycardia known as the �red man syndrome�.� Vancomycin given by mouth is not absorbed and is not effective against MRSA.

Decolonization:

Decolonization is the elimination of MRSA carrier state through the use of infection control measures and/or antibiotics.� The indications for and efficacy of decolonization vary depending on the unique circumstances surrounding a particular episode or outbreak of MRSA colonization/infection.� The effectiveness of permanent decolonization seems marginal, but special circumstances may warrant an attempt.� Examples of special circumstances include the following: 1) patients who are immunosuppressed and colonized, and therefore, might develop particularly serious infections, 2) patients who are more likely to spread the organisms, due to behavior (e.g. the mentally retarded), or 30 patients who have repeated infections caused by the MRSA strain that they carry.� Decolonization protocols may include the use of oral/topical antibiotics.� A physician should assess each situation (an infectious disease specialist may be consulted for decolonization protocol).

ADMISSION/DISCHARGE

The issue of MRSA status (negative culture, colonized, or infected) with regard to hospital and non-acute care facility admission and discharge warrants attention.� This issue is of great practical significance in light of the current misinformation, fear and the natural inadequacies of complete, preventive control measures for infection and colonization.

An institution should not deny admission to a person colonized or infected with MRSA if adequate facilities are available to deal with MRSA.

HOSPITAL ADMISSION

Admission Rationale:

Hospital admission because of MRSA infection is acceptable medical practice.� However, MRSA colonization does not, by itself, warrant hospital admission.� Treatment for infection with MRSA is usually accomplished in an acute-care setting.� However, treatment for infection can be accomplished in a non-acute care facility or at home.� Such decisions should be based on the clinical judgement of the attending physician.

Room Assignment:

A private room is preferred for MRSA infected of colonized patients.� The MRSA colonized patient can be placed with another colonized patient (cohort).� If cohorting is not possible, the MRSA colonized patient can be placed with a non-colonized patient.� The MRSA-colonized patient should not be placed in a room with a patient who is a high risk for infection (i.e. a patient with a tracheostomy, gastrostomy tube, central line, urinary catheter, open wound, or immunocompromised).� A colonized patient with poor hygiene may need to be in a private room.

Infection Control:

Standard infection control guidelines (See Appendix II) should be followed.� The facility may employ a stricter infection control policy if so directed by the Infection Control Committee.

HOSPITAL DISCHARGE

Upon completion of appropriate therapy for MRSA infection, and when the clinical manifestation have resolved (even if the patient has a positive culture) hospital discharge may be indicated.� A patient colonized with MRSA while hospitalized for another illness may be discharged once that illness is under control.� In other words, a patient may be discharged from an acute-care setting with a positive MRSA culture.� When this occurs, the hospital should notify, in advance any institution/agency receiving the patent that he/she is colonized with MRSA.� A negative culture should not be a prerequisite for transfer to another facility.

NON-ACUTE CARE FACILITY ADMISSION

Admission Rationale:

An institution should not deny admission to a person colonized or infected with MRSA if adequate facilities are available to deal with MRSA.� A person colonized with MRSA should be allowed admission to a non-acute care facility.

Under special circumstances, treatment for an MRSA infection can be accomplished in the no-acute care facility.� This decision is based on clinical judgment of attending physician and capabilities of the institution, and should be negotiated between the discharging and receiving physicians/facilities.

Room Assignment:

A private room is preferred for MRSA infected or colonized patients.� The MRSA colonized patient can be placed with another colonized patient (cohort).� If cohorting is not possible, the MRSA colonized patient can be placed with a non-colonized patient.� The MRSA colonized person should not be placed in a room with a person at high risk for infection (i.e., a resident with a tracheostomy, a gastrostomy, central line, urinary catheter, open wound or immunocompromised).� A colonized person with poor hygiene may need to be in a private room.

Infection Control:

Standard infection control guidelines (see Appendix II) should be followed.� The facility may employ a stricter infection control policy if so directed by the Infection Control Committee.

NON-ACUTE CARE FACITLITY

A patient may be discharged to home or hospital while colonized with MRSA.� When a MRSA-colonized/infected patients is transferred to and acute care setting, the receiving institution/agency should be notified, in advance, of the patients MRSA status.

DISCHARGE TO HOME:

If the patient is discharged from an acute or non-acute care facility to a private hone, the family should be educated that there is a difference in risk between MRSA infection in the setting of a health care facility versus the home setting.� The patient�s family will usually have noted the discharging institutions additional attention to infection control practices and my have questions regarding 1) the need to duplicate these infection control practices in the home setting, and 2) their risk of MRSA infection if they bring the patient home.� Information should be conveyed to the patient�s family that additional infection control practices are often employed in the health care facility to reduce the risk of transmission of MRSA to the highly susceptible patients/residents, such as those with open wounds, invasive devices, or server underlying disease.

The patient�s family needs to understand that they rarely need to practice extraordinary infection control measures in the home beyond good handwashing and careful handling of soiled dressings.� If there is a highly susceptible family member (e.g., diagnosis of cystic fibrosis, immunosuppressions, or cancer) more extensive precautions might be in order and should be discussed with a physician prior to patient discharge.

INTER-FACILITY COMMUNICATION DURING ADMISSION AND TRANSFER OF THE MRSA PATIENT

Communication between facilities is essential to provide information on patients being transferred so appropriate arrangements (i.e., room assignments, cohorting) can be coordinated.� It is preferred practice to notify the receiving facility about a patient known to have MRSA (i.e., either colonized or infected).

KEY ISSUES

The following statements summarize key issues regarding discharge/admission management of MRSA patients in acute and non-acute care facilities:

- Colonization with MRSA alone is not grounds for admission to a hospital.

- Colonization with MRSA does not require extension of hospitalization.� Arrangements for discharge to home or a non-acute care facility can proceed as the patient�s condition warrants.

- Colonization with MRSA alone should not be ground for exclusion from a non-acute care facility, if adequate facilities are available.

- For patients infected with MRSA, hospital discharge may occur when in the opinion of the attending physician, hospitalization is no longer required to treat a MRSA infection.� A hospitalized patient colonized with MRSA may be discharged whenever he/she is medically ready.

- Patients infected with MRSA, who may be ready for discharge except for completion on antibiotic therapy, may be discharged to another facility, such as a long-term care facility or rehabilitation center, as long as the required care/treatment is available at that facility.

- The receiving facility should request and the transferring facility should provide information about the patient�s conditions upon transfer.� This should include medical diagnoses, medications, therapies, activities of daily living, as well as pertinent information on any infection or colonization of the patients.� This information should be shard to insure appropriate and adequate care of the patients.� This will also assist facilities in placing the patient in the appropriate room with appropriate roommate, and allow for any special arrangements regarding patient care.

- Negative MRSA culture should note be required for transfer.

INFECTION CONTROL/PREVENTION

The preventive measures of infection control for MRSA include handwashing, gloving, linen handling and environmental cleaning.

Handwashing is the single most important factor in preventing the spread of MRSA.� Hands of caregivers much be washed after any skin-to-skin contact with a patient.� Handwashing should be done after any and all work related tasks.� Handwashing should also be done between care of different anatomical sites on the same patients, before eating and drinking, and before leaving work.

Gloves should be worn for any contact with a wound, sore, invasive site, or mucous membrane of a patient.� Gloves should also be worn when contact is anticipated with any blood/body fluids (weeping lesions, sputum, urine, feces, etc).� This should be done for any patients, regardless of MRSA status.� Also, gowns my be worn if extensive soiling is likely.� Masks and eye protection are indicated if exposure to aerosols generated by coughing patient is likely or when irrigating wounds.

Fomites (bed linens, towels, pajamas, dishes, etc.) have not been implicated as vectors in the transmission of MRSA.� Environmental surfaces, in most instances, are not important vectors of MRSA.� Daily routine cleaning must be done with a disinfectant registered with EPA and performed in a sanitary manner as is done in all rooms regardless of the presence of MRSA.� Equipment should be routinely cleaned, disinfected or sterilized per institution policy.

While not mandatory, the MRSA colonized or infected patient can be assigned to the same room, with another MRSA-colonized patient (this is not mandatory) if one has been identified.� However, the MRSA colonized or infected patient should not be placed in a room with a patient who is at high risk for MRSA infection (patients with a tracheostomy or gastrostomy tube, central line, urinary catheter, open wound or immunocompromised).

MRSA CULTURING

Routine culturing of patients of staff for MRSA is not recommended.� In the absence of an epidemic, cultures of patients should be done when is medically indicated.� During an outbreak, it may be necessary to culture patients or staff with out other medical indications for cultures.� Cultures of environmental surfaces or objects may be indicated in very unusual epidemiologic circumstances.

Methods for Culturing:

A. Nares

1. Use a sterile swab moistened in saline or a culture transport swab with transport media such as a CULTURETTE brand swab.� Both anterior nares should be cultured.� The same swab can be used for both nares.

2. Place the swab in the transport media and label correctly before sending the specimen to the hospital laboratory or to a reference laboratory.� The laboratory should be instructed to screen for MRSA only.

B. Invasive Sites (Tracheotomies, Decubitus Ulcers, G-tube sites, wounds, dermatitis, etc.)

1. Gently clean the skin with a sterile gauze sponge moistened with saline.

2. Swab the site gently with a rolling motion.� If pus or tissue destruction is present, culture the area most heavily involved.

Gloves should be worn when taking cultures.� Dispose of gloves appropriately and wash hands thoroughly when finished handling the specimens.

Additional Considerations:

A. During an outbreak situation, the laboratory should save all isolates for possible phage/plasmid typing or DNS chromosome analysis.

B. When culturing patients or staff, explain the reason for a positive culture and the process involved.� Culturing should be done in a private setting.

C. Screening cultures are not required as a prerequisite for transfer to another facility.

D. Cultures are expensive and cultures results can, at time, be misleading.

MANAGEMENT OF AN OUTBREAK

DEFINIT0IN OF AN MRSA OUTBREAK (EPIDEMIC)

Upon the recognition of an outbreak (or epidemic) of MRSA in an acute or non-acute care facility, several special precautions should be implemented.� The common definition of an MRSA epidemic is: 1) several (e.g. three or more nosocomially-acquired) cases which are epidemiologically associated by person, time, or place, or 2) a substantial increase in number of cases in a facility with endemic MRSA.� Each facility mush decide the criteria to define an outbreak.� For example, one MRSA case in a high risk area such as a burn unit might constitute an outbreak, whereas three nosocomially-acquired cases in a lower risk area might be required.� In a non-acute care facility, the most common definition of an outbreak is three or more nosocomially-acquired cases which are epidemiologically associated.

MANGEMENT OF A MRSA OUTBREAK

When recognized, immediate reinforcement of infection control procedures (e.g. handwashing and universal precautions/body substance isolation) to all staff is necessary.

A. Culturing

1. Patients:

When an epidemic is recognized, all patients in the unit or units where cases have occurred may be cultured.� If cultures are obtained, they should be done simultaneously on all potential candidates for culture.� Cultures of nares are invasive sites should be performed.� A hospital or reference laboratory may be consulted to help interpret results.

2. Patient-Care Personnel:

Patient-care personnel should only be cultured if epidemiologically implicated in transmission (see below).� If an employee is cultured, specimens should be taken from the nares plus any broken-skin site.� Multiple specimens may be required in order to identify the organism, but should be taken only if the evidence implicating the caregiver as the transmitter is strong.� An epidemiologically implicated culture-positive caregiver should be counseled regarding infection control precautions and any deficiencies should be corrected.� More definitive measures, such as removal of the employee from care of high risk patients, may be considered if these initial steps fail.

B. Cohorting

1. During an outbreak and when extra control measures are required, all MRSA positive patients should be physically separated with no staff crossover to MRSA negative patients (i.e. if feasible and necessary, a cohort should be established).

2. Immediate review of basic universal precautions/body substance isolation and the addition of more stringent isolation practices (e.g. strict or contact) for the type of infection should be established for the MRSA positive cohort.� Careful surveillance for additional infected or colonized patients should be undertaken.

3. To the maximal extent possible, staff assigned to the cohort should work with cohort patients only.

4. When crossover is unavoidable, hands should be THROUGHLY washed before a crossover.� Care should be given to the non-cohort patients first, on a given shift if possible.

5. The question is often asked (especially in the non-acute care environment) whether a cohort member can be permitted to ambulate in other sections of the facility and socialize with other patients.� Generally, this is permissible if the patient does not have MRSA pneumonia or heavy respiratory colonization, provided involved sites can be well covered, and the patient understands and practices basic hygiene.� Ambulation may be limited to the cohort area for patients with poor impulse control.

6. A patient with MRSA pneumonia may be transported to ancillary departments for special procedures if precautions are taken to contain respiratory secretions.

7. Two consecutive negative cultures 24 hours apart obtained 48 hours after completion of antibiotics are grounds for release from the cohort.

8. Special arrangements are necessary if either a newborn nursery or a newborn intensive care nursery is involved.� An infectious disease specialist may be consulted.

C. Decolonization

Decolonization of patients or staff is not routinely recommended.� This has not proved to be an effective control measure, because recolonization usually occurs.

D.�� Epidemiologic Investigation

In an MRSA epidemic, epidemiologic investigation should include the following data:

1. Patient�s location in the institution (before and after cohorting).

2. Date of admission and recent previous admissions.

3. Which caregiver had direct contact with patient.

4. Body site of infection or colonization.

5. Severity of decubitus ulcers, presence of other invasive sites/foreign bodies, and history of invasive or other special procedures.

6. Age, sex, and race.

7. Diagnosis especially conditions with negative impact on patient�s immunocompetence.

8. Treatments given, especially antibiotics.

E. ��Admissions/Discharge

During an MRSA outbreak, there is usually no reason to close the non-acute care facility or hospital to new admissions, provided there are available beds.� The facility should not be prevented from discharging patients, provided the guidelines for admission/discharge are followed.

F.�� Resources

�� An internal working group should be organized to assist the person primarily responsible

for investigating the epidemic.� In addition to the internal group, assistance may be

sought from physicians who specialize in infectious diseases, the Association for

Practitioners in Infection Control and Epidemiology Infection Control professionals

(APIC), from a microbiology reference laboratory, and/or from the local or state health

departments, as needed.� The local or state health department should be notified of the

epidemic.

G.�� Communication

�� Facts concerning the epidemic � such as the severity of the epidemic, the methods of

transmission, and prevention measures, as well as a general account of what direction the

investigation is taking � should be clearly communicated to all personnel.� A written

�report of the epidemic should be completed promptly after the investigation if over.

CONTINUING EDUCATION/COMMUNICATION

As mentioned in the introductory remarked, communication among health care providers is essential to implementation of these guidelines.� The key element in communication is education about MRSA: its epidemiology, treatment and control measures.� Health care workers who have struggled with this problem in other states say that education and communication are the most important steps in control of MRSA.� We agree.

Communication between transferring facilities is essential to provide information on patients colonized with MRSA so appropriate arrangements can be promptly coordinated.

If all facilities work together, the number of new cases of MRSA colonization and infection may be decreased because control measures to prevent MRSA transmission can be more effectively instituted.

It is unacceptable practice to transfer a patient known to be colonized or infected by MRSA without prior notification of the receiving facility.

APPENDIX I

MRSA FACT SHEET FOR EMPLOYEES

What is MRSA?

�MRSA is the acronym for methicillin-resistant Staphylococcus aureus.� MRSA is distinguished from other bacteria by its resistance to most antibiotics including all penicillins and cephalosporins.� MRSA can affect people in different ways.� People can carry it in the nose or on the skin without showing any symptoms of illness.� This is called MRSA colonization.� MRSA can also cause infections such as boils, wound infections, and pneumonia.

How is MRSA transmitted?

MRSA is spread from person-to-person by direct contact.� This means that if a person has MRSA on the skin (especially on the hands) and touches another individual, MRSA may be spread.� A person may have MRSA on hands as a result of being a carrier or from touching another person who is a carrier or infected with MRSA.

What can I do to prevent the spread of MRSA?

Handwashing, using soap and warm running water, is the single most important measure necessary to control the spread of MRSA.� Proper handwashing should be performed after the care of each patient, after handling soiled dressings and clothing, and after wearing gloves.� Other measures to prevent becoming infected or transmitting infection to others include avoiding cross-contamination between clean and dirty linen, daily environmental cleaning, wearing gloves for all dressing changes, proper handling of infectious waste and observing isolation procedures.� Report illness including unusual skin rashes or boils to your nursing director before working with patients.� WASH YOUR HANDS BEFORE AND AFTER CONTACT WITH EACH PATIENT!!!!

Will I take MRSA home to my family?

MRSA can live on linens and clothing but these generally do not transmit the organism.� Wear a protective garment at work if you are at risk of contaminating your clothing with wound or other body fluids or drainage.� If you have contaminated your clothing with wound drainage or other potentially infectious body fluids or drainage, change clothes.� Report any unusual rashes or skin lesions to your physician.� Always thoroughly wash your hands before going home from work.� Normal healthy people are not usually at risk of serious invasive MRSA disease.�

How is MRSA treated?

Persons who carry MRSA, but are not exhibiting symptoms usually do not need to be treated.� The antibiotic used to treat persons with MRSA infections is vancomycin given intravenously.� Oral vancomycin is not effective against MRSA.� Vancomycin can have serious side effects.

APPENDIX II

INFECTION CONTROL GUIDELINES

Minimum Precautions for ALL Patients

For patients with draining skin and decubiti lesions at any site:

- Cover lesions whenever possible.

- Contain visibly soiled dressings or linen in the appropriate leak proof container or bag.

- Wear gloves when touching drainage and wash hands well before and after gloving.

- Wear gowns only if soiling of clothing is likely.� Do not wear gowns outside the patient�s room.

- If a patient is undergoing hydrotherapy for wound care of his lesion or decubitus, careful routine disinfection with an EPA approved disinfectant is indicated.� Physical Therapy staff must follow appropriate precautions when caring for the patient and when cleaning equipment.

For patient with urinary catheters:

- Change catheters when necessary, such as when they become crusted or clogged.

- Use a closed drainage system.� Keep drainage bags off the floor, but below the level of the patient�s bladder.

- Use a separate graduate container for each patient, and thoroughly clean it after each use.� Avoid touching the catheter bag or drainage spout to the side of the graduate container.

- Cleanse the patient�s perineal area daily and as necessary.� Wear gloves during this procedure.� Avoid tension or movement of the catheter.

- Wash hands well after manipulating the catheter system and after removal of gloves.

For patients with respiratory symptoms:

- Teach the patient to cough into a tissue and provide a bag for tissue disposal.

- Wear masks when in close contact with the patient (i.e. when suctioning or giving mouth or tracheostomy care).

- Use good hand washing after removing gloves.

APPENDIX III

INFECTION CONTROL GUIDELINES

Precautions for MRSA Colonized/Infection Patients

For patients with MRSA colonization/infection of skin lesions and decubiti:

- Cover lesions whenever possible.

- Contain visible soiled dressings of linen in the appropriate leak proof container or bag.

- Wear gloves when touching drainage and wash hands well before and after gloving.

- Wear gowns only if soiling of clothes is likely.� Do not wear gowns outside the patient�s room.

- Masks are not necessary.

- If a patient is undergoing hydrotherapy for wound care of his lesion of decubitus, careful routine disinfection with an EPA approved disinfectant is indicated.� Physical Therapy staff must follow appropriate precautions when caring for the patient and when cleaning equipment.

For patients with MRSA colonization/infection of the urinary tract:

- Use minimum precautions, page 24.

- Use good handwashing and wear gloves.

- Masks are not needed.

- Wear gowns only if soiling of clothes is likely.

For patients with MRSA colonization/infection of the respiratory tract:

- Wear masks only if the patient is coughing or when performing suctioning procedures.

- Wear gowns only if clothes are likely to become soiled.

- Practice good handwashing and wear gloves when handling respiratory secretions.

General recommendations for patients colonized with MRSA:

- The physician will make the decision whether or not to treat the patient colonized with MRSA.� However, treatment for colonization is seldom indicated because MRSA is difficult to permanently eradicate.

Dishes

- Disposable dishes are unnecessary.� Never allow patients to eat food from another patient�s tray.

Linen

- All soiled linen should be bagged at the location where it is used.� It should not be sorted or rinsed in the patient care area.� Linen that is heavily soiled with moist body substances that may soak through a linen bag must be placed in a impervious bag to proven leakage.� Linen handlers must wear barrier protection, which includes gloves, and take special precaution with soiled linen by bagging to proven leakage.� Soiled linen need not be washed separately.

Trash

- Routine waste from all patients� rooms is considered dirty, not infectious.

- Persons assigned to handle trash should wear gloves, wash hands, and report all accidents.� It is important that all persons be discouraged from searching through trash (e.g. for aluminum cans).� Contaminated dressings should be placed in a leakproof bag and tied before placing in the trash receptacle

- Infectious waste shall be defined and treated according to the Nebraska Department of Health Regulations and appropriate local regulations.

Housekeeping

- Daily, routine cleaning must be done in all patients� areas to reduce bacterial load.� Cleaning must be done with a disinfectant registered with the EPA and performed in a sanitary manner as is done in all rooms regardless of the presence of MRSA.� Equipment should be routinely cleaned, disinfected or sterilized per hospital policy.

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GLOSSARY . . . . . . . . .� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ��