MRSA in Healthcare Settings

Methicillin-resistant (itals)Staphylococcus aureus(enditals)(MRSA) has been featured in the news and on television programs a great deal recently. This type of bacteria causes “staph” infections that are resistant to treatment with usual antibiotics. 

MRSA occurs most frequently among patients who undergo invasive medical procedures or who have weakened immune systems and are being treated in hospitals and healthcare facilities such as nursing homes and dialysis centres. MRSA in healthcare settings commonly causes serious and potentially life threatening infections, such as bloodstream infections, surgical site infections or pneumonia. 

In addition to healthcare associated infections, MRSA can also infect people in the community at large, generally as skin infections that look like pimples or boils and can be swollen, painful and have draining pus. These skin infections often occur in otherwise healthy people.

 

How MRS Spreads In Healthcare Settings

When we talk about the spread of an infection, we talk about sources of infections – where it starts, and the way or ways it spreads – the (itals)mode or modes of transmission(enditals). 

In the case of MRSA, patients who already have an MRSA infection or who carry the bacteria on their bodies but do not have symptoms (colonized) are the most common sources of transmission. 

The main mode of transmission to other patients in through human hands, especially healthcare workers’ hands. Hands may become contaminated with MRSA bacteria by contact with infected or colonized patients. If appropriate hand hygiene such as washing with soap and water or using an alcohol-based hand sanitizer is not performed, the bacteria can be spread when the healthcare worker touches other patients.

 

MRSA and the Expensive Results of Antimicrobial Resistance

Along with (itals)Staphylococcus aureus(enditals), many significant infection-causing bacteria in the world are becoming resistant to the most commonly prescribed antimicrobial treatments. What causes this and what does it mean? 

Antimicrobial resistance occurs when bacteria change or adapt in a way that allow them to survive in the presence of antibiotics designed to kill them. In some cases bacteria become so resistant that no available antibiotics are effective against them. At this time, treatment options still exist for healthcare-associated MRSA but are limited because healthcare-associated MRSA is resistant to many antibiotics. 

People infected with antibiotic-resistant organisms like MRSA are more likely to have longer and more expensive hospital stays, and may be more likely to die as a result of the infection. When the drug of choice for treating their infection doesn’t work, they require treatment with second- or third-choice medicines that may be less effective, more toxic and more expensive. 

So this means that if you or I get an MRSA infection, we may suffer more, and we may pay more for our treatment. Yet American society as a whole suffers more and pays more too because of the increased burden and expense in the healthcare system.

 

MRSA: A Growing Problem in the Healthcare Setting, But One with a Cure

MRSA is becoming more prevalent in healthcare settings. According to CDC data, the proportion of infections that are antimicrobial resistant has been growing. In 1974, MRSA infections accounted for two per cent of the total number of staph infections in 1995 it was 22 per cent; in 2004, it was 63 per cent. 

The good news is that MRSA is preventable. The first step to prevent MRSA is to prevent healthcare infections in general. Infection control guidelines produced by organizations such as Centers for Disease Control (CDC) and the Healthcare Infection Control and Prevention Advisory Committee (HICPAC) are central to the prevention and control of healthcare infections and ultimately, MRSA in healthcare settings. 

CDC welcomes the increased attention and dialogue on the important problem of MRSA in healthcare. CDC, state and local health departments and partners nationwide are collaborating to prevent MRSA infections in healthcare settings. For example, CDC:

• monitors trends in infections and MRSA through surveillance systems such as the National Healthcare Safety Network, formerly the National Nosocomial Infection Surveillance System and the Dialysis Surveillance Network to identify which patients are at highest risk and where prevention efforts should be targeted.
• Works with multiple prevention partners including state health departments, academic medical centres, and regional and national collaboratives to identify and promote effective strategies to prevent MRSA transmission.
• Developed an overarching strategy to help guide healthcare facilities to control antibiotic resistance called The Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. This campaign includes specific strategies for various healthcare populations, including hospitalized adults and children, dialysis patients, surgical patients, and long-term care patients.

 

Standard Precautions

1. Handwashing – Wash hands after touching blood, body fluids, secretions, excretions and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites.
2.  Gloves – Wear gloves (clean nonsterile gloves are adequate) when touching blood, body fluids, secretions, excretions and contaminated items; put on clean gloves just before touching mucous membranes and non-intact skin. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.
3.  Masking – Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions.
4. Gowning – Wear a gown (a clean non-sterile gown is adequate) to protect skin and prevent soiling of clothes during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions or cause soiling of clothing.
5. Appropriate device handling – Handle used patient-care equipment soiled with blood, body fluids, secretions and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed, and that single-use items are properly discarded.
6. Appropriate handling of laundry – Handle, transport and process used linen soiled with blood, body fluids, secretions and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments.

 

If MRSA is judged by the hospital’s infection control program to be of special clinical or epidemiologic significance, then Contact Precautions should be considered.

 

Contact Precautions

1. Placing a patient with MRSA in a private room. When a private room is not available, the patient may be placed in a room with a patient(s) who has active infection with MRSA, but with no other infection (cohorting).
2.  Wearing gloves (clean, non-sterile gloves are adequate) when entering the room. During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms (e.g. fecal material and wound damage). Remove gloves before leaving the patient’s room and wash hands immediately with an antimicrobial agent. After glove removal and handwashing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient’s room to avoid transfer of microorganisms to other patients and environments.
3.  Wearing a gown when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient’s room, or if the patient is incontinent, or has diarrhoea, an ileostomy, a colostomy, or wound damage not contained by a dressing. Remove the gown before leaving the patient’s room. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganism to other patients and environments.
4.  Limiting the movement and transport of the patient from the room to essential purposes only. If the patient is transported out of the room, ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment.
5. Ensuring that patient-care items, bedside equipment, and frequently touches surfaces receive daily cleaning.
6. When possible, dedicating the use of noncritical patient-care equipment and items such as stethoscope, sphygmomanometer, bedside commode, or electronic rectal thermometer to a single patient (or cohort of patients infected or colonized with MRSA) to avoid sharing between patients. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use on another patient.

 

Culturing of Personnel and Management of Personnel Carriers of MRSA

Unless the objective of the hospital is to eradicate all MRSA carriage and treatment all personnel who are MRSA carriers, whether or not they disseminate MRSA, it may be prudent to culture only personnel who are implicated in MRSA transmission based on epidemiologic data. MRSA-carrier personnel who are epidemiologically linked to transmission should be removed from direct patient care until treatment of the MRSA-carrier status is successful. If the hospital elects to culture all personnel to identify MRSA carriers) (a) surveillance cultures need to be done frequently, and (b) it is likely that personnel colonized by MRSA who are not linked to transmission and/or who may not be MRSA disseminators will be identified, subjected to treatment, and/or removed from patient contact unnecessarily. Because of the high cost attendant to repeated surveillance cultures and the potential of repeated culturing to result in serious consequences to health care workers, hospitals should weigh the advantages and the adverse effects of routinely culturing personnel before doing so.

 

Control of MRSA Outbreaks

When an outbreak of MRSA infection occurs, an epidemiologic assessment should be initiated to identify risk factors for MRSA acquisition in the institution; clinical isolates of MRSA should be saved and submitted for strain typing. Colonized or infected patients should be identified as quickly as possible, appropriate barrier precautions should be instituted, and handwashing by medical personnel before and after all patient contacts should be strictly adhered to.

 

All personnel should be reinstructed on appropriate precautions for patients colonized or infected with multiresistant microorganisms and on the importance of handwashing and barrier precautions in preventing contact transmission.

 

If additional help is needed by the hospital, a consultation with the local or state health department or CDC may be necessary.

 

 

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