Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities
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Journal of Hospital Infection (2006) 63S, S1eS44
www.elsevierhealth.com/journals/jhin
Guidelines for the control and prevention of
meticillin-resistant Staphylococcus aureus
(MRSA) in healthcare facilities*
J.E. Coia a, G.J. Duckworth b, D.I. Edwards c, M. Farrington d,
C. Fry e, H. Humphreys f,*, C. Mallaghan g, D.R. Tucker h,
for the Joint Working Party of the British Society of Antimicrobial
Chemotherapy, the Hospital Infection Society, and the Infection
Control Nurses Association
a
Department of Bacteriology, Glasgow Royal Infirmary, Glasgow, UK
b
Health Protection Agency, London, UK
c
39 Wallenger Avenue, Gidea Park, Essex, UK
d
Clinical Microbiology and Public Health Laboratory, Health Protection Agency,
Addenbrooke’s Hospital, Cambridge, UK
e
Department of Health, London, UK
f
Department of Microbiology, RCSI Education and Research Centre, Beaumont Hospital,
Dublin, Ireland
g
East Midlands (South) Health Protection Agency, Enderby, Leicester, UK
h
Department of Infection Control, St Thomas’ Hospital, London, UK
Available online 3 April 2006
KEYWORDS Summary Meticillin-resistant Staphylococcus aureus (MRSA) remains en-
Staphylococcus demic in many UK hospitals. Specific guidelines for control and prevention
aureus; Methicillin are justified because MRSA causes serious illness and results in significant
resistance; Meticillin;
additional healthcare costs. Guidelines were drafted by a multi-disciplinary
Cross infection;
Infection control;
group and these have been finalised following extensive consultation. The
Handwashing; recommendations have been graded according to the strength of evidence.
Decontamination; Surveillance of MRSA should be undertaken in a systematic way and should
Population be fed back routinely to healthcare staff. The inappropriate or unneces-
surveillance; Disease sary use of antibiotics should be avoided, and this will also reduce the like-
reservoirs; Vancomycin lihood of the emergence and spread of strains with reduced susceptibility
resistance; Microbial to glycopeptides, i.e. vancomycin-intermediate S. aureus/glycopeptide-
drug resistance; intermediate S. aureus (VISA/GISA) and vancomycin-resistant S. aureus
*
In this document, ‘meticillin’ has been used in place of the established ‘methicillin’ in accordance with the new International
Pharmacopoeia guidelines.
* Corresponding author. Tel.: þ3531 8093708/3710; fax: þ3531 8093709.
E-mail address: hhumphreys@rcsi.ie
0195-6701/$ - see front matter ª 2006 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2006.01.001S2 J.E. Coia et al.
Workload; Antisepsis; (VRSA). Screening for MRSA carriage in selected patients and clinical areas
Colonisation; should be performed according to locally agreed criteria based upon as-
Antibiotic stewardship; sessment of the risks and consequences of transmission and infection.
Patient isolation Nasal and skin decolonization should be considered in certain categories
of patients. The general principles of infection control should be adopted
for patients with MRSA, including patient isolation and the appropriate
cleaning and decontamination of clinical areas. Inadequate staffing, espe-
cially amongst nurses, contributes to the increased prevalence of MRSA.
Laboratories should notify the relevant national authorities if VISA/GISA
or VRSA isolates are identified.
ª 2006 The Hospital Infection Society. Published by Elsevier Ltd. All rights
reserved.
1. Preamble and the Health Management Information Consor-
tium Database. The focus of the review centred on
Guidelines for the control of meticillin-resistant the following questions:
Staphylococcus aureus (MRSA) infections in hospi-
tals in the UK have been published previously by e To what extent does the screening of patients
a Joint Working Party of the British Society for Anti- before or on admission to hospital reduce the
microbial Chemotherapy and the Hospital Infection incidence of MRSA transmission and what are
Society in 19861 and 1990,2 and together with the In- the costs?
fection Control Nurses Association in 1998.3 With e To what extent does the use of MRSA surveil-
the increased media and public interest, the advent lance data reduce the incidence of MRSA trans-
of glycopeptide-resistant S. aureus and new drugs, mission and what are the costs?
including linezolid and teicoplanin, the Department e To what extent does the isolation or cohorting
of Health’s Specialist Advisory Committee on Anti- of patients prevent the spread of MRSA and
microbial Resistance (SACAR) asked the three socie- what are the costs?
ties to revise the guidelines. SACAR also requested e To what extent does environmental cleaning
an enhanced focus on: (i) prophylaxis and therapy with detergent or detergent plus disinfectant
of MRSA infections; (ii) the laboratory diagnosis contribute to the control of MRSA infection
and susceptibility testing of MRSA; and (iii) the pre- and what are the costs?
vention and control of MRSA infections in the UK.
The last is the subject of this report. The first two
will be published elsewhere. These guidelines ex- 2. Grades of evidence and
clude evidence and recommendations for MRSA in recommendations
paediatric, neonatal and dental patients for whom
insufficient evidence exists. Where possible, rec- Each recommendation, as graded by the US Cen-
ommendations have been given based on the evi- ters for Disease Control and Prevention (CDC), is
dence available, even though the evidence base categorized on the basis of existing scientific data,
may be poor. Most of the evidence reviewed con- theoretical rationale, applicability and economic
cerns acute care settings. Nonetheless, many of impact. These grades were chosen in preference
the recommendations and principles in the guide- to those published by the Scottish Intercollegiate
lines will apply in other healthcare settings. Guidelines Network or the National Institute for
A systematic review was conducted covering the Clinical Excellence as they include scientific evi-
literature from the beginning of 1996 to the end of dence and are not exclusively clinical. The CDC/
June 2004, thus focusing on the period since the Hospital Infection Control Practices Advisory Com-
preparation of the last guidelines. This review has mittee (HICPAC) system for categorizing recom-
also been published in this supplement. Data sour- mendations is as follows.
ces included MEDLINE, EMBASE, the Cumulative
Index of Nursing and Allied Health Literature, the e Category 1a. Strongly recommended for
Cochrane Clinical Trials Register, the National implementation and strongly supported by
Health Service (NHS) Centre for Reviews and Dis- well-designed experimental, clinical or epide-
semination Database of Reviews of Effectiveness, miological studies.Guidelines for MRSA in healthcare facilities S3
e Category 1b. Strongly recommended for imple- e whether part of an outbreak; and
mentation and strongly supported by certain e antimicrobial susceptibilities.
experimental, clinical or epidemiological stud-
ies and a strong theoretical rationale. Other desirable items include the primary di-
e Category 1c. Required for implementation, as agnosis, an assessment of severity of underlying
mandated by federal or state regulation or illnesses, prior antimicrobial therapy and possible
standard. The UK equivalent is to operate risk factors for infection (Category 2).
within European Union or UK Health & Safety
Legislation.
2.2. Antibiotic stewardship
e Category 2. Suggested for implementation and
supported by suggestive clinical or epidemio-
e Avoidance of inappropriate or excessive antibi-
logical studies or a theoretical rationale.
otic therapy and prophylaxis in all healthcare
e No recommendation. Unresolved issue. Practices
settings (Category 1a).
for which insufficient evidence exists or for which e Ensuring that antibiotics are given at the cor-
there is no consensus regarding efficacy.
rect dosage and for an appropriate duration
(Category 1b).
e Limiting the use of glycopeptide antibiotics to
2.1. Surveillance situations where their use has been shown to
be appropriate. If possible, prolonged courses
Surveillance must be undertaken routinely as part of
of glycopeptide therapy should be avoided
the hospital’s infection control programme and must
(Category 1a).
be a recognized element of the clinical governance e Reducing the use of broad-spectrum antibi-
process. As such, there should be clear arrangements
otics, particularly third-generation cephalo-
identifying those responsible for acting on the results
sporins and fluoroquinolones, to what is
in individual hospital directorates (Category 1b).
clinically appropriate (Category 1b).
For benchmarking purposes, surveillance data
e Instituting antibiotic stewardship programmes
should be collected and reported in a consistent
in healthcare facilities, key components of
way, to agreed case definitions and using agreed
which include the identification of key person-
specialty activity denominators, with stratification
nel who are responsible for this, surveillance of
according to case mix (Category 1b). antibiotic resistance and antibiotic consump-
Surveillance data should be fed back to hospital
tion, and prescriber education (Category 1c).
staff routinely, readily intelligible to most hospital
staff, considered regularly at hospital senior man-
agement committees, and used in local infection 2.3. Screening
control training.
MRSA surveillance should include: Active screening of patients for MRSA carriage
should be performed and the results should be
e any mandatory requirements (Category 1c); linked to a targeted approach to the use of
e results of microbiological investigations for isolation and cohorting facilities (Category 2).
clinical purposes (Category 1b); and Certain high-risk patients should be screened
e results of microbiological investigations under- routinely, and certain high-risk units should be
taken for screening purposes (Category 1b). screened at least intermittently in all hospitals.
The fine detail regarding which patients are
The dataset should include: screened should be determined locally by the in-
fection control team and must be discussed with the
e patient, laboratory, unit/ward and hospital appropriate clinical teams and endorsed by the
identifiers; relevant hospital management structure. They will
e patient demographics (address, age, sex); be influenced by the local prevalence of MRSA in the
e date of admission; hospital and unit concerned, the reason for admis-
e date of onset of infection (if appropriate); sion of the patient, the risk status of the unit to
e site of the primary infection, if appropriate (if which they are admitted, and the likelihood that the
bacteraemia, source of the bacteraemia); patient is carrying MRSA. Patients at high risk of
e date specimen taken; carriage of MRSA include those who are:
e site of specimen (blood culture, wound, etc.);
e where the MRSA was acquired (hospital, com- e known to have been infected or colonized with
munity, specialty, etc.); MRSA in the past (Category 1b);S4 J.E. Coia et al.
e frequent re-admissions to any healthcare facil- are sufficient local isolation/cohorting resources
ity (Category 1b); to manage carriers effectively, and if local poli-
e direct interhospital transfers (Category 1b); cies for clearance of carriage and/or use of
e recent inpatients at hospitals abroad or hospi- surgical prophylaxis with glycopeptides are in
tals in the UK which are known or likely to place.
have a high prevalence of MRSA (Category The following sites should be sampled for
1b); and patients (Category 1b): anterior nares, skin lesions
e residents of residential care facilities where and wounds and sites of catheters, catheter urine,
there is a known or likely high prevalence of groin/perineum, tracheostomy and other skin
MRSA carriage (Category 1b). breaks in all patients, and sputum from patients
with a productive cough. The umbilicus should be
Other risk groups may be defined by local sampled in all neonates. One should also consider
experience, based on screening initiatives or out- sampling the throat.
break epidemiology. Published examples have in- The decision whether to perform screening of
cluded injecting drug users, patients infected with patients on admission to other wards or regular
human immunodeficiency virus, and members of screening of inpatients on other wards should be
professional contact sport teams (Category 2). decided by the local infection control team in
Units caring for patients at high risk for suffering consultation with the senior clinical staff of the
serious MRSA infections or with a high proportion units, and as agreed with the relevant hospital
of MRSA infections among colonized patients in- management structure (Category 2). In principle,
clude: intensive care, neonatal intensive care, hospitals with significant problems with MRSA
burns, transplantation, cardiothoracic, orthopae- transmission or a high prevalence of MRSA car-
dic, trauma, vascular surgery, renal, regional, riage or infection should consider performing
national and international referral centres (all more widespread and regular screening than units
Category 1b), and other specialist units as de- with a low prevalence. However, this approach
termined by the infection control team and as has resource implications and should first be used
agreed with the senior clinical staff of the units in areas where the clinical impact of high MRSA
and relevant hospital management structure. prevalence is highest (i.e. in the ‘high-risk’
Patients on elective surgical units (e.g. ortho- clinical areas). The aim is to identify all positive
paedic, vascular), usually with short inpatient patients within the hospital to allow targeting of
stays, are at lower risk of MRSA acquisition than isolation and cohorting facilities in order to
patients on trauma and emergency units, or mixed minimize the risk of onward transmission to other
units. Due account of these differences should be patients.
taken when local screening policies are being When possible, patients awaiting elective ad-
established (Category 2). mission who satisfy local requirements for screen-
All patients who are at high risk for carriage of ing should be screened before admission by their
MRSA should be screened at the time of admission general practitioners or in pre-admission clinics
unless they are being admitted directly to isolation (Category 2). Patients who are at high continuing
facilities and it is not planned to attempt to clear risk of acquiring MRSA between the time of pre-
them of MRSA carriage (Category 2). admission screening and that of admission (e.g.
Regular (e.g. weekly or monthly, according to they reside in a residential care facility which is
local prevalence) screening of all patients on known to have a high prevalence of MRSA) must be
high-risk units should be performed routinely rescreened on admission, and should be isolated or
(Category 2). cohorted according to policies in place on the
In addition, screening all patients (regardless admitting unit until both sets of screening results
of their risk-group status) should be considered are known.
on admission to high-risk units (Category 2). The
decision about whether or not to perform routine Action to be taken if screening
admission screening should be made explicitly by results are positive
the infection control team in consultation with In general, detection of patients colonized or
the senior clinical staff of the units, and should infected with MRSA on a ward should be an
be agreed with the relevant hospital management indication for increased screening (Category 2).
structure. Such ‘blanket’ screening may be used Little evidence exists to guide the details of an
intermittently, and may be especially worthwhile appropriate response, but this should be influ-
if the local prevalence of MRSA carriage in such enced by the risk group of the affected unit, by
patients is higher than usual for the UK, if there the number of newly detected MRSA-positiveGuidelines for MRSA in healthcare facilities S5 patients, by the adequacy of nurse numbers to perineum of staff members found to be MRSA staff the ward, and by the availability of isolation positive. and cohorting facilities. There is always a delay It is recommended that a minimum of three between MRSA acquisition by a patient and its screens at weekly intervals, while not receiving presence being detectable by screening samples, antimicrobial therapy, should be performed before so it is recommended that at least three screens at a previously positive staff member can be consid- weekly intervals should be performed before ered to be clear of MRSA (Category 2). Local a patient can be considered to be at low risk of policies should be developed to guide postclear- having acquired MRSA if they have been nursed in ance sampling of staff (Category 2), and due note proximity to unknown and unisolated MRSA- should be taken of the individual’s risk of trans- positive patients or by the same staff (Category 2). mission to patients when agreeing their continua- The screening for MRSA in each unit within a tion or return to work. In principle, only staff hospital should be the subject of regular audit, members with colonized or infected hand lesions with the results reviewed by the hospital’s in- should be off work while receiving courses of fection control committee. The results should also clearance therapy. be made available to management. No recommendation is made about performance Screening of staff is not recommended routinely, of ‘discharge screening’. but if new MRSA carriers are found among the Performance of active screening for MRSA in patients on a ward, staff should be asked about skin each unit within a hospital must be the subject of lesions. Staff with such lesions should be referred regular audit, with the results reviewed and for screening and for consideration of dermatolog- minuted by the hospital’s infection control com- ical treatment by the relevant occupational health mittee and made available to the appropriate department (Category 1b). Staff with persistent hospital management structure (Category 1b). carriage at sites other than the nose should be Units with highly prevalent, endemic MRSA considered for referral for appropriate specialist should consider focusing screening, control mea- management (e.g. ear, nose and throat; dermatol- sures and other resources on high-risk units at ogy) who should arrange follow-up screening first, with the intention of rolling them out to according to local protocols (Category 1b). lower-risk areas after the position has improved Staff screening is indicated if transmission (Category 2). Screening should not be seen as an continues on a unit despite active control mea- end in itself, but rather it should be linked to sures, if epidemiological aspects of an outbreak specific, locally determined packages of control are unusual, or if they suggest persistent MRSA measures. carriage by staff (Category 2). Geographically adjacent healthcare facilities, Care is needed to distinguish between transient and those exchanging large numbers of patients carriage (i.e. nasal carriage which is lost within because of clinical links, should liaise to agree a day or so of removal from contact with MRSA- common and efficient screening measures that positive patients and carries little risk of onward should be linked to common and efficient control transmission) and prolonged carriage (especially measures (Category 2). Such links should capitalize associated with skin lesions) (Category 1b). This is on any developing networking relationships among usually best achieved by screening staff as they clinical and laboratory units, such as those en- come on duty at the beginning of their shift and couraged through the Pathology Modernization not as they leave at the end of their shift. initiative. Nurses, doctors, physiotherapists, other allied Results of screening cultures should be made health professionals and non-clinical support staff available promptly to the clinical and infection (e.g. porters) should be considered for screening, control teams of other healthcare facilities to and the implications for onward spread by staff whom a patient is to be, or has recently been, working on other wards should also be considered transferred (Category 1b). Refusal to accept trans- (Category 2). fer of a patient is not justifiable on the basis of the The special difficulties and risks posed by risk posed to other patients by an individual’s agency and locum staff should be considered carriage of or infection with MRSA. All units should (Category 1b). have procedures in place and adequate facilities Appropriate sampling sites for staff screening for containment of MRSA. include anterior nares, throat and any areas of Trusts should develop local protocols for inform- abnormal or broken skin (Category 1b). As a ing patients, carers, relatives and staff members guide to use of eradication measures, one of their MRSA status with due regard for confiden- should consider screening the hairline and groin/ tiality (Category 2).
S6 J.E. Coia et al.
2.4. Decolonization After satisfactory completion of a course of
treatment, i.e. each bath and hairwash, clean
Nasal decolonization clothing, bedding and towels should be provided
Patients receiving prophylaxis for an operative (Category 2).
procedure and in an outbreak situation under the For patients with eczema, dermatitis or other
advice of the infection control team should un- skin conditions, attempts should be made to treat
dergo nasal decolonization. This should be the underlying skin condition. Advice on suitable
achieved by applying mupirocin 2% in a paraffin eradication protocols for these individuals should
base to the inner surface of each nostril (anterior be sought from a consultant dermatologist. Oil-
nares) three times daily for five days. The patient atum bath additive or Oilatum plus (with added
should be able to taste mupirocin at the back of benzalkonium chloride 6% and triclosan 2%) may be
the throat after application (Category 1b). used with these patients; these should only
Mupirocin should not be used for prolonged be prescribed on the advice of a dermatologist
periods or used repeatedly (i.e. for more than (Category 2).
two courses for five days) as resistance may be
encouraged (Category 1a).
Nasal decolonization using topical nasal mupir- 2.5. Patient management
ocin should be used with other forms of intervention
such as skin decolonization with 4% chlorhexidine General principles
gluconate aqueous solution (Category 2). The general principles of infection control should
be adopted for the management of patients with
Throat decolonization MRSA. Good infection control practice should be
Systemic treatment should only be prescribed on placed at the centre of clinical practice, and
the advice of the consultant microbiologist in the requires the explicit support of the organizational
hospital, with appropriate monitoring [e.g. regular executive to ensure that it is seen as having an
liver function tests (LFTs) to monitor effects of the appropriate position within the organization and
drugs on the liver]. If treatment is required, this can be enforced as a matter of clinical governance
should be restricted to one course of treatment, (Category 1b).
the course should not be repeated and the possible
side-effects should be explained to the patient
(Category 1b).
Systemic treatment should be given in conjunc- Standard infection control principles
tion with nasal mupirocin and skin decolonization A standard approach to isolation precautions
(Category 1b). should be adopted in accordance with the general
Local treatment for throat carriage such as principles of infection control, rather than intro-
antiseptic gargles or sprays may be used to reduce ducing specific guidance for the management of
the organism load (no recommendation). MRSA that may lead to differing standards (Cate-
gory 1b).
Skin decolonization
Skin decolonization using 4% chlorhexidine body- Management of MRSA-infected
wash/shampoo, 7.5% povidone iodine or 2% triclo- or -colonized patients
san is useful in eradicating or suppressing skin Patients should be managed in accordance with
colonization for short times, particularly pre- the type of facility in which they receive care, the
operatively to reduce the risk of surgical site resources available, and the level of risk that is
infections (Category 1a). posed to them and to others. Patients (and the
Patients should bathe daily for five days with facilities that may house them) classified as being
the chosen antiseptic detergent. The skin should at high risk of contracting MRSA or for whom the
be moistened and the antiseptic detergent should consequence of infection may have a high impact
be applied thoroughly to all areas before rinsing in will require a rigorous approach to screening,
the bath or shower. Special attention should be placement and treatment. Patients identified
paid to known carriage sites such as the axilla, with MRSA infection or colonization should be
groin and perineal area. The antiseptic should also informed of their condition, and local arrange-
be used for all other washing procedures and for ments should be made to ensure ease of identifi-
bed bathing. Hair should be washed with an cation if re-admission to the facility occurs
antiseptic detergent (Category 1a). (Category 1b).Guidelines for MRSA in healthcare facilities S7
Patient isolation to be called forward when the department is ready
Patient isolation for those infected or colonized for them and to ensure that they are not held in
with MRSA will be dependent on the facilities communal waiting areas. Staff should adopt iso-
available and the associated level of risk. Where lation precautions whilst in contact with the
new buildings or refurbishment are planned, patient.
published guidelines should be adopted to provide Arrangements for transfer to other healthcare
the most appropriate facilities for patient care. facilities, e.g. hospitals, residential care homes,
Isolation should be in a designated closed area etc., should include notification of the individual’s
that should be clearly defined; in most facilities, MRSA status, as appropriate (Category 1b).
this will be either single-room accommodation or
cohort areas/bays with clinical handwashing fa- Surgical/invasive procedures
cilities. Consideration should be given to the Prior to any planned invasive procedure, efforts
provision of isolation wards to contain MRSA should be made to minimize the level of risk of
spread. The procedures for isolation should be infection through topical and systemic decoloniza-
clearly stated, and where necessary explained, to tion, and prophylactic antimicrobial therapy, as
staff, patients and visitors. Hospital staff entering appropriate.
isolation facilities should be required to adopt the It may be considered desirable to place the
prescribed isolation precautions rigorously and individual at the end of a procedure list. However,
these should be audited regularly. Non-staff in mechanically filtered environments such as
visitors should be requested to adopt the neces- operating theatre suites, the number of air ex-
sary level of precautions to minimize the risk of changes should render this unnecessary. Good
spread of MRSA to other areas of the facility infection control practices, which should be in
(Category 1b). place between all patients, should reduce the risk
of cross-infection (Category 1b).
Cleaning and decontamination
Management of the environment and equipment Transportation
should be considered as central to decrease the The risk of cross-infection from an MRSA-colonized
spread of MRSA. Cleaning regimens for isolation or -infected patient to other patients in an
facilities should focus on the minimization of dust ambulance is minimal. Good infection control
and the removal of fomites from contact areas. This practices and routine cleaning should suffice to
should be a two-fold approach; firstly, the manage- prevent cross-infection (Category 2).
ment of the occupied facility, and then the termi-
nal clean of the facility after discharge of the Discharge
patient. Cleaning regimens and products should be Generally, there is no requirement for patients
in accordance with local policy, but should include colonized with MRSA to continue with extended
the removal of organic material with a general- eradication protocols after discharge. This may be
purpose detergent. Cleaning regimens and their varied in the event of anticipated re-admission to
performance should be audited regularly. a hospital, especially for a planned invasive pro-
Patient equipment, e.g. wheelchairs, hoists, cedure. It is appropriate that individuals/groups
slings, sphygmomanometer cuffs, etc., should involved in further care are informed of the
either be capable of being decontaminated and individual’s known MRSA status at discharge.
be decontaminated before use with other pa- Patients and their appropriate contacts should
tients, or should be single-patient use and dis- be fully briefed and given relevant information on
carded as clinical waste at the end of a period of MRSA, its implications and significance prior to
usage (Category 1b). discharge in order to reduce unnecessary anxiety
and concern when returning to the home environ-
Patient movement ment (Category 2).
The movement of patients with MRSA within
a facility should be kept to a minimum to reduce 2.6. Nursing staff workload and MRSA
the risk of cross-infection and any potential em- transmission
barrassment for the patient. Where patients need
to attend departments for essential investigations, The Working Party emphasizes that inadequate
the receiving area should be notified of the nurse staffing is incompatible with effective in-
patient’s MRSA status in advance of the transfer, fection control. Infection control teams and hos-
and arrangements should be put in place to pital managements should bear nursing workload
minimize their contact with other patients, i.e. in mind (including staff numbers, grades and levelsS8 J.E. Coia et al.
of experience, and patient acuity) when planning programmes. The detection of intermediate-level
local responses to MRSA and when reacting to resistance is challenging for laboratories. This is es-
outbreaks, and adequate staffing resources must pecially true for strains that are heterogeneous in
be given a high priority for all patient care areas their expression of glycopeptide resistance. A high
(Category 1a). level of suspicion must be maintained, particularly
Improving nurse staffing levels on an affected in patients who have received multiple and/or pro-
ward may allow improved adherence to local longed courses of glycopeptide antibiotics or who
infection control policies (Category 2), and should are known to be colonized/infected with MRSA
be considered as a component of a package of and vancomycin-resistant enterococci (VRE). De-
measures to control local outbreaks (Category 2). tailed recommendations and levels of evidence for
the laboratory detection of these strains are given
2.7. Control of vancomycin-intermediate in the Guidelines for the Laboratory Diagnosis and
and -resistant S. aureus (VISA and VRSA) Susceptibility Testing of MRSA 3a.
The laboratory must notify the relevant clini-
In the absence of randomized controlled trial data cian and infection control personnel as soon as
and on the basis of the descriptive studies outlined possible after the isolation of a presumptive S. au-
above and a strong theoretical rationale, recom- reus isolate with reduced glycopeptide sensitivity
mendations for the control of these organisms in order that control measures can be imple-
remain the province of existing best practice and mented with minimum delay. It is also important
professional opinion. These measures can be con- that the relevant national surveillance network is
veniently considered under the headings of pre- notified to ensure that accurate information about
vention, surveillance and precautions. the epidemiology and spread of these organisms is
gathered (Category 1b).
Prevention Control precautions (all Category 1b)
Antibiotic resistance flourishes when antimicrobial Action to be taken on identification
drugs are abused, misused and dispensed at levels of a case of VISA/glycopeptide-intermediate
lower than treatment guidelines dictate. Virtually S. aureus (GISA) or VRSA
all strains of S. aureus with reduced susceptibility
to glycopeptide antibiotics described to date are e The laboratory should immediately notify the rel-
thought to have arisen from pre-existing reservoirs evant clinician and infection control personnel.
of MRSA, usually in patients with chronic underly- e The infection control team should immediately
ing disease who have received multiple and/or identify where the patient is and where the pa-
prolonged courses of glycopeptide treatment. It tient has been during all of the current admis-
seems logical, therefore, to ensure that measures sion, including transfers from other healthcare
outlined elsewhere in this document for control facilities.
of MRSA are implemented within the healthcare in- e The relevant national surveillance organiza-
stitution, and that careful antibiotic stewardship is tion, e.g. Health Protection Scotland, Health
employed to minimize the inappropriate use of Protection Agency in England and Wales, and
glycopeptide agents (Category 1b). the Health Protection Agency (Communicable
Where the use of such agents is deemed Disease Surveillance Centre) in Northern Ire-
appropriate, clinicians should ensure that ade- land, should be notified.
quate dosages are given to ensure that therapeu-
tic levels are obtained at the site of infection and If the patient is still an inpatient
that duration of therapy is not unnecessarily
prolonged. These measures will help to reduce e The number of healthcare workers caring for
the likelihood of resistant strains arising de novo the patient should be reduced. This will cause
(Category 1b). problems for those who are allocated to care
for the patient. These healthcare workers will
need support.
Surveillance e Healthcare workers with chronic skin condi-
It is vital that clinicians and microbiologists remain tions, e.g. eczema or psoriasis, should not be
aware of the potential for emergence of strains of involved in direct care of the patient.
S. aureus with reduced susceptibility to glyco- e All staff caring for the patient should be made
peptide antibiotics, and that this awareness is aware of how the organism is transmitted and
reflected in ongoing laboratory-based surveillance the precautions necessary to prevent this.Guidelines for MRSA in healthcare facilities S9
e The patient should be cared for in a single room Screening (all Category 1b)
with toilet facilities and a wash hand basin. Patients
e The patient and visitors must understand the
need for isolation. e Nose, axillae, perineum, skin lesions and ma-
e Fans should not be used to control the patient’s nipulated sites of the index case and all other
temperature. patients in the unit should be screened for car-
e Appropriate infection control procedures riage of VISA/GISA or VRSA.
should be implemented: e The infection control team should review the
1. Standard precautions should be used. admission history of the patient and determine
Gowns/disposable aprons and disposable if screening needs to be extended to other
gloves should be worn by all those entering areas and other units alerted.
the patient’s room. Clean, non-sterile
gloves and gowns/aprons are adequate. Staff
Consideration should be given to use of the-
atre-style greens in addition to protective e Agreement with staff on the need for screening
clothing to ensure that healthcare workers should be sought.
do not take uniforms home to launder. e Nose, axillae and perineum of healthcare
2. Disposable masks and eye protection should workers and others with close physical contact
be worn by carers for procedures likely to with the case should be screened for carriage
generate aerosols/splashing. Use of closed of VISA/GISA or VRSA.
suction systems will help to reduce e Healthcare workers who maintain contact
aerosols. with the patient will require weekly screen-
3. Hand hygiene should be performed with ing. This may require significant support for
an antibacterial preparation before and these staff.
after patient contact. Visibly soiled hands e Feedback of results and maintenance of confi-
should be washed with soap prior to dentiality should be considered.
disinfection.
4. Non-disposable items that cannot be easily
cleaned or disinfected (e.g. sphygmoma- Eradication (all Category 1b)
nometer cuffs) should be dedicated for use
only by the infected/colonized patient. e Eradication of colonization/carriage of pa-
5. Patient charts and records should be kept tients and healthcare workers should be at-
outside the isolation room. tempted (see section on eradication of MRSA
6. Linen should be treated as infected. It must carriage).
be discarded into alginate bags within the e Colonized staff should be excluded from work
patient’s room and a secondary bag outside until eradication of carriage is achieved.
the room.
7. All waste should be discarded into a clinical
waste bag inside the room, and bags should
subsequently be disposed of according to 3. Background
hospital policy.
8. Transfers of colonized/infected patients MRSA was first reported in 1961;4 it has since been
within and between institutions should be regarded both as a rare condition and of doubtful
avoided unless essential, and the receiving clinical significance,5 and as a major pathogen in
institution should be made aware of the pa- many countries.6 Control is necessary because of
tient’s colonization/infection status prior to the recent emergence of VISA and VRSA.7,8 In
transfer. some countries, such as The Netherlands, the pro-
9. After discharge, the room in which the pa- portion of S. aureus bloodstream infections that
tient was cared for should be cleaned ac- are meticillin resistant is small9 (under 1%) com-
cording to local disinfection policy, with pared with Germany (19%), Belgium (28%), France
special attention given to horizontal sur- (33%), the USA (50%) and the UK (40%).9,10 The
faces and dust-collecting areas. Hot water low rates in some northern European countries
and detergent are usually satisfactory. Cur- may reflect a more vigorous ‘search and destroy’
tains should be changed. policy combined with lower bed occupancy rates,
10. Compliance with infection control proce- or may reflect exposure to different strains of
dures should be monitored. MRSA with less propensity for spread.S10 J.E. Coia et al.
3.1. Why is control and prevention in the non-endemic situation to control the
still important? spread of MRSA and also to eradicate it.20,21
Whether it is possible to eradicate MRSA in hospi-
MRSA remains common in the UK.11 Nonetheless, tals where MRSA is endemic is debatable, but it is
up to the early 1990s, MRSA accounted for less possible to control spread and minimize the clin-
than 5% of S. aureus blood culture isolates. How- ical impact.
ever, there has been a dramatic change in the MRSA control measures have additional advan-
last 10 years. The prevalence of meticillin resis- tages to those of controlling MRSA alone as they
tance amongst strains of S. aureus causing blood- accentuate the awareness of the importance of
stream infection in the UK between 1990 and the healthcare-associated infection and assist in the
early 2000s increased from 2% to >40%, and the containment of other multi-antibiotic-resistant
mean overall rates of MRSA bacteraemia per 1000 bacteria.22 One of the reasons for the relative
occupied beds ranged from 0.10 to 0.19.12 In an lack of success in the control of MRSA may be inad-
all-island prospective study of MRSA in Ireland, equate resources and the failure of healthcare
the prevalence rate per 100 000 population was professionals to comply with good infection con-
higher in the south (14.0) compared with the north trol practice. A recent report, which incorporated
(11.4), and the incidence of invasive infection a literature review and surveillance cultures in
ranged from 5% to 10%.13 Throughout Europe, a 500-bed hospital in North America, confirmed
there is considerable variation in the prevalence that, amongst other things, poor adherence to iso-
of MRSA, varying from low in the Scandinavian lation precautions and handwashing accounted for
countries to high in the UK, Ireland, Spain and the apparent ineffectiveness of control mea-
Italy, with the proportion of MRSA of S. aureus sures.23 Furthermore, an investigation of contact
isolates amongst blood cultures increasing signifi- transmission of MRSA in Australia showed that
cantly between 1999 and 2002 in both the UK and 17% of contacts between a healthcare worker
Ireland.14 and an MRSA-colonized patient resulted in trans-
The reasons for continuing efforts to control mission of MRSA from the patient to the health-
MRSA, i.e. to prevent its occurrence in clinical care worker’s gloves.24 However, compliance
areas that are MRSA free and minimize the prev- rates with glove use in the same study were 75%
alence and clinical impact (see below) where MRSA amongst the healthcare workers surveyed but
is not uncommon or even endemic, remain valid in only 27% amongst doctors.24 In a study of risk fac-
the opinion of the Working Party. Nevertheless, tors for MRSA transmission in an adult intensive
justification for not implementing specific mea- care unit (ICU), staff shortages were the only sig-
sures has been argued by others.15e17 Amongst the nificant variable associated with clusters of cases,
reasons offered for relative inactivity include the but a mean of only 59% of patient contacts were
view that these bacteria do not spread easily, are followed by recommended hand disinfection pro-
not virulent, specific measures advocated to con- cedures.25 Furthermore, the authors calculated
trol MRSA are counter-productive and, further- that an increase of 12% in hand hygiene compli-
more, they divert energies from other important ance would have decreased the potential for
areas of infection prevention. Finally, it is argued MRSA transmission significantly.
that the clinical impact of MRSA is no greater Recent North American guidelines for the control
than that of meticillin-sensitive S. aureus (MSSA). and prevention of both MRSA and multi-drug-
Others acknowledge the clinical impact of MRSA resistant enterococci emphasize the importance
but have been obliged, due to other consider- of good infection control practice such as hand
ations, to relax control measures and have docu- hygiene protocols, but also recommend specific
mented the consequences.18 measures to control MRSA such as decolonization,
It is mistaken to believe that specific measures active surveillance cultures and barrier precau-
to control MRSA are at the expense of measures tions.26 The arrival of clinically significant strains
to control and prevent infection with other of vancomycin-heteroresistant S. aureus and strains
pathogens such as Gram-negative bacteria, as that are fully resistant to vancomycin may mean
suggested in one study from a burns unit.19 The that there will be fewer effective therapeutic op-
experience of some countries such as Finland, tions available to treat S. aureus.27,28 Consequently,
where two successive MRSA outbreaks in the early specific measures to control MRSA as part of an over-
1990s were managed successfully and where MRSA all strategy of hospital infection prevention will help
is largely confined to long-term facilities rather to reduce the number of patients likely to acquire
than acute hospitals, suggests that it is possible both MRSA and strains resistant to vancomycin.Guidelines for MRSA in healthcare facilities S11
3.2. What is the true impact of MRSA? Inadequate or inappropriate infection control
measures, including those directed at controlling
Clinical MRSA, may have an adverse impact on hospital-
Although the majority of patients who acquire acquired infection. There was a significant in-
MRSA are merely colonized, not ill and do not crease in the overall rate of hospital-acquired
require antibiotic therapy, a proportion (about infection in a US hospital from 4.5% to 5.9% at
one-third, depending on the patient population) a time when MRSA spread in that particular
of patients develop infection, including invasive institution.36
infection, which may result in death. The number
of patients in whom infection with MRSA has been Financial
associated with death as recorded on death cer- A variety of attempts have been made to docu-
tificates increased from 8% in 1993 to 44% in 1998 ment the increased costs associated with MRSA,
in England and Wales.29 In a retrospective compar- but separating the true cost of MRSA infections
ison of 504 bacteraemia patients with either MSSA compared with the cost of MSSA, and the cost of
or MRSA bacteraemia, mortality was greater in the the actual interventions to control and prevent
MRSA group (14% vs 8%, P < 0.05).30 Many historical MRSA from the consequences of colonization and
or retrospective studies are difficult to assess be- infection, are very difficult. In a prospective case-
cause of deficiencies in data capture and because control study, the median hospital stay attribut-
due allowance has not been made for inadequate able to primary nosocomial MSSA bacteraemia was
initial antibiotic therapy. In a prospective study four days compared with 12 days for MRSA,
carried out over a four-year period, 84 patients and the overall costs were $9661 and $27 083,
with MRSA bacteraemia were compared with 100 respectively.37
patients with MSSA bacteraemia.31 Multi-variate It is difficult to extrapolate from local data to
analysis revealed that overall mortality was high- national data when assessing the true costs of
est in the MRSA group and that meticillin resis- MRSA in the healthcare sector and in society
tance was independently associated with death. generally, because the incidence and prevalence
A meta-analysis of nine suitable studies revealed varies from hospital to hospital, and it is difficult
that all but one found an increased risk of death to standardize costs between hospitals. Nonethe-
from MRSA bacteraemia, the relative risk com- less, in a Canadian hospital in which 20 patients
pared with MSSA bacteraemia arising from all of with MRSA infections were compared with 79
these studies being 2.12.32 A more recent publica- colonized patients between 1996 and 1998, the
tion that assessed studies published between 1980 cost of isolation and management of colonized
and 2000 found no studies that showed a lower patients was 1363 Canadian dollars per admission;
mortality in patients with MSSA bacteraemia com- extrapolating that throughout Canada, the authors
pared with MRSA bacteraemia, seven studies that concluded that the annual costs associated with
showed a higher mortality in patients with MRSA MRSA infection in Canadian hospitals were be-
bacteraemia, and 24 studies where there was no tween 42 and 59 million Canadian dollars.38 In
difference in mortality.33 However, when the stud- The Netherlands, where MRSA is relatively uncom-
ies were combined in a meta-analysis, the odds ra- mon, it has been calculated that the cost of keep-
tio for increased mortality from MRSA bacteraemia ing one medical centre in Utrecht free of MRSA
was statistically significant.33 over a 10-year period (1991e2000) by implement-
There is also significant morbidity and mortality ing a ‘search and destroy’ policy, i.e. vigorous
associated with other invasive MRSA infections. In screening of possible MRSA cases, isolation, decon-
a prospective study of patients with ventilator- tamination with topical agents and effective
associated pneumonia caused by MRSA or MSSA, follow-up, was V2.8m.39 The implementation of
the presence of bacteraemia and septic shock was this policy was associated with 2265 lost hospital
more frequent in the MRSA group, and mortality bed-days and wards being closed on 48 occasions.39
directly due to pneumonia was significantly higher The financial consequences of MRSA, if it had
amongst patients with MRSA infection.34 In a pro- spread and caused infection requiring treatment
spective study of patients with MRSA and MSSA sur- over the 10-year period, were not calculated but
gical site infections, patients with MRSA had would probably have been well in excess of this.
a longer mean duration of hospital stay with MRSA isolated from superficial sites and in long-
a higher mortality.35 Meticillin resistance remained stay patients in the community may have little
an independent factor influencing mortality on clinical or financial impact. In contrast, MRSA in
multi-variate analysis in this study. the ICU often results in bloodstream infection,S12 J.E. Coia et al.
ventilator-associated pneumonia, intravascular- antibiotic-resistant Klebsiella pneumoniae also de-
device-associated infections and urinary tract in- clined (1.7% to 0%).44 In one of the largest resource-
fections, with significant financial implications. A limited hospitals in the world, targeted intervention
carrier in the ICU may also act as a reservoir for programmes, in which staff and patients were
MRSA acquisition by many very ill patients at risk of screened for MRSA carriage, patient carriers were
invasive infection over many days or even weeks. isolated, and mupirocin and chlorhexidine were ad-
In a case-control study of patients in a medical ministered to carriers, resulted in the percentage of
ICU in France between 1993 and 1997 with a prev- patients with MRSA bacteraemia in the ICU declining
alence of MRSA carriage of 4%, the mean attribut- from 1% to 0.5%; however, this increased one year
able cost associated with MRSA infection was after the study when the intervention measures
calculated as $9275, and the total cost of an were withdrawn.45 Feedback of MRSA rates is also
MRSA control programme ranged from $340 to important; when this was undertaken for Clostrid-
$1480 per patient.40 The authors also made an ef- ium difficile infections, there was a decrease in in-
fort to calculate the impact of control measures, cidence but this increased again when the feedback
depending upon the cost of those control measures was discontinued.46
and their success in reducing incidence. A study of In a French study assessing the efficacy of
two tertiary neonatal units where efforts to con- a control programme during the mid 1990s, the
trol spread and prevent infections were different rate of MRSA infection decreased from 5.9 to 0.8/
revealed interesting findings. In the first hospital, 1000 patient-days as did the prevalence of MRSA
where there were 18 colonized patients and four carriage and the ratio of MRSA to all S. aureus.47 In
infections over a 10-month period, the costs a Spanish study, three time periods were studied,
ranged from $48 617 to $68 637. In the second hos- i.e. pre-outbreak, during an outbreak of MRSA and
pital, where efforts at control were less success- when a control programme was instituted. The num-
ful, 75 bacteraemias and 14 deaths over 31 ber of cases per 1000 patient-days was 3.2, 8.2 and
months were recorded, with costs totalling $1.3 2.0 during the respective periods in the ICU.48 The
million.41 There are, of course, the additional authors estimated that the programme prevented
costs to patients and their families (e.g. loss of in- 76% of expected MRSA cases and 85% of expected fa-
come), and to society (e.g. absence from the talities due to MRSA in the ICU. Another study in an
workforce) that also need to be considered. ICU on the effect of application of mupirocin oint-
ment to the nose with whole-body washing using
3.3. Do control measures work and are chlorhexidine in patients colonized with MRSA to
they worthwhile? prevent pneumonia showed that there was a signifi-
cant reduction in infection.49
The objective of control measures should be to In contrast, in a recent UK study conducted in two
prevent the acquisition of MRSA and eradicate it ICUs to assess the effectiveness of patient isolation
when it does arise in centres where it is not currently during two periods, one of which involved not
prevalent. In hospitals where MRSA is endemic, the moving positive patients to an isolation room, the
objective is to minimize spread and, in particular, authors found no difference in the MRSA acquisition
avoid as far as possible the clinical impact in high- or transmission rates, and concluded that isolation
risk patients such as those in the ICU or in other key policies should be re-evaluated.50 An accompanying
clinical areas. Harbarth et al. argued that the num- commentary argued that their conclusions were
ber of patients with MRSA bacteraemia correlates premature because admission cultures were ob-
with the hospital-wide prevalence of MRSA, and tained in only 80e87% of patients (possibly insuffi-
that even where control measures are delayed, con- cient to prevent dissemination) and because
trol measures have a substantial impact on both the compliance with hand hygiene was only 21%.51
reservoir of MRSA patients and the attack rate of Nonetheless, this study demonstrates the need for
MRSA bacteraemia.42 This is also supported by the well-designed studies to be carried out on specific
modelling studies in the Health Technology Assess- interventions, addressing confounding factors.
ment systematic review of isolation policies.43 Fur- When assessing the cost-effectiveness of MRSA
thermore, some recent studies have suggested that control programmes, a number of variables have to
MRSA control measures as part of an infection con- be considered. These include the cost of the
trol programme can also reduce the impact of other intervention and the cost of MRSA infection.
multi-resistant bacteria in ill patients.44 After the Laboratory costs for MRSA screening are quite
institution of good infection control practice, the low; in one Canadian hospital, these were found
incidence of MRSA colonization decreased (from to be $8.34 per specimen with a total cost of
7.7% to 2.6%) and the percentage of patients with $30 632 during 1996 for a 980-bed hospital.52Guidelines for MRSA in healthcare facilities S13
A model has been proposed to explore the impact health data essential to the planning, implemen-
of MRSA acquisition and different MRSA screening tation, and evaluation of public health practice,
tests; it was concluded that taking a sample from closely integrated with the timely dissemination of
the nose alone and inoculating directly on to a ci- these data to those who need to know. The final
profloxacin Baird-Parker agar, without broth incu- link in the surveillance chain is the application of
bation, was the most cost-effective approach.53 these data to prevention and control.’
However, other aspects have to be costed and
these include hospital-wide programmes of ade-
quate cleaning and environmental decontamina- Thacker SB, Berkelman RL. Public health surveil-
tion. Interventions to improve hospital hygiene lance in the United States. Epidemiol Rev 1998;10:
decreased the percentage of environmental sites 164e190.
positive for MRSA from 32% to 0.47% in one re-
port.54 Enhanced environmental decontamination
is likely to assist in controlling the spread of 4.1. Background
MRSA as well as other bacteria such as C. difficile.
It is also likely to improve the aesthetic appear- Most reviews of interventions to prevent and
ance of the hospital, resulting in other beneficial control MRSA document the difficulty of establish-
health and psychological effects and demonstrat- ing the effect of particular infection control in-
ing the values of the organization. terventions, as multiple interventions are usually
used together. Surveillance, however, is a critical
3.4. Conclusions part of any infection control programme. It must
not be an end in itself, but should be undertaken to
The data available to date strongly implicate MRSA improve the quality of care. It is the instrument for
as a significant hospital-acquired infection result- early recognition of changes in patterns of infec-
ing in additional morbidity and mortality as well as tion, identifying the size of the problem, monitor-
contributing to healthcare costs. This applies to ing trends and comparing rates, evaluating the
patients at particular risk, e.g. patients requiring effectiveness of interventions, identifying areas
intensive care and patients following major sur- for further investigation or research, re-inforcing
gery, and the elderly, which comprise an increas- good practice, and influencing key hospital staff
ing proportion of patients in acute hospitals and in and decision makers. Robust surveillance cannot be
other healthcare institutions. Furthermore, pa- undertaken on a ‘shoestring’ budget, but requires
tients and the public are increasingly seeing resourcing for the collection, collation, analysis
MRSA and rates of MRSA infections as indicators and interpretation of data. Typically, this requires
of the quality of patient care. They require re- input from staff with information technology skills
assurance that all healthcare professionals are to the infection control team.
taking reasonable and sensible precautions to Seminal work in this area has demonstrated that
minimize spread. Although it is very difficult to hospitals with infection surveillance and control
carry out double-blind randomized controlled tri- programmes reporting wound infection rates back
als on specific aspects of recommended control to surgeons reduced rates of hospital-acquired
programmes, because MRSA colonization and in- infection by 20%, highlighting the importance of
fection rates vary considerably from time to time feeding back data to inform decision makers.
and from centre to centre, control measures have These reductions were further augmented incre-
been shown to be effective, resulting in reduced mentally when surveillance had been in operation
mortality as well as helping to contain healthcare for at least one year and there were dedicated
costs. Consequently, the Working Party is of the infection control practitioners (this study also
strong opinion that an active MRSA control and demonstrated the cost-effectiveness of such pro-
prevention programme, as part of an overall in- grammes).55 More recent work has also empha-
fection control strategy within a hospital, con- sized the importance of feedback of surveillance
tinues to be the recommended approach. information. For instance, Stone et al. demon-
strated that feedback of C. difficile rates with
involvement of clinicians was associated with re-
4. Surveillance ductions in the incidence of C. difficile diarrhoea.
When feedback was relaxed, rates rose, as did
those for MRSA.46 In addition, a descriptive study
‘Epidemiologic surveillance is the ongoing system- by Curran et al. investigated the hospital-wide
atic collection, analysis, and interpretation of feedback of MRSA acquisition data monthly toYou can also read
