Author Shila Patel MSc, BSc, RGN, is clinical nurse specialist infection control, Epsom and St Helier University Hospitals NHS Trust
The incidence of MRSA continues to rise in hospitals and the community (Morrison, 2005). There are national guidelines for its management in both of these settings as guidance for hospitals are not applicable to the community and vice versa. This can be confusing for both health workers and patients. Health workers need to understand these differences so that they can explain them to patients.
Managing MRSA in hospitals
The Guidelines for the Control and Prevention of MRSA in Healthcare Facilities (Joint BSAC/HIS/ICNA Working Party on MRSA, 2006) state that specific control measures should be implemented for patients who are either colonised or infected with MRSA.
Patients should be isolated in a single room with en suite facilities. Where there are insufficient single rooms available patients may be nursed in a cohort bay with clinical handwashing facilities. Risk assessment will be important in this situation. Patients considered to be most vulnerableto cross-infection are those with large open wounds or invasive devices such as intravenous cannulae, and those who are immunosuppressed. The door to an isolation room should be kept shut to minimise the spread of infection to adjacent areas.
Standard infection-control precautions
Hand hygiene should be undertaken before and after all patient contact and on leaving the isolation facility. Protective clothing, such as disposable plastic aprons and gloves, should be worn when handling patients or their immediate environment, dealing with body fluids, handling an invasive device, such as an indwelling urinary catheter, or contaminated items, such as equipment. Used gloves and aprons should be removed inside the isolation room.
If staff enter an isolation room but are unlikely to come into contact with patients or objects in the environment – for instance when conveying a message to patients – gloves and aprons are not required. Care should be taken not to stigmatise patients through unnecessary glove and apron use. All waste generated within the isolation facility should be categorised as clinical waste and all linen should be categorised as contaminated/infected and managed according to local policy.
The environment is thought to play a fairly minor role in MRSA transmission (Ayliffe et al, 1999) but MRSA can survive in dust, so minimising dust on environmental surfaces and fomites, such as equipment, is necessary (Duckworth and Jordens, 1990). Wherever possible, equipment should be for single-patient use; if multipatient-use equipment is required it should be decontaminated according to local policy and the manufacturer’s instructions.
Treatment and screening
Skin decolonisation treatment will help reduce the number of bacteria on patients with MRSA, which will reduce the risk of cross-infection to other patients. Skin decolonisation protocols should be given to patients in accordance with local infection-control policies. Protocols usually last for 5–7 days and consist of an antiseptic nasal ointment and antiseptic skin and hair wash. Re-screening for MRSA should be undertaken following treatment if requested by local infection control teams.
If patients remain MRSA positive, the skin decolonisation protocol may be repeated but usually they will receive no more than two courses in an inpatient episode. This helps to reduce the risk of the bacteria developing resistance to the treatment, in particular to mupirocin antiseptic nasal ointment, often used as part of this protocol (Joint BSAC/HIS/ICNA Working Party on MRSA, 2006). It also limits the potential for skin breakdown as prolonged and repeated use of the antiseptic body wash may damage skin integrity, thus increasing the risk of infection. Systemic antibiotics may be recommended if a clinical infection is present.
The Department of Health has asked trusts to review their policies for the initial screening of patients on admission to hospital and decolonisation policies for MRSA in an attempt to reduce transmission rates (DH, 2006).
MRSA screening protocols often identify categories of patients who are more likely to carry these bacteria. Examples are listed in Box 1. The DH (2006) has provided an extensive list of groups of patients that could be screened (see Update, p38).
Managing MRSA in the community
Patients can be discharged back to the community with MRSA. However, the community is made up of a variety of care settings from patients’ own homes to nursing/residential care-home facilities.
Guidance issued by the DH (1998) for nursing and residential homes states ‘there is no justification for discriminating against people who have MRSA by refusing them admission to a nursing or residential home or by treating them differently from other residents’. However, it is vital that national guidelines on the control of MRSA in the community are adhered to (Combined Working Party of the British Society for Antimicrobial Chemotherapy and the Hospital Infection Society, 1995).
Isolation is generally not needed in the community as Staphylococcus aureus does not pose a serious infection risk to people in their own homes or residents in nursing/residential homes (Combined Working Party of the British Society for Antimicrobial Chemotherapy and the Hospital Infection Society, 1995). Therefore people in residential and nursing homes who are colonised with MRSA should be encouraged to be mobile and join in with social activities in communal areas of the care facility.
Infected wounds must be kept covered, preferably with an impermeable dressing; this precaution should be taken irrespective of whether or not a person in a nursing or residential home has MRSA.
If there are vulnerable residents in a nursing home, such as those with open postoperative wounds, isolation of the resident with MRSA will be required following the principles used in hospital. In addition, if a resident is colonised with MRSA and has an open wound, they should not share a room for sleeping purposes with other residents.
Standard infection-control precautions
It is important to implement standard infection-control precautions at all times irrespective of whether a person in the community is diagnosed with MRSA.
Treatment and screening
The need for skin decolonisation for patients in the community should be assessed individually. Factors that should be considered include:
- If the patient is midway through a decolonisation treatment protocol;
- If the patient is discharged to her or his own home or to a nursing home;
- If the patient is in contact with vulnerable residents in the care facility;
- If the patient has an acute wound.
As there are a number of variables health workers should refer to their local policies and consult with their local community infection control teams.
The need for MRSA screening in the community should be individually assessed. Where patients with MRSA are discharged from hospital to their own home they do not need routine MRSA screening, and it should only be carried out if there are clinical indications, for instance where a wound appears infected. In some situations screening may be required if the patient needs to be readmitted into hospital in the near future.
If a patient with MRSA is discharged to a nursing/residential home, screening should be undertaken according to local guidelines and the potential risk to others in the care facility needs to be considered. Following skin decolonisation treatment the need for screening will vary and depends on the level of cross-infection risk. Again local infection control policies should be followed.
All health workers should understand the different MRSA-management protocols so that effective communication may be achieved. This will help to minimise anxiety and enable patients to make a seamless transition from hospital to community care or vice versa.
Ayliffe, G.A.J et al (1999)Hospital-acquired Infection: Principles and Prevention (3rd edn). Oxford: Butterworth-Heinemann.
Combined Working Party of the British Society for Antimicrobial Chemotherapy and the Hospital Infection Society (1995) Guidelines on the control of Methicillin-resistant Staphylococcus aureus in the community. Journal of Hospital Infection; 32: 1, 1–12.
Department of Health (1998)MRSA: What Nursing and Residential Homes Need to Know. Leeds: DH.
Department of Health (2006) Screening for Meticillin-resistant Staphylococcus aureus (MRSA ) colonisation. A strategy for NHS trusts: a summary of best practice. London: DH.
Duckworth, G.L., Jordens, J.Z. (1990) Adherence and survival properties of an ‘epidemic’ methicillin-resistant strain of Staphylococcus aureus compared with those of methicillin-sensitive strains. Journal of Medical Microbiology; 32: 3, 195–200.
Joint BSAC/HIS/ICNA Working Party on MRSA (2006) Guidelines for the control and prevention of methicillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. The Journal of Hospital Infection; 63: Supplement 1, S1–S44.
Morrison, D. (2005)MRSA – from hospital superbug to community threat. The Bulletin of the RoyalCollege of Pathologists; 129: 14–16.