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MRSA: false economy may lead to dangerous practices

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VOL: 97, ISSUE: 38, PAGE NO: 54

CARMEL EDWARDS, SEN, RGN, MA, is infection control nurse, Wirral Hospital, Merseyside

Three patients on an acute orthopaedic ward contracted the same strain of methicillin-resistant Staphylococcus aureus (MRSA) in their wounds within two weeks of each other, suggesting cross-contamination from a common source. An investigation was conducted in order to identify how this had happened. The spray foam canisters used to clean incontinent, dependent patients were identified as being contaminated with a number of bacteria, including MRSA.

Three patients on an acute orthopaedic ward contracted the same strain of methicillin-resistant Staphylococcus aureus (MRSA) in their wounds within two weeks of each other, suggesting cross-contamination from a common source. An investigation was conducted in order to identify how this had happened. The spray foam canisters used to clean incontinent, dependent patients were identified as being contaminated with a number of bacteria, including MRSA.

The first case, Annie Brown, was admitted on February 22 after sustaining a fractured pelvis. She had sustained a brain injury several years earlier and was immobile.

On admission she was found to have severely excoriated skin under both breasts, which she had suffered for the past 12 months. On March 1 a specimen was obtained from the excoriated skin site and MRSA was isolated. The primary nurse looking after her was informed of the result on March 5.

An assessment was made as to whether Ms Brown needed to be nursed in isolation. It was decided that, because the dermatologists had assessed the wounds and had recommended treatments that were dramatically improving them, the wound exudate was contained adequately in the dressings and she was immobile, that she could remain in the bay. She was treated daily with liquid soap containing triclosan antiseptic, bed baths and mupiricin nasal ointment, inserted into both her nostrils four times a day as per hospital protocol.

All staff were reminded of the importance of diligence in hygienic practices. The medical staff did not consider antibiotic therapy to be appropriate, as the excoriated area appeared to be colonised with the bacteria rather than infected.

Janet Smith was admitted on March 1 with a fractured neck of femur and underwent a hemi-arthroplasty the following day. She had been taking warfarin before admission and a few days after surgery her wound started to ooze serosanguineous fluid, a not uncommon finding in someone on anticoagulant therapy.

A postoperative wound swab specimen was obtained on March 12 and MRSA was isolated. Following a risk assessment it was agreed that Mrs Smith could also remain in the bay because the wound exudate was contained in the dressing, the wound did not appear infected and she needed the stimulation of the company of other patients. She was also treated daily with liquid soap containing triclosan antiseptic and mupiricin nasal ointment regime and the importance of high standards of hygiene was reiterated. Mrs Smith was being nursed in the same bay as Mrs Brown.

Agnes Fowler was admitted on March 7 after sustaining a fractured neck of femur in Spain where she had had external fixators applied to her thigh. On March 14 a swab was taken from the wound site and MRSA was isolated. Although Mrs Fowler was not nursed in the same bay as the other two patients, the same team of staff were nursing her.

Mrs Fowler's wound did appear infected and she was put on intravenous teicoplanin together with liquid soap containing triclosan antiseptic and mupiricin nasal ointment. As with Mrs Brown and Mrs Smith, she was not isolated in a side ward because her wounds were covered.

The infection control team undertook an investigation and the three MRSA isolates from the patients were sent to the Public Health Reference Laboratory at Colindale, north London, for identification by phage type to see whether they were all the same strain. The results revealed that the MRSA strain from the three isolates was 42E/81.

A meeting was held on the ward and all staff were asked if they had any thoughts on to how this outbreak of MRSA had occurred. All the patients were either immobile or mobile with assistance and received a great deal of nursing intervention from the nurses. The local clinical governance standard for hand decontamination had recently been launched and all staff were adamant that they were decontaminating their hands between every patient contact.

Asked whether they used any creams or lotions communally, the staff all stated that they did not. Asked whether they used a foam wash for freshening up patients, the nurses agreed they did and that this was used communally. The staff did not consider the foam to be a cross-infection risk because they sprayed the foam directly on to the skin or a clean wipe. However, on inspection of the canisters of foam, visual evidence of body fluids and faeces were found on some of them. The canisters were removed from the ward and taken to the microbiology department for testing.

Four canisters of the foam were submitted for microbiological examination on March 28. Each canister had dried foam around the nozzle and brown stains on the outside. The dried foam and brown stains were sampled, using a moistened swab that was inoculated onto bacterial culture media, including a selective medium for MRSA. The media were incubated and examined for growth. Any bacterial growth was identified using standard microbiological techniques.

The results showed scanty to moderate growth of the following micro-organisms: coagulase negative staphylococci, aerobic spore-bearing bacilli, faecal streptococci, alphahaemolytic streptococci and MRSA. The MRSA was found on two nozzles where the fingers press to release the foam. These two isolates were sent to the Public Health Reference Laboratory for phage typing and one was identified to be the same strain, 42E/81, that had been responsible for causing the outbreak on the ward. The other strain was untypeable.

There is plenty of evidence that outbreaks of infection have been associated with the communal use of creams, lotions and antiseptics (Oie and Kamiya, 1996; Russell et al, 1999). The foam is a cleansing agent and should be sprayed directly on to the patient's skin or on to a clean wipe - therefore the outside of the canister may not be perceived as contaminated. However, in practice extra foam is often needed during the cleansing process and the gloved hands of staff, having been in contact with the patient's skin, are able to contaminate the nozzle/depressor. Consequently, every time the foam is used thereafter the canister becomes a source for cross-infection. Even when such items are used on a single-patient basis, care must be taken to ensure that practices do not lead to recontamination of that patient.

Foam spray is preferable to soap and water for maintaining skin integrity of elderly incontinent patients who have a high risk of developing pressure sores due to repeated washing of their sacral areas (Cooper and Gray, 2001). Ward staff find it convenient to use for any bedfast or dependent patient. As long as staff are aware of the potential cross-infection risks associated with the product it still has its place in the clinical setting, providing it is used effectively and safely.

Regular liaison and discussion with the ward staff was essential throughout the investigation to ensure that other potential risks had not been overlooked. Having a committed, enthusiastic infection control link nurse on that ward improved communication immensely because she was able to disseminate the updated information to all the staff at regular intervals.

This was the third time within the past two years in our hospital that communal use of lotions, creams and ointments has been implicated in an episode of cross-infection. Communal use of soft paraffin ointment was identified when several patients developed MRSA nasal colonisation on another unit. In addition, tubes of KY jelly have now been replaced with single use sachets throughout the hospital because of cross-infection associated with the insertion of nasogastric tubes.

As a result of this incident, the infection control team has recommended that, if spray foam is to be used, it must be used for a single patient only, labelled with the patient's name and discarded when the patient goes home. Smaller canisters are available at reasonable cost, avoiding wastage and excessive expenditure.

The cost of hospital-acquired infection to the NHS has been estimated at £1bn a year (Plowman et al, 1999). Although not all of these infections are preventable, it has been estimated that between 15-30% can be avoided (Plowman et al, 1999). This outbreak of infection could have been prevented and it has had considerable financial implications for the trust - for example, in extra bed days for these patients, antiseptics, antibiotics and microbiological sampling. It was distressing psychologically for the patients, particularly Mrs Smith, who would not allow her family to kiss her in case they 'caught' something, and not least for the nurses who felt responsible for causing such problems for the patients.

It would be surprising if the staff in our hospital is unique in communal use of such products, and we suggest that others should audit their practice. Constant vigilance and education on this matter are essential due to staff changes and the possibility of staff reverting to old practices.

Staff may feel that the disposal of unused lotions, creams and ointments is wasteful, resulting in false economies; saving pennies could result in hundreds or thousands of pounds being spent unnecessarily. These cases of infection highlight how apparently innocuous aids to patient care can potentially do them more harm than good. Where there is transmission of micro-organisms that cannot be explained by failure of hand-washing, the possibility of shared use of such items must be considered.

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