Recommendations
Colonized
Methicillin-Resistant
in
between
Acute
Oklahoma
Oklahoma
with
and
Facilities
In
conjunction
State
Antibiotic
State
Extended-Care
for
MRSA
Department
the
and
Staphylococcus
with
Transfer
Working
Resistant
the
the
of
Control
Health
Facilities
Group
of
Bacteria
Patients
aureus of
Recommendations
Antibiotic
Control
Thomas
James
Cindy
Gall
Scott
Gregrn
Gwen
Douglas
William
Pamela
David
Dee
Tern
Judy
Patrice
Collins,
Klein,
In
J.N.
of
Averlil,
Barber,
Harrington,
Lyons,
Resistant
Cobb,
P.
Boden,
Greenfleld,
Acute
Ktahk,
Methlcillln-Reslstant
R.
Downham,
P.
Hutton,
McNabb,
ADVISORY
Istre,
RN.
FIne,
for
R.N.
MD.
RN.
RN.
R.N.
R.N.,
and
M.D.
the
MD.
M.D.
MD.
Bacteria
RN.
RN.
Jr.,
Ph.D.
Extended.Care
M.S.
Transfer
M.D.
i
COMMITtEE
between
of
Staphylococcus
John
Jon
Cliff Eric
Maggie
Leonard
Shirley
Venusto Patients
Stanley
Mark
Philip Vadeke
Jan
Cynthia
Tamra
Facilities
Facilities
D.
L
Wiodaver,
Probst,
E.
Rowland,
Tlfllnghast,
Westermnn,
pat
Rettig,
K.
Tannehlll,
Ward,
Schwartz,
San
Slater,
Miller,
Meadows,
Colonized
Shores,
Ramgopal,
RN.
Joaquin,
and
M.D. aureus
MD.
MD.
M.D.
M.D.
RN.
M.D.
R.N
C.LC.
M.D.
RN.
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ERADICATION
EPIDEMIC
ENDEMIC
I)ECOLONI7ATION
COLONIZATION
CORORT
CARR
implementation
Three
endemic
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epideznio]ogicaliy
The
facility.
outbreak
(immunocompromised
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grouped
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usual
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situation.
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or
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of
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rate
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cases
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or
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each
carrier
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decreases
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patients
control
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through
for
facility
nosocomially-acquired
of
methicillin-resistant
by
manifestations
nares
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by
persons
persons
colonized
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staff
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colonization
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home
the
direct
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presence
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of
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aurcus
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number
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stool
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methicillin
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oxacillin.
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load.
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linked
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manifestation
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number
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infection
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furuncles,
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home).
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to
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infections
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boils,
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effective
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treatment.
infections
other
boils,
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to
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the
methicillin,
affected
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particular
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sympto
hands
persons.
drainage
MRSA
agmt
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are
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•
•
•
•
•
•
•
•
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Decolonization
accepting
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infectious
symptoms
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Treatment
vancomycin
facility.
infections
MRSA
A
MRSA
anticipated).
of
Body
MRSA
most
MRSA or
particularly Methicillin-rcsstant
physician
each
infect
or
substance
antibiotics
by
colonization
may
Infection
infection
is
and
indicates
a
the
basis.
to
(e.g.
transmitted
or
people.
of
patient
is
not
every
makes
antibiotic
others.
by
by
choice
illness
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attending
not
if
of minor
itself, isolation
itself,
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already
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means
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resistance
patient
effective
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this
effective.
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patient
Staphylococcus
due
skin
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patient
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resistant.
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patient
grounds
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with
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patient
infection
person-to-person
practiced
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for
3 be
antibiotics
MRSA.
can
does
decision
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aureu.
for
this
for
considered
hospital
when
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is
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exclusion
reports
admission
from
regard
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effectively
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usually
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contact
to
ccpha]osporins.
admission.
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attempt
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potentially
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contact.
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is
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other
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a
may
organism
a
patient
a
hospital
nursing
decolonization
bactena
or
moist
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be
not
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bacteria
illness
to
colonized.
before
in
evaluated vancomycin.
can
be
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body
or
but
home, an
that
indicated
due
for
extended-care
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and
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some
because
substances
can
prolonged
or
to
however,
must
after
for
on MRSA.
colon
MRSA
have
Oral
and
not
sp
care
an
be
it
to
is is
included:
exclusion
to
resistant it’s
Staphylococcus
these
(4)
(3)
(2)
(1)
The
(3)
(2)
(1)
Even
basic
The
attending
regarding
nursing
interested
An
The
the
health The
The
and
care
patients
The
key
Development
Discussion
Identification
control
increasing
though
infection
bacteria,
advisory
from
overall
problems
epidemiological
extended
increasing
need
need
affected
facilities.
care
home
problems
prompted
of
admission
MRSA.
aureus
private
we
for
for
provision
committee
not
MRSA.
facilities.
of
control
number
arc
industry
open
identified
education
health
of
the
of
by
incidence
unlike
(MRSA)]
addressing
physicians,
a
must
health
The
options
and
these
plan
to
resistant
principles
necessity
of
of
care
Pseudomonas
was
nursing
composed
purpose
adequate
patients
not
patient
by
for
about
care
of
guideline:.
facilities.
formed
this
available
and
MRSA
be these
future
the
to
professionals
strains
INTRODUC1ION
homes
group
such
MRSA blown
concern
care.
of
Oklahoma
in
view
communication
of
guidelines
with
the
meetings.
Oklahoma
colonization
aeruginosa
for
representatives
as
4
of
are
acute
out
committee
of
for
handwashing.
the
health
regarding
planning
neither
of
bacteria
health
City-County
purpose
and
throughout
to
perspective.
institutions
care
MRSA
in
and
extended
between
this
statewide
necessary
included:
care
treatment,
professionals
from
infection
of
respect.
[including
in
Additional
professionals
addressing
Health
Oklahoma
particular,
acute
acute
care
such
It
guidelines.
nor
is
in
control,
Attention
facilities
and
Department,
as
a
health
patients
reasonable.
at
Methiclllin-resistant
relatively
nursing
several
measures
interested
the
extended
this
in
and
care
first
aD
orgaithm
together
must
from
key homes
transfer
types
meeting
antibiotic
facilities,
and
health
such
be
acute
in
issues
paid
in
of
the
the
and
and
as of
model
sources,
recognition
of
MRSA
colonized
receiving
identification
and
control
infection
these
These
We
The
(5)
identification
of
The
recognize
colonization
and
guidelines.
need
including
guidelines
state
institution.
in
patient
need
should
contain
and
of
for
MRSA
between
to
risk
that
without
open
of
go
all
For
and
the develop
and
MRSA
It
to
factors,
guidelines. education
available
spread
is
that
the
and
the
infection
an
notifying
acute
epiderniological
reason,
guidelines
Kentucky
patients
frank
unacceptable
and
of
and
concerning
MRSA
medical
in
the
the
communication
a
Oklahoma
extended-care
is
separate
State
to
promotion
receiving
mandatory
within
control
literature
practice
5
principles
Health
the
section
these
is
facility.
epidemiolor,
the
critical
of
for
to
Department
facilities
about
on
institutions.
spread
infection
of
behind
transfer
the
the
the
for
purposes
patient
guidelines
is
of
the
them
subject.
a
paramount
control
MRSA.
control,
for
known
effective
Effective
MRSA
are
of
providing
addresses early
derived
precautions
MRSA
However,
and
implementation
colonion
cotnxnuznjcadon
in
treatment,
treatment
an
the
from
infected
this
excellent
effort
special
in
many
issue.
the the
of
or
or to BACKROfl4D
Szaphylococx aureus (Gr. “a bunch of golden grapes”) is a gram-positivecoccusnamed for its tendency to grow in clusters, like grapes, as seen when eammed roscopically. S. aureus can multiply on human skin and on mucous membranes for long periods of time without causingsymptoms (colonization). Alternatively, S. aurezs can multiply and invade host tissue causing symptoms of disease (Infection), especially in patients who are immunocompromised, mainounshed or debilitated, or who have chronic illnesses such as diabetes and renal failure.
The organismwas first identified in 1880by a surgeon, Alexander Ogston,who note1 that the majority of abscesses he studied whichwere inflamed and warm to the touch we caused by the same organism. In 1928,penicillin was discovered and was fatmcj tt be effectivein treating S. azsreurinfections. Due to the antibiotic selectivepressure of penicillin usage, S. aureus evolved the enzyme peniciilinasc. Peniciliinase inactivates penicillinby breaking its structural beta-lactam ring,rendering the penicillin ineffective.
In 1959,the first semi-syntheticpenicillin,methicillin(then calledcelbenin),wasproduced by altering the chemical composition of penicillin. Two years later, the first mcthkifljn resistant strains of S. aureus (MRSA) were reported in England and in the United States. However, there is some evidence that methicillin resistance may predate widespread methiclllinuse.
Staphylococcus aureur is transmitted primarily through direct person-to..personcontact. It can remain viable in the environmentfor long periods of time in clothing,linens,anddust. However, it is not thought that fomitesor environmental surfaces represent significantrisk of infectionifappropriately handled. Siaphylocxcusaureu, has alsobeen found throughair sampling techniques, but outbreaks caused by airborne transmissionof the orrnim are rare. The most significant mode of transmissionis by direct person-to-personcontact..
The first documented nosocomial (hospital-acquired) outbreak of MRSA in the U.S. occurred at the Boston City Hospital in 1968. The investigationof this outbreak suppurted transmission by the direct contact of hands of the personnel to patients in the ward. Since the Boston City Hospital outbreak, numerous outbreaks have been described in nursing homes, hospitals, neonatal units, intensivecare units, hospital wards,and in the couwuity at large.
Methicillin-resistant S. aureur (MRSA)colonizationarid infectionin acute and extended- care facilitieshave increased dramaticallyover the past two decades. This is evidencedby the increasingnumber of reported outbreaks in the medical literature. Although no cial statewide data are coilected on MRSA infection in Oklahoma (because MRSA is not a reportable disease), the General CommunicableDiseases Divisionof the OklahomaState Department of Health (OSDH) has receivedan increasing number of outbreak reportsfrom acute and extended-care facilities. Outbreaks are no longer just reported fromlarge,tertiary
6
resistant
transfer logistic
strain.
colonizer. susceptible
personneL prevaicut
smaller,
care,
medical
It
problems
between
bacteria.
comniimity
is,
in
It
S.
however,
It
simply
nature
awur.
school
must
nursing
concerning
Is
based
be
and
causing
ffThated
resistant
However,
noted
more
homes
hospitals
significant
patient
here
important
hospitals
to
and
according
more
and
that
care
hospitals,
morbidity
antibiotics.
nursing
7
MRSA
in
as
and
Oklahoma.
to
a
sonic
cause
treatment,
homes.
due
and
is
no
It
mortality
to
reports
of
Is
more
the
not
The
acute
We
isolation,
lack
a
pathogenic
have
it
or
and
superbug
infections
may
aiuszn
of
is
received
presenting
education
bosp
be
is
or
a
or
becoming
in
an
more
alzatiou,
vinzleut
reports
patients
andromed
signicarn
regarding
eciern
more
from
than
and and
vancomycin,
The
known could
MRSA
by
to
Vancomycin disease death.
skin
illness.
who
mentally
infections
circumstances
experiences
Decolonization
disposition
infected. care.
MRSA
and
colonization presumably
permanently
physicians colonized.
Hospital
(methiclllin
an
symptoms
colonization
When the Treatment
culture
The
Treatment
It
standard
open
lesions
are
hospital
include
is
kidneys
as
It
such definition
colonization
Clinical
In
immunosuppressed
important
retarded).
present,
workers
Colonization
is
of
the or
wound
are
addition
of
can
vary.
such Seventy
especially
the
these
can
because
patients
as
rate
ototodcity
susceptible
and
antibiotic
colonizes
for
illness.
“red
for
ward
may
or
50%
fever,
be
manifestations
is
responsibility
have
an
renal
as
The
S.
the
with
of such
infection.
areas.
are
made
warrant
man
for
not
more
infection
does
to
aureus
attendants
A
boils
lnfecton
to
who
Colonization
of
purposes
malaise,
effectiveness
serious
more
when
with
S.
the
physician
local
as
system),
therapy
in
90%
(loss
usually
syndrome”.
increased
(e.g.
Clinical
not
aureus
likely
or
are
to
a
the
health
an
colonization
MRSA
and
decubitus
likely
too
symptoms
deeper
of
Colonization
require
of
due
more
side resistant)
discharge
attempt.
is
anterior
and
of
of
of
to
DIAGNOSISJTREATMEN’r
heating
for
are
and colonized,
recommended.
all
rapid,
is
should
tissue
infection
infections
to
the
decolonization be
care
effects, to
can
exposure.
is
seen
leukocytosis
infections
of
likely
individuals
MRSA
allergic
90%
infections
further
not colonized,
Vancotnycin
be
permanent
physician
ulcer.
occur
can
invasion
or professional
nares
and
Examples
of
assess
to in
colonized
in
an
to
especially
other
more
caused
and
the indicates
result
home).
health
indication
spread
caused
*
is
hospitalIzation
the
signs
reactions
The
in
caused
of
usually
lncomparison
therefore,
nares,
each
such
are
nurses
are
the
auditory
to
by
decolonization
about
likely
may
in
anterior
by
patient
However,
care
given
of
of
than
the
by
determine
the
often
intermittently
flushing, nares,
situation.
in
as
S.
to
the
by
special
infection,
rectum,
or
for
an
such
S.
are
aureux
elderly organisms,
workers
pneumonia
to 20-30%
understand
MBSA
organism
persons
by
dimgc),
aureus
presence
may
indication
might
hospital
present
does
70%
trachea,
be
nares.
if
as
mouth
circumstances
]typotcnsion,
scientific
appropriate
not
or
with
can
fever
persons.
colonized..
if
not
is develop
systemic
more
seems
can
who
of
skin
in
a
intravenous
with
be
be
admission.
due
nephrotoxicity colonized
of
is
the
exhibit
the
skin
patient
the
for
which
the
and
range
Staphylococcus
indicated
provide
identified
not
can
likely
the
marginal,
to
consequent
data
hospital
genera]
general
general
particularly
These
difference
folds,
rash.
manifestations
behavior
be effecth’e
arrangements
organism
and
can
from
include
symptoms
Thus,
to
is
with
and
detected
Furthermore,
direct
vancowycin
be
colonized
rectum,
tachycardia
or
progress
side
Infusion
by
population,
admiccion.
population.
pop
superficial
but
colonized,
(damage
effecnve.
cultures
S.
personal
a
(e.g.
patients
galuict
between
clinicaL
serious
effects
special
withozt
patient
higher
aw’r
aww..s
ation,
wben
the
for
of
of
to
or m
consulted
be susceptibilities
Resistance
testing
appropriate
of
After
resistant
blood,
by
S.
when
sputum,
aureus
the
in
to
for
viva, should
questions
Kirby
oxacilfin
the
is regardless
urine,
particular
identified,
not
Bauer
be
arise.
also
percutaneous
reported
technique
of
infection.
susceptibilities
defines
in
vrav
on
susceptibilities.
is
MRSA
resistance
aspiration,
9
the
should
preferred
isolates
to
be
or
performed.
since
all surgically
Reference
method
penicffllns.
all
isolates
obtained
of
laboratories
Oxacillin
identifying
are
Cephalosporin
considered
specimens
susceptibility
should
MRSA.
be
to as SURVEILLANCX
The issue of MESA status (negative, colonized, or infected) with regard to hospital and nursing home admission and discharge warrants deliberate attention to detail. This issue is of great practical significance in Ugh! of the current misinformation, fear, and the natural inadequaciesof complete, preventive control measures for infectionand coIonitjon.
HospitalAdmission:
Hospitaladmissionbecause of MRSA Infection is acceptable tnedicalpractice. However, MRSAcolonization does not by itscif warrant hospital admission. Treatment for infection with MRSA can best be accomplished in an acute-care setting. However, given special circumstances,treatment for infection can be accomplished in an extended care facilityor at home. This decisionis based on the clinical judgement of the attending physician.
Hospital Discharge:
Upon completion of appropriate therapy for MRSA infection, and when the clinical manifestationshave resolved (even if the patient has a positive culture) hospital discharge maybe indicated. A patient colonized with MRSA while hospitalizedforanother Illnessmay be dischargedonce that illnessisunder controL In other words, a patientmay be discharged from an acute-care setting with a positive MRSA culture. When this occurs, the hospital should notify, in advance, any institution receiving the patient that s/lie is colonized with MRSA
NursingHome Admission:
There are no reasons to deny nursing borne admission for a person colonized with MRSA. MRSA, alongwith other bacteria, may be present in anypatient Therefore, strict attention to handwashingis indicated at all times. A patient colonizedwith MRSA should be admitted to a nursinghome. The MRSA colonized patient can be placed withanother colonizedpatient (this is not mandatoty), if one has been identified,but should be placed in a room with a patient who is not at high risk for MRSA infection (ic. a patient with a tracheostomyor a gastrostomytube). A patient with clinicalMESAinfection, however,may be admittedto a nursingborne under special circumstances (e.g.minorskin)woundinfection, UTI’s,or terminI illness)provided clinicaljudgment, fmiU1 consent, and nursing home adrninñtrarionagree.
NursingHome Discharge:
A patient may be discharged to home while colonized with MRSA. If the colonized patient is transferred to an acute-care setting. the receiving facilityshould be notified, in advance.
10
as:
local
strict
careful
to
rule
release (i.e.
cultures
patients
should
cultured
wing
institutiocm.
substance
immediate cnterioa
nosocomially-acquired
risk
burn ciumbet
are
a
care
(RSA
4.
3.
2..
Epidemic
I.
be
Imniediate Decolonization
MRSA
Outuig
Upon
epdeologtcaUyassxtated
arc
if
area
county
isolation
where
facility,
unit
an
Body
Which Date Patient’s
feasible
surveillance
be
from
Outbresk
Listed
24
should
of
eective
if
to
might
might te
epidemic
an isolation)
assessed
symptomatic
bouts
4RSA
reinforcement
analyses health
cases
of define
size
several
the
recognition
carcgivers
body
outbreak
(znanditory
in
and
admission
be
constitute
location
be
of
a
cohort.
apart
control
have
of
previous
physically
department
substance
an
cases
infection
required.
nccessaiy,
for
is:
on
special
to
of
patients
outbreak..
cases
occurred
additional and all
the a
(I)
obtained
had
or
in
in
gowns) of
and case-by-case
an
measure,
staff
outbreak
of
the
epiderniologicaLly
several
precautions
when
section.
a
an
outbreak,
or
direct
separated
which
isolation or
facility
lii
recent
a
infection
institution
should
outbreak
colonization.
is
cohort
staff
by
should a
should
48
lor
extra
necessary.
infections
nursing
(e.g.
contact
person,
because
are
hours
should
previous
endemic
is
example,
be
whereas
(use
basis
with
should
control
not should
be three
be
control
epideuiiolocal1y
(or
notified
(before
11
after home,
tuEe.,
with
cultured
established
of
be
routinely
recolonization
no
or with
epidemic)
linked
When
or
admissions.
gloves
lot
made,
be
be
three
colozuzatiotis
measure.s
staff
one
the
completion
procedures
or
more
the
and
an
of
implemented.
established).
MRSA.
place
patient.
to
for
MRSA
recogxthed,
crossover
the nosocomially-acquired
and
outbreak
including
recommended.
Employee
after
transmission.
for
rtosocormally-acquired)
of
MRSA.
epidemic
or
handwasbing)
are
the MRSA
occurs.
associated.
cohorting).
(2)
of case
(e.g.
should
Each
required,
MRSA
collecting
to
is
antibiotics
a
Two
Health
all
The
Personnel
defined
MRSA in
substantial
in
bandwashing
facility
The
patients
a
be
an
Culture-positive
common
consecutive
This
positive
high
ail
and
undertaken.
V/ben
acute
exceptions
Guidelines
information
negative
as
are
MRSA must
has
risk
ca.ses
should
perhals
three
increase
in
cohort,
or
gtnss
not
definition
cases
recognized,
the
area
decide
and
in
excN1e4-
nepuve
patients
or
positive
proven
onl
a
to
unit
of
such
even
like
kiwcr
which
in
more
The
body
and
staff
this
fot
the
the
the
be
or
of a
facility.
foflowed. closed
prevented
the
6.
During
5.
7.
facility
to
Treatments
Age,
Diagnosis.
However,
a
new
from
is
MESA
sex,
not
admissions,
discharging
and
following
given.
outbreak,
restriction
ra
the
patients,
provided
there
of
proper
admissions
are
provided
there
protocols
no
U
reasons
is
or
the
room.
discharges
in
guidelines
the
caring
nursing
The
will
for
nursing
for
occur
the
home
admissions/discharges
residents
if
home
or
it
hospital
is
determined
should
already
should
act
in
that
the are
be be
patient
gastrostomy
(this
generated
may regardless
latex
a
of
control
transmission regardless of
(e.g.
should
before
between
done
Lifting,
Hands
gloving,
disinfectant
The
Body
Fomites
MRSA.
a
Gloving,
Handwashing The
is
be
patient.
gloves
weeping
after
not
MRSA
who
be
or
leaving
of
for
worn
preventive
substance
linen
care
by dressing
caregivcrs
done
of
of
mandatory),
all
(bed
However,
when
tube). as
any
is
of
infection
a
MRSA
to
Gloves
of
if
outlined
not
colonized
lesions,
patients,
handling.
coughing
MRSA.
work..
for
and
extensive
reduce
linens, different
is
there
at
patients
any
isolation issues
the
must
status.
all
high
should
fornites
or
in
sputa,
hand
is
Environmental
if
regardless
towels,
the
single
patient
or
of
INFECtiON
environmental
colonization
the
of
one
contact
anatomical
risk
be
soiling
involves
infected
these
bacterial
Body
infection
must
contact
be
CDC
washed
and
urine,
has
for
most
pajamas,
worn
is
to
is
work
environmental
substance
been
be
of
likely.
MRSA
guidelines
extensive
with
a
patient
likely.
important
feces,
sites
load.
MRSA
after
status.
control
when
maintained
mucous
surfaces,
CONTROIJPREVENT1O
related
identified,
cleaning,
etc.)
a
on
infection
any
13
wound,
etc.).
contact
can
Masks
isolation
status.
on
This
for
the
skin-to-skin
have
membrane
skin-to-skin
factor
in
tasks.
universal
be
surfaces
MRSA
same
and
most
in
involves
sore,
but
This
not
placed
are
is
(ic.
the
is
anticipated
in
body
should
patient,
instances,
Handwashing
been
the
invasive
a
indicated
should
include
preventing
facility,
should blood
or
contact.
patient
the
with
contact
minimum
substance
body
implicated
be
mandatory
before
another
and
be
site,
be
attention
placed
are
for
with
with
if
substance.
with
Handwashing
done
routinely
body
exposure
the
not or
every
standard
should
eating,
Isolation.
a any
mucous
a
colonized
as
in
important
spread
trachcostomy
fluid
patient.
use
for
to
a
body
a
single
room
vector
cleaned
also
hasidwashing,
drinking,
Also,
of
any
precautions,
to
of
membrane
of
plastic
substance
should
aerosols
infection
patient,
Turning,
be
patient
patient,
vectorx
with
MRSA
gowns
in
with
done
the
and
or
or
a be
goal
provide possibility
(COPIC) Oklahoma
Association care
the Control workers
in
communication
education
is
vital
It
As
several
uniformity
is
staff
is
mentioned
to
our
to
Practitioners
funding
who
in
develop
in
solicits
the
about
ways.
to
charge
providing
should Oklahoma
send
CONTINUING
have
implementation
of
are
for
MRSA
the
in
information
One
this
their
in
assume
the
the
time
struggled
who
support
Oklahoma
a
team,
(including
possibly
group
most
staff
introductory
and
its
can
responsibility
assist
epidezniolo’,
to
&om
important
travel
provide
is
of
with
HEALTh
of
the
would
not
volunteers
to
physicians,
these
in
the
nursing
this
develop
expenses.
controlled.
remarks,
preparing
inservice
Central
place
guidelines.
steps
problem
EDUCAr1ON/COMMUMCATIO
for
homes
14
treatment,
to
one
nurses,
the
the
in
communication
staff
Oklahoma
training
slides,
En
control
or
education
responsibility
they
in
addition,
the
more
The
aides,
other
outlines,
and
serve.
inservice
about
of
key
Practitioners
core
ctc).
MRSA
control
states
of
the
MRSA
element
This
among
their
literature
working
on
team(s).
Oklahoma
This
say
is
measures.
each
employees.
We
not to
health
can
in
of
that
acute
teams
agree.
very
for
major
communication
Infection
The
be
Nursing
education
care
their
accomplished
and
ecient,
committee’s
Health
of
hospital
A
extended providers
Infection
use,
Control
second
Home
and
care
and
and
in is
ii.
12.
10.
9.
8.
7.
6.
5.
4.
3. 2.
1.
Nosocomial Steere
Starch,
Home”.
pp
Observation Saravolatz,
Assoc.
aureus
O’Toolc,
Mandeil,
Infectious
Hospital”.
Outbreak
Klimek,
pp on
Medicine Isseibacbcr,
aureus
Haiduven-Grifflths,
StapIylococcu.x
Methods
Davies, Corticdlli,
Transmission
Bloodborne
Centers
Hospital”.
Barrett,
11-16.
a
608-10.
Surgical
Allen
1970.
in
Gregory
E.A.
Joseph,
InL
Gerald,
Fred,
for
Richard
of
a
Ninth
of
Diseases:
Infection
N.EJ.M.,
A.S.,
Am..
Louis,
Infections”.
Special
During
Infection
Cont.
Z1
Pathogens
Methiclilin-Resistant
Kurt,
and
Disease
Service”.
of
“An
aureus.”
et
3.
Edition:
et
A.,
et
Zpp
Douglas, Maflison,
Ct
Human
D.,
Med.,
a1
1987.
3.,
a1
Outbreak
Care
Donna; a1
a
et
a1
Wiley
Observations 1968.
Community-Acquired
Control”.
“Methicillin-Resistant
et
Control
257-63.
Am.
“Clinical,
a1
Ann.
in
Adams,
Microbiologica.
“Methicillin
“Intensive
1976.
Baby
a
a1
McGraw-Hill
Health
R.
“Methicillin-Resistant
Medical
Irnmunodeficiency
1:
2
George;
3.
“Outbreak
tnt.
Gordon
pp
of
“An
tnL Unit:
j:
“Update:
BIBUOGRAPHE
9,
3.
Raymond,
Epidemiologic,
Infection
Med.
24-29
Care
Staphylococcus
Cant.
pp
Hosp.
in
Outbreak
pp
Care
Publication,
-Resistant
“Handwashing
Hospital
and
441-48
Value
15
340.45.
1975.
Settings”;
Book
of
1987.
1988.
lnf.
Units
Bennett,
Methicillin-Resistant
with
Universal
et
Outbreak”.
of Staphylococcus
of
Company,
1987.
:
Staphylococcus
and
1:
a1
Virus,
Topical
1
a
and
New as
Methicflhin-Resistant
Staphylococcus
aureus
MMWR,
pp
Methicillin-Resistant
pp
3:
Nursing John
a
Harrison’s
Practices
j:
Bacteriologic
683-90.
pp
York,
Source
187-97.
Precautions
Hepatitis
Mupirocui
pp
Ann.
E.; at
New
123-27.
a
1988.
Home”.
120-28.
Principles
1979.
aureus
Large
York,
tnt. aureus
for
of
Principles
Staphylococcus
aurezu
MetbiciEin.Resistant
B
The
Mcd.
:24,
Observations
pp
and
Community
for
1980;
at
3.
Virus
Staphylococcus
and
1530-SL
Epidemiologic
Prevention
Am.
Staphylococcus
in
of a
Prevention
1982.
pp
Boston
of
Practice
a
TraditionaJ
and
Med.
345-51.
Nursing
1nter
:
aureus
of
other
City
of
an
of of 91
£331 WJ3Jd V APPENDIXI
MRSA FAC1 SHEEr FOR EMPLOYEE3
WRAT IS MRSA?
N{RSAstands for methicillin-resistant &aphylxoccu aureus. It is a straIn of £ aureurthat isdisnnguisli4 frosts most other bacteria byits resistance to most arnibzoticsincluding all pemcllhnsand cepbalospoym MRSA can affect peopLein different ways People can carry it in the nose or on the skinwithoutshowuzj any symptoms of illness. This is called MRSAcolomzanon. MRSA can also cause infectionisuch as boils wound infections, and pneumonia
BOW IS MRSA TRANSMITFED?
MRSA is spread from person-to-person by direct contact. This means that if a person has MRSA on hi5 skin (especially on the hands) and touches another individual, he may spread MRSA. A person may have MRSA on his hands as a result of being a carrier or from touching another person who is a carrier or infected with MRSA. V/RAT CAN I DO ‘ I’REVENTTEE SPREAD OF MRSA? Handwasbing,using soap and warm runningwater for 20 seconds, is the single most Important messnxe necessaiy to control the spread of MRSA. Proper handwashing should be performed after the care of each patient, after handling soiled dressingsand clothing and after wearing gloves. Other measures to prevent becoming infected or transmittinginfectionto others include avoidingcross-contmn2tion betwech clean and dirty linen, daily environmental cleaning wearing gloves for all dressingchanges,proper handlixzj of infectious waste, and observing isolation procedures. Report Illness includingunusual skin rashes or boils to your nursing director before workingwithpatients. WASH YOURBANDSBEFOREANDAF!EP% CONTACF WITI! EACH PATIENT!
WILL I TAKE MRSA ROME TO MY FAMILY?
MRSA can liveon linens and clothing but these generally do not transmit the organism. Wear a protective, garment a: work if you are at risk of contnxninathigyour clothing with wound or other body flUidS or drainage. If you have cont2miited your clothingwith wound drainage or otherpotentiallyinfectiousbodV fluids or drainage, change your clothes before going house. Report any unusual rashes or skin lesions to your physician. Alwaysthoroughlywashyourbands before going home from work.Normalhealthy people. are not usually at risk of serious invasiveMRSA disease.
ROW IS MRSA TREATED?
Persons who are carrying MRSA but are not exhibitingsymptoms usuallydo not need to be treated. T1 antibiotic used to treat persons with MRSAinfectionsisvancomycin givenintravenously.Oralvancomycia is not effective against MRSA. Vancomycincan have serious side effects.
17 APPENDIXU
NURSING BOME INFECTION CONTROLGUIDELINES Routine Precautions For All Patients
For patients with draining lesions at any site:
• Draining lesions should be covered whenever possible.
• Contain dressings or linen visiblysoiled with drainage in separate bags.
• Wear gloveswhen touchingdrainage and wash hands wellbefore and after gloving.
• Wear gowns only if soilingof clothes is likely. Gownsmay be kept in the patient’s room and reused until they become soiled; however,replace them withnewgowns cacti shift. Do not wear gownsoutside the patient’s room.
For patients with urinary catheters
• Change catheters when necessary,such as when they become crusted or cIoed.
• Alwaysuse 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 thoroughlyclean ft after each use. Avoid touching the catheter bag or draining spout to the side of the graduate container.
• Wash the patient’s penneal area withsoap and water and thoroughlydry it eachday and when it becomes soiled. Avoid tension or movement of the catheter.
• Wash hands well after manipulatingthe catheter system.
For patients with respiratory symptoms: • Teach the patient to cough into a tissue, and provide a bag for tissue disposal.
• [I the patient has MRSA and is coughing.personnel should wear masks when ii close contact with the patient (Le.when suctioningor givingmouth or tracheostour care).
• Use good handwashingafter removinggloveswhen touching respiratorysecretion: is APP4DIX II (Continued)
NURSTNGHOME INFECTION CONTROL GUIDELINES MRSA Prerautlonj
For patients with MRSA colonization o( the respiratory tract:
• Place patients in a private room or cohort them with other MRSA colonized patients if possible. This is not mandatmy.
• Avoid placing them in rooms with high riskpatients.
• 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 respiratozy secretions.
For patients with MRSA colonization of the urinary tract:
• Use routine precautions, Page 18.
• Use good handwashing and wear gloves when emptyingthe catheter.
• Masks are not needed..
• Wear gowns only if soiling of clothes is likely.
For patients with MRSA colonization of skin lesions and decubith
• Use routine precautions.
• Cover the area with a dressing.
• Use good haudwashing and wear gloves when touchingthe area.
• Masks are not necessary.
• Wear gowns only if soiling is likely.
I, APPENDIX II (Continued)
• If a patient is undergoing physical therapy for treatment of ha lesion or decubitus, schedule him as the last appointment of the day. Personnelsa physicaltherapy must follow body substance isolation techniques (Appendix lii). Also, careful disinfection of the whirlpool or tub with an E.P.A. approved disinfectant is indicated.
General recommendations for patients colonized with MRSA
• If the patient is discovered to be colonized with MRSA, evaluate the patient’s roommate for risk factors which may predispose slhe to serious infection. To determine colonization in the absence of overt symptoms of MRSA infection, culture the patient’s anterior nares.
• Once a patient is determined to have MRSA, consider him colonized until two negative cultures are obtained 24 hours apart and when he has been off all antibiotics for 48 hours.
• 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.
• Disposable dishes are an unnecessary added expense. 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 heavilysoiled with moist body substances that may soak through a linen bag must be placed in a plastic bag to prevent leakage. Linen handlers must wear barrier protection which includes gloves, and take special precautions with soiled linen by bagging to prevent leakage. Soiled linen need not be washed separately.
TRASH • Routine waste from all patient’s 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 aiuminum cans). Contirninted dressings should be placed in a separate plastic or foil lined bag and tied before placing in the trash receptacle.
Adapted from Guidelines prepared by Patricia Lynn Meyer, ILN., M.P.H., and Becky Clapper, R.N., St. Louis, Mo.
20 APPENDIX UI
Bdy Substance Isolation Precaution!
1. Wash hands often and well, payingparticular attention to around and under 5ngernailsand between the fingers. Wash handsbefore and after glovingand before and after any and all direct patient care.
2. Wear gloves when it is likely that bands will be in contact with moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, or votnitus).
3. Protect clothing with a gown when it is likelythat clothingwill be sQiledwith body substances.
4. Wear masks and/or eye protection when it is likelythat eyes and/or mucous membranes will be splashed with body substances (e.g., when suctioninga patient with copious Secretions).
5. Discard uncappcd needle/syringe units and sharps in puncture-resistant containers designed for this purpose.
6. Discard trash in impervious plastic bags.
7. Bag linen so that no leakage of moist body substanceswilloccur.
21 ___
Joan K.L.cvftt, M.D. olcwioua,st.m Comms*net DEPARMLNTOFHEAUH- Iocw — #0. CS3U1 ft WOfl.( Scoff Mc I S Ca1cOI OO.L 1000 UNTIl t Prsaø.N L EdQ. M.D * Uit ‘41V a.Wl £4 * mest 0 U*t. LP?. .U H.A.ear DO ‘‘ — “ ‘‘ ‘. Vhe Pr.ud.v kicq. F. Gi..n. MD. Woaac. a. M.D. a U. joty*on. MO. Sacr.ty4mtet ai W.
APPENDIX ZY
POLICY STATEMENT ADDRESSING ANTIBiOTIC-RESISTANT ORGANISMS, INCLUDiNG METHICULIN-RESISTANT STAPHYLOCOCCUSAUREUS
The prevalence of antibiotic-resistant organisms, such as tnethicilliu-resistaut Staphylococczuaureus (MRSA) and certain gram negative bacilli,is increasIng. MethiciZZLu resistantStaphylococcusaureus has drawn particular attention..
The followingrecommendationsarc suggested to help controlthe spread of antibiotic- resistantbacteria:
I. Since it is often not possible to know which persons arc colonizedor infectedwith resistant organisms,all persons should be considered potential carriers. This is analogousto the concept of universal precautions appliedto the prevention of HJV transmission.
2. flaadiiishing should be practiced before and after contactwith all patients. A programfor implementationof handwashIngmust be formulatedby ail institutions. Glovesshouldbe wornwhen in contact with all bodysubstances,but this does not precludethe importanceof bandwashing. Gownsshouldbe wornif soilingis likely. Masksarc indicatedonlywhen closecontact withinfectedaerosols(e.g. respiratory droplets&oma coughingpatient) may occur. Physicalisolationofindividualpatients colonizedwithresistantorganismsis not indicatedunder most circumstances.
3. Colonizationwitha resistant organism is neither an indicationfor hospitalizationnor a reasonto restrictadmissionto a nursing home.
4. Infectionsshouldbe evaluated and treated on a case-by-casebasis.
23