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.

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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

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Ward,

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San

Slater,

Miller,

Meadows,

Colonized

Shores,

Ramgopal,

RN.

Joaquin,

and

M.D. aureus

MD.

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M.D.

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M.D.

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ERADICATION

EPIDEMIC

ENDEMIC

I)ECOLONI7ATION

COLONIZATION

CORORT

CARR

implementation

Three

endemic

Flirnination

epideznio]ogicaliy

The

facility.

outbreak

(immunocompromised

and/or

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of

Presence

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grouped

organism

organism

or

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group

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on

usual

the

antibiotics.

Endemic

rate.

of

together,

situation.

of

or

who

may

to

rate

skin

MRSA

more

MRSA

infection.

of

another

of

is

be

of

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or

colonized

infections

related

rate

present

infection

and

prevalence

positive

cases

on

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persoa

in

tissue

cared

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or

carried

clinical

in

each

carrier

in

decreases

of

with

otherwise

a

patients

control

the

and/or

without

through

for

facility

nosocomially-acquired

of

methicillin-resistant

by

manifestations

nares

is

by

persons

persons

colonized

and

(infected

staff

GWSSAR4

colonization

the

home

the

direct

will

highly

(nose),

hygiene

presence

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who

risk

be

infected

or

contact,

through

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susceptible

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sputum,

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of

disease.

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of

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and/or

usually

symptoms

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care

urine,

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of

persons)

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increase

who

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by

infection

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an

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or contact

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in

carrier

are open

infections

antibioti.

clinical

high

aurcus

or

a

in

physically

wound,

with

number

control

negative

facility

to

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with

risk

manifestations

(MRSA).

others

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which

transmit

hands.

individuals

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separated,

from

measures

through

patients.

the

in

in

stool

are

the

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an

the a

SUSCEPTIBILITY SURVEILLANCE

SA

OUTBREAK

MZRSA

MODE

INVASiVE

of

INFECtiON

A Monitoring

distnbution

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antibiotic.

cepbalosporins,

which

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A

methicillin

appropriate

environmental

one

techniques The

MRSA

carbuncies,

Clinical

from

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infections

gram-positive

laboratory

gram-positive

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(MErRICILLIN-RES1STANT

individual

method

OF

a

are

is

break

manifestations

and

TRANSMISSION

DISEASE

transmitted

acquired

is

three

and

of

in

such

septicemia,

for

to

test

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multiplication

by

a

in

patient

surfaces

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to

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cleaning

or

skin

bacteria

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data

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of

play

or

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and

symptoms

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of

bacterial

osteomyelitis.

antibiotics.

to

of

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oxacillin.

linens

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determine

if

significant

grows

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by

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intravenously.

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and

(i.e.

direct

individual).

spread

organism

caused

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load.

in

and

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in in

in

blood

Antibiotic

clusters

tissue

the

clusters

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role

2

an

into

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linked

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cell

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in

with

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like

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MRSA

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therapy

count,

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cases

grapes; is

environment

effectively

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or

such

grapes;

in

not

manifestation

of

nursing

transmission.

number

of

AUREUS)

of

fever,

contact

as

does

SA thought

environmental

infection

choice

furuncles,

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is

treated

home).

warrant

sensitive

lesions,

is

of

and

(ie.

for

not

new

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of

caused

is

from

to

with

infections

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boils,

dlinicai

effective

not

treatment.

infections

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boils,

bed

to

surfaces

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the

methicillin,

affected

pneumonia,

by

particular

linens

sympto

hands

persons.

drainage

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agmt

caused

proper

and

are

by

or of

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accepting

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indMdual may

made

hospitnlizntion

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infectious

symptoms

MRSA

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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

Every

attending

not

if

of minor

itself,

itself,

be

already

including

means

is

the

resistance

patient

effective

often

this

effective.

means

for It

patient

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due

skin

is

patient

is

by

resistant.

is

determination.

not

MRSA

the

not

hospitalized.

must

physician,

grounds

direct

to

distinguished

and

wounds)

all

the

against

grounds

patient

grounds

must

(some

MRSA.

with

peniciilins

be

gloving

SYNOr

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patient

infection

person-to-person

practiced

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for

3 be

antibiotics

MRSA.

can

does

decision

and lab

aureu.

for

this

for

considered

hospital

when

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is

be

exclusion

reports

admission

from

regard

and

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have

attempts

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usually

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contact

to

ccpha]osporins.

admission.

may

symptoms

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it

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potentially

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contact.

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is

intravenous

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with

other

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a

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organism

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patient

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hospital

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be

not

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bacteria

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body

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prolonged

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to

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for

on MRSA.

colon

MRSA

have

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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)

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basic

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attending

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interested

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the

health The

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and

care

patients

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key

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Discussion

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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

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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

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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,

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simply

nature

awur.

school

must

nursing

concerning

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based

be

and

causing

ffThated

resistant

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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

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more

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not

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acute

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isolation,

lack

a

pathogenic

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be

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alzatiou,

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patients

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signicarn

regarding

eciern

more

from

than

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vancomycin,

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known could

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by

to

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skin

illness.

who

mentally

infections

circumstances

experiences

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disposition

infected. care.

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and

colonization presumably

permanently

physicians colonized.

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(methiclllin

an

symptoms

colonization

When the Treatment

culture

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standard

open

lesions

are

hospital

include

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kidneys

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colonization

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immunosuppressed

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present,

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DIAGNOSISJTREATMEN’r

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health

indication

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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 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