Guidelines for Prevention and Management. Methicillin Resistant Staphylococcus aureus (M.R.S.A.)

Transcription

1 Ratified by: ICC Date of Ratification: 16 th April 2012 Date of Review: April 2015 Guidelines for the Prevention and Management of Methicillin Resistant Staphylococcus aureus (M.R.S.A.) ID # Author s Name Frances Stratford / Katrina Walker Author s Job Title Infection Control Nurses Division Corporate Nursing Department Infection Control Version Number 4 Ratifying Committee Infection Control Committee Ratified Date 16 th April 2012 Review Date April 2015 Date uploaded to the intranet 22 May 2012 Name of Manager Responsible for Review Colin Johnston Job title of Manager Responsible for Review Director of Infection Prevention and Control Address for this Manager colin.johnston@whht.nhs.uk Source of Evidence (if applicable) N/A Level of Evidence Indicated N/A Key Words (To aid Searching) Guidelines for Prevention and Management Methicillin Resistant Staphylococcus aureus, MRSA, Infection, Staff to View All Staff The Trust is committed to promoting an environment that values diversity. All staff are responsible for ensuring that all patients and their carers are treated equally and fairly and not discriminated against on the grounds of race, sex, disability, religion, age, sexual orientation or any other unjustifiable reason in the application of this Policy, and recognising the need to work in partnership with and seek guidance from other agencies and services to ensure that special needs are met.

2 Contents Page 1. Introduction Admissions, Transfers And Discharges Admission of Known MRSA Colonised or Infected Patients Admission of Patients at High Risk for MRSA Colonisation Admission of Low Risk Patients MRSA Screening Movement of MRSA Positive Patients Action to be Taken when New Cases of Infection or Colonisation are Found Clinical Risk Group; Medicine / Elderly Care (Low Risk) Clinical Risk group; Surgery, Obstetrics and Gynaecology, Coronary Care Unit (Moderate Risk) Clinical Risk Group: ITU/SCBU/Orthopaedic (High Risk) Treatment of Clinical MRSA Infection Infected Skin Lesions Systemic Infection MRSA Bacteraemia Deceased Patients Staff Significance and Risk to Staff Reducing the Risk of MRSA Acquisition by Health Care Workers Staff Screening Policy Treatment of Carriers Agency and Bank Staff Infection Control Training Process for Audit, Monitoring & Review of the Policy References Appendix 1 MRSA Screening and Decontamination for High Risk Patients Appendix 2 Decontamination Protocol For MRSA Positive Patients Appendix 3 Management of MRSA Colonisation in Staff Page 2 of 16

3 Change History Version Date Author Reason Ratification Required Version 3 March 2010 Frances Stratford NHSLA Requirement. Yes Katrina Walker Update due Version 4 March 2012 Frances Stratford Katrina Walker Update due Yes 1. Introduction Methicillin Resistant Staphylococcus aureus (MRSA) is an antibiotic resistant form of the bacteria Staphylococcus aureus (Staph. aureus). Staph. aureus is a bacteria which is found on approximately 30% of the skin of normal healthy people, usually causing no harm. In some circumstances, particularly if the skin is broken, the bacteria can cause skin and other infections. MRSA behaves in the same way as Staph aureus, however in the event of it causing an infection, it can be more difficult to treat as it is sensitive to fewer antibiotics. 2. Admissions, Transfers And Discharges MRSA colonisation/infection should not prevent access to appropriate medical or surgical treatment in acute settings; nor should it create undue difficulties or delays in discharge of patients from acute settings to other environments where care is provided. The same principle applies to the transfer of patients between different clinical areas in acute settings or between acute hospitals. However, avoiding unnecessary movement between clinical areas has been a fundamental part of good infection control practice for many years. 2.1 Admission of Known MRSA Colonised or Infected Patients MRSA status and details of carriage sites should be communicated between medical and nursing staff and, where relevant, the Infection Control Team (ICT) involved in the admission of an MRSA positive patient to the Trust. This should be an integral part of the admission process and should therefore take place in advance of the patient's arrival if admitted electively. a) The case notes of MRSA affected patients should be suitably labelled and, in some instances, computer records and patient administration systems may also contain such a label. b) The patient should be admitted to a side-room and nursed with the standard isolation precautions. c) A full MRSA screen (Refer Section 2.4) should be performed on admission and the patient assumed to be positive until the results are known. d) Skin decontamination with Triclosan/Hibiscrub wash should be commenced. e) The Infection Control Nurse (ICN) should be advised of the admission. 2.2 Admission of Patients at High Risk for MRSA Colonisation Other groups of patients are recognised as being at excess risk for MRSA colonisation. These include: i) Previously positive patients Page 3 of 16

4 ii) Admissions from environments with an increased incidence of MRSA e.g. hospitals, and residential/nursing homes. iii) Patients who have had recent hospital admissions iv) Patients with chronic wounds v) Patients with long term indwelling devices vi) Healthcare workers For actions to be taken refer Section 2.1 b, c, d and e. It is also acknowledged that in addition to specific groups of patients there are high-risk areas, which include specialist wards/units where the consequence of MRSA can be a serious risk because of the risk of invasive infection and difficulties in treatment. This includes the intensive care unit and special care baby unit. In such areas the measures in Appendix 1 MRSA Screening and Decontamination for High Risk Patients should be implemented. Where side-room availability is exceeded, priority of isolation is demonstrated in Table Admission of Low Risk Patients All other patients are regarded as low risk. A proportion of low risk patients will however be unrecognised MRSA carriers hence the need for standard infection control precautions for all patients. 2.4 MRSA Screening Table 1 When an MRSA screen is required the following swabs/specimens should be obtained: Nose (anterior nares - one swab to both nostrils) Perineum (groin if not easily accessible) CSU (if catheterised) Sputum (if expectorating) Insertion sites of any indwelling device e.g. Gastrostomy sites, long-term intravenous device All wounds Ensure that it is identified on the microbiology request form that an MRSA screen is required. Risk Assessment Criteria for Risk of Transmission from MRSA Colonised / Infected Patients * Factors related to site(s) of colonisation/infection Anatomical site Is site exposed, covered, dressed? Size of site Single or multiple sites Capacity for dissemination (consider size/exposure of site) * Active colonised exfoliating skin condition (eczema or psoriasis) and its extent * Presence of an MRSA colonised urinary catheter/intravascular line/other device * Mupirocin sensitivity/resistance of strain and recent/current use of mupirocin. Page 4 of 16

5 Table 2 Admission Screening and Isolation Admission Screening Isolation Known/previous positives Nursing / residential homes Recent hospital admissions Inter-hospital transfers Intra-hospital transfers ITU/SCBU Clinical Risk Group Surgery (inc. orthopaedics), obstetrics and gynaecology, CCU MRSA Policy / Version 4 Medicine (inc elderly care), paediatrics All All All Yes Yes Yes No Page 5 of 16

6 2.5 Movement of MRSA Positive Patients MRSA Policy / Version 4 It is good practice that patients should not be moved unnecessarily within wards or between wards. This applies particularly to patients colonised or infected with transmissible pathogenic micro-organisms including MRSA. MRSA should not prevent patients accessing departments within the hospital for investigations or treatment Transfers within the Hospital a) Prior to transfer Medical and nursing staff should liaise with the receiving ward/unit and bed manager (where appropriate) to ensure that staff in the receiving area are aware of the patients current status and treatment regime. The ICN should be advised of the transfer. Whenever possible, the patient should: Have clean clothing Be transferred to a bed with clean linen (the original bed linen should be left behind on the ward) Lesions including wounds and pressure sores and insertion sites for intravenous devices should be covered, whenever possible, with a dressing. b) At the time of transfer Staff should wear disposable plastic aprons if they are likely to be in direct contact. Aprons must be removed after this contact has finished and disposed of as clinical waste. Disposable gloves need only be worn if there is potential contact with bodily fluids during the transfer. After use, the trolley or chair should be cleaned with a detergent/disinfectant eg. Chlorclean. The staff involved in transferring patients should wash their hands after dealing with the patient and equipment used Visits to Specialist Departments and Outpatients Prior arrangements should be made with senior staff of the receiving department so that control of infection measures for that department can be implemented. These will include: Dealing with these patients at the end of session. Ensuring that such a patient spends a minimum of time in this department and has the minimum contact with other patients. Staff should wear disposable gloves and aprons and wash their hands before and after contact with the patient. Minimising the number of staff in contact with and equipment used for, that patient. Surfaces with which the patient has direct contact should be cleaned appropriately. Linen in contact with the patient should be treated as fouled/infected linen. Page 6 of 16

7 2.5.3 Surgical Procedures Ideally MRSA colonisation or infection would be eliminated/treated prior to surgery. This will require close liaison with the ICT and others involved in the care including those who may receive the patient for rehabilitation or convalescence. In any case: a) Prior to theatre Refer to 2.5.1a, and in addition: Theatre staff must be informed and the patient treated last on the operating list, if practicable. The decontamination protocol will have been instituted. On the day of the operation the patient should be washed using antiseptic wash eg. Triclosan. MRSA affected lesions should be covered with an impermeable dressing. Antibiotic prophylaxis is appropriate. Substitution or addition of Teicoplanin to the usual regime should be considered. The advice of the Consultant Microbiologist may be required regarding prophylaxis. b) Transfer to Theatre Refer Section b c) At the end of the operation If possible, patients should be allowed to recover in theatre or in an area not occupied by other patients. Theatre surfaces in contact with the patient or near the patient should be decontaminated with a detergent and disinfectant eg. Chlorclean before reuse Transfers to other Hospitals The communication and screening requirements of the receiving hospital should be followed. Where MRSA colonisation/infection is known, this information should be communicated to staff at the receiving hospitals prior to transfer. The former will need to notify those involved in transport arrangements. Ambulance services have their own protocols for the safe transport of MRSA patients. These are likely to include: The use of an alcoholic hand rub after contact with an MRSA patient. Changing linen and bedding used by an MRSA patient. It is not usually necessary to transfer MRSA patients individually. Patients with wide spread colonised skin lesions (e.g. eczema or psoriasis) or with discharging lesions not completely covered by an impermeable dressing present a higher than average risk of cross-infection. It may be necessary to transport patients alone who are considered to be high risk of cross-infection. Ambulance staff will be required to wear personal protective equipment. The onus is on the clinical team to inform the ambulance service when these circumstances arise. Page 7 of 16

8 2.5.5 Discharge of Patients MRSA Policy / Version 4 MRSA patients should be discharged from the hospital as soon as possible when their clinical condition allows. Communication of MRSA status, details of decontamination protocol being administered, antibiotic treatment, etc must be part of the transfer process. MRSA carriage should not be a barrier to the transfer of patients to a nursing/residential home or rehabilitation unit. The completion of five days decontamination protocol following discharge from the hospital to the community is recommended. Screening post-treatment in the community is generally not recommended. Routine screening before hospital discharge is not usually indicated (refer Section 2.5.4). 3. Action to be Taken when New Cases of MRSA are Identified The detail of action taken on discovering new cases varies to some extent with the clinical area involved (refer Table 1). There is some evidence that adherence to the general principles of Infection Control reduces the overall numbers of colonised or infected patients. The importance of promoting and monitoring compliance with Infection Control Policies, ensuring high levels of domestic hygiene, controlling antibiotic use (both for prophylaxis and therapy) and reducing unnecessary movement of patients between wards cannot be overemphasised. 3.1 Clinical Risk Group; Medicine / Elderly Care (Low Risk) Patients found to be colonised or infected should be given appropriate information on the significance of this and have the actions to be taken and their rationale explained. Their medical records must be tagged to ensure early recognition of MRSA positivity on subsequent admissions to hospital. Standard isolation should be instituted. Where this is impractical individual patient risk assessment should be performed to establish a priority for side-room accommodation. Rudimentary criteria are given in Table 1. The ICT should be consulted. A full MRSA screen must be undertaken as soon as is practicable if MRSA has been identified from a clinical specimen (Refer Section 2.4) The decontamination protocol (refer Appendix 1) and subsequent screening regimen must be commenced. Records must be kept by both the ward nursing staff and the ICN. Screening of other patients/contacts is not necessary. The ICN will advise. 3.2 Clinical Risk group; Surgery, Obstetrics and Gynaecology, Coronary Care Unit and (Moderate Risk) As above and in addition Standard isolation is a minimum standard. Where this is not possible, the ICT should be involved in a risk assessment to help identify appropriate actions to be taken. Screening of other patients on the ward/bay may be considered in the light of surveillance data and is at the discretion of the ICT. Page 8 of 16

9 Active screening of staff may be advocated if transmission continues. This decision will be made by the ICT in conjunction with the Occupational Health Department 3.3 Clinical Risk group: ITU/SCBU/Orthopaedic (High Risk) As above and in addition Patients in ITU and SCBU are screened routinely on admission and at weekly intervals thereafter. 4. Treatment of MRSA Infection 4.1 Infected Skin Lesions Refer to Appendix 2 for topical treatment. 4.2 Systemic Infection Decisions concerning antimicrobial treatment should be made in conjunction with a microbiologist. Page 9 of 16

10 5. MRSA Bacteraemia MRSA Policy / Version 4 An MRSA bacteraemia is when MRSA is isolated from a blood culture In the event of a patient being identified as having an MRSA bacteraemia, this must be reported as a clinical incident and a Root Cause Analysis (RCA) must be undertaken by the relevant clinical staff. The template is available from the ICT. The purpose of the RCA is to identify how/where the patient acquired the bacteraemia and lessons learnt from the findings. Algorithm to follow in the event of identifying MRSA positive blood cultures: Trust MRSA Bacteraemia RCA Investigation MRSA bacteraemia identified Incident reporting form completed Relevant staff notified by: Infection Control Nurse ICN completed RCA to DIPC/Director of Nursing plus the reporting Microbiologist (for MESS reporting) Within 24 hours DIPC to completed RCA to PCT Discuss RCA at bi-weekly local HCAI Meeting 6. Deceased Patients 7. Staff MRSA is a negligible risk to relatives, mortuary staff or undertakers. The usual procedures for dealing with dead bodies apply. Lesions should be covered with an impermeable dressing. Body bags are not necessary. The usual basic infection control procedures employed by morticians and undertakers are sufficient and notification of MRSA status is therefore not essential. These guidelines have been interpreted to reflect local circumstances and experience, and perceived developments and have been agreed with the Occupational Health Service (OH). Page 10 of 16

11 7.1 Significance and Risk to Staff MRSA Policy / Version 4 There is no evidence that MRSA poses any more of a risk to normal, healthy people i.e. health care workers and their families, including babies, children and pregnant women, than that presented by Methicillin sensitive strains of Staph. aureus. There is therefore no argument for prospective screening of staff as a health surveillance exercise. The rare case of MRSA infection will be treated as appropriate to the clinical circumstances. The Health Care Worker will be screened for MRSA carriage in other sites and standard action taken (Refer Section 8.4) to eradicate colonisation where this is demonstrated. Work restriction will be similar to that described below for carriers but will be extended to include clinical and bacteriological resolution of the index infection. The major importance of MRSA colonisation of health care workers is that colonised staff are a source of the organism for patients in their work environment. By their presence and the nature of their activities in the health care environment staff are a source from which efficient transmission may occur; this is the rationale for staff screening policies (see below). 7.2 Reducing the Risk of MRSA Acquisition by Health Care Workers Staff with active eczema or psoriasis or other skin conditions known to be more susceptible to Staph. aureus colonisation or those who are taking antibiotics should not knowingly care for MRSA colonised or infected patients. Staff with skin conditions such as eczema or psoriasis must report to OH. Adequate environmental cleaning, effective implementation of a source isolation procedure and successful outbreak management can be expected to reduce the magnitude of the source and therefore the risk of spread to staff. Observance of handwashing protocols and the details of eg. wound dressing procedures may be expected to decrease transmission to other patients and staff. 7.3 Staff Screening Policy Indications for staff screening would include the occurrence of an unexplained increase in the incidence of new cases in an endemic area, which continues despite the introduction of control measures. Staff screening may also form part of an intervention strategy in an area with a stable endemic incidence, which is deemed to be unacceptable. Logistics and resource in the Microbiology Laboratory are further influences. Therefore, only the ICT will initiate screening exercises and determine their frequency and timing. Members of staff may not initiate screening themselves. Where there are doubts about the legitimacy of a request this will be explored and the result sent to OH. It is acceptable, but not ideal, for staff to collect their own screening specimens when asked to do so by the ICT. All specimens must be adequately labelled with name, site and date. Specimens must be accompanied by a completed request form. Screening should be done at the start of the working day/shift. If OH is not involved in obtaining specimens, it will be the responsibility of the Ward Manager to ensure that specimens are sent as required. Results positive and negative will be returned to OH. Page 11 of 16

12 Occasionally, a colonised member of staff is found to be in close or intimate contact with another Health Care Worker (eg. by sharing accommodation). In this circumstance the ICT should be notified and the contacts screened. 7.4 Treatment of Carriers Attempts will be made to eliminate MRSA colonisation in staff (Refer Appendix 2). This treatment will be undertaken by OH. It is also the responsibility of OH to advise the relevant line manager about working arrangements and inform the staff member s General Practitioner. The ICT will provide advice concerning further treatment and work restriction if the protocol at Appendix 2 has failed after two courses of treatment. 7.5 Agency and Bank Staff Where possible, agency and bank staff should not be asked to care for known MRSA patients. 8. Infection Control Training All new employees must undertake infection control training on induction to the Trust. (Refer to Corporate & Local Induction Policy). All employees must undertake infection control training as outlined in the Trust training needs analysis. 9. Process for Audit, Monitoring & Review of the Policy This policy will be reviewed bi annually or earlier in light of new national guidance or other significant change in circumstances The MRSA policy will be monitored for effectiveness by the following processes: Quarterly reports as part of the monthly updates as defined within the Management of Infection Control Prevention Policy Progress with the annual Infection Control Programme, compliance with the Hygiene Code, and trends in Healthcare Associated Infections (HCAI) rates. As part of the Infection Control Audit Plan. Page 12 of 16

13 10. References British National Formulary (2007). BMJ Publishing. Coia, J.E. et.al. (2006) Guidelines for the Control and Prevention of Meticillin-Resistant Staphylococcus Aureus (MRSA) in Healthcare Facilities. Journal of Hospital Infection. 635 (S1-S44). Neonatal Formulary, 5 th Ed, (2007). Blackwell Publishing. Report of a combined working party of the British Society for Antimicrobial Chemotherapy, the Hospital Infection Society and the Infection Control Nurses Association. (1998). Revised Methicillin-Resistant Staphylococcus aureus Infection Control Guidelines for hospitals. Secretary of State (2004) Health Protection Bulletin %20OCT%20+%20NOV% pdf This Policy should be read in conjunction with the following Policies: Uniform Policy Management of Infection Prevention & Control Policy (February 2008) Incident Reporting & Investigation Policy (December 2007) All other related Infection Control Policies as outlined within the Management of Infection Prevention & Control Policy under Section 6.2. (Please refer to Section 6.2 for the list of Policies and dates) Elective admission MRSA Screening Protocol (August 2009) Page 13 of 16

14 Appendix 1 MRSA Screening and Decontamination for High Risk Patients ITU/HDU Irrespective of a patient s MRSA status the following should be undertaken for all ITU/HDU patients. All patients to be screened for MRSA on admission to and discharge from ITU/HDU All patients to be screened for MRSA weekly during their stay in ITU/HDU, usually undertaken on a Monday All patients to be screened for MRSA on the day of transfer out of ITU/HDU to other areas/wards/departments, (but not necessary if patient is being transferred from ITU to HDU or visa versa) All patients in ITU/HDU to be washed daily with skin disinfectant e.g. Triclosan/Hibiscrub, as per policy/manufacturers instructions Medical Including A&E/RAU/Surgical & Orthopaedic Divisions All patients to be screened on admission (refer to the MRSA Emergency Screening Policy) High risk patients to commence skin disinfection regime e.g. Triclosan/Hibiscrub as per manufacturers instructions. To continue this treatment until admission screen results are known to be MRSA ve. Any patients who have a central device inserted should have a full MRSA screen prior to insertion if a planned procedure or following insertion as soon as possible if undertaken in an emergency. Commence skin disinfection regime e.g. Triclosan/Hibiscrub. Continue this treatment until the line is removed. Patients known to be MRSA +ve currently or previously Source isolation to be instigated on admission Full MRSA screen obtained within 24 hours of admission Topical treatment to commence on admission (Triclosan/Hibiscrub only) Systemic treatment if clinically indicated following discussion with Microbiologist if required. Page 14 of 16

15 Appendix 2 Decontamination Protocol for MRSA Positive Patients 1. SKIN Adults and children - Wash patient daily with an antiseptic detergent e.g. Triclosan or 4% Chlorhexidine gluconate for 5 days. Apply directly to the skin on a wet disposable cloth, and do not dilute in water. Rinse with water and dry thoroughly. Neonates - Wash daily with Triclosan diluted 50% in water. Apply to the skin with a disposable cloth. Rinse with water and dry thoroughly. Premature babies wash with Octenisan apply directly to the skin without dilution. Rinse with water and dry thoroughly. 2. HAIR - Wash hair with an antiseptic shampoo e.g. Triclosan/Hibiscrub twice a week if the patient's condition allows. 3. LINEN Change bed linen daily after antiseptic bath/wash. 4. CLOTHES Change all nightclothes daily (after washing). 5. NASAL CARRIAGE: - a) Mupirocin sensitive strains of MRSA 2% Mupirocin in a paraffin base (Bactroban nasal cream) is applied to the anterior nares three times a day for five days. b) Mupirocin resistant strains of MRSA Naseptin Cream is applied to the anterior nares four times a day for five days. 6. WOUNDS/LESIONS Topical ointment / creams are generally not appropriate for use on wounds. Application is required three times a day which can be detrimental to wound healing. Alternative products such as silver or iodine impregnated dressings may be appropriate. Advice should be sought from a Tissue Viability Nurse or ICN. Mupirocin ointment / creams: Do not use on burns greater than 10% or other large areas. Do not use on indwelling plastic or polyurethane catheters e.g. central line sites or gastrostomy sites. 2% Mupirocin in a paraffin base may be used instead. 7. UMBILICUS (NEONATES) FOLLOW UP 4% aqueous chlorhexidine daily for five days a) 48 hours after stopping treatment, a full screen is required b) If this screen is negative, then the patient is screened for a second time. If negative, a third screen is to be taken. c) If all three sets of screening are negative, then the patient is considered to be MRSA negative and may be nursed on the open ward. Seek the advice of the ICN before discontinuing isolation. Page 15 of 16

16 Appendix 3 Management of MRSA Colonisation in Staff MRSA Policy / Version 4 Staff should not routinely be screened for MRSA. If it is necessary to screen staff, the Occupational Health Department have the primary responsibility for taking the swabs and the subsequent treatment and management of staff carriers. Staff who are Carriers of Mupirocin Sensitive MRSA 1. Apply Mupirocin in a paraffin base (Bactroban nasal) three times daily to anterior nares for five days; The decision of whether exclusion from work is necessary will be undertaken by a Microbiologist following a risk assessment. 2 Use antiseptic solution for washing and shampooing if awaiting full screening results. Shower or bath with antiseptic daily, shampoo hair with antiseptic at least twice a week. 3 Stop treatment after five days. Wait 48 hrs and then take another full screen 4 If negative, repeat full screen and then take third screen if negative. 5 If all three sets are negative, the staff member is now considered to be clear and can resume work. 6 If any of the three sets are positive, recommence decontamination protocol for a second time. 7 Repeat steps 4 and 5. 8 If still positive following two courses of topical eradication therapy, see below: Failure to eradicate MRSA after two courses of topical treatment. Staff who are Carriers of Mupirocin Resistant MRSA 1. Use Naseptin cream four times a day for five days; 2. Exclusion from duty: This will be determined by an individual risk assessment undertaken by a Microbiologist. 3. Use antiseptic solution for washing and shampooing as above, if awaiting full screen results 4 6 As above Failure to Eradicate MRSA After Two Courses of Topical Treatment This should be reviewed by OH together with the ICT/Microbiologist and the line manager. Exclusion of staff for infection control purposes is medical suspension and not deemed as sick leave. Page 16 of 16