MRSA Perineum by mikeholy

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									Title: MRSA - Meticillin Resistant Staphylococcus Aureus

NB. In line with the new International Pharmacopoeia guidelines, ‘meticillin’ has been used throughout the
document instead of the established ‘methicillin’.

Purpose:        To provide guidance on infection control measures required to identify, treat
and
               prevent the spread of MRSA within the Trust.
To be read in conjunction with the following Trust policies:
Patient Isolation Policy
Hand Hygiene Policy
Standard Precautions

Policy application:
Trust-wide

Responsibilities for implementation:
Director of Infection Prevention and Control
Divisional Directors
Divisional Managers
Divisional Lead Nurses
Infection Prevention and Control Team
Heads of Department
Wards Managers
All Staff

Date issued:       April 2007

Date Revised; September 2008

Review Date         September 2010

Authors:      Oonagh McGugan, Lead Nurse Infection Control
              Linda Wild, Infection Control Nurse Specialist

Reference:
   • Joint Working Party BSAC/HIS/ICNA on MRSA (2006) ‘Guidelines for the control and
      prevention of meticillin-resistant Staphylococcus Aureus in healthcare facilities.’
      Journal of Hospital Infection (2006) 63S S1-S44
   • Department of Health (2006) ‘Screening for Meticillin-resistant Staphylococcus aureus
      (MRSA) colonisation: A strategy for NHS trusts: a summary of best practice’.

Intranet Category for Location: trust documents/policies and guidelines/infection control




                                                       1
                                         Index

Contents                                          2

Introduction                                      3

Key points                                        4

Standard infection control measures as            5
applied to MRSA
   o Hands
   o Gloves
   o Aprons/gowns
   o Masks
   o Laundry
   o Waste disposal
   o sideroom
Cleaning                                          6
   o environment
   o wall washing/floors
   o equipment
   o room cleaning port discharge
Screening                                         7
   o inpatients
   o outpatients
   o surgical patients
   o antibiotic prophylaxis
   o critical care unit
Central Venous Catheter/PICC line insertion       9

Eradication/decolonisation treatment              9

Internal patient transfers                        10

Deceased patients                                 12

Wig fitting service                               12




                                              2
INTRODUCTION

This policy is based on two principal documents produced in 2006.

The National guidelines for the control and prevention of Meticillin-resistant staphylococcus
aureus (MRSA) in healthcare facilities were reviewed and published in May 2006. Produced
as a joint project by the British Society for Antimicrobial Chemotherapy (BSAC), the Hospital
Infection Society (HIS) and the Infection Control Nurses Association (ICNA), these followed a
systematic review of the available evidence for preventing and controlling this organism.

In November 2006, the Department of Health produced a strategy for NHS trusts to reduce
the risk of infection from MRSA. The strategy advised all trusts to review their programme of
screening all ‘at risk’ patients and to implement a decolonisation regimen to prevent the
spread of MRSA to other vulnerable patients.

This policy will cover all areas of patient management throughout their journey at the
Christie. The layout will provide easy access to guidance on their management. However,
each patient must be dealt with individually and further advice should always be obtained
from the Infection Control Team.

Staphylococcus aureus is a bacterium that commonly colonises skin, particularly the nose,
throat and perineum. Staph. aureus can cause infections only if there is an opportunity for
the bacteria to invade the body resulting in skin and wound infections, urinary tract
infections, pneumonia and bacteraemia (blood stream infections). Most strains of Staph.
aureus are sensitive to many antibiotics, and infections can be effectively treated.

      MRSA stands for meticillin-resistant Staphylococcus aureus. Meticillin is a marker
      which indicates resistance to all beta-lactamase antibiotics, in addition, many MRSA
      have developed resistance to other antibiotics such as Ciprofloxacin and Gentamicin.
      Treatment options for such organisms, perhaps better termed multi-drug resistant, are
      limited.
      MRSA can be carried as an asymptomatic colonisation of normal skin sites, (eg, nose,
      perineum, axillae,) or abnormal sites such as leg ulcers and eczema.
      Infections vary in severity and patients particularly at risk from infection are surgical
      patients; intensive care patients; immunocompromised patients; patients with open
      wounds or intra- vascular devices.
      Both colonised and infected patients must be viewed as potential sources of infection.

The main means of transmission of MRSA are:


          Direct spread from the hands of colonised/ infected patients.
          Indirect spread- staphylococci can survive in the environment and may spread
          via bedding and equipment.
          Airborne- some colonised/ infected patients may shed large numbers of
          organisms into the environment. Individuals with dermatitis conditions can be a
          particular hazard.




                                              3
Key Points
The single most important measure to contain MRSA is effective hand hygiene.

All patients at the Christie are at a ‘high-risk’ of infection and therefore strict, standard
infection control measures should be adhered to at all times.

All patients undergoing surgery should be screened at pre operative assessment.
Consideration should be given to the timing of screening, obtaining results and
implementation of a decolonisation regimen prior to admission.

All patients referred for insertion of a central venous catheter should be screened and
commenced on eradication treatment.

Patients admitted to the Haematology and Transplant Unit (HTU) and to the Critical Care
Unit (CCU) should be screened on admission and at weekly intervals while they are
inpatients.

Any patients whose MRSA status is unknown should be considered at a high risk of MRSA
colonisation. If they are to be transferred from another healthcare facility and are to be
admitted to the HTU or CCU, they should be isolated, screened and treated as positive until
results known. A course of eradication treatment should be started, and stopped if results
prove negative.

All patients transferred directly to the Christie from another hospital or healthcare facility
should also be considered at a high risk of MRSA colonisation. Their MRSA status should be
clarified prior to transfer and if unknown, the patient should be isolated, screened and treated
as positive until results known.

(NB. Some studies suggest around 20% of nursing and care home residents are colonised
with MRSA and are therefore at a greater risk of developing an MRSA infection and
transmitting the organism to other vulnerable patients).

Known MRSA positive patients should be isolated and infection control precautions
continued when attending other departments within the hospital. It is the responsibility of the
transferring staff to inform the receiving staff of the precautions required.

Isolation precautions should be stopped only after discussion with the infection control team.

A patient will be deemed negative only when three consecutive negative screens have
been reported. These must include all wounds/lesions and invasive devices present.

Patients placed in isolation should be made aware of the risks of cross infection to others
and should receive education about the importance of effective hand hygiene




                                                  4
STANDARD INFECTION CONTROL MEASURES – and their application to MRSA

Hands

Hibiscrub and an alcohol hand rub are placed at every handwash basin. Alcohol gel is
in place at every patient’s bedside or at the point of patient care. Hands must be
washed with Hibiscrub before and after any clinical contact with the patient or his
immediate surroundings and, after exiting the sideroom.

This applies to all staff, medical, nursing and domestic, and includes any visitor who
attends to the patient in their isolation.

This is the single most important measure taken to prevent transmission of MRSA.

Gloves

Gloves do not replace the need for hand hygiene. Disposable non-sterile gloves
should be worn when coming into contact with body fluids and contaminated
dressings. These should be disposed of as clinical waste inside the room.

Gloves are required if the member of staff has any skin lesions/abrasions.

Aprons/gowns

Single use, disposable plastic aprons should be kept outside the isolation room or
cubicle and should be worn whenever a member of staff attends to the patient or his
immediate surroundings. Aprons should be discarded into a yellow bag inside the
room before washing hands.

Masks

There is no evidence to suggest that the use of masks decreases the risk of becoming
a nasal carrier and they do not need to be worn when caring for a patient. However,
they should be worn when performing procedures likely to generate respiratory
secretions, for example during chest physiotherapy and sputum suction.
Liaise with Infection Control for further advice.

Laundry

All linen should be placed in a red alginate bag within the patients room prior to going
into a white linen bag, and sent to the laundry as infected/soiled linen.


Waste disposal
All disposable items and clinical refuse should be regarded as infected, placed into a
yellow clinical waste bag inside a foot operated bin within the room and sent for
incineration.

Sideroom
The door to the sideroom should remain closed to prevent aerosolisation to adjacent
clinical areas, especially during bed making and room cleaning. A risk assessment
may be necessary if this will compromise patient care.
                                               5
Visitors/Relatives

Visitors/relatives are not required to wear aprons and gloves when visiting a patient
socially unless they are assisting with personal care, and should decontaminate their
hands before leaving the room.

NB. Visitors generally do not move from patient to patient, therefore hand washing or
use of alcohol gel before leaving the room is adequate.

Cleaning

Environment

Daily cleaning of all horizontal surfaces and equipment should be undertaken to
minimise dust. All surfaces should be cleaned using a solution of Actichlor Plus at a
dilution of one tablet in 1 litre of cold water = 1000ppm (parts per million) available
chlorine. This product combines ‘cleaning’ and ‘disinfection’ in one action.
(See Actichlor Plus dilution chart in the ward sluice).

Wall washing/floors

Floors, walls and ceilings are low infection risk areas and only floors need daily
cleaning.
Wall washing is not necessary in all clinical areas. (Liaise with infection control)

Equipment

       Medical devices eg. stethoscopes, sphygmomanometers, drip stands etc.,
       should be dedicated for use with that particular source patient and kept inside
       the room for the duration of the patient's stay.
       If a piece of equipment is required for use with another patient, this must be
       cleaned prior to removal from the room with a 1,000 ppm (parts per million)
       solution of Actichlor Plus.
       Any other medical device used for patient procedures should be capable of
       being decontaminated appropriately or be single use and disposable. Non-
       disposable, autoclave sensitive items should be cleaned and disinfected
       according to the manufacturers’ instructions.
       Do NOT clean any medical devices in clinical areas.

Room Cleaning on Discharge/Transfer

On discharge/transfer of a patient a ‘terminal clean’ of all the horizontal surfaces and
equipment within the room should be undertaken using a solution of Actichlor Plus at
a dilution of one tablet to one litre of cold water = 1,000 ppm available chlorine. (See
Actichlor Plus dilution chart in the ward sluice).This includes:
            all horizontal surfaces ie bed, window sills, locker, over bed table, etc
            all equipment within the room ie drip stands, furniture, bedside table and
            locker.
            pillows and curtains (if applicable) should be sent for laundering
            disposable curtains should be changed and replacements dated
            Floor and bathroom to be cleaned by domestic services.

                                                6
Once the area is thoroughly dry the room can be used immediately.

Recording of MRSA status
When a patient is identified with MRSA either the Consultants secretary or the nurse looking
after the patient will document the patients infective status in the alert section of the patients
case notes

An ‘alert’ will be placed on Medway by the ICN. A ‘Medical Alert’ stating MRSA, and a
‘Clinical Alert’ stating ‘Contact Infection Control’. This will appear on the screen when
patient’s details are accessed.



                               PATIENT, PETER




Screening
Swabs should be placed in one microbiology form and marked ‘MRSA Screen’

Swab screens should be taken on a weekly basis until 3 negative screens are obtained. A
routine full swab screen consists of

       both nostrils (one swab)
       the back of the throat (one swab)
       the perineum (one swab), groins may be swabbed if the perineum is difficult to
       access.
       Any wounds/lesions/tracheostomies/PEG site/ or invasive devices/central line sites
       need to be included in the screen. They should be placed in a separate microbiology
       form and marked for ‘C+S’ (culture and sensitivity) to rule out other pathogens.

A positive result arises when MRSA is detected in any one or more sites.

Inpatients

   •   All elective patients and all emergency admissions to the Christie must be screened
       prior to or on admission to the trust.
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   •   All patients admitted to HTU and/or the CCU should be screened on admission and
       weekly thereafter.

   •   All surgical patients should be screened pre-operatively or on admission if they have
       not had a pre-operative assessment. All elective patients admitted to the surgical unit
       must be screened on admission..

   •   All patients admitted to the Admissions unit must be swabbed and started on
       eradication treatment for five days. The treatment will be stopped if the patient has a
       negative screen.

   •   All patients admitted to the Admissions unit to undergo a procedure for example;
       blood transfusion and ascitic drainage should be screened and positive results will be
       acted upon as required.

   •   All transfers directly into the Christie from another hospital or healthcare facility should
       be deemed to be at a high risk of MRSA colonisation and therefore should be
       screened on admission.

   •   MRSA status should be clarified prior to transfer and if unknown, the patient should be
       admitted to a sideroom, screened and commence on a decolonisation regimen which
       should be discontinued if the results prove negative?
       NB. transfer may be delayed until results known.

Outpatients

Known MRSA positive patients attending as an outpatient/day case may require screening.
Some may require follow up by the Infection Control Team (ICT). Check recent results on
Medway and in the patient notes. Liaise with the ICT for advice about eradication treatment.

Surgical Patients

   •   All planned surgical patients should be screened at their pre-operative assessment.
       Note that results may take up to 4 days to be verified and eradication treatment is
       usually given over 5 days. Therefore patients should ideally be screened 10 days in
       advance of their surgery in order for treatment to be completed.

   •   If screened at pre-operative assessment, adequate time should be allowed in which to
       receive the results and for the patient to receive a course of decolonisation treatment,
       which may be over 5 or 10 days dependant on sensitivities.

   •   Clearance of MRSA carriage should be attempted before surgery whenever possible,
       but should not compromise patient safety.

   •   A sideroom will need to be booked through Triage prior to admission. Surgical
       theatres should be notified by admitting staff.


Antibiotic prophylaxis for surgery



                                                8
Patients undergoing surgical procedures may require peri-operative antimicrobial treatment.
Medical staff are advised to discuss with the Consultant Microbiologist.

The ICT recommends that patients who are currently or who have previously been
colonised/infected with MRSA should undergo a course of eradication treatment immediately
prior to surgery.

Critical Care Unit

Any patients whose MRSA status is unknown should be considered at a high risk of MRSA
colonisation. If they are to be transferred from another healthcare facility and are to be
admitted to the CCU, they should be isolated, screened and treated as positive until results
known. A course of eradication treatment should be started, and stopped if results prove
negative.

All MRSA positive patients should be cared for in a sideroom post operatively with the
appropriate medical and nursing care.
On discharge of the patient, the bed area should be terminally cleaned with Actichlor Plus.

Central Venous Catheter Insertion (CVC)
All patients referred for CVC insertion should be screened for MRSA no more than two
weeks prior to date of line insertion if outpatients or within one week if inpatients.
The result must be conveyed to the line team or the infection control team prior to line
insertion by the referring clinician.
Patients that have not been screened will not have a line inserted.
The patient should be commenced on a course of eradication treatment in anticipation of
these results. Mupirocin 2% nasal ointment (Bactroban) applied to the inner surface of each
nostril 3 times daily for 5 days. Aquasept or Hibiscrub to be used daily in place of their usual
soap for the duration of the line.

Hair should be washed with the antiseptic solution twice weekly

Staff Screening

Staff are not routinely screened for MRSA. The ICT in liaison with the Infection Prevention
and Control Doctor and the Occupational Health Department will advise if staff require
screening as part of an ongoing investigation.

Eradication/Decolonisation Treatment

Patients may receive decolonisation treatment to help eradicate the MRSA from the nose,
throat and skin. Advice should be sought from the ICT. This can be prescribed by either a
Doctor or an Infection Control Nurse and should consist of a nasal ointment, a throat gargle
and a bodywash.

For the treatment of MRSA infections, please refer to the Trust Antibiotic Prescribing policy
and/or liaise with the Microbiologist at MRI.

Nasal decolonisation



                                                9
Mupirocin 2% (Bactroban) in a paraffin base, applied to the inner surface of each nostril 3
times daily for 5 days.

NB. Mupirocin resistance is increasing internationally. Repeat treatment should be discussed
with the ICN’s.

Alternatively a chlorhexidine based nasal ointment (Naseptin) may be recommended. This is
to be applied to the nostrils 4 times a day for 10 days.
NB. Patients who have a nut allergy should not receive Naseptin

Throat decolonisation
Chlorhexidine as a throat gargle to be used 4 times a day
Systemic treatment for persistent throat carriage may be advised only following discussion
with the Consultant Microbiologist. Corsodyl throat gargle should NOT be used for patient
with head and neck cancers.


Skin and hair decolonisation

The prescribed antiseptic bodywash should replace the patient’s usual soap for the
duration of the treatment (either over 5 or 10 days) and be used daily in either the
bath or the shower.
If a patient is unable to use the bath or shower, the bodywash should still be used for
daily personal hygiene using a disposable or fresh cloth, concentrating on both the
axillae and the perineum area. The hair should also be washed with the antiseptic
skin cleanser twice weekly.

For colonised/infected wounds and other skin lesions, Bactroban cream as (Mupirocin
calcium 2%) may be used following swabs taken for bacteriological examination, and
should be applied 3 times daily for up to 10 days. Avoid prolonged use on large raw
areas. An alternative is a chlorhexidine based cream. Liaise with the Microbiologist.

       Bed linen and towels should be changed daily following a bath/shower. These
       should be removed from the bed gently to minimize dispersion of skin scales
       and treated as infected linen.

       All nightclothes should be changed daily after the bath or shower. Other
       washable garments should be changed as often as possible.

       All patients should be issued with individual bowls, towels and other items
       required for their personal hygiene needs.




Internal transfer of patients

Maintaining dignity and confidentiality is important for patients at all times.

   •   It is not necessary for staff members to wear aprons and gloves when transferring a
       patient throughout the hospital. Plastic disposable aprons need only to be worn when


                                                10
       in physical contact with patients such as when assisting onto the wheelchair or from
       bed to chair.
   •   Gloves are required only when coming into contact with body fluids and contaminated
       dressings.
   •   Gloves should also be worn in addition to covering any skin lesions/abrasions with an
       adhesive dressing.
   •   Hands should be washed after removal of the gloves.
   •   Gloves and aprons should be removed before leaving the ward or department.
   •   The trolley or chair should be decontaminated with Actichlor Plus immediately after
       use.
   •   Staff should wash their hands after handling the patient, the trolley or chair.
   •   Transfers to other departments should be kept to a minimum, but should not
       compromise patient care. The receiving department/ward should be notified of the
       patients’ MRSA status prior to the transfer in order that arrangements can be put in
       place.
   •   Standard precautions (previously Universal Precautions) should be adopted by all
       staff whenever they are in physical contact with the patient.



Deceased patients

   Mortuary staff should be made aware of the MRSA status of the patient and standard
   precautions should continue to be used by all medical, nursing staff and mortuary staff
   when handling deceased patients known to have MRSA.

   Refer to Last Offices Policy.

Hairdresser/Wig Fitting Service

Careful consideration should be given to patients with MRSA who require the services
of the hairdresser or fitting of a wig.

An individual assessment can be made following discussion with the Infection Control team
and advice will be given.

See Wig Fitting guidelines

Contact Information
For further information, contact the ICT on extension 3731, bleep 12560 or pager via the
hospital switchboard.




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