Staphylococcus aureus (MRSA & MSSA) Management Policy
Version
10
Name of responsible (ratifying) committee
Infection Prevention Management Committee
Date ratified
28 January 2015
Document Manager (job title)
Dr Caroline Mitchell, Consultant in Infection Prevention
Date issued
12 February 2015
Review date
01 January 2017
Electronic location
Infection Prevention and Control Policies
Related Procedural Documents
Trust Policies:
Hand Hygiene policy
Isolation Policy
Standard Precautions policy
Decontamination policy
Key Words (to aid with searching)
MRSA, MSSA Staphylococcus aureus, staph aureus
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
10
28/01/2015
Previously ‘Interim Staphylococcus Aureus Policy’
New elective pathway and renal dialysis pathway
diagrams
Infection
Prevention
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 1 of 23
CONTENTS
1. INTRODUCTION.......................................................................................................................... 4
2. PURPOSE ................................................................................................................................... 4
3. SCOPE ........................................................................................................................................ 4
4. DEFINITIONS .............................................................................................................................. 4
5. DUTIES AND RESPONSIBILITIES .............................................................................................. 5
6. PROCESS ................................................................................................................................... 5
7. TRAINING REQUIREMENTS .................................................................................................... 16
8. REFERENCES AND ASSOCIATED DOCUMENTATION .......................................................... 16
9. EQUALITY IMPACT STATEMENT ............................................................................................ 18
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS ........................................ 19
Appendix 1 ........................................................................................................................................ 20
Appendix 2 ........................................................................................................................................ 22
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 2 of 23
QUICK REFERENCE GUIDE
Screening for MRSA:
Not all elective patients need to be screened for MRSA. Some elective specialties are required to
screen all patients due to the prevalence and risk of MRSA in their populations. Other elective
specialties only need to screen patients with specific risk factors for MRSA. See section 6.7 for
relevant screening requirements and risk assessments.
All patients admitted as emergencies must be screened for MRSA at the time of admission.
Patients attending the Emergency Department but not needing admission do not require screening.
Screening for S. aureus should be performed using a dry charcoal swab (one swab per site)
Screening Sites:
 Anterior nares (all patients) the same swab should be used for both nostrils
 Groin (inpatients only) the same swab should be used for both groins
 Wounds/skin lesions if multiple lesions, swab representative sample
 Intravenous devices do not disturb covered/dressed sites unless site looks infected
 Urinary catheters specimen of urine should also be obtained
All emergency admissions (and admissions to ICU) must be given topical S aureus protection until
their screening results are known:
1st Line Suppression:
 Octenisan wash once daily until screening results known
Confirmed MRSA positive patients should receive suppression therapy under the guidance of the
Infection Prevention Team:
1st Line Suppression:
 Mupirocin 2% applied to the inner surface of each nostril 3 times a day for 5 days
 Chlorhexidine Gluconate 4% (Hibiscrub) or Octenisan wash once daily for 5 days
2nd Line Suppression (for Mupirocin Resistant Strains):
 Naseptin applied to the inner surface of each nostril 4 times a day for 10 days
 Chlorhexidine Gluconate 4% (Hibiscrub) or Octenisan wash once daily for 10 days
Once a patient is confirmed MRSA positive they should always be assumed to have a
continuing positive status irrespective of current screening results. There is no requirement to
obtain 3 negative screens post suppression therapy. The patient should be screened weekly after
suppression therapy but assumed to remain positive
The purpose of suppression therapy is to achieve a short-term reduction in skin +/- nasal flora.
Patients should not be given more than two courses of full suppression therapy in six months.
Patients with nasal or skin carriage of MSSA, or MSSA Blood Stream Infection do not routinely
need to be isolated.
Where possible, all patients with MRSA positive isolates should be placed in side rooms. High
Staphylococcal dispersers must, without exception, take priority for side rooms:
 MRSA positive sputum with productive cough
 MRSA positive tracheostomy
 MRSA/MSSA positive with severe skin shedding (e.g. severe eczema, psoriasis)
 MRSA positive in uncovered discharging wound
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 3 of 23
1.
INTRODUCTION
Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus
aureus (MRSA) are types of S. aureus bacteria present in community and healthcare settings
capable of causing significant healthcare associated infection (HCAI).
2. PURPOSE
This policy defines the actions taken by Portsmouth Hospitals NHS Trust to reduce the
transmission of S. aureus within relevant acute and community environments by reducing or
managing their reservoirs and preventing onwards transmission. This policy will inform all
hospital workers of their individual responsibilities to effectively manage S. aureus.
This policy should be read in conjunction with the Standard Precautions, Hand Hygiene and
Isolation policies.
3. SCOPE
This policy applies to all Portsmouth Hospitals NHS Trust staff, health and non-healthcare,
including agency, bank and locum staff, as well as contractors and external agencies.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
Colonisation: Presence of S. aureus (often nose, sputum, urine, faeces, open wounds or on
the skin) without the presence of symptoms or clinical manifestations of illness or infection. A
colonized individual may transmit the organism to another person.
Suppression Therapy: Temporary suppression of the S. aureus carrier state through use of
topical agents (e.g. Octenisan or Chlorhexidine washes +/- antimicrobial nasal cream). This
decreases the risk of transmission to others.
Infection: Invasion and multiplication of S. aureus in tissue with the manifestation of clinical
symptoms of infections such as increased white blood cell counts, fever, lesions, furuncles,
drainage from a break in skin continuity and erythema. Infection warrants treatment.
Mode of Transmission: The method by which S. aureus is spread into the environment and to
other persons. S. aureus are transmitted primarily by direct person-to-person contact (i.e. from
the hands of one individual to a susceptible individual). Contaminated bed linen, surfaces,
medical equipment and high levels of environmental dust also play a significant role in
transmission.
Meticillin Resistant Staphylococcus aureus (MRSA): A gram-positive bacteria, found on
approximately 3% of the general population and up to 7% of hospital patients that is not
inhibited by meticillin or oxacillin and many other antimicrobials.
Meticillin Sensitive Staphylococcus aureus (MSSA): A gram-positive bacterial, carried by
approximately 50% of the healthy adult population at any one time (20% persistent carriers,
60% intermittent carriers, 20% non carriers). Most MSSA are sensitive to meticillin,
cephalosporins and oxacillin. MSSA is a common cause of localised skin and soft tissue
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 4 of 23
infections or serious disease like discitis, osteomylitis, septic arthritis, endocarditis, pneumonia
or systemic sepsis.
5. DUTIES AND RESPONSIBILITIES
Infection Prevention Team:
 Review and update MRSA/MSSA policy
 Give additional advice regarding the management of patients with MRSA/MSSA
 Include MRSA/MSSA in all induction and update training for clinical staff
 Promote good practice and challenge poor practice
Microbiologists:
 Alert Infection Prevention Team and clinical teams (where appropriate) of patients with
clinically significant MRSA/MSSA infections
 Follow the antimicrobial prescribing policy for patients with or at risk of MRSA/MSSA
Patient Flow / Duty Hospital Managers:
 Facilitate placement of patients with MRSA into appropriate isolation rooms
 Escalate difficulties in management/placement of MRSA/MSSA patients to the Infection
Prevention Team
 Ensure effective communication of patients risk and carriage status
Matrons / Ward Managers:
 Must establish a culture of compliance with infection prevention practice across their units
 Ensure admission and weekly screening for MRSA occurs as per policy
 Promote good practice and challenge poor practice
Medical Staff:
 Ensure compliance with infection prevention and antimicrobial prescribing policies
 Ensure prudent antimicrobial prescribing and stringent use/removal of indwelling devices
 Follow advice of the Infection Prevention Team relating to patients with MRSA/MSSA
All Healthcare Staff:
 Must be familiar with and adhere to the relevant infection prevention policies to reduce the
risk of cross infection of patients
 Must adhere to the full terms and conditions documented in this policy
 Refer to the infection prevention team if unable to follow the policy guidelines
 Must check the MRSA status of their patient prior to any invasive procedure
6. PROCESS
6.1 General Principles:
Standard precautions, including strict hand hygiene and appropriate use of personal protective
equipment should be applied to all patients without exception, regardless of known S. aureus
colonisation or infection (refer to standard precautions and hand hygiene policy).
6.2 Screening of patients:
Screening for S. aureus should be performed using a dry charcoal swab (one swab per site)
6.2.1 Screening Sites:
 Anterior nares (all patients) the same swab should be used for both nostrils
 Groin (inpatients only) the same swab should be used for both groins
 Wounds/skin lesions if multiple lesions, swab representative sample
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 5 of 23
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Intravenous devices do not disturb covered/dressed sites unless site looks infected
Urinary catheters specimen of urine should also be obtained
6.3 Suppression Therapy:
The purpose of suppression therapy is to achieve a short-term reduction in skin +/- nasal flora
to protect the patient during specific events in their admission (e.g. immediately on admission
for blood cultures, lines, catheterisation etc. and for certain invasive procedures thereafter). The
goal is not to achieve long-term eradication and patients should not be given more than two
courses of full suppression therapy in six months to try and achieve this.
6.4 Directions for Administering Suppressive Agents:
Suppression therapy should be prescribed on the patients medication chart or as an out-patient
prescription and clearly limited in duration, dependant on the agent used
6.4.1 Topical Washes:
Octenisan is a gentle, non-perfumed antimicrobial wash, suitable for use in all age groups
(including neonates greater than 28 weeks gestation) and those with eczema and psoriasis.
Hibiscrub (Chlorhexidine 4%) is an antimicrobial wash suitable only for adults and should not
be used on patients with hibiscrub allergy or infected, dry, or flaking skin.
 Patients should wash once daily for 5 days as follows:
Days 1 and 5 wash the whole body, neck, face and hair
Days 2, 3 and 4 wash the whole body, neck and face
 Patients should use approximately 50mls of Octenisan or Hibiscrub per wash
 Patient should wet their skin prior to application of Octenisan or Hibiscrub
 Octenisan or Hibiscrub should not be diluted in washing water – it must be applied neat
 Special attention should be paid to sites such as axillae, groin, perineum and buttock areas
or other skin folds
 Fresh towels and facecloths should be used each day
 A daily change of bedding and clothing is required and should occur at the same time as
the patient washes with Octenisan or Hibiscrub
 Suppression should be discontinued immediately and the IPCT contacted if the patient
experiences excessive skin irritation or allergic reaction
6.4.2 Nasal Creams:
Mupirocin and Naseptin are antimicrobial ointments for use in the nasal passages.
Repeated or prolonged courses of Mupirocin or Naseptin must be avoided due to possible
development of resistance.
General Directions:
 Using a clean finger, the patient should wipe a pea-sized amount of ointment around the
inside of each nostril and squeeze their nose
 Patients should be able to taste the ointment at the back of their throat. If they cannot, they
should apply a small amount of extra cream
6.5 Ongoing S. aureus status:
Suppression therapy is designed to reduce the burden of S. aureus on a patient’s skin. It is
highly unlikely to achieve long-term eradication and a large number of patients will have
detectable levels of S. aureus within one year of treatment. Once a patient is MRSA positive
they should always be assumed to have a continuing positive status irrespective of
current screening results. Repeated courses of suppression should not be offered unless the
patient is undergoing invasive procedures.
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 6 of 23
 There is no requirement to obtain 3 negative screens post suppression therapy. The
patient should be screened weekly after suppression therapy but assumed to remain
positive
6.6 Continuation of suppression therapy after discharge:
Confirmed MRSA positive patients discharged before completing suppression therapy should
complete the remainder of their course in the community. Suppression therapy should be
clearly written on the TTO chart and documented in the discharge letter.
6.7 ELECTIVE SURGICAL PATHWAY:
All relevant patients booked as electives should be screened for MRSA. At present, there is no
requirement to risk assess or routinely screen patients for MSSA, with the exception of patients
undergoing spinal surgery.
The following specialties must screen all elective cases for MRSA prior to procedures:
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Cardiology
Clinical haematology
Gastroenterology
Medical oncology
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Nephrology
Obstetrics (caesareans)
Pain relief
Plastic surgery
Renal surgery
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Rheumatology
Transplant surgery
Trauma and orthopaedics
Urology
Vascular surgery
The following specialties only need to screen patients identified as high risk:
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Breast surgery
Colorectal surgery
Day case dental
Dermatology
ENT
Elderly medicine
Endocrinology
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Endoscopy
General medicine
General surgery
Gynaecology
Hepatobiliary
Neurology
Obstetrics (ex caesareans)
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Ophthalmology
Oral surgery
Orthodontics
Paediatric medicine
Radiotherapy
Rehabilitation
Thoracic medicine
Upper GI surgery
6.7.1 Risk Assessment:
A patient is regarded as ‘high risk’ for the carriage or acquisition of MRSA if they fulfill one or
more of the following criteria:
 Have been MRSA positive at any point in the past
 Had a previous admission to any healthcare facility in the last 6 months
 Have been admitted from a residential home (inc Nursing Homes, Military Barracks, HM Prisons)
 Have been admitted with indwelling devices (inc urinary catheters, PICC, tunneled lines)
 Have chronic open wound(s) (skin breaks, pressure sores, ulcers) or cellulitis
 Have any chronic skin condition (inc psoriasis, eczema, dermatitis)
 Have been or are an IV drug user
 Have been or are a healthcare worker
 Are admitted for a high risk procedure (joint replacement or implant surgery)
‘High risk’ patients must be identified at the point of pre-operative assessment or clerking.
Patients with none of the above risk factors are considered to be ‘low risk’ for the carriage or
acquisition of MRSA.
Screening of elective patients should occur no greater than 6 weeks prior to surgery.
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 7 of 23
For those patients seen in pre-operative assessment more than 7 days before surgery:
 Screening should be performed and a result obtained. Confirmed positive patients should
then be treated with Hibiscrub/Bactroban in the 5 days leading up to surgery, completing
their suppression course on the day of surgery. No repeat screening is required prior to
surgery and the patient should be treated as colonised for the purposes of theatre –
appropriate intra-operative antibiotics covering MRSA should be used
Confirmed MRSA positive patients under the guidance of the Infection Prevention Team:
1st Line Suppression:
 Mupirocin 2% applied to the inner surface of each nostril 3 times a day for 5 days
 Chlorhexidine Gluconate 4% (Hibiscrub) or Octenisan wash once daily for 5 days (see
appendix 1)
2nd Line Suppression (for Mupirocin Resistant Strains):
 Naseptin applied to the inner surface of each nostril 4 times a day for 10 days
 Chlorhexidine Gluconate 4% (Hibiscrub) or Octenisan wash once daily for 10 days
For those patients seen in pre-operative assessment less than 7 days before surgery:
 Patients should be screened, risk assessed (see criteria 6.7.1), with patients deemed as
high risk given antimicrobial wash to start immediately in order to complete as many days
as possible prior to surgery
 For patients that cannot be screened prior to surgery, a screen should be obtained on the
day of surgery and a risk assessment (see criteria above) performed. High-risk patients
should receive an antimicrobial wash prior to going to the operating theatre.
As part of Elective Pre-Operative Assessment for patients assessed as high risk of MRSA
carriage:
1st
Line Suppression:
 Chlorhexidine Gluconate 4% (Hibiscrub) or Octenisan wash once daily for 5 days
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 8 of 23
6.8 EMERGENCY ADMISSION PATHWAY:
6.8.1 Screening for MRSA:
All patients admitted as emergencies must be screened for MRSA at the time of admission.
Patients attending the Emergency Department but not needing admission do not require
screening. For minimum screening requirements see section 6.2.1
As part of the Emergency Admission Pathway for all emergency admissions prior to
screening results or any admission to ICU:
1st Line Suppression:
 Octenisan wash once daily until screening results known
Confirmed MRSA positive patients under the guidance of the Infection Prevention Team:
1st Line Suppression:
 Mupirocin 2% applied to the inner surface of each nostril 3 times a day for 5 days
 Octenisan wash once daily for 5 days (see appendix 2)
2nd Line Suppression (for Mupirocin Resistant Strains):
 Naseptin applied to the inner surface of each nostril 4 times a day for 10 days
 Octenisan wash once daily for 10 days
6.8.2 Instructions for using Octenisan Wash
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 9 of 23
Emergency Admission
1 HOUR
4 HOURS
Routine admission swabs (every patient)
Nose & Groin & Site of Infection (e.g. wound[s])
Start Daily Octenisan Washes (every patient) – pre-prescribed as above
Once daily body wash 30-50mLs used undiluted over whole body
(do not use nasal Bactroban)
Wait for Admission Screening Results
48-72 HOURS
Negative MRSA Screen
Option to discontinue Octenisan washes. If
patient has chronic wounds, eczema/psoriasis
or invasive procedures planned, suppression
may be continued with no time limit
Positive MRSA Screen
Start full suppression therapy for 5 days
Mupirocin 2% (Bactroban) nasal ointment 3
times daily
Octenisan body wash once daily
Positive MRSA
Screen
Negative MRSA
Screen
Rescreen every 7 days
or on designated ward
screening day
Continue daily
Octenisan washes
Rescreen every 7 days
or on designated ward
screening day
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 10 of 23
6.9 RENAL DIALYSIS PATHWAY:
Patients receiving Renal Haemodyalysis should be screened every 3 months. If the result is
MRSA positive, the patient should be offered a full course of suppression for five days, followed
by routine Octenisan washes prior to each haemodialysis session. The patient should be
assumed to remain MRSA positive despite treatment. If multiple negative MRSA screens are
achieved over a period of months, the patient’s positive status should be discussed with the
Infection Prevention Team.
Established Haemodialysis
Routine swabs
Nose & Groin & Site of Infection (e.g. wound[s])
Positive MRSA Screen
Start full suppression therapy for 5 days
Mupirocin 2% (Bactroban) nasal ointment 3
times daily
Octenisan body wash once daily
Positive MRSA
Screen
Negative MRSA
Screen
Screen every 3 months,
manage as positive /
isolate / barrier
Screen every 3
months
Octenisan washes
prior to HD
6.10 Isolation and transmission precautions for MRSA and MSSA:
Healthcare staff must provide patients and families with appropriate verbal and written
information about MRSA or MSSA and explain the need for isolation and transmission
precautions where indicated. Written information can be obtained from Infection Prevention.
It is important that all relevant staff involved in patient care is aware of the patient’s
MRSA/MSSA status and of the infection prevention and control precautions required to reduce
the risk of transmission. It is the responsibility of ward staff to inform other departments of the
patients MRSA/MSSA status.
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 11 of 23
Standard precautions should be applied to all patients, routinely.
Patients with nasal or skin carriage of MSSA, or MSSA Blood Stream Infection (BSI) do not
routinely need to be isolated.
Where possible, all patients with MRSA positive isolates should be placed in side rooms. High
Staphylococcal dispersers must, without exception, take priority for side rooms:
 MRSA positive sputum with productive cough
 MRSA positive tracheostomy
 MRSA/MSSA positive with severe skin shedding (e.g. severe eczema, psoriasis)
 MRSA positive in uncovered discharging wound
6.10.1 Patient movement – internal:
The movement of patients with MRSA should be minimised to reduce the risk of cross infection.
Where patients need to change specialties or attend departments for essential investigations,
the risk posed to other patients should be managed by strict infection control procedures.
Staff who are transferring patients must ensure that:
 The receiving area is aware of the patient’s MRSA status
 The receiving area has the appropriate level of isolation nursing available
 The patient is wearing clean / fresh clothes and is on a bed with clean linen
 Lesions are covered with an impermeable dressing wherever possible
 All transfer equipment is decontaminated before and after transfer
Portering staff who transfer patients do not need to wear gloves. They MUST cleanse their
hands before and after the transfer using soap and water or alcohol hand gel
6.10.2 Patient movement - external/discharge:
 MRSA is not a valid reason for delaying appropriate care, interventions, transfer or
discharge. These should occur when clinically appropriate
 Prior to transfer to other healthcare facilities (e.g. hospitals, residential care homes, etc)
the receiving facility must be notified of the individual’s MRSA status
 Specialised care relating to the patients MRSA status (e.g. wound management,
suppression therapy, and antibiotic therapy) should be discussed by the patient’s
physician with relevant agencies (e.g. GP, community Infection Prevention Team, District
Nurses) prior to discharge.
 Transfer / referral letters must clearly state the MRSA status of the patient
 Carriage of MRSA is not a valid reason for exclusion from residential care homes
 Staff are encouraged to contact the IPCT (7700 6261) to discuss problems relating to
delay in discharge due to MRSA status
6.10.3 Patient movement - deceased patients:
No additional precautions are required
6.10.4 During the Patient Stay:
All patients should:
 be actively encouraged to keep the bed space free from clutter to enable cleaning
 be actively discouraged from touching wounds
 be actively encouraged to observe good hand hygiene at every opportunity including
using the alcohol hand gel at the bedside
 be encouraged to challenge poor hand hygiene practice
6.10.5 Visitors and MRSA/MSSA:
Visitors of patients with MRSA/MSSA are encouraged
 Visitors must wash/decontaminate their hands before entering the clinical area and
immediately prior to leaving, Alcohol hand rub gel is suitable for visibly clean hands
 Protective clothing does not need to be worn unless a visitor is providing hands-on care
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 12 of 23
6.10.6 MRSA/MSSA in the Operating Theatre:
Apart from rigorous surgical skin preparation, no additional precautions are required for MSSA.
Every effort should be made to reduce the risk of MRSA colonisation or infection before surgery
or procedures. A patient’s MRSA status should not prejudice their surgical management.
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MRSA positive patients can be scheduled for surgery at any time on the list, providing the
required level of decontamination can be achieved between cases
Rigorous surgical skin preparation using 2% Chlorhexidine 70% Isopropyl alcohol should
be observed
At the end of every surgical procedure with an MRSA positive patient, anaesthetic and
any other equipment must be decontaminated with 1000ppm of Actichlor plus. Refer to
Trust Decontamination Manual. Extra time may need to be allocated for procedures to
allow appropriate cleaning of area
Equipment and the staff attending the patient should be kept to the minimal level without
compromising the patient safety or care. All equipment must be cleaned after each MRSA
case
Lesions not involved in the surgical procedure should be covered with an impermeable
dressing
Discuss with a medical microbiologist the need for specific antibiotic prophylactic cover –
see Trust antibiotic policy – surgical prophylaxis
MRSA positive patients in recovery must be segregated wherever feasible and nursed by
dedicated staff adhering to isolation procedures
6.10.7 Environmental Cleaning:
The management of the environment and equipment should be considered central to
minimising the spread of MRSA/MSSA. Cleaning regimens should focus on the elimination of
dust and the removal of fomites (see decontamination policy)
6.10.8 Terminal Cleaning on patient discharge / transfer / death
MRSA (or potential MRSA) contaminated patient areas must be cleaned / disinfected after the
patient’s discharge.
Within PHT between the hours of 0800 – 2100 ‘Terminal Cleans’ are provided by Domestic
Services via Carillion helpdesk on Ext 7700 6321.
Areas situated off-site (not QA hospital) are to request cleaning as per their local procedure.
6.10.9 Out of Hours Terminal Cleaning:
Patient areas vacated outside of Domestic Services hours must be cleaned by Clinical staff.
The ‘Terminal Clean’ includes:
The cleaning and disinfection of the bed space using a chlorine and detergent based product at
1000ppm of Actichlor plus. The equipment within the bed space includes:
 The bed – mattress, pillows, bed frame and bed rails. Pillows and mattress covers should
be checked for damage and changed if necessary. (Therapy beds may need specialist
cleaning in accordance with the manufacturer’s/hirer’s instructions)
 High and low level dusting
 Washing of floors
 The bedside locker
 The over bed table
 The chair
 The patient call buzzer
 Any plastic patient files stored at end of bed
 The alcohol gel dispenser
 Any extra equipment that is no longer required should be removed and stored after
cleaning and disinfection
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 13 of 23

Patientline equipment must be wiped over with a soap and water wipe only and foam ear
pads replaced
6.10.10 Completion of Clean:
The bed is then safe to admit another patient; however the Carillion helpdesk must be informed
that a ‘Terminal Clean’ requires completion. This would include:
 The removal and laundering of curtains including shower curtains
 Cleaning of the floors
 Damp dusting of the wider area including radiators and shelves
 Walls do not require cleaning unless physically contaminated
6.11 VISA (Vancomycin intermediate S. aureus) GISA (Glycopeptide intermediate S.
aureus) VRSA (Vancomycin resistant S. aureus):
VISA / GISA and VRSA infections are still relatively rare and typically occur in patients with
MRSA colonisation/infection after persistent exposure to glycopeptides. It is prudent to assume
that VISA/GISA (and by inference VRSA) is as transmissible as MRSA in the healthcare
setting. The care and management of the patient must be discussed with a medical
microbiologist or IPCT before the patient is admitted or as soon as the infection is discovered.
In addition to the standards outlined in this policy for MRSA management the following must be
applied:
 The patient must be admitted / transferred to a side room within a specialised area
depending on the patient’s clinical needs
 The number of staff looking after the patient must be reduced to the minimum in line with
the needs of the patient. These staff must not look after any other patient during the shift
or do another concurrent shift without showering and changing uniform
 Single use gloves and aprons must be worn at all times whilst in the room
 Door to the room MUST BE SHUT at all times
6.12 MRSA and MSSA Blood Stream Infection (BSI):
The Trust is actively engaged in the mandatory surveillance and reduction MRSA and MSSA
BSI inline with national and local targets. The Trust is required to report all cases of MRSA or
MSSA BSI acquired >48 hours after admission. A Post Infection Review (PIR) will be
undertaken for all MRSA BSI jointly by clinicians and the infection prevention team to identify
learning in these cases. The IPCT will notify clinicians of the need for a PIR.
6.13 Staff Screening for Staphylococcus aureus (MRSA or MSSA):
The following primarily refers to MRSA colonisation of staff but may be used for screening for
MSSA if required
6.13.1 General Principles:
Staff members, particularly those involved in direct clinical care, are likely to come into contact
with a wide range of organisms, including MRSA as part of their normal daily work. Staff must,
therefore, apply standard precautions to all patient interaction, including strict hand hygiene and
appropriate use of PPE, to prevent transient acquisition and onwards spread of any bacteria.
Persistent MRSA carriage in staff members who act as a reservoir for the bacteria is less
common and regular or routine screening of staff members is not thought to be useful.
Where screening is undertaken, staff can be assured that the process will be:
 confidential
 transparent
 fair and impartial
 as far as possible, non-detrimental to the persons career pathway
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 14 of 23
6.13.2 Pre-employment screening:
Pre-employment screening of staff members is not routinely required. However, where there is
a history of colonisation, the applicant may be screened through the Occupational Health
Department (OHD) and suppression given prior to commencing employment if found to be
positive.
6.13.3 Staff Screening:
Screening of staff for MRSA will only be undertaken if there is unexplained and persistent
onwards transmission of MRSA within an area and all other active control measures have
failed.
The purpose of screening is to identify and eradicate any potential reservoir of MRSA which
may be contributing to onwards transmission.



Staff screening will be initiated on the advice of the Infection Prevention Team and
undertaken by the OHD, who will co-ordinate screening and subsequent management as
required
Staff are reminded that it is a disciplinary offence to look up their own or other peoples
screening results
Staff must not carry out their own screening as it can be difficult to distinguish between
transient and persistent carriage.
6.13.4 Process:





The Infection Prevention Team will identify the extent and scope of screening. This will
normally be limited to staff members involved in direct patient care
Staff will receive prior written notice of the intention to screen, along with a copy of the
screening protocol which clearly identifies each stage of the process
Staff will be asked to undertake a short questionnaire to identify any skin lesions
(eczema, psoriasis, dermatitis, paronychia etc.) or any recent courses of antibiotic
treatment
All screens will be taken prior to the staff starting their shift and before any patient contact
has occurred to minimise the risk of identifying transient carriage
Screening sites will depend on the epidemiology of the MRSA cases but will usually
include specimens for the nasal passages, throat and any areas of broken skin (eczema,
psoriasis, dermatitis etc).
6.13.5 Management of Colonised Staff Members
 Confirmed positive isolates from staff members will be managed confidentially through
the OHD. However, isolates will be sent for epidemiological typing via the microbiology
department and individual case discussion may occur involving OHD, IPCT and Infection
Control Doctor (ICD)
 The action taken will depend upon the site of colonisation of MRSA and the clinical area
and duties of the staff member
 Colonised staff who are required to take time off work will be considered medically
suspended and not on sick or annual leave. Treatment will be funded by Portsmouth
Hospitals NHS Trust
6.13.6 Nasal Colonisation alone: Where nasal colonisation only is detected, staff members
will be asked to undergo 5 days of topical treatment with nasal mupirocin (or equivalent) and
Octenisan wash and will not be excluded from work.
6.13.7 Throat carriage: will initially be treated with antibacterial throat wash and dental gel (in
conjunction with mupirocin and Octenisan) and staff members will not be excluded from work
unless they have an active cough.
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 15 of 23
6.13.8 Colonised/Infected Lesions: Staff members with infected or colonised hand lesions,
which render effective hand hygiene impossible, should be referred to OHD/dermatology, and
should be off work or removed from clinical duties whilst receiving treatment. An individual risk
assessment will be required for staff colonised with MRSA at other sites (e.g. local infections in
non-exposed areas).
6.13.9 Subsequent Management:
 Colonised staff members will be re-screened for MRSA 2-7 days after treatment. If found
to be negative, 2 further screens, one week apart over a three week period will be
obtained to ensure clearance. Successful clearance will be defined as 3 negative screens
each taken one week apart. A routine follow up screen will be offered at 6 months to
ensure persistent success
 If initial decolonisation is unsuccessful, a second attempt will be made. In consultation
with the ICD, regimes may be modified dependent on the site of colonisation and any
underlying medical conditions. This may involve usage of systemic (oral) antibiotics and
involvement of other specialists
 Persistently colonised staff members will be managed on a case by case basis. A multidisciplinary team consisting of OHD, the IPCT & ICD and HR will undertake an
assessment of risk of transmission to patients cared for by the staff member. Whilst every
effort will be made to support the staff member to continue practicing in their current role,
patient safety is paramount and consequently it may be necessary to make appropriate
adjustments to the role of the staff member. As a last resort, in the unlikely event of
persistent colonisation at a site posing a significant risk of ongoing transmission of
infection to patients, re-deployment of the staff member may be considered in
consultation with senior line management via existing Trust HR frameworks
6.13.10 Health & Safety:
If a staff member is sent off work because of an MRSA infection likely to have been acquired at
work, the incident needs to be reported under RIDDOR (Reporting of Injuries, Diseases and
Dangerous Occurrences Regulations, 1995). This should be done in consultation wit the OHD.
Reporting is not required for colonisation.
7. TRAINING REQUIREMENTS
a. Clinical and non-clinical staff to receive practical hand hygiene training on induction and
every 2 years thereafter (Infection Prevention Team)
b. Clinical and non-clinical staff to receive face-to-face induction training on aspects of
infection prevention & MSSA/MRSA (Infection Prevention Team)
c. Update training to be delivered as part of Patient Safety & Quality Days, departmental
and drop in days, Link Advisor days and Senior Doctors Training (Infection Prevention
Team)
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Centres for Disease Control and Prevention. Staphylococcus aureus resistant to vancomycin –
United States, J Am Med Assoc 2002; 288: 824-825.
Cepeda JA, Whitehouse T, Cooper B, et al. Isolation of patients in single rooms or cohorts to
reduce spread of MRSA in intensive-care units: prospective two centre study. Lancet 2005;
365: 295-304.
Coia, et al, Guidelines for the control and prevention of meticillin-resistant Staphylococcus
aureus (MRSA) in healthcare facilities Journal of Hospital Infection, Volume 63, Supplement 1,
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 16 of 23
May 2006, Pages1-44 The Joint Working Party of the British Society of Antimicrobial
Chemotherapy, the Hospital Infection Society, and the Infection Control Nurses Association
Cooper BS, Stone SP, Kibbler CC, Cookson BD, Roberts JA, Medley GF, Duckworth G, Lai R,
Ebrahim S. Isolation measures in the hospital management of methicillin resistant
Staphylococcus aureus (MRSA): systematic review of the literature. BMJ 2004; 329:
Department of Health (2008) The Health and Social Care Act 2008: Code of Practice on the
prevention and control of infections and related guidance. Department of Health, December
2010. London. HMSO
Geffers C, Farr BM. Risk of transmission of nosocomial methicillin-resistant Staphylococcus
aureus (MRSA) from patients colonized with MRSA. Infect Control Hosp Epidemiol 2005; 26:
114-5.
Guidelines for the Treatment of Meticillin-Resistant Staphylococcus aureus (MRSA) In
publication J Hosp Infect 2005
Guidelines for the Control and prevention of Meticillin-Resistant Staphylococcus aureus
(MRSA) In publication J Hosp Infect 2005
Loveday et al (2014). epic3: National Evidence-Based Guidelines for Preventing HealthcareAssociated Infections in NHS Hospitals in England. Journal of Hospital Infection 86S1 (2014)
S1–S70
National Institute for Health and Care Excellence. Infection prevention and control. Issued: April
2014 NICE quality standard 61
Salgado CD, Farr BM and Calfee DP. Community-acquired methicillin-resistant Staphylococcus
aureus: a meta-analysis of prevalence and risk factors. Clin Infect Dis 2003; 36: 131-139.
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
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9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
All policies must include this standard equality impact statement. However, when sending for
ratification and publication, this must be accompanied by the full equality screening assessment
tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy
Documentation
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 18 of 23
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
Minimum requirement
to be monitored
Lead
Tool
Frequency of
Report of
Compliance
Monthly reporting of
MSSA and MRSA
bacteraemias (post 48
hours) to Trust board
IPCT
Trust Board Report
Monthly
Weekly reporting of
MSSA/MRSA
bacteraemias to CSC
IPCT
Daily monitoring of MRSA
acquisition and reporting
via DATEX system
IPCT
Reporting arrangements
Lead(s) for acting on
Recommendations
Policy audit report to:
C Mitchell, HoN
 Trust Board, HoN, MM,
Consultants, Ward Managers,
IPMC
Weekly CSC Infection
Prevention Dashboard
Weekly
DATEX
As required
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Policy audit report to:

HoN, MM, Consultants
HoN, MM, Consultants, Ward
Managers
Policy audit report to:
 HoN, MM, Consultants, Ward
HoN, MM, Consultants, Ward
Managers
Managers
Page 19 of 23
Appendix 1
MRSA/MSSA Avoidance/Suppression Regime
Before you read this, you may find it helpful to read the booklet ‘MRSA - Wash it
Away’ / ‘MRSA – Information for Patients in Hospital’ / MSSA – Patient
Information
MRSA (Meticillin-Resistant Staphylococcus aureus) or MSSA (MeticillinSensitive Staphylococcus aureus)
The hospital has confirmed that you have, or are higher risk of having MRSA or
MSSA on your skin or up your nose. We have decided to treat this to reduce the
risk of complications. This is known as suppression.
Please read this sheet carefully and follow all of the instructions. If you
need help to do this, please ask a nurse / carer / relative to assist you.
What should I do?
You will be given a special soap to wash with and some nasal cream to put up
your nose. You should use both for 5 days.
 Wash all over with the special soap once a day for 5 days
 Put the cream up your nose 3 times a day for 5 days
What is the special soap?
The special soap is called Hibiscrub. It is a pink, nonperfumed soap containing chlorhexidine. You should not use
it if you have an allergy to chlorhexidine (alternatives are
available). Hibiscrub should not be used on children.
How often should I use the special soap?
You should wash your whole body using this special soap
neat once a day for 5 days.
How do I use this special soap?
 You can use the special soap in the bath or shower
 Do not dilute the soap in water but use it neat on a
washcloth
 Wet your face and body first, then wash all over, leaving the soap on your
skin for at least 1 minute. Pay special attention to your face, armpits and groin
but do not use inside the body. You should use a clean face cloth each day
 Wash you hair with the special soap on days 1 and 5 of treatment. You can
use your normal shampoo/conditioner in between
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 20 of 23
 Clean towels and fresh clothes should be used after washing. Bed sheets,
pillows and nightclothes should be changed daily
What is the ointment that I put up my nose?
The ointment is called Mupirocin (Bactroban®). It is an antibiotic ointment. It
does not contain penicillin. You should not use the ointment if you are allergic to
Mupirocin or paraffin cream.
How do I use this ointment?
Using a clean finger, you should wipe a pea-sized amount of
ointment around the inside of each nostril and squeeze your
nose. You should be able to taste the ointment in the back of
your throat when you have finished. If you cannot, you
should apply a small amount of extra cream. You must
wash your hands after this.
How often should I put the ointment up my nose?
You should put the ointment up your nose three times a day
for 5 days.
Are there any risks to me?
The ointment sometimes causes irritation to the skin in your nose. If this
happens, stop using the ointment and talk to a member of staff.
After 5 days, your treatment is complete. You should not use the nasal
cream for longer than this time. You can continue to use the special soap if
you wish to. Unless you remain in hospital we will not routinely re-swab you for
MRSA.
Further Information:
Infection Prevention & Control Department – Portsmouth Hospitals NHS
Trust
telephone 02392 286000 x6261
Public Health England:
https://www.gov.uk/government/organisations/public-health-england
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 21 of 23
Appendix 2
MRSA/MSSA Avoidance/Suppression Regime
Before you read this, you may find it helpful to read the booklet ‘MRSA - Wash it
Away’ / ‘MRSA – Information for Patients in Hospital’ / MSSA – Patient
Information
MRSA (Meticillin-Resistant Staphylococcus aureus) or MSSA (MeticillinSensitive Staphylococcus aureus)
The hospital has confirmed that you have, or are higher risk of having MRSA or
MSSA on your skin or up your nose. We have decided to treat this to reduce the
risk of complications. This is known as suppression.
Please read this sheet carefully and follow all of the instructions. If you
need help to do this, please ask a nurse / carer / relative to assist you.
What should I do?
You will be given a special soap to wash with and some nasal cream to put up
your nose. You should use both for 5 days.
 Wash all over with the special soap once a day for 5 days
 Put the cream up your nose 3 times a day for 5 days
What is the special soap?
The special soap is called Octenisan. It is a clear, nonperfumed soap and comes in a 150ml bottle. It can be
used even if you have dry skin, eczema or psoriasis.
How often should I use the special soap?
You should wash your whole body using this special soap
neat once a day for 5 days.
How do I use this special soap?
 You can use the special soap in the bath or shower
 Do not dilute the soap in water but use it neat on a
washcloth
 Wet your face and body first, then wash all over,
leaving the soap on your skin for at least 1 minute.
Pay special attention to your face, armpits and groin but
do not use inside the body. You should use a clean face
cloth each day
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 22 of 23
 Wash you hair with the special soap on days 1 and 5 of treatment. You can
use your normal shampoo/conditioner in between
 Clean towels and fresh clothes should be used after washing. Bed sheets,
pillows and nightclothes should be changed daily
What is the ointment that I put up my nose?
The ointment is called Mupirocin (Bactroban®). It is an antibiotic ointment. It
does not contain penicillin. You should not use the ointment if you are allergic to
Mupirocin or paraffin cream.
How do I use this ointment?
Using a clean finger, you should wipe a pea-sized amount of
ointment around the inside of each nostril and squeeze your
nose. You should be able to taste the ointment in the back of
your throat when you have finished. If you cannot, you
should apply a small amount of extra cream. You must
wash your hands after this.
How often should I put the ointment up my nose?
You should put the ointment up your nose three times a day
for 5 days.
Are there any risks to me?
The ointment sometimes causes irritation to the skin in your nose. If this
happens, stop using the ointment and talk to a member of staff.
After 5 days, your treatment is complete. You should not use the nasal
cream for longer than this time. You can continue to use the special soap if
you wish to. Unless you remain in hospital we will not routinely re-swab you for
MRSA.
Further Information:
Infection Prevention & Control Department – Portsmouth Hospitals NHS
Trust
telephone 02392 286000 x6261
Public Health England:
https://www.gov.uk/government/organisations/public-health-england
Staphylococcus aureus (MSSA, MRSA) Management Policy
Version: 10
Issue Date: 12 February 2015
Review date: 01 January 2017 (unless requirements change)
Page 23 of 23