MRSA surveillance and optional
strategies for elective surgeries
Dianne M Kendall M.D.
Medical Laboratory Director
St Joseph’s Medical Center
Brainerd, MN
Tell me and I’ll forget.
Show me, and I
may
not
remember.
Involve me, and
I’ll understand.
Objectives
• Review concepts of MRSA surveillance
projects
• Review optional approaches for elective
surgical patients
Surveillance
• The monitoring of behavior, activities or
other changing information, usually of
people and often in a surreptitious
(clandestine, undercover, covert) manner.
– What behavior/activities are we monitoring
with MRSA surveillance?
– How is it covert?
– What do we do with the information gathered?
– What is the goal of this surveillance program?
MRSA surveillance
• MONITOR the effectiveness of your isolation/contact
precautions/infection control practices of known MRSA
patients to PREVENT spread to adjacent patients in the
facility via HEALTHCARE WORKERS or HEALTHCARE
ENVIRONMENT
– Surveillance annual report: We had 5% of inpatients identified
with MRSA. Patients adjacent to these admitted patients had a
0% transmission rate of MRSA.
• Contact precautions instituted within 2 hours of discovery of MRSA
in 85% of cases.
• Hand hygiene audit revealed 77% of nurses used appropriate hand
hygiene at work, and 42% of physicians used appropriate hand
hygiene (random sampling by blinded observation of Units 7a, 2d,
ED and Resp Therapy). 100% rooms cleaned properly at
discharge.
MN State Statute 144.585
• Section 15 [144.585] MethicillinResistant Staphylococcus aureus
control programs
• In order to improve the prevention of hospitalassociated infections due to MRSA, every
hospital shall establish an MRSA control
program that meets MDH MRSA
recommendations as published Jan 15, 2008. In
developing MRSA recommendations, the
Department of Health shall consider the
following infection control practices:
Cont..
• 1. identification of MRSA-colonized patients in all
intensive care units, or other at risk patients identified by
the hospital;
• 2. isolation of identified MRSA-colonized or MRSAinfected patients in an appropriate manner;
• 3. adherence to hand hygiene requirements, AND
• 4. monitor trends in the incidence of MRSA in the
hospital over time and modify interventions if MRSA
infection rates do not decrease.
MDH to review MRSA recommendations annually and
revise as necessary.
MRSA Background
• MRSA: methacillin resistant
Staphylococcus aureus
– 30% of humans colonized by S. aureus at any
point and time, usually anterior nares
• Other sites hands, skin (intact and non-intact),
throat, urine, perineum, stool
– MRSA discovered in 60’s and has increased
since that time
MRSA vs MSSA
• MRSA colonized more likely to have MRSA
infection compared to MSSA colonized pts
with MSSA infections
• MRSA easier to transmit between patients
and caregivers compared to MSSA
transmission
• Hospital acquired versus community
acquired
– Different strains, Comm. Acq.(CA) more
virulent
Infection prevention and control
strategies
• Standard Precautions
– Any blood, body fluid, secretion, excretion, non-intact
skin and mucous membranes contain transmissible
infectious agents
• Hand hygiene, gloves
• When exposure anticipated, gown, mask, eye protection or
face shield
• Transmission-Based Precautions:
– Contact precautions (MRSA)
• Direct and indirect contact
– Droplet precautions
– Airborne precautions
Specific IP/IC strategies
• Private patient room or cohort strategy
– Private room patient rooms/isolation may
have higher anxiety and depression, less
interaction with healthcare providers, have
shorter direct examination times, are less
likely to have vital signs recorded, fewer
physician progress notes, more likely to
complain and more likely to experience an
adverse event (as compared to non-isolation
patients)
Personal protective equipment
• Before entering room, wear gloves and
gown.
– Gloves to prevent contaminating hands with
MRSA from patient (direct) or patient
environment (indirect)
• Glove use positively associated with hand hygiene
compliance
– Gown use with glove use associated with
increased compliance with all precautions
• Compared to periodic/procedure based use when
contact is anticipated type system.
Hand Hygiene
• If you care for MRSA patient, is there MRSA on
you?
– MRSA found on 65% of uniforms and gowns or
healthcare workers caring for MRSA patients
– 42% of healthcare workers who ONLY had contact
with patient environment had MRSA on their gloves
– 13% - 29% of healthcare workers’ hands were
contaminated with same organism present on the
outside of their gloves
• How compliant are we with hand hygiene?
– Not great with figures ranging between 5-81%,
average 40%
What about visitors?
• Instruction on basic precautions including
hand hygiene, to reduce the risk of
transmission
• Visitors are not required to follow glove
and gown recommendations UNLESS
participating in direct care of patient
– Institution specific policies
Environment
• MRSA can live on a surface for 1-56 days
• Up to 25% of patients with MRSA found to have
objects in environment (over-bed table, door
handle, etc.) contaminated with MRSA
– Proper facility cleaning
• EQUIPMENT: dedicated patient only equipment
including stethoscope, blood pressure cuff,
tourniquet, computer, etc… or thorough cleaning
between patients
– How would you accomplish this in peri-operative
setting?
Screening
•
Population
– If low risk hospital, then select high
risk patients
• ICU, long term care residents/skilled
nursing facilities, history recent
hospitalization, dialysis, correctional
facilities with recent antibiotic use,
chronic skin wounds, elderly
• If high risk hospital, screen all admits
– Screen these and identify those
colonized
ACTIVE SURVEILLANCE CULTURES
– Place in contact precautions
– Monitor other patients to make sure
no transmission to neighbors;
monitoring compliance with IC/IP
practices
•
Individual
– Consider patient risk factors,
history, procedure, etc..
– Screen patient prior to procedure
– Attempt to decolonize prior to
procedure
Why screen populations?
• ICU patients more prone to infections and
MRSA infections
– Many receiving antibiotics and have
indwelling invasive medical devices
– ICU patient colonized with MRSA 4X likely to
get MRSA bacteremia compared to MSSA
colonized patient
–Prevent spread of MRSA to
vulnerable patient population.
Why screen individual?
• Identify with intent to decolonize prior to procedure.
• Prevent surgical site infections
– Cardiothoracic surgery
– Orthopedic surgery with implants
– Elective surgeries
• Adherence to SSI prevention measures such as proper
selection, timing and administration and discontinuation
of antibiotics; skin preparation practices, etc… probably
have bigger impact than screening and decolonizing
patients
– See
www.ihi.org for more information
• If SSI rates do not decrease with SSI prevention
measures, consider screening for MRSA and
decolonizing strategy.
What about screening healthcare
workers? BAD IDEA
• Although healthcare workers can become
colonized with MRSA, HCW are rarely the cause
of MRSA outbreaks in acute care settings.
– Transmission of MRSA from HCW (as primary source
of MRSA) to patient is thought to be rare
– Unless epidemiological evidence of HCW linked to
epidemic, screening NOT recommended
– HCW may have transient carriage
– Disruption to staff routine, stigmatization,
decolonization and furloughed, etc..
Don’t screen Healthcare Workers
How to decolonize for individual
model of MRSA screening?
• Several protocols in literature.
– Most involve mupurocin ointment alone in
combination with antimicrobial body washes
• How effective are decolonization efforts and how
long do they last?
– Several studies:
• Initial success 90%
• After 90 days: 54-61%
• Multiple colonized sites: 6%
• What about resistance to mupurocin?
– It is reported and increasing in frequency
Other strategies to reduce MRSA
• Antibiotic stewardship
–
–
–
–
About 50% of antibiotic usage is inappropriate
Use narrow spectrum agent rather than broad
Do not use abx for viral infections
Clinically unnecessary doses and extended duration
of treatment
• Education and Training of Healthcare workers
– Education, accountability, feedback with
administrative support and participation of
organization leadership with champions
– Be a good role model for your co-workers
Apply these principles to
Perioperative setting
• How will you put some patients into “virtual isolation” ?
– More space around them
– Last case of the day?
– Have them wait in room, not OR
• How will you segregate equipment?
– Special stethoscopes?
• How will make sure hand hygiene is optimized?
– Where does hand sanitizer get placed? Sinks?
• How will you comply with gown portion of contact
precautions in open room with multiple patients?
– Do you need extra soiled hamper by bedside?
• How to clean environment after patient taken to surgery
or returned to room post surgery from recovery?
– How much environment would be impacted compared to patient
room?
Summary
• MRSA Surveillance will usually identified
small group of patients needing contact
precautions, with intent to prevent infection
to other patients by optimizing infection
control and infection prevention practices
• Optional individuals could be screened for
MRSA with attempts to decolonize
• Perioperative environment presents with
unique challenges in complying with the
usual contact precautions