GENERAL MANUAL – POLICY
Page:-
VI-d-65-69
Date:-
April 2005
MOUNT SINAI HOSPITAL
Form MS 204 A
Issued By:-
Reference:
Infection Control Team
Original: March 1998 (VI-d-65)
Revision: April 2005
Infection Control Policies & Procedures Manual
Title:-
PREVENTION AND CONTROL OF METHICILLIN RESISTANT
STAPHYLOCOCCUS AUREUS (MRSA)
PURPOSE:
To prevent and control the spread of Methicillin Resistant Staphylococcus aureus
(MRSA) at Mount Sinai Hospital.
RATIONALE: MRSA is a type of Staphylococcus aureus which is resistant to many of the
antibiotics usually to treat staphylococcal infections (eg. cloxacillin,
erythromycin, and cephalosporins). Although MRSA does not cause more severe
infections than sensitive strains, it is difficult to eradicate and control because of its
resistance to commonly used antibiotics.
POLICY:
Patients known or suspected to be at risk for infection or colonization with MRSA will
be managed in consultation with the infection control team.
PROCEDURES
1. Upon Admission:
1) All patients admitted to 17 North, 17 South, 17 Step-down, 12 South, and ICU must have nasal
(1 swab, both nares) and rectal swabs, as well as swabs of any open skin lesions taken and
submitted for MRSA screening.
2) On admission to 16 North, CCU, 14 North, 14 South, 14 Step-down, 11 North and 11 South,
PAU, all patients who fall into one of the following categories must have nasal (1 swab, both
nares) and rectal swabs, as well as swabs of any open skin lesions taken for MRSA screening.
(i) a direct transfer from a hospital or long term care facility
(ii) have had an overnight stay in any hospital (including Mount Sinai) or long term care
facility in the last 6 months
(iii) are previously known to be colonized or infected with MRSA and /or VRE
(iv) whose history of hospital admission is unknown
3) Swabs must be sent to the Microbiology Lab (14th floor) within 12 hours of admission.
4) Obstetrical patients who are health care workers are to be swabbed for MRSA and VRE during
prenatal screening. When the patient is swabbed for Group B Streptococcus, MRSA and VRE
screening are to be ordered with the vaginal/rectal swab. A nasal swab (1 swab of both nares) is
also needed for MRSA screening. If the patient is MRSA positive, she should be treated with:
(i) Mupirocin 2% ointment to nares and any open wounds tid for 7 days.
(ii) Chlorhexidine sking cleanser 4% for all personal hygiene for 7 days.
In addition, obstetrical patients are screened as requested by Infection Control.
5) Other patients (ie. psychiatry, neonates) are screened as requested by Infection Control.
6) Any patients who have stayed overnight in hospital outside of Canada (including the USA) in
the last 6 months must be put into MRSA and VRE precautions:
http://info/microbiology/InfectionControl/InfectionControlEducation/precautions/mrsavre.html
GENERAL MANUAL – POLICY
Page:-
VI-d-65-69
Date:-
April 2005
MOUNT SINAI HOSPITAL
Form MS 204 A
2. Notification regarding patients who are colonized or infected with MRSA:
1) When MRSA is identified from a patient, the Microbiology Laboratory will notify Infection
Control and the nursing unit on weekdays. The Microbiologist on-call will be notified via pager
through locating (ext. 5133) on weekends, off hours, and holidays.
2) Infection Control will assess whether transmission (nosocomial acquisition) has occurred.
3) When an investigation is warranted, Infection Control will request nasal, and rectal swabs be
collected from all patients present on the same nursing unit.
3. Implementation of Isolation Precautions:
1) All patients who are colonized or infected with MRSA must be managed on MRSA precautions
(private room, gown, gloves and surgical mask) until the precautions are discontinued by
Infection Control.
2) Patients judged by Infection Control or other hospital staff to be at high risk for acquiring or
being colonized with MRSA, will be managed on MRSA precautions until discontinued by
Infection Control (i.e. contact of MRSA positive patient).
3) If in doubt about a patient's status for MRSA, any member of the health care team may
initiate MRSA precautions. Infection Control can be paged via locating (ext. 5133) at any
time for advice about decisions related to patient accommodation.
4. MRSA Precautions:
1) Order an isolation supply cart from Central Dispatch (ext. 5124) STAT.
2) Place the patient in a single room and place a MRSA Isolation Precautions sign on the door
of
the
room
(available
for
download
on
the
intranet
site:
http://info/microbiology/InfectionControl/InfectionControlEducation/precautions/mrsa.html).
3) Infection Control should be consulted prior to moving patients.
4) Patient should stay in their room unless special arrangements have been made by Infection
Control.
5. MRSA Precaution Requirements for Staff:
1) Wash hands (either with liquid soap and water or alcohol hand rinse) prior to entering the
patient’s room.
2) Don a clean yellow gown, gloves, and surgical mask. These must be worn by all staff
members who enter the room.
3) Remove gloves, gown and surgical mask prior to leaving the room, and discard into the linen
hamper and garbage bins upon exiting the room.
4) Wash hands immediately upon exiting the room. The patient bathroom should not be used for
hand washing.
5) Staff should not bring personal belongings/equipment into the patient room if it cannot be
decontaminated upon leaving (laptops, palm pilots, charts and clipboards, etc.).
6. MRSA Precaution Requirements for Visitors:
1) Patients’ visitors (unless they are health care workers, care providers to or visit other people in
hospitals and/or long term care facilities) are not required to wear gown, gloves, and surgical
GENERAL MANUAL – POLICY
Page:-
VI-d-65-69
Date:-
April 2005
MOUNT SINAI HOSPITAL
Form MS 204 A
mask. They should be instructed by staff to use good hand hygiene upon entry into and exit
from the patient’s room.
2) Patient and visitor education may be facilitated using patient information sheets and brochures:
http://info/microbiology/InfectionControl/brochures/brochure_mrsa.pdf . Infection Control is
available for consultation as needed.
7. Cleaning of Equipment:
1. All equipment used for patient care must be dedicated exclusively for the patient.
Stethoscopes, flashlights, portable blood pressure cuffs, rehab equipment, commode
chairs, etc. must be left in the patient’s room and used only for the patient.
2. The need for use of non-dedicated equipment must be assessed individually, and
discontinued if necessary. If equipment cannot be dedicated and must be used, it must
be wiped down thoroughly with VIROX wipes before being taken out of the room, and
then once again outside the room.
3. All portable equipment such as ECG machines, X-ray machines, ultrasound equipment
must be wiped down thoroughly with VIROX wipes before being taken out of the room,
and then once again outside the room.
8. Transportation of Patients on MRSA Precautions:
Note: Patients do not need to wear gown, gloves or surgical mask during transportation. They
should be directed to wash their hands prior to exiting their room.
1) When arranging diagnostic tests or procedures, the nursing unit is responsible for informing
and instructing the receiving department about the MRSA precautions.
2) Personnel who are transporting the patient must:
(i) Wash hands before contact with the patient, stretcher/ wheelchair.
(ii) Put on a clean yellow gown, gloves, and surgical mask when entering the room.
(iii) Transport and handle the patient in MRSA precautions.
(iv) Upon completion of transfer, remove the gown, gloves, and surgical mask and
discard in laundry and garbage bins, and wash hands immediately.
(v) Repeat the above steps (i, ii, iii, iv) when transporting the patient back to the nursing unit.
3) All patients who require transport to another department must go directly to that department.
4) The patient must be taken directly into the room where the test will take place. Patients must
not be held in a waiting area or a corridor.
5) All staff in the receiving department working with the patient must adhere to MRSA
precautions (wash hands, gown, gloves, and surgical mask).
6) If a stretcher or wheelchair is to be used from the main hospital supply pool, it must be
wiped down thoroughly with VIROX wipes before it can go back into circulation.
9. Dietary Requirements:
1) There are no special requirements needed for dietary utensils, trays, etc.
10. Pharmacy Requirements:
1) There are no special pharmacy requirements.
11. Transfer of MRSA patients to other institutions, home care, or the community
1) Patient may not be transferred to any other facility until the receiving facility’s infection
control department and the receiving unit have approved the transfer. Mount Sinai’s Infection
GENERAL MANUAL – POLICY
Page:-
VI-d-65-69
Date:-
April 2005
MOUNT SINAI HOSPITAL
Form MS 204 A
2)
3)
4)
5)
6)
7)
Control Team will help facilitate such communication. Transfer approval must be documented
in the chart.
Patient should have the MRSA information brochure upon discharge.
Patients can be discharged home as usual.
For patients requiring Home Care, the Home Care Coordinator must be informed to facilitate
organizing any additional precautions necessary for the patient.
Infection Control must be notified of any discharged patients on isolation precautions
scheduled to return for appointments at Mount Sinai or another health care facility, so
arrangements can be made for the use of appropriate precautions.
Patients should be instructed to advise any institution they visit or are admitted to that they had
recently been on special precautions for MRSA.
Ambulance services must be advised of MRSA status when booking is being arranged.
12. Housekeeping Requirements Upon Patient Discharge/Transfer
1) There are no special housekeeping requirements for room cleaning upon discharge/transfer.
The room should receive a regular terminal clean when the patient is discharged/transferred.
13. Housekeeping Requirements for MRSA patients in Ambulatory Care Areas
1) There are no special housekeeping requirements for room cleaning in ambulatory care areas.
All equipment must adhere to the cleaning procedure as outlined in #7.
14. Treatment/Eradication of MRSA
1) If patient is a carrier or is colonized but not infected, and is not receiving other antibiotics, the
following combination therapy is usually successful in eradicating carriage, and should be
prescribed if possible, and if the isolate is susceptible to rifampin, doxycycline (isolates
susceptible to tetracycline will be susceptible to doxycycline) and mupirocin.
(i) Mupirocin 2% ointment to nares and any open wounds tid for 7 days
(ii) Chlorhexidine skin cleanser 4% for all personal hygiene for 7 days.
(iii) Rifampin 300mg po bid for 7 days as long as liver function tests are ALP <200U/L, ALT
<70 U/L, AST <100 U/L, or GGT <100 U/L.
(iv) Doxycycline 100mg po bid for 7 days.
Note: If the organism is resistant to Doxycycline but susceptible to rifampin and mupirocin, either
Septra (1 DS bid) or fusidic acid 500mg po tid may be substituted for doxycycline. If the organism is
resistant to mupirocin, polysporin triple ointment (not other polysporin preparations) may be used..
2) If patient is clinically infected with MRSA:
(i) Treat with appropriate antibiotic according to lab sensitivities (consult with Infectious
Disease service if desired)
(ii) Mupirocin ointment tid x 7 days to nares and all positive open skin lesions plus
chlorhexidine 4% skin cleanser for all personal hygiene x 7 days. .
3. If patient is receiving antibiotics for another infection, MRSA eradication therapy should
generally be deferred until the patient no longer requires antibiotics. Infection control may be
consulted if the patient will require long term antibiotic therapy, or is thought to be at high risk
of infection with MRSA.
15. Discontinuing MRSA Precautions
1) MRSA precautions can only be discontinued by a member of the Infection Control Team
GENERAL MANUAL – POLICY
Page:-
VI-d-65-69
Date:-
April 2005
MOUNT SINAI HOSPITAL
Form MS 204 A
2) Patients who have received combination eradication therapy and are not on other antibiotics
will have MRSA precautions discontinued when eradication therapy is completed. They will
remain in a private room for at least three months because there is some risk of relapse.
3) Patients who have not received eradication therapy, usually require 3 sets of negative cultures
one week apart before additional precautions are discontinued. Such patients, while at MSH,
must stay in single room for at least three months and continue regular screening for the
duration of hospitalization because patients can become re-colonized with MRSA up to 6
months after initial eradication.
4) If re-colonization occurs, MRSA precautions will restart.
16. Management of Roommates, or other close contacts of patients colonized or infected with
MRSA
1) Patients who have been roommates of a patient who was colonized or infected with MRSA are
at risk of becoming colonized
2) Any patient who has shared a room with an unrecognized MRSA colonized/infected patient for
more than 48 hours, and any other patient who, in the infection control practitioner’s judgement
is at significant risk of becoming colonized with MRSA as a result of the exposure must be
managed in MRSA precautions until cleared by infection control
5) Roommates who have been exposed to MRSA will have nasal, rectal, and open skin/wound
lesion swabs for MRSA on the day that the exposure is recognized, and on day 5 and day 7
after the exposure has ended (usually after they or their MRSA colonized roommate has moved
out of the room). If all three sets of swabs are negative for MRSA, additional precautions will
be discontinued.
17. Prevalence screening of in-patient units
1) Admission screening for MRSA is not 100% sensitive, and prevalence screening will be
conducted periodically to ensure that undetected transmission of MRSA is not occurring.
2) A prevalence screen of an in-patient unit (nasal, rectal and wound/open skin lesion swabs of all
in-patients) will be conducted when
(i) a new nosocomial case of MRSA infection is identified in a patient not recognized to be at
risk
(ii) one or more unrecognized MRSA colonized/infected patient(s) have been on the unit for
more than 5-8 days total (the degree of exposure warranting a prevalence screen for each unit
is based on the past history of the unit related to MRSA transmission
(iii) at intervals of 2-3 months on each unit, if situations (i) or (ii) have not occurred; the interval
depends on the past history of the unite related to MRSA transmission.
18. Staff screening – refer to staff policy
http://info/GeneralManual/Section%205/v-h-5-6.doc
References:
Methicillin-resistance Staphylococcus aureus
Lim 2004,www.idrounds.ca
Health Canada. Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare. An Infection
Control Guideline. CCDR 2002;28S1:1-264.
Surveillance for Methicillin-resistant s aureus in Canadian hospital- A report update from the Canadian nosocomial Infection surveillance
program CCDR Volume 31-03 2005
GENERAL MANUAL – POLICY
Page:-
VI-d-65-69
Date:-
April 2005
MOUNT SINAI HOSPITAL
Form MS 204 A