IPC 3.5 Methicillin-Resistant Staphylococcus Aureus (MRSA)

Contents

1.0 Introduction
2.0 Procedure principles
2.1 Mode of transmission
2.2 Risk factors
2.3 Signs and symptoms - clinical indications
2.4 Screening
2.5 Antimicrobial treatment guidance
2.6 Surveillance
3.0 Infection prevention and control principles
3.1 Isolation
3.2 Hand hygiene
3.3 Respiratory / Cough hygiene 
3.4 Personal protective equipment
3.5 Equipment
3.6 Environmental cleaning
3.7 Linen
3.8 Body fluids
3.9 Waste standard
3.10 Occupational exposure
3.11 Outbreak management
4.0 References/Source documents
5.0 Record of changes
Appendix 1 MRSA risk assessment form upon admission
Appendix 2 Five day MRSA decolonisation therapy
Appendix 3 Podiatric Surgery Screening Protocol
Appendix 4 Podiatric Surgery Pre-operative Screening Flowchart
Appendix 5 Summary of MRSA screening
Appendix 6 HCAI Transfer Form

 

1.0 Introduction

Organism

Methicillin-resistant Staphylococcus aureus (MRSA) is a resistant strain of the pathogen Staphylococcus aureus (Methicillin sensitive Staphylococcus aureus (MSSA)). MRSA often colonises the skin, inside of the nostrils, throat and perineum. However, in some instances it can cause an infection which can vary in severity, such as from mild skin and soft tissue infections to more serious and life threatening conditions such as endocarditis and bacteraemia (bloodstream infections).

 

Individuals at risk

All individuals are at risk of colonisation of MRSA but the following are at increased risk of developing a MRSA infection/bacteraemia:

• General Population
• Patient with a history of or current MRSA
• Patients with invasive/indwelling or vascular access devices
• Patients with any wounds
• Injecting Drug users
• Patients with psoriasis or other skin conditions causing excessive flaking of skin
• Patient with Diabetes
• Immuno-compromised patients
• Patients with a long-term use of antibiotic therapy
• Patients living in residential care and/or frequent admissions to hospitals

 

Notifiable disease

MRSA is not a notifiable disease but all MRSA bacteraemia (bloodstream infections) are considered to be serious untoward incidents and are reportable via the Ulysses system and required to be investigated using a post infection review (PIR) process.

 

Informing IPC team

MRSA bacteraemia must be reported via Ulysses.

IPC team can advise on colonisation/wound infection, all key information contained within this guidance.

 

2.0 Procedure principles 

 

2.1 Mode of transmission

MRSA can be transmitted either:

• Endogenously - this occurs when a person already colonised with MRSA spreads the organism from one part of their body to another.
• Exogenously - this occurs when MRSA is spread from one person to another.
• Direct spread via the hands of healthcare workers
• Indirect spread through equipment that has not been appropriately decontaminated.
• Via transfer of micro-organisms from the environment, where contamination is highly significant, as Staphylococcus can survive for long periods in dust

 

2.2 Risk factors 

A person can be colonised with MRSA without producing disease or symptoms on body surface. Presentation of MRSA infection can be varied. Signs of infection may include redness, swelling, pain or discharge in a wound or invasive device site, urinary tract infection symptoms and it can produce toxin and spread to other sites, e.g. bacteraemia (bloodstream infection).

 

2.3 Signs and symptoms - clinical indications 

A person can be colonised with MRSA without producing disease or symptoms on body surface. Presentation of MRSA infection can be varied. Signs of infection may include redness, swelling, pain or discharge in a wound or invasive device site, urinary tract infection symptoms and it can produce toxin and spread to other sites, e.g. bacteraemia (bloodstream infection).

 

2.4 Screening 

Patient screening for MRSA colonisation should be carried out using a targeted, risk-based approach, considering the presence of risk factors that increase the risk of that patient developing a MRSA bloodstream infection. Please see  Appendix 1 MRSA risk assessment form upon admission

A full routine screen consists of:

• Nose swab (anterior nares) - one swab can be used for both nostrils and swab should be pre moistened with sterile saline
• Perineum swab (if patients consent)
• Wound swab- any surgical wounds, other lesions or breaks in the skin
• Swabs from indwelling or medical device sites i.e. cannulae, drains, PEG sites etc., sterile catheter sample of urine, if catheterised
• Sputum sample if patient has a productive cough

If rescreening is advised, then this should be undertaken after 48-72 hours after completing 5 days decolonisation treatment.

 

2.5 Antimicrobial treatment guidance 

Antibiotics are not indicated unless there are clinical signs suggestive of infection.

Decolonisation treatment may be offered  Appendix 2 Five day MRSA decolonisation therapy  and should not be implemented for prolonged periods or repeatedly i.e., more than two 5 day courses, as drug resistance may occur.

Prescribers should refer to the Antimicrobial guidelines (Nottinghamshire APC, 2021) see  Meticillin Resistant Staphylococcus Aureus (MRSA) (Notts APC)  and discuss with the duty Microbiologist for further advice if needed.

Any wounds positive for MRSA should be assessed by Tissue Viability Nurse/Physical Healthcare Nurse for appropriate wound management.

 

2.6 Surveillance 

 

3.0 Infection Prevention and Control Principles 

 

3.1 Isolation 

In-patients: Isolation may be required depending on risk factors and this should be discussed on a case-by-case basis with the Infection Prevention and Control Team (IPC Team)

Offender Health settings: Not usually require isolating unless advice given by IPC Team

Microsoft Word - appendix 11a (NHS England)

 

3.2 Hand hygiene 

Hand hygiene (NHS England)

 

3.3 Respiratory / Cough hygiene

Respiratory and cough hygiene (NHS England)

 

3.4 Personal protective equipment 

• FFP3 or Hood for Aerosol Generating Procedures if pneumonia only

Personal protective equipment (PPE) (NHS England)

Appendix 5b (NHS England) 

Putting on and Removing PPE v3 (NHS England)

Appendix 11a: Aide memoire for optimal patient placement and respiratory protective equipment (RPE) for infectious agents in hospital inpatients (based on evidence from WHO, CDC and UKHSA) 

 

3.5 Equipment 

Safe management of patient care equipment in an isolation room/cohort area (NHS England)

 

3.6 Environmental cleaning 

Safe management of the care environment (NHS England)

 

3.7 Linen 

Safe management of linen (NHS England)

 

3.8 Body fluids 

Safe management of blood and body fluid spillages (NHS England)

 

3.9 Waste standard 

Safe disposal of waste (including sharps) (NHS England) 

 

3.10 Occupational exposure 

Occupational exposure to MRSA can be prevented by adhering to precautions outlined above. Contact the Occupational Health Department if you have any concerns regarding exposure to MRSA.

 

3.11 Outbreak management

The number of infections that are linked in time or place is more than would normally be expected within the organisation. Seek advice from IPC Team

 

4.0 References/Source documents

Coia J.E., Wilson J.A., Bak A., et al. (2021) Joint Healthcare Infection Society (HIS) and Infection Prevention Society (IPS) guidelines for the prevention and control of methicillinresistant Staphylococcus aureus (MRSA) in healthcare facilities. The Journal of Hospital Infection, 118 (Suppl), pp. S1-S39.

Department of Health (2014) Implementation of modified admission MRSA screening guidance for NHS. (Accessed: 15 February 2024)

Friedman B, Hassoun A Linden PK (2017). Incidence, prevalence, and management of MRSA bacteremia across patient populations-a review of recent developments in MRSA management and treatment. Crit Care. 2017 Aug 14;21(1):211

Health and Safety at Work etc. Act 1974, c. 37. (Accessed: 15 February 2024)

Health and Social Care Act 2008 Code of Practice of the prevention and control of infections and related guidance (updated 2022). (Accessed: 15 February 2024)

National Health Service England (2023) National infection prevention and control manual (NIPCM) for England. (Accessed: 15 February 2024)

National Patient Safety Agency (2008) Clean Hands Saves Lives: Patient Safety Alert. (Accessed: 15 February 2024)

NHS England (2014) Guidance on the reporting and monitoring arrangements and post infection review process for MRSA bloodstream infections from April 2014. (Accessed: 15 February 2024)

Nottinghamshire APC (2023) Antimicrobial guidelines. (Accessed: 15 February 2024)

 

5.0 Record of changes

Version	Date	Expert writer	Status (New or edited)	Comments and details of changes being made
HS/GS/21	Mar 2009	S Williamson	Edited	Section 4.0 updated
18.07	Sep 2010	A Kirkland	Edited	General Changes throughout to comply with recent legislation and guidance
18.07	Sep 2012	P Strazds	Edited	Changes to section 4 in light of legislation
18.07 (Issue 5)	Oct 2012	P Strazds	Edited	Removal of Section 7.2 and 7.3, addition of new 7.2 and subsequent paras in section 7.0 renumbered
18.07 (Issue 6)	Aug 2013	Sheila Smith	Edited	Complete review in light of organizational changes and legislation, national and local requirements
18.07 (Issue 7)	Oct 2013	Sheila Smith	Edited	Section 8.1 Minor amendments to wording for clarification of process
18.07 (Issue 8)	Feb 2015	Sheila Smith	Edited	Additional bullet point in section 5.6 and additional section 5.5.3 in response to new DH guidance on screening requirements. Minor Amendments to Appendix 3 and 4 to reflect this.
18.07 (Issue 9)	Nov 2016	Sheila Smith	Edited	Review of document, minor amendments only to wording and headings to reflect recent Organisational changes.
07.07 (Issue 10)	Mar 2023	Shirley Chau	Edited	Minor grammatical and formatting amendments throughout. Section 4.3, 6.2, 8.3 and reference added Section 5.2, 5.4, 5.5, 6.6, 7.2, 8.1 and 8.2 updated Section 5.6 removed Appendix 1 replaced by a risk assessment form Appendix 2 replaced by decolonisation therapy table and instruction sheet References to “Oral” prophylaxis removed from Appendix 3 Healthcare workers added as Risk factor for carriage.

 

Appendix 1 - MRSA risk assessment form upon admission 

Admission screening questions	Yes/No/ N/A
1.  Has the patient previously tested positive for MRSA and is not currently on decolonisation treatment or has no documented evidence of successful decolonisation treatment? If YES, please obtain nasal swab and perineum (if patients consent), plus any wounds or indwelling or invasive devices. Obtain sterile catheter sample of urine if urinary catheter is present. Obtain sputum sample if patient has productive cough.  (Please allocate single room or contact IPCT for advice if this cannot be achieved until result returned) If NO, go to question 2
2.  Has the patient any indwelling or medical device? If YES, please swab* If NO, go to question 3
3.  Does the patient have any wounds which have been present for more than 2 weeks and/or showing signs of infection (including the chronic wound)? If YES, go to question 4 If NO, not screening advised
4.  Is there evidence of any wound infection/skin abscess? (i.e. the skin red, swollen, hot or painful or green or yellow coloured discharge (pus) or patient unwell or feverish or you have a high temperature above 38 oc) If YES, please obtain wound swab for M,C S and MRSA If NO, No screening is required
5.  Types of specimens collected: Nasal swab and perineum (if patients consent), plus any wounds or indwelling or invasive^ devices. Obtain sterile catheter sample of urine (CSU) if urinary catheter is present. Obtain sputum sample if patient has productive cough
6.  Invasive/ indwelling/vascular access devices: Peripheral vascular access device/ Central venous access device, e.g. peripherally inserted central catheter (PICC), skin-tunnelled catheter, implanted port - Urinary catheters, Suprapubic catheters, Wound drains, Gastrostomy tube
7.  Remarks: If patients have excessive skin shedding (e.g. severe psoriasis and eczema), please consider to isolate in a single room until negative result returned.

 

Appendix 2 - Five day MRSA decolonisation therapy

Skin decolonisation  Octenisan Wash or Chlorhexidine 4%	Nasal decolonisation  Mupirocin (Bactroban) nasal ointment
Wet skin and/or hair *Bath/ shower daily; hair washing twice in 5 days	Always wash your hands before and after applying nasal ointment Three times a day
Apply an adequate amount of antimicrobial skin solution undiluted onto a damp wash cloth	Squeeze a match-head size of nasal ointment onto a cotton-tip. Apply it to the inside surface of each nostril.
Apply it evenly all over the body and hair (recommended skin contact time 1 min) * Focus on armpits, groin and perineum	Use fingers to press both nostrils and massage gently to spread the ointment.
Rinse off
Dry with a clean towel
Put on clean clothing and clean bedding

*Please refer to the manufacturers’ instructions for detail

 

 

 

 

 

Appendix 3 - Podiatric Surgery Screening Protocol

MRSA Screening protocol for podiatric surgery patients

 

Screening Regime of Elective Podiatric Surgery Patients / Clients

Please refer to flow Chart Appendix 4

• At the initial appointment with the Podiatric Surgeon or Advanced Podiatrist, the patient will be given treatment options.

• If surgery is decided upon and the patient in deemed to be at risk, the patient will be informed about the need for MRSA screening

• MRSA information leaflet should be given to patient

• MRSA Screening will be undertaken at the pre-operative. A nasal swab of both nostrils (anterior nares) pre-moistened with sterile saline. This appointment should ideally be around 4 weeks prior to surgery. If more than 6 weeks from the surgery date, then another pre-operative appointment must be made to carry out the screening.

• If the patient screens negative for MRSA, no further action is needed.

• If the patient screens positive for MRSA, the patient should be recalled by Podiatric Surgery staff to issue decolonisation topical treatment.

• Treatment should start on a specific date, prior to surgery as advised by the Podiatric Surgeon or Advanced Podiatrist,

• Patients who have a positive screen should be treated at the end of the theatre list

• If there are clinical signs of infection present, this will be treated with appropriate antibiotics, following discussion with a consultant medical microbiologist.

 

Decolonisation Treatment of Podiatric Surgery Patients

• Podiatry staff to issue and explain patient information leaflet on MRSA Screening regimes and confirm they understand contents.

• Podiatric Surgery staff to telephone the patient a week before surgery to remind them to undertake decolonisation treatment.

• Staff to ensure details of screen results and decolonisation treatment have been captured in the patient’s records.

 

Antibiotic Prophylaxis Prior to Podiatric Surgery

All patients undergoing Podiatric Surgery who require the use of an implant, e.g., screw fixation, temporary wire stabilisation or joint replacements are required to have a prophylactic bolus of an antibiotic prior to the planned procedure. The need for antibiotic prophylaxis prior to surgery is at the discretion of the Podiatric Surgeon, based on clinical assessment and MRSA screening results. Antibiotic treatment for complex cases should be decided in consultation with a Consultant Medical Microbiologist.

 

Screening Regime for Podiatric Emergency Surgery

In case of emergency surgery, such as incision and drainage of wound abscess or bone biopsies, please take screen samples and label “for MRSA admission screen” at the point of surgery. Results should be followed up after 48hrs. If positive, please contact IPCT for advice.

 

Staff Responsibility for Follow up of Results

• Podiatric Surgery staff to follow up all patient results within 48 hours of sample being taken. Details normally available on NOTIS.

• If negative result, no further action is required. No further screen is required prior to surgery.

• If positive,

  • Podiatric surgery staff to inform patient by telephone and recall to Park House Health Social Care Centre.

  • The patient will require decolonisation treatment as per section 6 and flow chart (appendix 4)

  • Post treatment screening is not routinely carried out in Podiatric Surgery

  • GP must also be informed of positive MRSA result.

 

Appendix 4 - Podiatric Surgery Pre-operative Screening Flowchart

 

 

Appendix 5 - Summary of MRSA screening 

 

Summary of MRSA screening in in-patients setting and podiatry surgery

Routine Admission Screening within 24 hours of admission	No, based on risk assessment Appendix 1 and section 5.5.1
Pre-op assessment Screening	Follow Appendix 3 protocol and all high-risk patients should be screened during the pre-operative assessment process including the risk factors listed in 4.3 This list is not a definitive, and clinicians should apply their own clinical judgment when assessing patients.
Risk Factors of MRSA carriage (Extracted from section 4.3)	Patients with a history of or current MRSA Patients with indwelling devices such as urinary catheters, syringe drivers, nephrostomies Patients with wounds or any break in the skin including those who self harm Injecting drug users Patients with psoriasis or other skin conditions causing excessive flaking of skin Long term care placement/nursing residential homes Patients with a family member or someone living with them, who is currently being treated for MRSA Diabetic patients Immuno-compromised patients, e.g. rheumatoid, oncology, high dose steroids Patient with a long-term use of antibiotic therapy

 

Appendix 6 - HCAI Transfer Form