|Title:||Guidelines for the Management of Methicillin-Resistant Staphylococcus Aureus (MRSA) in Residential Care Facilities|
|Document ID:||Operational Circular OP 1854/04|
|Date of issue:||Thursday, 14 October 2004|
|Status:||NO LONGER APPLICABLE|
|Description:||The purpose of this Operational Circular is to provide guidelines, based on a risk assessment approach, that outline infection control measures for the management of methicillin-resistant Staphylococcus aureus in Residential Care Facilities (RCFs), including nursing homes, hostels, group homes, psychiatric facilities, hospices and rehabilitation facilities.|
|Period of effect:||from 14 October 2004|
|Authorised by:||Dr Shirley Bowen, Director, Communicable Disease Control Directorate, 12-Oct-2004|
|Print version:||View print version|
Guidelines for the Management of Methicillin-Resistant Staphylococcus Aureus (MRSA) in Residential Care Facilities
This Operational Circular is designed to advise Department of Health staff on Departmental policies and procedures.
To provide guidelines, based on a risk assessment approach, that outline infection control measures for the management of methicillin-resistant Staphylococcus aureus in Residential Care Facilities (RCFs), including nursing homes, hostels, group homes, psychiatric facilities, hospices and rehabilitation facilities.
The term "methicillin-resistant Staphylococcus aureus" (MRSA) refers to those strains of Staphylococcus aureus bacteria that have acquired resistance to the antibiotic methicillin and to all other beta-lactam antibiotics. The incidence of MRSA has increased in health care facilities since the mid-1970s and is not a problem limited to hospitals.1-6 Approaches to the control of MRSA vary widely, primarily because controlled studies establishing the efficacy of specific infection control measures are lacking. However, once MRSA has become firmly established in a facility, it is rarely eliminated.2 This guideline recommends the most widely used approaches to the control of MRSA in residential or long term care facilities.3
VIRULENCE OF MRSA
MRSA is not a "super bug". While Staphylococcus aureus itself is a virulent (disease causing) pathogen, methicillin-resistant strains are not more virulent than methicillin-sensitive strains.4 Many health care workers (HCWs) incorrectly assume that MRSA strains are more virulent because of the special isolation precautions implemented in the acute care setting. MRSA is of special concern because it is often multi-drug resistant, thus limiting treatment options for residents.7
Methicillin-resistant Staphylococcus aureus (MRSA)
Staphylococcus aureus which are resistant to methicillin (and consequently to all other beta-lactam antibiotics).
The subtypes of MRSA are identified by the pattern of antibiotic resistance to an extended range of antibiotics, and confirmed by specialised laboratory methods.
The terminology of the subtypes of MRSA is complex and evolving. For the purposes of infection control management they can be divided into epidemic (EMRSA) and non-epidemic strains (MRSA).
Epidemic strains of MRSA (EMRSA)
Epidemic strains of MRSA are strains that have demonstrated the potential to cause outbreaks in health care facilities. The epidemic strains include those known as multiresistant, e.g. Irish 2 and Eastern Australia, as well as strains which are less resistant such as UK-EMRSA-15.
MRSA Colonisation or Infection
MRSA Carrier Status
MRSA Contact: Any person who has been:
RESERVOIRS OF MRSA
Colonised or infected residents serve as a major reservoir of MRSA in long term care facilities.3,4 Elderly residents are at increased risk for colonisation with MRSA, in addition to having a potential to carry MRSA for long periods of time. Asymptomatic colonisation of residents' noses with MRSA is common. Point prevalence studies have found that 23% ? 35% of residents in Veterans' Affairs affiliated facilities may become colonised over a period of 1 or 2 years.8,9 In the few prevalence surveys performed in freestanding (RCF) located in areas where MRSA is common, 9% ? 12% of residents were colonised.10-14 MRSA colonisation may disappear with treatment, and reappear weeks or months later.
The main mode of transmission of MRSA is person-to-person via hands, usually of HCWs. Colonisation of the hands of staff may be either transient, such as a single day, or of longer durations, such as several weeks. Colonisation of the HCW may occur if proper hand hygiene and protective clothing are not used appropriately.
MRSA may be aerosolised in the droplet nuclei from a coughing resident or from a ventilator exhaust port of an intubated resident who has MRSA in his or her sputum. The organism may also be aerosolised during the irrigation of a wound containing MRSA. However, the role of aerosolisation in the transmission of MRSA is not known.15 Although MRSA has been isolated from environmental surfaces and fomites such as bed linen, transmission to residents is thought to be minimal, except in burns units and intensive care units.3,4
RISK FACTORS FOR MRSA16
The following factors have been identified as increasing the risk of a resident acquiring MRSA:
ADMISSION OF RESIDENTS WITH MRSA TO RCFs
Admission to RCFs should not be denied on the basis of MRSA status alone, as long as the facility is able to place the resident accordingly.
Before transfer of a resident to a RCF there should be full communication between the transferring and receiving personnel. The transfer documents accompanying the resident should clearly state details relating to the person's MRSA colonisation/infection status, screening and treatment requirements where indicated.
Standard Precautions apply at all times, regardless of MRSA status (refer to Operational Circular OP 1856/04). However, each colonised/infected resident should be individually assessed on admission according to the type of MRSA and for risk factors that may increase dissemination and/or transmission of MRSA (e.g. exfoliating skin condition, large wound or lower respiratory tract infection). Additional precautions (see Appendix 1 and 2) may be indicated for a resident who is colonised or infected with EMRSA. Precautions should be continued for as long as the resident continues to have secretions or excretions that cannot be contained. When the condition of the resident changes (e.g. wound drainage is contained), additional precautions can be modified or discontinued.
All staff should receive initial and periodic continuing education and training in infection control procedures such as hand hygiene, and standard and transmission-based additional precautions. When a resident acquires MRSA, appropriate infection control procedures should be reviewed with all health care staff who will have contact with the resident.
All prospective staff who have been hospitalised or have worked in a hospital (including Christmas Island) or RCF outside of Western Australia in the previous 12 months shall be required to be screened for MRSA prior to employment (refer to Operational Circular OP 1853/04).
There is no role for routine screening of staff for MRSA carriage as a general control measure.
Staff MRSA carriers detected by pre-employment screening or during employment as a result of infection control investigations should be referred to a Clinical Microbiologist or Infectious Diseases Physician for advice and topical decolonisation treatment where indicated.
Routine screening for the presence of MRSA is not required. However, in certain at-risk populations a screening program may be appropriate, e.g. residents admitted to acute health care facilities from residential aged care facilities. This screening will be performed by the acute health care facility where the resident is admitted.
Surveillance cultures should only be done if staff and/or residents are epidemiologically implicated as the source of an outbreak, and only as directed by a Clinical Microbiologist or Infectious Diseases Physician.
An outbreak of MRSA in the facility represents an increase in the incidence of MRSA cases in the facility above the baseline level, or a clustering of new MRSA cases that are epidemiologically linked.
RCF should maintain a surveillance record of the names and other appropriate information of residents that are found to be colonised or infected with MRSA.
If a resident known to be colonised or infected with MRSA is transferred to a hospital or other health care facility/service, the admitting facility should be informed of the resident's status prior to transfer wherever possible.
Every effort should be made to encourage prudent use of antibiotics so as to control the emergence of resistance.
Dr Shirley Bowen
BIBLIOGRAPHY / REFERENCES:
This circular last updated: Thursday, 14 October 2004 at 12:00am