Antimicrobial resistance
Recommendations l Minimise transmission l Patient screening lUse either targeted or universal screening.
Screening is completed largely for specified pre-operative patients or other high-risk patients, such as those entering the ICU. Despite this, there is disagreement in the literature about the clinical effectiveness of targeted screening in preventing transmission of MRSA. There is also a cost element to universal screening. The working party concluded that universal screening had no benefit over targeted screening. l There is no need to perform repeat screening routinely for MRSA positive patients.
If patients screen negative at admission, repeat screening can identify if they acquired MRSA in hospital. It is unclear whether repeat screening is clinically or cost effective.
Staff screening and management l Do not routinely screen staff for MRSA unless there is a clear epidemiological reason for doing so.
Often staff will undergo screening if an MRSA outbreak persists, staff are suspected to be carriers, or when the source of the outbreak is unclear. The literature did not highlight any benefit in routine staff screening. l If staff are identified as MRSA positive, consider excluding staff from work, reducing their interaction with patients and offering decolonisation therapy as deemed appropriate.
Redeployment of staff, if they test positive for MRSA, may be necessary until treatment is effective. Local protocols should be developed to guide practice and should be based on risk assessments, depending on the acuity of the area where they work.
Decolonisation The most widely used topical decolonisation therapy offered to patients and staff is chlorhexidine (CHG) and mupirocin, either in combination or alone. It is generally acknowledged that complete eradication is not always possible, but the literature does not agree whether topical decolonisation is clinically effective. However, temporary suppression of MRSA is sufficient in some circumstances i.e. prior to surgery. In previous guidelines, skin decolonisation was recommended for pre- operative patients who were found positive in the carriage of MRSA, using a 4% CHG wash, 7.5% povidine-iodine or 2% Triclosan. There are, however, also risks that overuse
of topical decolonisation therapies leads to resistance, which has lead some hospitals to finding alternative solutions, such as isolating patients in single rooms to prevent transmission. l Use mupirocin for nasal decolonisation, selectively for those who are colonised or universally for high-risk patients.
l Use chlorhexidine for body decolonisation, selectively for those who are colonised or universally for highrisk patients.
l Consider alternatives (e.g. octenidine) where mupirocin and chlorhexidine are not feasible.
l Monitor the emergence of resistance, especially to mupirocin and chlorhexidine.
Infection control practices For patients who are known to be colonised or infected with MRSA, consider using contact precautions for direct contact with the patient or their immediate environment. If contact precautions are used, gloves and aprons must be discarded between uses and hand hygiene must be performed after glove removal. Where isolation of the patient is considered necessary, it should be for the shortest time possible to minimise feelings of stigma, loneliness and low mood.
l Use standard infection control precautions in the care of all patients to minimise the risk of MRSA transmission; contact precautions as may be recommended in your local policy.
l Consider placing MRSA patients in a single room; isolate patients for as short a time as possible.
Surveillance It is recognised that surveillance plays two roles in respect of infection control practices. It enables detection of infected/ colonised individuals necessary for their removal from the general population and it allows quantification of control success. Since the last guidelines were published, many countries have set up surveillance systems for MRSA, including England where acute Trusts are required to report all cases of bloodstream infections. The working party discussed the evidence and concluded that hospital surveillance must remain an element of any strategy to prevent and control MRSA. l Undertake surveillance routinely as part of your IPC strategy and to comply with mandatory national requirements.
Restrict movement The potential transmission of MRSA between patients is considerable. Moving patients from ward to ward and between healthcare settings, such as a hospice or residential care home, is likely to increase the transmission of MRSA. Epidemiological links can be established if genotyping is undertaken to track the transmission. Previous guidelines recommended that patient transfers should be kept to a minimum. l Avoid the transfer of patients between wards or other clinical settings unless it is clinically necessary.
l Inform the receiving setting and the transport service that the patient is colonised/infected with MRSA.
Safe and clean environment MRSA resists desiccation and survives in hospital dust for up to a year. It is found throughout the hospital environment particularly around patient areas. Transmission may therefore occur by hand contact by healthcare workers. There is currently insufficient evidence to support the routine sampling of the environment and equipment but it is possible that during outbreaks this might be of benefit. There are too many variables to suggest one particular cleaning agent over another and they are very varied from hospital to hospital. New approaches have been suggested, such as room decontamination with UV or hydrogen peroxide
December 2023 I
www.clinicalservicesjournal.com 13
t
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48
