Professional Documents
Culture Documents
Debby Boyle, Nicole Cory, Anne Hendricks, Linda Hansen, Suzette Ploughman
Running head: MRSA Prevention
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Abstract
Emergence of antibiotic-resistant bacteria has added new and challenging issues in healthcare.
An analysis of multiple research articles was performed to find the best practice for prevention of
Importance to nursing includes: protecting critical medical resources, decreasing morbidity and
mortality, and decreasing over-all health burden. Certain patients are at higher risk for
contracting MRSA and avenues must be explored to prevent transmission. These include: early
identification, isolation precautions, antibiotic therapy, and hand washing. This paper will serve
to show the best evidence for the prevention of the spread of this potentially lethal bacterium.
Running head: MRSA Prevention
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What does the literature show is the best way to control the spread of MRSA in the
health-care setting? The aim of this paper is to analyze the best evidence to control the spread of
hospital setting to protect critical medical resources, to decrease morbidity and mortality, to
protect both patients and health care workers, and to decrease the over-all health burden created
by MRSA.
MRSA was first reported in the United Kingdom in 1961, when it was found that Staph
aureus infections were becoming resistant to beta-lactum inhibitors such as methicillin (Romero,
Treston, & O’Sullivan, 2006). MRSA ranks “among the most prevalent pathogens in hospitals
worldwide” (Diekema & Climo 2008, p.1192). Infections caused by multidrug-resistant gram-
positive bacteria represent a major public health burden in terms of morbidity and mortality,
hospital environment and when it becomes multidrug resistant, it complicates therapy (Woodford
& Livermore, 2009). The "superbug", MRSA, regularly attracts media interest and there is
political pressure to reduce MRSA infection rates (Woodford & Livermore, 2009).
According to the article Invasive MRSA infections in the United States by Klevins et al,
2007), 126,000 patients hospitalized develop MRSA and 5,000 of those patients die each year
and today’s numbers state that 46 out of 1,000 patients have MRSA. Klevins et al (2007) reports
Running head: MRSA Prevention
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nearly 9,000 cases of invasive MRSA were reported from July 2004 through December 2005.
Of these cases, 26.6% or 2,389 cases were hospital acquired MRSA (HA-MRSA). HA-MRSA
patients have an increased length of stay up to nine and one-tenth days and incur costs of roughly
$30,000 per episode (Richmond et al, 2007). The numbers of HA-MRSA are rising and hospitals
Certain patients are at higher risk for contracting MRSA which include: patients with
known previous MRSA infection, patients who have been hospitalized three or more times in
one year, residents of long-term care facilities, and patients with chronic wounds (Kucina et al.,
2008). Through the screening of high-risk patients for the infection, appropriate isolation
precautions can be put into place so transmission to other patients or caregivers may be avoided
Isolation and antibiotic therapy alone are not sufficient to stop the transmission of MRSA
from one patient to another. According to the CDC, “The main mode of transmission to other
patients is through human hands, especially healthcare workers' hands” (Siegel et al, 2007).
According to both hand washing studies, hand washing has been shown to be a key factor in
reducing the spread of microorganisms (Laustsen et al., 2009; Thomas et al., 2005). However,
these studies show that many healthcare workers still do not practice effective hand hygiene
when taking care of patients (Laustsen et al., 2009; Thomas et al., 2005).
According to Mertz et al., (2007), “approximately 30% of the healthy population carries
S. aureus in their anterior nares” (p.475). This carriage of S. aureus is associated with increased
risk of infection post surgery (Mertz et al., 2007). “Approximately 80% of invasive nosocomial
infections are of endogenous origin in nasal carriers (Mertz et al., 2007, p. 475).”
Running head: MRSA Prevention
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Early detection of carriers is important in prevention of the spread. Most screening
programs include a swab of the anterior nares (Mertz et al., 2007). Swabbing the throat is not
standard because of increased discomfort, costs, and limited research (Mertz et al., 2007). This
article suggests that selective colonization of the throat may be more common than presently
acknowledged (Mertz et al., 2007). Unrecognized carriers render infection control programs
futile, therefore evaluation of the benefit of screening both the nares and throat was examined in
In the Mertz et al., (2007) study, there were 5,041 participants in different roles of the
healthcare organization and each were swabbed in different manners for the bacteria. In groups
one though three, 2,966 people were screened for carriage of S. aureus (Mertz et al., 2007). A
fourth group consisted of 2,075 people who had nasal and throat swabs pooled in the laboratory
(Mertz et al., 2007). Fifty and four tenths percent of the subjects were female with the average
age of 50 + 21 years (Mertz et al., 2007). Group one included health care workers and patients
screened after exposure to MRSA during 2000-2005 (Mertz et al., 2007). Group two consisted
of healthcare workers who participated in a prevalence survey of S. aureus carriage among Swiss
population in 2004 (Mertz et al., 2007). The third group was healthy blood donors screened for
S. aureus in 2005 (Mertz et al., 2007). Group four consisted of nasal and throat swabs pooled in
the lab from patients and healthcare workers exposed to MRSA (Mertz et al., 2007).
In 2007, the US Food and Drug Administration (FDA) approved the first rapid blood test
for MRSA, the BD GeneOhm Staph SR assay (Kucina et al, 2008). This test is able to identify
whether it is MRSA or a less dangerous staph that can still be treated with Methicillin. Clinical
trials were 100% correct in identifying MRSA and 98% positive of identifying the less
shown in an article by Hardy, Oppenheim, Gossain, Gao, & Hawkey, (2006) which studied
environmental contamination. Multiple sites in a nine bed intensive care unit (ICU) were
swabbed including under the bed, the workstation, the control buttons on the monitors, and a
ledge that was behind each bed as well as samples from nose, perineum, and wound sites of the
patient’s admitted to this unit (Hardy et al, 2006). Compliance for cleaning the environment of
the ICU was followed according to the standards of the National Health Service (Hardy et al.,
Hand washing has been shown to help prevent the transmission of many infection
producing organisms, but compliance with hand washing has been shown to be less than optimal
in many situations (Laustsen et al., 2009; Thomas et al., 2005). In the focus group study
(Thomas et al., 2005), initial compliance was deemed to be 20% in the one unit where baseline
compliance was measured (during direct but random observations). This study indicates that a
belief is held that overall compliance rate estimates are actually a little higher, in the 30%-50%
range.
In the cohort study conducted by Laustsen et al., (2009), the compliance rate was
measured before and after care was rendered to patients with both the patients and staff aware of
the study. The compliance rate was significantly higher (in the 60%-70% range) for this group
(Laustsen et al., 2009). According to the article Listen Up MRSA: The Bug Stops Here, hand
hygiene is the single most effective way to prevent the spread of healthcare related infections
therefore proper hand hygiene is imperative to decrease the spread of disease (Yamamoto &
Marten, 2007).
In the past, a culture of wound or sputum has been the standard method of detection,
which could take up to 72 hours (Kucina et al, 2008). A rapid MRSA assay has been instituted in
some hospitals which detect the bacteria utilizing nasal, throat, and skin swabs, and some sets
contained only nasal and skin swabs (Kucina et al, 2008). This rapid screening test requires a
maximum of 3hours 40 minutes to complete (Kucina et al, 2008). It has been demonstrated to be
most accurate when all three swabs are pooled and tested (Kucina et al, 2008).
contact precautions can be used to avoid disease spread. According to the CDC (Siegel et al,
The CDC outlines several procedures based on the assessed risk beginning with private
rooms for high-risk patients, three feet of separation in multi-patient rooms, and placing patients
with the same pathogen in the same room. In rooms designated for contact precautions, cleaning
and disinfecting should be done daily focusing on frequently-touched surfaces (Siegel et al,
2007).
For health care professionals and staff, protective attire (gowns, masks, gloves) must be
changed and hand hygiene performed between patient contacts. Furthermore, patient equipment
several factors are listed as contributory to the increased and persistent nature of MRSA in the
• Lack of adequate surveillance together with inadequate isolation resources for colonized
pharmacology and infection control have also been singled out (Gould, 2003)
Contact transmission is probably the most important factor in its dissemination as MRSA is
readily spread in this way, usually via the hands of healthcare workers (Barnes & Jinks, 2008).
According to Capprioti (2003), the average rate of compliance with MRSA precautions was
28%. “There was a general lack of awareness regarding the likelihood of MRSA contamination
during superficial contacts with an infected patient” (Afif et al., 2002). Surfaces of inanimate
objects utilized in care of the patient have also been implicated as sources of MRSA
contamination. Many investigators contend that limiting the spread of MRSA depends on health
care personnel using proper hand hygiene practices, contact isolation, and barrier precautions in
the clinical setting (Afif et al., 2002; Boyce, 2001; Pittet, 2001; Simor, 2001).
The following is a list of interventions to aid in preventing the spread of infection in the
hospital setting:
Running head: MRSA Prevention
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• Wash hands after contact with patient fluids and contaminated items, whether or not
• Wash hands immediately after gloves are removed between patient contacts.
• Wash hands between tasks and procedures on the same patient to prevent cross-
• Use gloves (clean, non-sterile are adequate) when in contact with patient or patient items.
• Use clean gloves when touching patient mucous membranes and non-intact skin.
• Wear masks and eye protection during procedures that are likely to generate splashes or
• Ensure that reusable equipment is not used in the care of another patient until it has been
appropriately decontaminated.
• Isolate patient in a private room or in room with other patients on MRSA precautions.
• If possible, divide patient assignments so that health care personnel are not required to
One study regarding rapid MRSA testing utilizing nasal, throat, and skin swabs had a
limited sample size of only 292 samples (Kucina et al., 2008). Some of the participants were
tested using both throat and nasal swabs (Kucina, 2005). There are a few drawbacks to this
study, the test was performed over a period of only one year, and a new method of culture
utilizing the three swabs had to be formulated for this study to be completed (Kucina et al.,
2008). Earlier batches of samples were found to be less sensitive and specific, and during the
Running head: MRSA Prevention
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testing period the methods were modified (Kucina et al., 2008). After testing was modified,
results became more sensitive and specific for MRSA, further research may demonstrate an even
higher rate of success now that the testing process has been perfected (Kucina et al., 2008).
In the Mertz, et al (2007) study, groups 1-3, 49.9% tested positive for S. aureus and a
total of 37.1% had nasal carriage of S. aureus with/without positive throat cultures while a total
of 25.7% of the carriers were colonized in the throat solely. Among the third group, the throat
swab yielded more positives than the nasal swab (Mertz et al., 2007). In group 4 the carriage
rate was 52.1% which is similar to the combined results of groups 1-3 both nasal and throat
The addition of throat swab cultures increased the sensitivity by 25.7% (Mertz et al.,
2007). Group 4, the combined nasal and throat pooled specimens yielded a S. aureus carriage
result of 52.1% (Mertz et al., 2007). These results suggest that pooling combined results from
both nares and throat may be the most effective method of analysis.
Admission screening to identify and control MRSA focuses on the nares alone in many
institutions, and this data confirms that the nares is the most prevalent site for colonization
(except in group 3) (Mertz et al., 2007). The addition of throat cultures to cultures from the
nares increased the sensitivity by 25.7%, and 12.8% had positive throat cultures alone;
suggesting that both nares and throat cultures should be pooled to attain greatest sensitivity
The environmental study results indicate that MRSA can live on surfaces for long periods
of time and was isolated from surfaces in this ICU at every screening (Hardy et al., 2006).
According to Yamamoto, MRSA can survive on surfaces anywhere from hours up to 3-5 days
(2007). In addition to this, “the environmental strains were more often identical to those
Running head: MRSA Prevention
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colonizing another patient elsewhere in the ward, possibly indicating the spread of bacteria”
(Hardy et al., 2006, p. 130). This study showed that the highest area (81 of 216 sites) of MRSA
contamination was obtained in the samples from under the beds which led the researchers to
speculate as to possible reasons for this finding (Hardy et al., 2006). Speculation included this
area being closest to the floor or the accumulation of dust. Other surfaces were also
contaminated “although workstations and monitors have lower levels of contamination than do
the areas under the bed, the consequences of contamination of the workstations and monitors are
potentially greater, in terms of transmission of MRSA to patients” (Hardy et al., 2006, p. 129).
This studied showed that even if the bed space was not occupied with a patient colonized with
MRSA, the space still tested positive for MRSA 20.2% of the time (Hardy et al., 2006).
Data from the focus group study indicated posters were updated four times over the
period of the study and made a difference in improving hand washing from 20% at baseline to
37% overall at the end of the twelve month campaign (Thomas et al., 2005). This study
employed techniques of using incentives to increase compliance. Focus groups met to develop
the posters as well as brainstorm a reward system for compliance. The group felt that physicians
were the most non-compliant but were least impacted by the rewards or the posters. The group
felt that the posters gave educational information and increased the knowledge of the reader to
Most healthcare workers have encountered more than one undiagnosed MRSA infection
in their practice. A rapid test with results obtained in a 3 to 4 hour period could prevent this
unseemly event. Furthermore, patients in high-risk categories will not need to be placed in
Running head: MRSA Prevention
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isolation for three days only to find they are negative for the bacteria. This practice is costly and
time-consuming.
The rapid testing for MRSA is performed utilizing swabs, which is a fairly non-invasive
and inexpensive procedure (Kucina et al., 2008). Patients may prefer to have this testing done to
avoid being placed in tentative isolation, or to avoid potentially exposing other patients. Many
patients, in years of practice, will warn health care workers upon entering the patient room, to
don gloves due to communicable illnesses that they are aware they have.
Patients have expressed anger and resentment at contracting the infections and express
dismay at missing work, costs of travel and time/duration of the treatment. Patients are now
hospital (Barnes & Jinks, 2008). MRSA has occurred, on several occasions, in post-operative
patients. When one patient is diagnosed with MRSA, others soon follow which leads one to
workers. Some insurance companies do not cover home IV antibiotics which can be a dilemma
for further treatment. Non-compliance with hand hygiene has been personally observed on
The evidence that appropriate and early detection could prevent or even eliminate the
nosocomial infections are of endogenous origin in nasal carriers” (Mertz et al., 2007, p. 475). To
save critical medical resources, decrease morbidity and mortality, and decrease over-all health
burden should be the goal of healthcare. The evidence demonstrates the rapid assay culture to be
highly accurate for testing patients at high-risk for MRSA (Kucina et al., 2008).
Running head: MRSA Prevention
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The rapid culture may be implemented using specific criteria. Performing an initial
assessment for MRSA prior to admission or transfer of a hospitalized patient can prevent
transmission between patients and healthcare workers. If the patient has a chronic wound, has
been hospitalized three or more times in the last year, or is a resident of a long-term care facility
they must be tested according to the research (Kucina et al., 2008). If the patient is found to be
at high risk, swabs should be obtained and sent for analysis to the lab. The patient should remain
in isolation in a private room until culture results are obtained. As always, with every patient,
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