This action might not be possible to undo. Are you sure you want to continue?
MRSA Prevention in the Healthcare Setting Ferris State University Debby Boyle, Nicole Cory, Anne Hendricks, Linda Hansen, Suzette Ploughman
Running head: MRSA Prevention 2
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 the spread of methicillin-resistant staphyloccocus aureus (MRSA) in health care settings. 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 3
MRSA in the Healthcare Setting Aim of the Paper 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 antibiotic-resistant bacteria. It is imperative to implement strategies for prevention in the 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. Support for Relevance 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 grampositive bacteria represent a major public health burden in terms of morbidity and mortality, increased expense in patient management, and implementation of infection control measures (Woodford & Livermore, 2009). Staphylococcus aureus is an established pathogen in the 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 4
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 need to enforce infection control measures. 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 (Kucina et al., 2008). 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). Summary of the Evidence 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 5
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 four study populations (Mertz et al., 2007). 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 dangerous strain (Overby, 2008).
Running head: MRSA Prevention 6
MRSA can exist on environmental surfaces and lead to the transmission between patients as 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., 2006) yet sites still tested positive for MRSA. 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 (Yamamoto & Marten, 2007).
Running head: MRSA Prevention 7
Health care workers are the principal mode of transmission for MRSA 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). By identifying patients with MRSA or other potential hospital acquired infections, contact precautions can be used to avoid disease spread. According to the CDC (Siegel et al, 2007), isolation precautions, or contact precautions, are one category of Transmission-Based Precautions aimed at preventing transmission of infectious diseases that spread by direct or indirect contact with an infected patient or the patient’s environment. 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 should be handled using standard precautions, but disposable or dedicated equipment, is recommended. Equipment for patients in isolation should be disposed of in waterproof
Running head: MRSA Prevention 8
containers, while reusable equipment should be placed and transported in plastic bags for disinfection (Siegel et al, 2007). In the article Methicillin-Resistant Stapholococcus Aureus: The modern day challenge, several factors are listed as contributory to the increased and persistent nature of MRSA in the healthcare setting (Barnes & Jinks, 2008). These include: • Longstanding inappropriate prescribing practice (compounded by the use of antimicrobial agents in veterinary and agricultural practices) • • Poor and inconsistent infection control measures such as hand washing Lack of adequate surveillance together with inadequate isolation resources for colonized or infected individuals (Kelly, 2001) • In addition nurses’ lack of knowledge and understanding of epidemiology, microbiology, 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
Wash hands after contact with patient fluids and contaminated items, whether or not gloves are worn.
Wash hands immediately after gloves are removed between patient contacts. Wash hands between tasks and procedures on the same patient to prevent crosscontamination of different body sites.
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 sprays of patient body fluids.
Use single-use disposable, equipment; discard in biohazard waste container. Ensure that reusable equipment is not used in the care of another patient until it has been appropriately decontaminated.
• • •
Assure that patient environment is cleaned daily with antiseptic solution. 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 care for both (Capriotti, 2003). Critical Appraisal of the Evidence 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 10
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 swabs (Mertz et al., 2007). 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 (Mertz et al., 2007). 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 11
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 the importance of hand hygiene. Integration of the Evidence 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 12
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 understandably fearful of the possible consequences of healthcare interventions or a stay in the 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 wonder about a hypothesis of environmental contamination versus spread from healthcare 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 multiple occasions and it seems that physicians are frequent offenders. Recommendations to Utilize the Evidence The evidence that appropriate and early detection could prevent or even eliminate the spread of antibiotic-resistant bacteria is impressive. “Approximately 80% of invasive 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 13
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, standard precautions should be maintained.
Running head: MRSA Prevention 14
References Afif , W., Huor, P., Brassard, P., & Loo, V. G. (2002). Compliance with methicillin-resistant Staphylococcus aureus precautions in a teaching hospital. American Journal of Infection Control, 30(7), 430-433. American Medical Association. (2007). Invasive methicillin-resistant staphylococcus aureus infections in the united states. Journal of American Medical Association, 298 (15), 17631771. Retrieved October 17, 2009, from Centers for Disease Control and Prevention: http://www.cdc/gov/ncidod/dhqp/pdf/ ar/InvasiveMRSA_JAMA2007.pdf. (Barnes T Jinks A 2008 Methicillin-Resistant Staphylococcus Aureus: the modern day challenge)Barnes, T., & Jinks, A. (2008). Methicillin-Resistant Staphylococcus Aureus: the modern day challenge. British Journal of Nursing, 17(16), 1012-1018. (Boyce J M 2001 MRSA patients: Proven methods to treat colonization and infection)Boyce, J. M. (2001). MRSA patients: Proven methods to treat colonization and infection. Journal of Hospital Infection, 48(Suppl. A), S9-S14. (Capriotti T 2003 Preventing nosocomial spread of MRSA is in your hands)Capriotti, T. (2003). Preventing nosocomial spread of MRSA is in your hands. Dermatology Nursing, 15(6), 535-538. Diekema, D. J., & Climo, M. (2008). Preventing MRSA infections: Finding it is not enough. Journal of American Medical Association , 299 (10), 1190- 1192.
Running head: MRSA Prevention 15
(Gould D 2003 Hand decontamination)Gould, D. (2003). Hand decontamination. Nursing Standard, 15(6), 45-50. Guidelines for Evidence Based Paper, (2009). Retrieved August 31, 2009, from Ferris State University, Research Class Web site: http://www.ferris.edu Hardy, K., Oppenheim, B., Gossain, S., Fang, G., & Hawkey, P. (2006, February). A Study of the Relationship Between Environmental Contamination with Methicillin-Resistant Staphylococcus Aureus (MRSA) and Patients’ Acquisition of MRSA. Infection Control and Hospital Epidemiology, 27(2), p. 127-132. (Kelly J 2001 Addressing the problem of antiobiotic resistance)Kelly, J. (2001). Addressing the problem of antiobiotic resistance. Professional Nurse, 17(1), 56-59. Klevins, M., Morrison, M., Nadle, J., Petit, S., & Gershman, K. (2007). Invasive methicillinresistant staphyloccous aureus infections in the united states. Journal of American Medical Association, 298 (15), 1763-1771. Retrieved October 17, 2009, from Centers for Disease Control and Prevention: http://www.cdc.gov/ncidod/dhqo/pdf/ar/Invasive MRSA_ JAMA2007.pdf.Klevins, M., Morrison, M., K Kola, A., Schwab, F., Bärwolff, S., Eckmanns, T., Weist, K., Dinger, E. et al. (2009, September 16). Is there an association between nosocomial infection rates and bacterial cross transmissions? Critical Care Medicine, [E Pub ahead of print]. Retrieved October 25, 2009, from www.ncbi.nlm.nmed/19770743? ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed.
Running head: MRSA Prevention 16
Kucina, Natasa, Mateja Pirs, Manica Mueller-Premru, Vesna Cvitkovic-Spik, Romina Kofol, and Katja Seme. "One-year experience with modified BD GeneOhm™ MRSA assay for detection of methicillin-resistant Staphylococcus aureus from pooled nasal, skin, and throat samples." Diagnostic Microbiology 63.2 (2009): 132-9. 27 Oct. 2009 http://<shelcat.org/sfxlcl3/menu ?&issn =&volume=63&issue=2&date=2009&pages =132-9&title=Diagnostic+Microbiology +%26+Infectious+ Disease&atitle=One Lahey, T., Shah, R., Gittzus, J., Schwartzman, J., & Kirkland, K. (2009, September 1). Infectious diseases consultation lowers mortality from staphylococcus aureus bacteremia. Medicine, 88(5), 263-267. Retrieved October 25, 2009, from www.ncbi.nlm.nih.gov.libcat.ferris.edu/pubmed/19745684? ordinalpos=7&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_De faultReportPanel.Pubmed_RVDocSum. Laustsen, S., Lund, E., Bibby, B., Kristensen, B., Thulstrup, A., & Moller, J., (2009, February). Cohort Study of Adherence to Correct Hand Antisepsis Before and After Performance of Clinical Procedures. Infection Control and Hospital Epidemiology, 30(2), 172-178. Mertz, D., Frei, R., Jaussi, B., Tietz, A., Stebler, C., Fluckiger, U. et al. (2007, August 15). Throat swabs are necessary to reliably detect carriers of staphylococcus aureus. Clinical Infectious Diseases, 45, 475-477. Newton, J., Constable, D., & Senior, V. (2001). Patients’ perceptions of methicillin-resistant Staphylococcus aureus and source isolation: a qualitative analysis of source-isolated patients. Journal of Hospital Infection, 48 (4), 275-280. Retrieved October 17, 2009 from the CINAHL database.
Running head: MRSA Prevention 17
Nieswiadomy, R. M. (2008). Foundations of Nursing Research. Upper Saddle River, New Jersey: Prentice Hall. Overby, B., (2008). Evidence-Based Nursing Monographs: Methicillin –Resistant Staphylococcus Aureus. Mosby’s Nursing Consult, Retrieved October 29, 2009 from CINAHL database. (Pittet D 2001 Compliance with hand disinfection and its impact on hospital-acquired infections)Pittet, D. (2001). Compliance with hand disinfection and its impact on hospital-acquired infections. Journal of Hospital Infection, 48 (Suppl. A), S40-S46. Richmond, I., Bernstein, A. Creen, C., Cunningham, C., & Rudy, M., (2007). Best practice protocols: reducing harm from MRSA [Electronic version]. Nursing Management, 38 (8), 22-27.Richmond, I.RiR Romero, D.V., Treston, J., & O'Sullivan, A.L. (2006). Hand-to-and combat: Preventing MRSA infection Advances in Skin and Wound Care, 19 (6), 328-333. (Simor A E 2001 Containing methicillin-resistant S. aureus: Surveillance, control and treatment methods)Simor, A. E. (2001). Containing methicillin-resistant S. aureus: Surveillance, control and treatment methods. Postgraduate Medicine, 110(4), 43-48. Siegel, J., Rhinehart, E., Jackson, M., & Chiarello, L., (2007). Guidelines for isolation precautions: Preventing transmission of infectious agents in healthcare settings [Data file]. Atlanta, GA: National Center for Preparedness, Detection, and Control of Infectious Diseases.
Running head: MRSA Prevention 18
Woodford, N., & Livermore, D. M. (2009, September). Infections caused by gram-positive bacteria: A review of the global challenge. The Journal of Infection, 59(Supplement 1). Retrieved October 25, 2009, from <http://0www.ncbi.nlm.nih.gov.libcat.ferris.edu/pubmed/19766888? ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_De faultReportPanel.Pubmed_RVDocSum>. Thomas, Mckinley, Gillespie, Wanda, Krauss, Janis, Harrison, Steve, Mederios, Regina, et al. (2005). Focus group data as a tool in assessing effectiveness of a hand hygiene campaign. Association for Professionals in Infection Control and Epidemiology, Inc. Retrieved October 21, 2009, from cinahl database via ILIAD Yamamoto, Linda & Marten, Molly (2007). Listen up, MRSA: The bug stops here. Nursing 37 (12), 56-58. (Afif W Huor P Brassard P Loo V G 2002 Compliance with methicillinresistant Staphylococcus aureus precautions in a teaching hospital) (Kelly J 2001 Addressing the problem of antibiotic resistance)
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue listening from where you left off, or restart the preview.