Meticillin Resistant Staphylococcus Aureus

(MRSA) Policy Template for General Practice Use

Providedby

Community Infection Prevention & Control Team

Mansfield & Ashfield CCG

Birch House

Ransom Wood Business Park

Southwell Road West

Mansfield

Nottinghamshire

NG210HJ

Direct dial: 01623 673081

March 2017

Contents

Section / Page Number
1.Introduction / 3
2.Scope / 3
3. Purpose / 3
4. Definitions / 3
5. Responsibilities / 4
6. Delivery of Care / 5
7. Control of MRSA / 8
8. Monitoring and Review / 9
9. Equality and Diversity Statement / 9
10.Protocol / 11
11. How to apply Chlorhexidine / Octenisan bodywash and Mupiricin (Bactroban) ointment / 12
12. References / 13

1. Introduction

The aim of this policy is to provide information to staff working within Primary Care organisations within Nottinghamshire Clinical Commissioning Groups (CCG) (excluding Bassetlaw) to ensure that people with MRSA (Meticillin Resistant Staphylococcus Aureus) are managed appropriately and effectively in order to limit the spread within primary care. The Department of Health have stated that all Organisations are directly accountable for reducing the rate of MRSA bacteraemia in their local population. Each organisation has been given a zero tolerance target for avoidable MRSA bacteraemia infections

2. Scope

This policy has been written for all staff working within Primary Care to:

  • Explain what MRSA is and to highlight the standard infection prevention and control principles that should be applied by staff to minimise the spread.
  • Ensure that patients who are found to be MRSA positive are informed of their diagnosis, given the correct information about MRSA, its treatment and any follow up required.
  • Ensure that patients who are found to be positive for MRSA are offered decolonisation treatment in accordance with this policy.
  • Ensure that all patients who require screening for MRSA are screened according to this policy

3. Purpose

The Health and Social Care Act 2008, states the need for health and social care providers to have policies in place that will help to prevent and control infections. The purpose of this policy is to ensure that staff,working within Primary Care in Nottinghamshire CCGs,have sufficient information to effectively care for and manage patients with MRSA.

4. Definitions

4.1 MRSA - Staphylococcus aureus (SA) is a common bacteria, which may be found on the skin of around one third of healthy adults. Meticillin Resistant Staphylococcus aureus (MRSA) is a strain of SA that is resistant to many antibiotics, in particular flucloxacillin, which is the standard treatment for many staphylococcal infections. Although MRSA is no more likely to cause an infection than sensitive SA, the infection can be more difficult to treat due to a limited choice of antibiotics. It can be carried on the skin or in the nose of healthy people (colonisation) without causing any adverse effects. However, colonisation is considered to be a major risk factor for infections, which may range from mild to life threatening.

4.2 Panton Valentine Leukocidin (PVL) -Staphylococcus aureus (SA) is a bacterium that commonly lives on healthy skin. About one third of healthy people carry it quite harmlessly, usually on moist surfaces such as the nostrils, armpits and groin. Some types of SA produce a toxin called Panton Valentine Leukocidin and they are known as PVL-SAs. (Panton and Valentine were the two doctors who first found the toxin which can kill white blood cells called leukocytes – hence leukocidin).

PVL-SAs can cause skin and softtissueinfections e.g. boils and abscesses. They can also cause invasive infections affecting the lungs, blood, joints and bones.

The PVL toxin can be produced by both meticillin-sensitive Staphylococcus aureus (MSSA) and meticillin-resistant Staphylococcus aureus (MRSA). (Refer to the CityCare Policy for Managing and Treating Patients in Primary Care available on the POD).

If patients attends with recurrent boils or skin abscesses please consider additional testing for PVL infection. This will need to be specifically requested on the laboratory form

4.3 Colonisation- occurs when a microbe establishes itself in a particular environment such as a body surface, without producing disease or symptoms. This is sometimes referred to as asymptomatic carriage and can be identified by screening. Around 30% of the general population are colonised with Staphylococcus aureus. It may be present on the skin, in the nose, axillae, groin or perineum. It can also colonise wounds and other areas of non-intact skin without causing harm.

4.4Decolonisation – refers to the application of antimicrobial products to body surfaces cavities in order to eradicate colonising micro-organisms (e.g. MRSA)

4.5 Infection - occurs when the bacteria gain access to the body tissues and multiply, causing a host reaction and clinical signs of infection, which may include redness, swelling, pain or discharge in a wound or invasive device site. Depending on the properties of the infecting micro-organism and the capacity for resistance of the infected host, there may be other effects in the body, including toxin production and spread to other sites.

4.6Bacteraemia – occurs when there is evidence of spread of infection into the blood stream.

5. Responsibilities

5.1 Infection Control Lead in the practiceInsert Name______

The Infection Control Lead has overall responsibility for ensuring that there are effective arrangements for infection prevention and control within the practice and for meeting all statutory requirements.

5.2 The Practice Manager Insert Name______

The Practice Manageris responsible for ensuring that there are the necessary policies and training to reduce the risk of infections being transmitted and for ensuring that appropriate governance arrangements are in place to provide effective care and management of patients with MRSA in accordance with this policy.

5.3 The infection Prevention and Control Team (IPC):

Receive laboratory reports which provide information about the positive MRSA screens and samples from primary care and receive discharge information on patients requiring further follow up and treatment interventions from hospital

The Infection Prevention and Control team will receive the results from the source laboratory and will provide clinical expertise and advice and support clinicians with the choice of treatment and management appropriate for the patient.

The IPC team provide support and leadership for providers in implementing the Post Infection Review process (PIR) for all pre-48 hour MRSA bacteraemia cases in line with the criteria in the NHS England PIR process and policy for serious incidents.

The team will disseminate the findings to the clinicians involved and the wider lessons for all clinicians

5.4Line managers

Line Managers have responsibility to ensure staff are aware of this policy, have read and signed to say they have read it and for ensuring their staff adhere to the policy

5.5All staff

  • Ensure all staff that have contact with a patient with MRSA adhere to the relevant this policy and guidelines
  • Take screens in accordance with the policy and communicate screen results to the patients
  • Inform the patient of their diagnosis and document this within the patients’ medical /care records.
  • Explain and document treatment regimens.
  • Implement standard infection prevention and control principles (seesection 7 Control of MRSA).
  • Ensure when care is transferred to another provider, that the diagnosis is communicated to the provider after consultation with the patient.

6. Delivery of Care

6.1Transmission

MRSA infections occur in all types of healthcare settings, however it is well known that controlling the spread of MRSA outside of the acute hospital environment has often been overlooked or deemed to be unnecessary. The recent trends towards earlier discharge from hospital, day surgery, minor surgery and interventions in community settings, along with the increased need for the use of indwelling devices significantly increases the risk of patients developing infections in the community. The often continuous and repeated movement of patients between different healthcare settings also increases the risks of HCAI to patients, as well as the emergence of Community Associated strains of MRSA e.g. Panton- Valentine Leukocidin (PVL) which is also a significant factor.

6.2Routes 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. This can happen in a variety of ways including:
  • 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 staphylococci can survive for long periods in dust

6.3 Screening

  • A new diagnosis of MRSA is often made from a clinical specimen (e.g. wound swab) and not from an MRSA screen. In this instance, please contact the Infection Prevention and Control team for advice on the correct management of the patient.

A screen consists of swabs / samples being taken from the following sites:-

  • Nose swab– one swab from both nostrils,pre-moisten the swab with saline if needed and roll around both nostrils
  • Perineum or groinswab
  • Wound swab- swab all wounds and other lesions or breaks in the skin
  • Swabs from manipulated sites- lines, cannulae, drains, PEG sites etc
  • Urine specimen from patients with a catheter in situ only or mid-stream urine (MSU) if MRSA has been isolated in a urine specimen previously. If the patient has a supra pubic catheter in situ then the entry site should also be swabbed
  • Sputum sample if patient has a productive cough
  • Swabs from invasive medical devices such as PEG tubes, tracheostomies and supra-pubic catheter sites.
  • The laboratory request form should be clearly request an MRSA screen and give details of why the screen is being performed,the clinician requesting the screen should ensure the site of the screen is documented on each individual swab and on the laboratory request form.
  • The clinician should ensure that the individual is fully aware of the screens to be taken and ensure consent to the procedure,documenting in their records.

6.4 Rescreening

A patient should be re screened one month after completion of decolonisation treatment. A negative screen will suggest that the decolonisation treatment has been effective. If the screen results identify a positive MRSA result a second decolonisation treatment can be offered.

Sometimes a third might be attempted if the patient has increased risk factors, but this will need to be reviewed with the Infection Prevention and Control Team (after discussion with Infection control doctor/medical microbiologist)and assessed on an individual patient basis.

Further re screening is not recommended

Some patients in primary care will remain colonised with MRSA, it is important that this is documented in the patient’s records and communicated effectively to the patient and when transferring care to another provider or out of hours provider

Further advice should be sought from the Infection Prevention and Control Team.

6.5Treatment

Decolonisation

  • MRSA decolonisation refers to the use of topical agents such as nasal ointment and body wash/shampoo to eradicate or reduce nasal and skin carriage.
  • Complete eradication is not always possible but a decrease of carriage may reduce the risk of transmission into the healthcare setting and therefore the risk to other patients. It will also reduce the risk of transmission into any wounds or indwelling devices that the patient may have.
  • Compliance with the treatment is important and once commenced should be completed for the full 5 days.
  • Decolonisation treatment should not be implemented for prolonged periods or repeatedly i.e. more than 2 courses for 5 days, as resistance may be encouraged.
  • In cases of repeated colonisation the advice of a medical microbiologist should be sought.
  • For patients with eczema, dermatitis or other skin conditions, attempts should be made to treat the underlying skin condition. Advice on suitable eradication protocols for these individuals should be sought from the consultant Dermatologist/Microbiologist

Nasal decolonisation

  • Currently the treatment is 2% Mupiricin (bactroban) nasal ointment (or other Microbiological approved product) which should be applied to the inner surface of each nostril (anterior nares) three times daily for five days. Nasal decolonisation should always be used in conjunction with skin decolonisation.
  • Whilst Mupiricin (bactroban) nasal ointment is the treatment of choice, Naseseptin cream can be prescribed and applied to both nostrils four times daily in the event of a supply problem with Mupiricin (bactroban) treatment period is between 5-10 days.This should be prescribed with caution as it contains arachis oil so should be avoided in those with peanut allergies

Skin decolonisation

  • Skin decolonisation is useful for eradicating or suppressing skin colonisation for short periods, particularly pre-operatively. Patients should bathe/shower daily for five days using the prescribed antiseptic detergent as below
  • The current recommended agents are either Chlorhexadine 4% or Octenisan. For neonates and children under 5 Octenisan should be used.The body wash should be applied neat to wet skin and left on the skin for 3 minutes (refer to product instructions). Applying a diluted solution to the skin will affect its efficacy. Special attention should be paid to all carriage sites, such as the axilla, groin and perineal area. The patient should be advised not to use normal soap or shower gels following the treatment being applied.
  • Hair should also be washed on days 2 and 4 within the five-day treatment using the same product. Clean clothing, bedding, wash cloths and towels should be provided after each bath/shower/bed bath and hair wash.

Peg Sites

  • If Peg site is positive on screening, and site is dry, 2% Mupiricin (bactroban) nasal ointment should be prescribed and applied around the site three times daily for five days.
  • If Peg site is positive on screening and site is moist or sticky seek advice from Nutrition team or Tissue Viability team.

Antibiotic Therapy

  • As antimicrobial use is a recognised risk factor for MRSA acquisition, all patients with MRSA should have their current antibiotic therapy reviewed. Any unnecessary agent should be stopped.
  • Antibiotics are not indicated unless there are clinical signs suggestive of infection. Prescribers should refer to the Antimicrobial Prescribing Guidelines (2015) and discuss with the duty Microbiologist for further advice if needed.
  • If antibiotics are required they should be in line with the given sensitivities and antimicrobial prescribing guidance. If uncertain then contact the Medical Microbiologist for advice

NUH - 0115 9249924 ext. 61163

SFHT – 01623 622515

Consider the temporary use of an antimicrobial dressing for wounds where there are signs of clinical infection, refer to the Wound Care Formulary for wound care products or the Tissue Viability team on 01623 784759.

7.Control of MRSA

7.1 Basic Principles

Standard IPC precautions must be implemented at all times in all settings to reduce the risks and should include all of the following:-

  • Hand Hygiene –Compliance with hand hygiene is essential and will significantly reduce the risk of transmission and cross infection. Decontamination of hands should be carried out before and after every episode of direct patient care or contact with the patient’s environment and equipment. Effective hand hygiene can be achieved using soap and water or alcohol gel (on visibly clean hands), using the National Patient Safety Agency (NPSA) recommended technique.(NPSA 2008)
  • The Correct use of Personal Protective Equipment (PPE)
  • Decontamination of Equipment according to manufacturer’s guidance. Single Use equipment should always be considered where possible.

7.2 Advice for Patients in their own Home

  • MRSA does not present a risk to other healthy individuals and colonisation should not prevent an individual from continuing with normal unrestricted activities
  • Wherever possible, patients with a known MRSA infection should be seen at the end of the healthcare professionals visiting list.
  • Good hand hygiene and standard basic precautions should be employed by all staff involved in the care of a patient at home
  • Avoid taking non-essential equipment in to the home.
  • Encourage patients and carers to undertake good hand washing.
  • Family members should be advised to cover any skin lesions they may have with an impermeable dressing and to maintain good hand hygiene.
  • Advise the patient/family that regular environmental cleaning using detergent and water is an effective method of reducing levels of MRSA.
  • Patients should be advised that their laundry should be washed at the hottest temperature suitable for the fabric and that it can be washed with other household laundry. Laundered garments should be dried thoroughly before re-use. Drying in a hot air dryer or ironing will help further reduce the amount of MRSA present.
  • Patients should be encouraged to continue with their normal activities/routines.

7.3Advice to parents about school aged children

  • Children should not normally be excluded from school as a result of MRSA
  • Wounds must be kept covered to reduce the risks of transmission.
  • Encourage and promote good hand washing and the use of liquid soap, rather than bar soap which will reduce to risk of transmission
  • An alert should be added to the patient’s records to highlight that the patient is at risk of acquiring MRSA again in the future

8.Monitoring and Review

  • Infection prevention and control principles are monitored through a rolling programme of peer reviews
  • This procedure will be reviewed in 3 years or in light of organisational or legislative changes

9. Equality and Diversity Statement

The organisation aims to design and implement services, policies and measures that meetthe diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others.