Policy and Code of Practice for the Screening and Management of Patients Colonised or Infected with Meticillin (Flucloxacillin) Resistant Staphylococcus aureus (MRSA)

Corporate Policy No: Group: Review: Date of first issue: Current date of issue: Review date:

020/12 Infection Control Infection Control Team 1995 (annual review and update) September 2008 March 2010

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Objective of this Policy and Code of Conduct To identify, treat and prevent nosocomial spread of MRSA to patients. Principles of this Policy and Code of Conduct All patients who fit the MRSA screening criteria must be screened within 24 hours of admission. All patients attending hospital as elective admissions and attendees require MRSA screening in accordance with guidance from the Department of Health (2008). MRSA positive patients will be treated with appropriate decolonising agents whilst an in-patient, e.g. Octenisan body wash, nasal mupirocin 2% if judged appropriate by the Infection Prevention and Control Team. MRSA positive patients will be screened as directed by this policy. Patients found to be MRSA positive in high risk clinical areas will need to be nursed in a single room Standard infection control precautions must be adopted on all patients regardless of their diagnosis. Staff screening for MRSA will only be conducted at the discretion of the Infection Prevention and Control Team. The Occupational Health Department and microbiologist will coordinate this MRSA positive patients should only be transferred to wards/departments when adequate arrangements have been made to cater for these patients. Prior to discharge patients found to be MRSA positive must have their notes labelled as well as being flagged on the iPM system. Practice Guidelines Introduction Patients who are colonised or infected with Meticillin resistant Staphylococcus aureus (MRSA) may require special arrangements. MRSA presents different risks to different patient groups and within different care environments. MRSA infection or colonisation in hospital inpatients is particularly significant. Patients in Intensive Care Units (ITU’s), Oncology Units, Orthopaedic wards, Vascular wards and Renal Units are considered to be at greatest risk. Patients in general surgical areas are at more risk than those for instance in general medical or care of the elderly. Therefore the management of MRSA requires to be adapted to meet the needs of each of the services. This Policy outlines the steps to be taken by staff within the Trust. The risk categories used are based on those recommended by the MRSA Working Party Report (2006).

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Elective screening All elective patients must be screened by clinic staff prior to or on admission or attendance e.g. at Preoperative Assessment Clinic, Day Surgery Unit, Antenatal Clinic or any other unit facility. Staphylococcus aureus Staphylococcus aureus is a common skin organism found on 20-30% of the population. The majority of these people are colonised with the organism. For example it is present on their body but causing them no harm. Certain individuals such as those that have surgical wounds, invasive devices (Intravenous cannulas, endotracheal tubes and urinary catheters) or those whose immune system is impaired may develop infections. In these patients antibiotics such as flucloxacillin may be used. Meticillin (Flucloxacillin) Resistant Staphylococcus aureus MRSA are strains of Staphylococcus aureus that have developed resistance to Meticillin. Although Meticillin is no longer used for treatment it is used as a marker to show that the bacteria is resistant to all beta-lactam antibiotics (penicillins and cephalosporins) many of which would normally be used to treat such infection. This does not mean that MRSA is untreatable, or that it results in more severe infections. However treatment may require the use of more toxic or expensive antibiotics. Spread The most important mode of transmission is by direct contact, usually hands. Spread may also occur via staff clothing, bedding and ward dust containing skin squames and MRSA can survive in dust for many months. Therefore direct contact with the patient and his/her bed linen or equipment, and dust-raising activities may lead to MRSA colonising staff member’s nostrils, hands and clothing with consequent spread to other patients. Appropriate use of aprons and gloves for patient contact and invasive procedures is important to minimise spread, as is efficient daily ward cleaning. The main way to prevent spread is through effective hand washing before and after all direct patient contact (See Code of Practice for Hand Hygiene and Hand Hygiene training). MANAGEMENT MRSA prevention and control strategies The risk from MRSA in terms of morbidity and mortality is considered to be different in different clinical areas. The Trust provides a variety of health services from a variety of settings. The strategy adopted for preventing and controlling MRSA will vary from service to service. The following guidance outlines the approach that will normally be taken within wards in each of the main risk categories. However it is not possible to be prescriptive for all circumstances, as decisions need to be based on the local situation. The Infection Prevention and Control Team, following discussion with clinical staff, will make initial assessments of risk.

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Northampton General Hospital (NHS Trust) wards are categorised into three risk areas for MRSA based on the risks and clinical consequences of healthcare associated infection. Risk Categorisation of Clinical areas High risk, Moderate risk and Lower risk.

High Risk Areas

Moderate Risk Areas

Intensive Therapy Unit High Dependency Unit Special Care Baby Unit Oncology Trauma Orthopaedics Vascular surgery Renal medicine

General Surgery Urology Neonatology Gynaecology/obstetrics Paediatrics Admission wards Cardiology Dermatology General Medicine

Lower Risk Areas

Acute and Continuing Care of the Elderly Rehabilitation wards Stroke unit

Prevention and control measures General measures As most patients with MRSA will be in clinical areas prior to their MRSA positive status being recognised, the importance of maintaining a high standard of infection control precautions within all clinical areas at all times cannot be over emphasised. This includes good hand washing practice, appropriate us of protective clothing and thorough environmental cleaning. If patients who are MRSA positive need to be moved to other wards or departments the ward sending the patient should notify the receiving area so that adequate precautions can be made. Screening Selective admission screening to facilitate early identification of positive patients has been shown to be beneficial in reducing the numbers of hospital acquired MRSA infections. Nose, groin, wound swabs including swabs form tracheostomies, any manipulated sites, Sputum if the patient has a productive cough and a catheter specimen of urine (CSU, if catheterised) should be taken from the following groups of patients; • Admissions from Nursing or Residential Home • Transfers from ward to ward • Previous known MRSA positive patients • Patients with multiple wounds/skin lesions or pressure ulcers • Multiple hospital admissions • Frequent attendees to a Healthcare Setting • Transfers from other hospitals or units • Patients with alcohol related liver disease Page 4 of 15

Please note that all patients that are admitted to Northampton General Hospital Trust should undergo a risk assessment utilising the Patient’s Checklist to reduce Healthcare Associated Infections. When taking swabs it is recommended to moisten the swabs in the sterile swab media or sterile saline before sampling. Use a zigzag method when sampling wounds depending on the amount of exudate present. The Infection Prevention and Control Team will coordinate required screening of whole wards. Screening of ward staff will be infrequent and will only be carried out when there is strong epidemiological evidence to suggest that it may be necessary, if so this will be coordinated by the Occupational Health Department. The infection Prevention and Control Team currently maintain a system of identifying previously positive patients. (I.e. Flagging of patients notes, computer Flagging). This is particularly helpful in preventing the re-introduction of MRSA into clinical areas. Ward staff must routinely inform the Infection Prevention and Control Team when patients known to have been previously positive are readmitted or transferred, in order that appropriate screening and patient management can be agreed. Isolation Precautions Patients found to be MRSA positive are usually nursed in a single room although this will vary depending on the type of ward, isolation facilities and patient risk assessment. The Infection Prevention and Control Nurse will provide specific advice for newly diagnosed MRSA positive patient in the form of a care plan. The psychological effects of isolation should not be underestimated and should be taken into consideration at all times by the named nurse. POSITIVE SITE Nasal positive and body sites negative

ACTION REQUIRED Nasal Mupirocin 2% (Bactroban) TDS for 5 days Octenisan body wash for 5 days Stop for 2 days and then rescreen. May be able to nurse on the ward if on treatment and away from patients with wounds and indwelling devices.

Body site positive

Source isolate until 3 negative Screens (as per IPCT advice).

Wound positive and body sites negative

Occlusive dressing. May benefit from topical treatment. May require systemic antibiotic therapy

Clearance criteria It is recommended that isolation precautions continue until three consecutive negative screens are obtained. Although when patients are isolated within highrisk areas they may require isolation beyond that. Screens should be taken weekly and 48 hours after completion of decolonisation treatment.

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Treatment and Prophylaxis Treatment of colonisation or infected patients should be discussed with a Consultant Microbiologist or a member of the Infection Prevention and Control Team. A MRSA care plan containing eradication programme will be issued to all new and previous MRSA positive patients. MRSA can be eradicated by using a number of antiseptic type products. Nasal positive Body site positive

Mupirocin 2% nasal cream TDS x 5 days Octenisan body wash x 5 days - hair wash x 2 days Body site negative but wound Occlusive dressing - may require topical positive antiseptics, inadine tulle, mupirocin in a polyethylene glycol base, +/- antibiotics. Liaise with Infection Prevention and Control Team Acute care of the elderly wards (lower risk areas) MRSA presents a lower infection risk within this type of setting. A good standard of basic hygiene, both personal and environmental is essential. Particular attention should be given to patients who are catheterised or who have wounds. There is no need to routinely isolate all patients who are colonised with MRSA. Patients reported to be MRSA positive would be assessed on an individual basis. The Infection Prevention and Control nurse will advise what additional precautions if any are required for infected patients. If a patient who is infected or colonised with MRSA requires transfer to a clinical area in lower, moderate or high risk categories the receiving ward must be notified of the patient s MRSA status prior to transfer in order that appropriate accommodation can be arranged. Screening of other patients and staff is not indicated. Outpatients Departments Attendance of Outpatients Departments MRSA colonisation/infection should not normally prohibit a patient’s attendance at other hospital departments where attendance has been necessary, eg, Outpatients departments, X-ray, Physiotherapy, and Occupational Therapy. The routine precautions particularly handwashing, which are routinely followed in these departments, are sufficient to control the spread of MRSA. Departments should be notified in advance if an inpatient is attending so that the patient does not have to wait for prolonged periods in waiting areas. Colonisation of staff Staff will only be screened if there is a particular problem on a ward identified by the Infection Prevention and Control Team. This screening will be arranged by the Occupational Health Department. Staff MUST NOT screen themselves without prior permission.

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Experience so far suggests that the risk of staff becoming colonised is low and usually dependent on the extent of contact with infected or colonised patients. It has been noted that staff carriage is usually transient and the organism will generally disappear within a few hours. Movement of patients Transfers of patients around the hospital should be kept to a minimum. Should this be necessary then prior arrangements must be with the department concerned so they can implement effective infection prevention and control arrangements. MRSA positive patients should visit departments at the end of the working session and should spend the minimum period of time in the department. Patients who are MRSA positive requiring surgical intervention will require appropriate antibiotic management; this can be obtained from the Consultant Microbiologist. MRSA positive patients attending the operating theatre ideally should be sent down last on the list after notifying the appropriate theatre co-ordinator. Equipment used to transfer the patient must be cleaned before re-use. Discharge planning. When an MRSA patient is discharged from hospital, the GP and District Nurse, Matron of the Residential or Nursing home or Primary Care Team involved must be made aware via the discharge letter and by verbal communication. Colonisation or infection with MRSA should not affect the discharge of patients back into the community setting. In the majority of cases topical treatment for MRSA need not continue on discharge but in some circumstances, e.g. planned readmission to hospital in the near future, advice to continue treatment will be given by the Infection Prevention and Control Team. Patients should be reassured that they pose no danger to their family members and offered an MRSA information leaflet. Surgical Operations These guidelines are intended to ensure efforts are made to identify and eliminate MRSA prior to surgery or at least reduce microbial load. Elective admissions All elective patients must be screened by clinic staff prior to or on admission /attendance e.g. Preoperative Assessment Clinic (POAC) -See Appendix In addition the following points should be followed: 1. Known MRSA cases should be scheduled last on the list if possible. 2. Patients should be allowed to recover after surgery at one end of recovery in an area to avoid possible contamination. (Please discuss individual patients with an Infection Prevention and Control nurse prior to surgery if required)

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3. Where antibiotic prophylaxis is indicated Vancomycin or Teicoplanin should be given in colonised or infected patients. Please contact the Consultant Microbiologist for advice regarding prophylactic treatment. In addition, prophylaxis with teicoplanin should be considered for any patient undergoing surgery, particularly if high-risk such as implant surgery, who may have been exposed to risk of acquisition of the strain during an outbreak on their ward. 4. Theatre surfaces in close contact or near the patient, such as operating table or instrument trolley, should be thoroughly cleaned before being used for the next patient. 5. Screening of Theatre staff is only recommended where: a) There is a serious deep-seated infection in a post-operative patient with evidence of transmission in theatre. b) A cluster of cases with epidemiological evidence of transmission in theatre. Intensive Care Unit (ITU) and high Dependency Unit (HDU) •

ALL patients admitted to ITU and HDU are to be screened on admission to the Units and screened weekly subsequently.



ALL ITU patients are to receive full decolonisation treatment, (both Octenisan body wash and nasal mupirocin 2%) for the duration of their stay on the unit. Also ventilated patients are to have Chlorehexidine mouthwash. Patients are to have a five- day course; 48 hours break then re-screen and recommence decolonisation treatment.

The Northamptonshire Kidney Centre (Finedon ward) •

ALL Renal patients should be screened on admission and re-screened at least once a week or sooner if signs of infection.



ALL Renal patients undergoing haemodialysis should be started on Octenisan body wash. If patient is found to be positive than nasal mupirocin 2% + or – systemic antibiotics may be required.

All Emergencies are to be screened on admission. –See Appendix

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MRSA DE-COLONISATION TREATMENT CHART (To be prescribed by Doctor or initiated by IPCN – see Patient Group Directive) MRSA POSITIVE RESULT

DO NOT Repeat antibacterial treatments for more than TWO 5-DAY COURSES. If patient is a non-responder and requires further treatment Contact ICN or Microbiologist for advice

Skin colonisation – Antimicrobial wash (Octenisan) once a day for 5 days Nasal colonisation –Mupirocin Antibacterial ointment, 3 times a day for 5 days Treatment given for either. After 5 days -STOP antimicrobial wash (use patients own soap)

STOP antibacterial ointment

Wait 2 days

Full screen (Continue to use patient’s own soap until result known)

POSITIVE

Result

NEGATIVE

Continue to use patient’s own soap Continue isolation precautions Octenisan recommended first choice antimicrobial wash Mupirocin 2% first choice antibacterial nasal ointment If any patients have adverse reaction – Contact ICN for advice

WEEKLY – FULL SCREENS Until 3 full consecutive negative screens

CONTACT INFECTION CONTROL to discuss appropriate precautions

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REFERENCES Coia J.E., Duckworth G.J., Edwards D.I., Farrington M., Fry C., Humphreys H., Mallaghan K., Tucker D.R. Guidelines for the control and Prevention of Methicillin Resistant Staphylococcus aureus (MRSA) in healthcare facilities by the Joint BSAC/HIS/ICNA Working Party on MRSA. Journal of Hospital Infection (2006) 63: 144. Cookson BD (1989) Staff carriage of EMRSA.Journal of Clinical Microbiology. Peters B27 (7) 1471-6. Duckworth G, Cookson B, Humphreys H, Heathcock R, Revised Methicillin Resistant Staphylococcus aureus Infection Control Guidelines for Hospitals. Journal of Hospital Infection (1998) 39: 253-290. Pratt et al (2007). Epic 2: National Evidence-based Guidelines for Preventing Healthcare associated infection in NHS Hospitals in England. Journal of Hospital Infection Vol. 65 (Supplement 1). Saving Lives, reducing infection, delivering clean and safe care (2007) Department of Health Further reading available from the Infection Prevention and Control Department

Corporate Policy No: 020/12 Group: Infection Control Review: Lead Infection Control Nurse Approved by: Trust Board

Date of first issue: 1995 Current date of issue: June 2006 Review Date: June 2008 Page 10 of 14

Appendix 1

MRSA

Contact Isolation Precautions

Patient Placement When isolation of MRSA positive in-patients is indicated the patient must be nursed in a single room using Contact Precautions. The room should have hand washing and toilet facilities. An isolation notice must be displayed outside the door. Unnecessary furnishings should be removed before the patient is admitted. Mattress and pillow covers must be intact, washable and impervious to water. The room must also be provided with an appropriate sized clinical waste bin. Hand washing Hands must be thoroughly washed using a liquid soap after removing gloves and before leaving the isolation room. Protective Clothing Gloves Non –sterile latex gloves must be worn on entering the room for activities that will involve close contact with the patient or their immediate environment. These must be changed between patient care activities that may result in gross contamination, e.g faeces, wound exudates. Gloves must be removed before leaving the room and discarded into clinincal waste bins provided. Aprons A disposable plastic apron must be worn on entering the room for activities that will involve close contact with the patient or their immediate environment. The apron must be removed on leaving the room and discarded into the clinical waste bin provided. Patient Care Equipment Where possible the sharing of patient care equipment should be minimised, by using disposable equipment. All disposable equipment must be disposed of as clinical waste. If patient care equipment must be shared between isolated and non-isolated patients ensure that it can undergo a suitable decontamination method after use on an isolated patient. Care should be taken with stethoscopes, BP cuffs, pens, and tympanic thermometers. Further advice can be obtained from the Infection Control Nurse. Linen Linen to be placed in a normal white linen bag, Crockery and Cutlery No additional precautions are required. All crockery and cutlery washed at ward level must be washed in a dishwasher so that thermal disinfection temperatures are reached. There is no requirement for disposable crockery and cutlery to be used. Waste Disposal All non-sharp waste must be disposed of into a clinincal waste bin placed in the room.

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Staff All staff must ensure that cuts and abrasions are covered with a waterproof dressing whilst on duty. Staff with dermatitis, psoriasis or other skin conditions should avoid direct contact with MRSA positive patients. They should consult with Occupational Health Department for further advice. There is no need to exclude pregnant staff. Visitors Visitors must report to the nurse in charge for instructions before entering the room. There is no requirement for visitors to wear protective clothing. Clear instructions should be given to visitors on performing thorough hand washing when leaving the room. Routine Cleaning and Terminal Disinfection Routine Cleaning Isolation rooms require routine cleaning and should be cleaned daily with Chlor clean (combined detergent and disinfectant). A red mop should be used and laundered on a daily basis. Terminal Disinfection Rooms that have been used to isolate patients with MRSA will require terminal cleaning and disinfection after the patient has been removed from isolation. All bed linen, including duvets, should be sent to the laundry in a white laundry bag. All waste will be discarded as clinical waste. All furniture, fittings and horizontal surfaces must be carefully cleaned Chlor clean, It is essential that the room is properly deep cleaned prior to being used by another patient. There is no need for the room to remain empty for a specified time.

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Elective patient attends OPD, Day Unit or POAC

Day Care Ophthalmology Day Case Dental Day Case Endoscopy Minor dermatology procedures Paediatrics Maternity non c-sections (Unless high risk then screen as per Trust MRSA policy)

• Ante-natal Unit – patients for Caesarean sections • Danetre Hospital • ENT OPD • Fracture clinic • Haematology, Chemotherapy, Radiotherapy & Talbot Butler • Gynae Day Care & OPD • Integrated Surgery • Max-fac OPD • Medical OPD • Pain clinic • Renal unit

NO SCREEN (Exempt)

ELECTIVE MRSA SCREEN

Pre-Operative Assessment Clinic (POAC): ENT, Gynae, General Surgery, Head & Neck, T&O, Urology, & Vascular

Patient is previously MRSA negative

NOSE, GROIN & MANIPULATED SITES ELECTIVE MRSA

Result is positive

• • • • • •

Patient is previously MRSA positive

NOSE, GROIN & MANIPULTAED SITES & Supply decolonisation treatment via PGD

Result is positive

Result is negative

• •

isation

POAC inform patient & provide decolonisation via PGD or via fax GP to request prescription

POAC inform patient & provide decolonisation from above treatment

Patient has 5 days of decolonisation

Rescreen if sufficient time before TCI date and requested by Consultant

Corporate Policy No: 020/12 Group: Infection Control Review: Lead Infection Control Nurse Approved by: Trust Board



Decolonisation from above three days prior to admission for five days

If patient is awaiting admission: IP&CT will send a letter to the GP requesting prescription for decolonisation treatment Need PCT liaison and an agreement – ideally IP&CT will send a letter to the

Date of first issue: 1995 Current date of issue: June 2006 Review Date: June 2008 Page 13 of 14

Infection Prevention & Control Team (I collects all positive results 1-2 days late IP&CT liaises with the Consultant team IP&CT advises on decolonisation in accordance with Trust MRSA policy an assessment

If patient is an in-patient: IP&CT will provide decolonisation treatment via PGD in drug chart as per

If patient has been disch IP&CT will send a letter GP with a risk assessme prescribing treatme depending on individual circumstances Need PCT liaison an agreement – ideally IP

Corporate Policy No: 020/12 Group: Infection Control Review: Lead Infection Control Nurse Approved by: Trust Board

Date of first issue: 1995 Current date of issue: June 2006 Review Date: June 2008 Page 14 of 14