Management of MSSA (Meticillin sensitive Staphylococcus aureus) carriage in patients undergoing elective hip/knee joint replacement surgery Classification: Policy Lead Author: Alex Peel Additional author(s): Ihab Boutros Authors Division: Clinical Support/Tertiary Med & Surgery Unique ID: TWCIC01(14) Issue number: 2 Expiry Date: May 2018

Contents

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Section

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Who should read this document? Key practice points Background What is new in this version? Policy Taking a swab Swab results Decolonisation therapy Admission to orthopaedic ward Surgical antimicrobial prophylaxis Standards Explanation of terms References and Supporting Documents Roles and Responsibilities

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Appendix Patient Information Leaflet Orthopaedic pre-op MSSA Screening Request form Fax pro-forma Information sheet for application of decolonisation treatment

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Document control information (Published as separate document) Document Control Policy Implementation Plan Monitoring and Review Endorsement Equality analysis

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Management of MSSA (Methicillin sensitive Staphylococcus aureus) carriage in patients undergoing elective hip/knee joint replacement surgery

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1. Who should read this document? All staff involved in the pre-operative care of patients undergoing elective hip and knee joint replacement surgery.

2. Key Practice Points All patients undergoing elective hip or knee joint replacement surgery should be screened for nasal carriage of MSSA (meticillin-sensitive Staphylococcus aureus). This is in addition to the normal routine screening for MRSA (meticillin-resistant Staphylococcus aureus). All patients found to be colonised with MSSA should receive a course of topical decolonisation therapy in the 5 days prior to their operation. Follow up screening is not required. Once admitted, patients colonised with MSSA do not need to continue MSSA decolonisation therapy or be barrier nursed. Patients colonised with MSSA should be treated as normal for antimicrobial prophylaxis in theatre (all prophylaxis regimens cover MSSA).

3. Background Meticillin-sensitive Staphylococcus aureus (MSSA) is a bacterium that is carried harmlessly by around one third of people. These people are said to be colonised. The most common site of carriage is the nose, but it may also be carried in other sites such as the throat, groins, axillae and other skin areas. Carriage of MSSA does not mean that the person has an infection and does not usually pose a risk to others. MSSA can sometimes cause skin infections, especially in people with wounds or indwelling devices such as intravenous lines. People carrying MSSA who undergo surgery have a higher chance of developing an infection of their surgical wound (a surgical site infection or SSI) caused by MSSA.1,2 The results of some studies have suggested that topical decolonisation therapy in MSSA carriers prior to surgery may reduce SSI rates.3,4 This involves a topical antibacterial applied intra-nasally such as mupirocin (e.g. Bactroban) and an antibacterial body wash. It is important to note that the aim of such decolonisation therapy is not necessarily to completely clear an individual of MSSA carriage. Rather it aims to reduce the amount of MSSA present around the time of surgery, when the risk of an MSSA surgical site infection is highest. Hence follow up screening is not normally required. Issue 2 June 2016

Management of MSSA (Methicillin sensitive Staphylococcus aureus) carriage in patients undergoing elective hip/knee joint replacement surgery

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4. What is new in this version? No significant changes. Mupirocin frequency changed to tds in GP fax (appendix 2) due to error in previous version. Timing of decolonisation therapy better clarified in GP fax (appendix 2).

5. Policy All patients undergoing hip or knee replacement surgery should be screened for MSSA carriage at pre-op assessment clinic. This is in addition to the screening for MRSA that is done (use a separate swab). Patients should be provided with a copy of the patient information leaflet “MSSA screening for orthopaedic hip or knee replacement surgery - Information leaflet for patients” (Appendix 1).

5.1 Taking a swab The nose is the only site that requires swabbing. Moisten the swab with sterile water. Use the same swab to collect a sample from both nostrils. Move the swab across the insides of both nostrils and direct it slightly upwards and gently rotate the swab. Please ensure that specimens are correctly labelled with the patient’s name, hospital number and swab site. The MSSA swabs from the clinic session should be sent to microbiology along with a completed “Orthopaedic Pre-op MSSA Screening Request Form“ listing the patients swabbed (Appendix 2).

5.2 Swab results Staff in pre-op clinic will review the results of all MSSA screens. Patients found to have MSSA in the nasal swab will have the result faxed to their General Practitioner using the pro-forma in Appendix 3. The instructions leaflet “Application of treatment” (detailing application of the body wash and nasal ointment - Appendix 4) should also be included in this fax.

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5.3 Decolonisation Therapy This has 2 components, which are detailed on the information sheet faxed to the General Practitioner (as above). They are used in the 5 days running up to admission for surgery.

Nasal decolonisation BACTROBAN (Mupirocin 2%) nasal treatment. This is used 3 times daily for 5 days. A small amount, about the size of a match head, is applied to a cotton bud or a gloved finger and then applies to the inside of each nostril (apply to the front part of the nostril). The nostrils should then be closed by pressing the sides of the nose together; this will spread the ointment through the nostrils. Antibacterial bodywash OCTENISAN body wash. Octenisan body wash should be used in place of other soap/skin washes every day for a shower, bath or wash in the 5 days running up to admission. The hair should be shampooed with it on 2 occasions during this time. More specific instructions are provided on the “Application of treatment” sheet (Appendix 4)

5.4 Admission to orthopaedic ward Once admitted, patients colonised with MSSA do not need to continue MSSA decolonisation therapy or be barrier nursed. 5.5 Surgical Antimicrobial Prophylaxis Patients colonised with MSSA should be treated as normal for antimicrobial prophylaxis in theatre (all prophylaxis regimens cover MSSA).

6. Standards 100% of patients undergoing elective hip or knee joint replacement surgery should be screened for nasal carriage of MSSA (meticillin-sensitive Staphylococcus aureus).

7. Explanation of terms MSSA – Meticillin-sensitive Staphylococcus aureus MRSA – Meticillin-resistant Staphylococcus aurues SSI – Surgical site infection

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Management of MSSA (Methicillin sensitive Staphylococcus aureus) carriage in patients undergoing elective hip/knee joint replacement surgery

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8. References and Supporting Documents 1. Kluytmans J,A, Mouton JW, Ijzerman EP, Vandenbroucke-Grauls CM, Maat AW, Wahenvoort JH, Verbrugh HA. Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery. J Infect Dis 1995;171(1):216-9 2. Kalmejer MD, van Nieuwland-Bollen E, Bogaers-Hofman D, de Baere GA. Nasal carriage of Staphylococcus aureus is a major risk factor for surgical-site infections in orthopaedic surgery. Infect Control Hosp Epidemiol 2000;21(5):319-23 3. Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, Vandenbroucke-Grauls CM, Roosendall R, Troelstra A et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010;362(1):9-17 4. Rao N, Cannella BS, Crossett LS, Yates AJ Jr. McGough RL 3 rd, Hamilton CW. Preoperative screening/decolonisation for Staphylococcus aureus to prevent orthopaedic surgical site infection: prospective cohort study with 2year follow up. J arthroplasty 2011;26(8):1501-7

9. Roles and responsibilities Staff in the preoperative clinic will ensure that all eligible patients are screened and provided with the patient information leaflet in Appendix 1. Staff in preoperative clinic will ensure that results are reviewed and for patients found to be colonised with MSSA will fax the result to the general practitioner along with a patient information sheet on use of decolonisation therapy (Appendix 3 & Appendix 4) General practitioners will issue the patient with the appropriate decolonisation therapy to be used as directed in the faxed communication.

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Appendices

Appendix 1

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MSSA SCREENING For Orthopaedic Hip or knee replacement Surgery

For further information: If you need more information about MSSA screening, your hospital doctors and nurses will be available to help.

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Information leaflet for patients

Management of MSSA (Methicillin sensitive Staphylococcus aureus) carriage in patients undergoing elective hip/knee joint replacement surgery

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The prevention and Control of infection in our hospital is our highest priority. Keeping the numbers of MSSA infections down in Orthopaedic Surgery is vital to the quality of care you receive and your confidence in us. What is MSSA? Meticillin Sensitive Staphylococcus Aureus (MSSA) is a type of bacteria (germ) which lives harmlessly on the skin and in the noses of about one third of people. People who have MSSA on their bodies or in their noses are said to be colonised.

How is MSSA different from MRSA? Meticillin Resistant Staphylococcus Aureus (MRSA) belongs to the same family of bacteria as MSSA. However, infections with MSSA can be treated with a wider range of antibiotics than MRSA, so are easier to treat.

The swab will be sent to the hospital laboratory to see if the MSSA germ is present (the laboratory will only look for MSSA). It can take up to five days to get the results.

What does a positive result mean? Carrying MSSA does not mean that you are ill and you are no risk to healthy people. However, to protect you and reduce the risk of an MSSA infection whilst you are in hospital, you will be given treatment to reduce the amount of MSSA that you are carrying prior to your Surgery.

What does the treatment involve? You will be given an antiseptic body wash/foam and nasal ointment which will help to suppress or in some cases even get rid of the MSSA that you are carrying. You will be given this treatment when you attend pre-op, or it maybe organised via your GP. This is a simple treatment that should be applied each day for 5 days prior to your admission to hospital for your surgery. The pre-op nurse will advise you on how to use this treatment.

Why will I be screened for MSSA? All patients who are having planned Orthopaedic surgery are routinely screened in pre-op clinic prior to admission. Discovering that you are carrying MSSA will assist us in protecting you from any potential MSSA infection.

What happens when I am screened? We will take a swab from your nose to see if you are carrying MSSA. This is done by placing one cotton bud into both your nostrils. This process is quick and painless. Issue 2 June 2016

What will happen to me when I am admitted to hospital? No further routine treatment or screening for MSSA will be required whilst you are an in-patient. Standard infection prevention and control practices will be carried out during your hospital stay to reduce the risk of MSSA infection.

What will happen if I develop an MSSA infection? You will be given appropriate antibiotics to treat your infection as is standard practice for any infection.

Management of MSSA (Methicillin sensitive Staphylococcus aureus) carriage in patients undergoing elective hip/knee joint replacement surgery

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What can I do to help when I am an in-patient?  Wash your hands regularly, especially after using the toilet,  



before meals and on entering and leaving the ward. Please do not touch any wounds or lines that you may have. Please highlight any concerns you may have regarding cleaning or hand hygiene to a member of staff. Please keep your personal belongings to a minimum to aid the effective cleaning of your bed area.

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Appendix 2

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Appendix 3

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Management of MSSA (Methicillin sensitive Staphylococcus aureus) carriage in patients undergoing elective hip/knee joint replacement surgery

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Preoperative Assessment Clinic, Salford Royal NHS Foundation trust, Stott Lane, Salford. M6 8HD Phone 0161 206 1412 Fax 0161 206 0896

Preoperative Assessment Clinic

Fax To:

From:

Pre-op sister

Fax:

Pages:

3 (including patient information letter)

Tel:

Date

Re:

DOB: Urgent

FAO OF GP

Dear Dr ……………….. All patients who are having planned Orthopaedic replacement surgery at SRFT are routinely screened for MSSA (Methicillin Sensitive Staphylococcus Aureus). The above patient of yours attended Pre-Op Assessment on ………. and was found to be carrying MSSA in their nose. To minimise the risk of an MSSA infection at the time of surgery we would be grateful if you could commence the treatment as suggested by our infection control team. Treatment suggested: Nasal Mupirocin Ointment – TDS for 5 days and Octenisan (or any iodine based body wash) in place of soap for 5 days (please find enclosed instructions for the patient regarding application). This should be administered by the patient in the five days leading up to surgery. No follow up screening or treatment is required. If you require any further information or advice please feel free to contact me on the above number. Thank you,

Preoperative assessment clinic.

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Appendix 4 APPLICATION OF TREATMENT Please use the treatment below for 5 days. Please use it in the 5 days running up to your admission date. OCTENISAN body wash    

Use Octenisan in place of other soap/skin washes. Use every day for a shower, bath or wash. Shampoo hair with Octenisan body wash twice during this time. DO NOT DILUTE THE OCTENISAN in water. Apply directly to the skin.

1.

2.

3.

Use 30 ml of solution

Ensure that hair and body are wet 4.

Rinse off thoroughly

Put the lotion onto a damp washcloth 5.

Dry with clean, dry towel

Leave the lotion on the skin for 3 minute before rinsing Apply all over hair and body paying special attention to the areas indicated in red 6.

Put on clean underclothes/ nightwear every day

If the octenisan wash causes irritation cease use immediately. BACTROBAN (Mupirocin 2%) nasal treatment  

Use 3 times each day for 5 days. Apply a small amount of the ointment, about the size of a match head, on a cotton bud or on a gloved finger and apply to the inside of each nostril (apply to the front part of the nostril).  The nostrils should be closed by pressing the sides of the nose together; this will spread the ointment through the nostrils. Issue 2 June 2016

Management of MSSA (Methicillin sensitive Staphylococcus aureus) carriage in patients undergoing elective hip/knee joint replacement surgery

Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue

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Management of MSSA (Methicillin sensitive Staphylococcus aureus) carriage in patients undergoing elective hip/knee joint replacement surgery

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