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Northern Territory Department of Health Library Services Historical Collection
DL HIST 614.57 MAN 1983
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I LMANAGEMENT OF METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS CASES
DARWIN HOSPITAL
May 1983
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HISTORICAL COLLECTION
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MANAGEMENT OF METI-IlCILLIN RESIST ANT STAPHYLOCOCCUS AUREUS CASES
DARWIN HOSPITAL
ISBN 0-7245-1064-8
CENTRAL LIBRARY
- 1 SEP 1998
TE ITORY HEALTH SERVICES
May 1983
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Methicillil!__Resistant Infections in-Darwin Ho-s-pital-May 198 1.0 Introduction:
Methicillin Resistant Staphylococcus Aureus (M.R.S.A.) first became a problem in this hospital in May 1981. Since then there have been more than 200 cases, mostly simple colonizations, but some with associated serious illnes·s. The threat posed by MRSA can be minimised only by constant care
and understanding. ·
1.1 Definitions
2.0
2.1
2.2
2.3
Colonization with MRSA is defined as an isolation from a site that shows no signs of invasive infection i.e. nose and groin swabs or open wounds showing no progression or cellulitis.
Infection is defined as invasion of normal host tissue by micro organism resulting in local or general infection.
Source of MRSA
Major sources of MRSA in a hospital are patients with burns, skin infection, pneumonia, large infected wounds, infected urine from patients, either with or without indwelling catheters, and overgrowth of MRSA in the bowel.
Additional sources are colonized or symptomless carriers.
Mode of Spread
Direct contact, especially via hands or airborne droplets from nose and mouth.
Indirect contact via contaminated articles and airborne dust and skin squames.
Susceptible patients
All patients with breaches in their normal body defences i.e. surgical wounds, especially with drains, burns, trauma, foreign material implanted, ulcers, pressure area sores, sites of instrumentation such as I.V.T., C.V.P.
sites, urinary catheters and endotracheal tubes. Debilitated patients, diabetics and immuno-compromised patients and small neonates are particularly susceptible to serious infection.
Antibiotics
Inappropriate and excessive use of antibiotics has lead to the development of this resistant organism. It is essential to be discriminating and sparing in the use of antibiotics. The use of broad spectrum antibiotics often precedes the acquisition of MRSA. Antibiotic therapy is not usually indicated for established MRSA colonization or infection unless there is evidence of progressive systemic illness. Antibiotic therapy in these patients should be under the control of SENIOR MEDICAL STAFF.
3.0 Control Measures Aims 1.
2.
Prevent spread of MRSA to "at risk" patients.
Prevent spread to clean areas of hospital where "at risk"
patients are nursed e.g. S.C.N., 3A.
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3. Identify patients harbouring MRSA as early as possible to limit spread and isolate source.
4. Quarantine presumptive and likely MRSA carriers.
3.1 Admission Policy
3.1.1 Adult MRSA Carriers - to be admitted to Ward 28.
3.1.2 Adult MRSA Contacts - Medical Administration will only permit readmission of non cleared patients for urgent reasons. Non urgent cases are to be discussed with the Director of Medical Services or the Regional Director to obtain permission to readmit.
3·.1.2.1 Emergency admissions to 28.
3~1.2.2 Approved elective admissions to appropriate ward and isolate pending Laboratory results.
These patients are to be isolated in the appropriate ward pending Laboratory clearance.
3.1.3 Child MRSA Carriers and Contacts - are to be admitted to Ward 78 (Admission Area only).
3.1.4 Chan Park Nursing Home Patients - are to be admitted to Ward 28.
3.1.5 Re-Admission of Patients with Hospital Acquired Infections - NOT known to be MRSA - to be admitted to appropriate ward and isolated pending Laboratory clearance.
3.1.6 Inter-Hospital transfers
3.1.6.1 From Hospitals with MRSA
Isolate in appropriate ward pending Laboratory clearance.
No isolation required if documented clearance established.
3.1.6.2 From Hospitals with no incidence of MRSA No isolation required.
N.8. If there is any doubt follow 3.1.6.1.
3.1. 7 Clean adult surgery to be allocated to the following areas (guideline only) 3A
3B 48 4A
Orthopaedic and neurosurgery
General surgery and gynae including implant surgery ENT and Ophthalmic, general, excluding implant surgery
Surgery overflow - excluding implant surgery
3.1.8 Mothers of Child MRSA Carriers (Boarder Mothers) - can be admitted to Ward 28.
3.1.9 Mothers of Child MRSA Contacts - are not to be admitted unless accommodation can be arranged in Ward 78.
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3.2 Patient accommodation
3.2.l All patients from ICU are to be transferred to Ward 28.
3.2.2 CCU patients to be transferred to 4A. Isolation is not required.
3.2.3 Patients in Ward 28 are not to be transferred out to other wards.
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$\3.2.4 All adult patients infected or colonized by MRSA are to be transferred to Ward 28 and nursed in standard isolation (blue card), unless strict isolation is indicated - i.e. MRSA pneumonia or extensive infected dermatitis or burns.
q,ildren with MRSA maybe isolated in 78 (depending on general condition).
Any exception to this must be arranged with the Director of Medical
Services. - -
3.2.5 Avoid unnecessary transferring patients and equipment between wards.
3.3 Surveillance
3.3.1 Swabs should be taken from all septic lesions when first noticed.
3.3.2 Swabs should be taken regularly (about fortnightly) from chronic lesions i.e.
ulcers, bed sores, burns etc.
3.3.3 The relevant investigation should be carried out weekly on patients with COAD producing sputum, patients with indwelling catheters, dermatitis etc.
Remember that on occasions severe diarrhoea may be caused by MRSA.
3.3.4 Swabs should be taken weekly on all patients in ICU and all mothers of children with MRSA (Boarder Mothers in Ward 28).
3.3.5 When a patient is found to have MRSA swabs must be taken from all other patients in the immediate vicinity. (Swab any open wounds, nose, axilla, umbilicus, groin and perianal area).
3.3.6 Routine investigations are not carried out on staff as exhaustive surveys have shown that the incidence of staff carriers is very low and carriage is usually transient. It is more important that staff with obvious chest infections, skin lesions, dermatitis or on antibiotics, do not work in areas accommodating MRSA patients. Investigations of staff are indicated if obvious infection is present, or antibiotics have been taken while in contact with MRSA.
3.3. 7 Medical records of patients from whom MRSA has been isolated are marked with an orange sticker indicating month and year MRSA detected. When a patient has been cleared (i.e. confirmed by 3 consecutive sets of clearance swabs), this is indicated on the orange sticker.
3.4 Isolation
3.4.1 Standard isolation is used for most patients with MRSA infections. For patients with severe chest infections with productive coughs and patients with extensive infected dermatitis or extensive infected burns STRICT isolation is required. (RED CARD)
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Note: Staff must be aware of the possible psychological deprivation of patients in isolation. Remember the aim is to isolate the organism not the patient. The patient's physical and emotional needs must be considered.
3.4.2 Patients with minor MRSA wound infections and colonization are permitted out into fresh air and sunshine provided the following precautions are taken.
1. the patient is freshly showered/bathed using Chlorhexidine based soap (Hibiclens) and has had a full change of clean linen.
2. all infected sites can be adequately covered by an occlusive dressing or a closed drainage system.
3. the patient is escorted outside and collected after a set time.
4. the patient is advised not to visit another ward or department.
3.5 Clearance of Patients with MRSA
3.5.l While open colonized wounds persist it is not practicable to consider a patient ready for clearance investigations.
3.5.2 Colonized or infected patients may be treated while carrying the organism·
to reduce dispersion, using Chlorhexidine based soap (Hibiclens) for bathing/showering and hibitane cream for nasal colonization.
Do not use topical antibiotics on skin lesions.
3.5.3 Once the wound or site of infection shows no growth of MRSA clearance swabs should be collected.
3.5.3 1.
3.5.3 2.
· one nasal swab used for both nostrils
one skin swab obtained by using the SAME swab to sample all the following sites: both axillae, umbilicus, groin and perianal areas.
3.5.4
3.5.5
Three consecutive sets of negative swabs are required before a patient is considered clear. Always wait for the first results before collecting further specimens. CARRIERS MUST BE CLEARED TO AVOID UNNECESSARY ISOLATION ON RE-ADMISSION.
Patients remaining positive should have twice daily treatment with hibiclens showers (including hair washing) and hibitane cream to nares for one week.
Swabs are repeated two days after the treatment is completed.
All Ward 28 patients are to have full clearance after discharge.
CONT ACTS - 1st set of swabs to be collected on day of discharge (Monday, Tuesday, Wednesday) or the following Monday.
CARRIERS - 1st set of swabs to be checked l week after discharge.
3.6 Transferring of Patients to other Hospitals for treatment
3.6.1 Collect clearance swabs (3 consecutive sets) on patients known to have been
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in contact with MRSA before transfer. If this is not possible advise the receiving hospital of the possibility of MRSA contact.
3.7 Management of known MRSA Patients in Casualty and Outpatients Department
3. 7 .1 Known MRSA p·atients returning to the Casualty Department are to be treated in cubicle marked. Linen changed and furniture washed after use.
3. 7 .2 Clinic patients are seen in the rooms normally used by the clinician attending. Linen changed and furniture washed after use.
References:
1. "Hospital Procedure Manual" for details of isolation technique.
2. "Sterilization, Decontamination Policy" for ~nformation regarding equipment decontamination.
3. "Hospital Cleaning Manual" regarding environmental control.
4. "Protocol for isolation of patients" for other conditions requiring patient isolation.
