Methicillin resistant Staphylococcus aureus (MRSA)
Methicillin resistant Staphylococcus aureus (MRSA) has been recognized since the 1970's as a major hospital acquired pathogen that has caused problems in hospitals and other health care institutions worldwide. MRSA is a type of staph that is resistant to certain antibiotics. These antibiotics include methicillin and other more common antibiotics such as, oxacillin, penicillin and amoxicillin. Staph infections, including MRSA, occur most frequently among persons in hospitals and healthcare facilities such as nursing homes, who have weakened immune systems. Infected and colonized residents may serve as potential sources for the spread of MRSA in long-term care facilities. Residents are at increased risk of resistant infection due not only to colonization, but also to chronic illness and debilitation, multiple exposure to antimicrobial agents, presence of pressure ulcers, and indwelling devices. Elderly residents are at increased risk for colonization with MRSA, in addition to having the potential to carry MRSA for long periods of time.
MRSA has emerged as one of the predominant pathogens in healthcare-associated infections. According to the Centers for Disease Control (CDC) data, the proportion of infections that are antimicrobial resistant has been growing. In 1974, MRSA infections accounted for two percent of the total number of staph infections; in 1995 it was 22%; in 2004 it was 63%. Approximately 20% to 25% of patients admitted to long-term care facilities are colonized with MRSA, and another 10% will acquire the organism during their stay.
Treatment options are limited and less effective, resulting in higher patient morbidity and mortality. And the high prevalence is a major influence on unfavorable antibiotic prescribing which contributes to the further spread of resistance. MRSA also adds to the overall staphylococcus aureus infection burden.
Through this learning module and clinical resource, you will learn to:
· Develop an overall understanding of Methicillin Resistant Staphylococcus aureus.
· Explain the prevalence of MRSA and the importance for further research
· Discuss behaviors that reduce the risk of transmission of MRSA
· Implement evidence based-practice guideline/strategies in your facility in the care of older adults with MRSA
Staph skin infections, including MRSA, generally start as small red bumps that resemble pimples, boils or spider bites. These can quickly turn into deep, painful abscesses that require surgical draining. Sometimes the bacteria remain confined to the skin. But they can also penetrate into the body, causing potentially life-threatening infections in bones, joints, surgical wounds, the bloodstream, heart valves and lungs. Fever, chills, low blood pressure, joint pains, severe headaches, shortness of breath, and "rash over most of the body" are symptoms that need immediate medical attention, especially when associated with skin infections.
Most MRSA infections are skin infections that produce the following signs and symptoms:
So: Any sign or symptom of skin infection or other infection needs to considered suspect as MRSA.
MRSA is a strain of staph that is resistant to the broad-spectrum antibiotics commonly used to treat it. Staph bacteria are normally found on the skin or in the nose of about one-third of the population. If you have staph on your skin or in your nose but aren't sick, you are said to be "colonized" but not infected. Healthy people can be colonized and have no ill effects. However, they can pass the germ to others.
Staph bacteria are generally harmless unless they enter the body through a cut or other wound, and even then they often cause only minor skin problems in healthy people. However, staph infections can cause serious illness especially among older adults and people who have weakened immune systems, usually in hospitals and long term care facilities
So: Consider nursing home residents at-risk for MRSA and potential transfer of germs needs to be considered at all times
Leading causes of antibiotic resistance include unnecessary antibiotic (inappropriate use and mutation of germs) use as well as exposure to antibiotics in food and water.
So: Avoid unnecessary exposure to antibiotic use
Control of Transmission :
As with vancomycin-resistant enterococci (VRE), an individual with MRSA can either be infected (showing clinical signs/symptoms, e.g. fever, lesions, wound drainage) or colonized (MRSA is present in or on a body site without clinical signs/symptoms), and in either case is capable of transmitting it to others.
So: Recognize that transmission can occur with or without clinical signs/symptoms
When we talk about the spread of an infection, we talk about sources of infection - where it starts, and the way or ways it spreads - the mode or modes of transmission. In the case of MRSA, patients who already have an MRSA infection or who carry the bacteria on their bodies but do not have symptoms (colonized) are the most common sources of transmission.
The main mode of transmission to other patients is through human hands, especially healthcare workers' hands. Hands may become contaminated with MRSA bacteria by contact with infected or colonized patients. If appropriate hand hygiene such as washing with soap and water or using an alcohol-based hand sanitizer is not performed, the bacteria can be spread when the healthcare worker touches other patients.
People with higher risk of MRSA infection are those with obvious skin breaks (surgical patients, hospital patients with intravenous lines, burns, or skin ulcers) and patients with depressed immune systems (infants, elderly, or HIV-infected individuals) or chronic diseases (diabetes or cancer). Patients with pneumonia (lung infection) due to MRSA can transmit MRSA by airborne droplets. Health-care workers as a group are repeatedly exposed to MRSA-positive patients and can have a high rate of infection if precautions are not taken. Health-care workers should use disposable masks, gowns, and gloves when they enter the MRSA-infected patient's room.
Residents and their families and visitors should be educated about MRSA infections and the precautions to be taken in the long-term care facility. Family and visitors should clean their hands before entering and leaving the room of a resident who has MRSA. Family/visitors should wear gloves when handling the secretions/excretions of the resident or when providing direct care. Families and visitors and other residents must have sufficient education to alleviate their concerns, ensure that precautions are maintained, and understand that residents with MRSA need to be avoided.
Common risk factors for acquiring MRSA:
A skin sample, pus on the skin, or blood, urine, or biopsy material (tissue sample) is sent to a microbiology lab and cultured for Staphylococcus aureus. If Staphylococcus aureus is isolated (grown on a Petri plate), the bacteria are then exposed to different antibiotics including methicillin. Staphylococcus aureus that grows well when methicillin is in the culture are termed MRSA, and the patient is diagnosed as MRSA-infected. The same procedure is done to determine if someone is an MRSA carrier (screening for a carrier), but sample skin or mucous membrane sites are only swabbed, not biopsied.
In 2008, the U.S. Food and Drug Administration (FDA) approved a rapid blood test that can detect the presence of MRSA genetic material in a blood sample in as little as two hours. The test is also able to determine whether the genetic material is from MRSA or from less dangerous Staph bacteria. The test is not recommended for use in monitoring treatment of MRSA infections and should not be used as the only basis for the diagnosis of a MRSA infection.
Administer vancomycin intravenously as prescribed.
Administer trimethoprim-sulfamethoxazole for minor MRSA infections as prescribed.
Advocate for avoiding unnecessary antibiotics to reduce the occurrence of resistant bacteria.
Avoid the use of topical or systemic agents for nasal or extra-nasal MRSA for decolonization. This is not supported
· Hand Hygiene after contact with blood, body fluids, secretions, excretions and any or all contaminated items whether or not wearing gloves. Immediately after patient contact, after gloves are removed, and/or between tasks on the same patient which may cause cross-contamination to other body parts completely clean hands.
Hand washing with soap or antiseptic –containing soap and water, and use of gels, foams or rinse agents that do not require water.
Hands should be dried with a dry, disposable paper towel, and facets should be turned off using a paper towel
Implement a system of alerting healthcare workers and visitors that a resident is on contact precautions without compromising the resident's privacy.
Colonized patients: only when the patients are a documented source of transmission to other patients (Nicolle).
Gloves: Gloves (single use, disposable) must be used when touching blood and all body fluids, non-intact skin, and mucous membranes. Gloves should be worn when providing care that involves substantial personal contact such as changing clothes, bedding, etc. If gloves become soiled with potentially infectious material (e.g. urine, stool, blood), they should be changed before further contact with clean surfaces, the patient, or other staff. Remove the gloves after caring for the patient and wash hands with an antibacterial soap before leaving the room. Staff should be trained in these procedures and a competency measured on a yearly or more frequent basis as need arises.
Gowns: Gowns should be worn if the caregiver's clothing is likely to have substantial contact with a MRSA-positive resident in the course of care (e.g. bed baths, lifting). Gowns should be removed immediately after care and the caregiver's hands should be washed prior to leaving the resident's room with an antibacterial soap.
Masks and eye protection: masks are recommended when the patient has MRSA bronchitis or tracheitis, lower bronchial colonization or a tracheostomy, and during care of MRSA-infected burns. If extensive splattering is expected, protective eyewear may be warranted. Eyewear is recommended for intubation, suctioning of the respiratory tract, irrigation of a wound, caring for open tracheostomies, and any condition with the potential for projectile secretions. The National Institute for Occupational Safety and Health (NIOSH) recommends using eye protection that could include goggles, face shields, safety glasses, or full-face respirators depending on the activity being performed. Selection of protective eyewear appropriate for a given task should be made from an evaluation of each activity, including regulatory requirements when applicable (NIOSH, 2004).
Linens: All linen, regardless of the diagnosis of the resident, should be collected and bagged at the bedside. If linen is wet, or saturated with urine or feces, is should be collected in a plastic or fluid impervious bag. All linen should be treated as potentially infectious
Environmental Cleaning: surfaces and equipment that may be contaminated with pathogens be cleaned and disinfected on a regular basis and according to institutional and national guidelines. The areas that are in close proximity to the patient (e.g., bed-rails, over-bed tables), and frequently-touched surfaces in the patient care environment (e.g., door knobs, toilet areas, sinks) should be cleaned on a more frequent basis with an approved disinfectant.
Cleaning of computer equipment used in multi-patient care: recommend that computer cleaning should be done using the same protocols to clean other environmental surfaces in the area and it should be done between each individual patient or patient room. It is also recommended that plastic covers be used if the equipment cannot be cleaned in the same manner, and that equipment being ordered contain as many smooth surfaces as possible. Good hand hygiene should be practiced before using the equipment between patients.
Group Activities: A long-term care facility is normally considered a resident's home. A MRSA-positive resident should be allowed to ambulate, socialize as usual, and participate in therapeutic and group activities as long as contaminated body fluids are contained. When residents leave their room, they should have their hands cleaned. In addition, they should have clean, dry dressings and wear clean clothes. Where appropriate, enhanced barrier protection to contain a contaminated body substance is preferred over restriction of the resident.
A private room is not necessary unless the patient has a condition that would increase the likelihood of transmission (e.g., eczema, a large MRSA-infected or colonized burn, or lower respiratory tract infection).
When placing residents with MRSA in multiple-bed rooms, their roommates should not be severely immunocompromised or have indwelling lines or open wounds.
When single-patient rooms are available, assign priority for these rooms to patients with known or suspected multi drug resistant organism (MDRO) colonization or infection. Give highest priority to those patients who have conditions that may facilitate transmission (e.g., uncontained secretions or excretions).
When single-patient rooms are not available, cohort patients with the same MDRO in the same room or patient-care area. Contaminated rooms may be a risk factor for the acquisition of nosocomial pathogens by unaffected patients.
Surveillance in an essential tool for case-finding of single patients or clusters of patients who are infected or colonized with epidemiologically important organisms such as MRSA, for which transmission-based precautions are required. Surveillance is defined as the ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event for use in public health action to reduce morbidity and mortality and to improve health. Surveillance is an important component of all infection control programs, including those in long-term care facilities.
This module was developed by Damita Carryer, Brenda Kirby, Melissa Miller, and Melinda Seifers as a part of the course requirements for N626 as graduate nursing students at Winona State University, Spring semester 2009 under the direction of course faculty member Phyllis Gaspar, Ph.D., RN. Review was completed by Constance Schein, M.Sc., RN July 2009.
The development of this module was supported through a Stratis Health Building Healthier Communities Award.
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