1. MRSA surveillance and optional strategies for elective surgeries
Dianne M Kendall M.D.
Medical Laboratory Director
St Joseph’s Medical Center
Brainerd, MN

2. Tell me and I’ll forget.
Show me, and I may not remember.
Involve me, and I’ll understand.

3. Objectives Review concepts of MRSA surveillance projects
Review optional approaches for elective surgical patients

4. Surveillance
The monitoring of behavior, activities or other changing information, usually of people and often in a surreptitious (clandestine, undercover, covert) manner.
What behavior/activities are we monitoring with MRSA surveillance?
How is it covert?
What do we do with the information gathered?
What is the goal of this surveillance program?

5. MRSA surveillance
MONITOR the effectiveness of your isolation/contact precautions/infection control practices of known MRSA patients to PREVENT spread to adjacent patients in the facility via HEALTHCARE WORKERS or HEALTHCARE ENVIRONMENT
Surveillance annual report: We had 5% of inpatients identified with MRSA. Patients adjacent to these admitted patients had a 0% transmission rate of MRSA.
Contact precautions instituted within 2 hours of discovery of MRSA in 85% of cases.
Hand hygiene audit revealed 77% of nurses used appropriate hand hygiene at work, and 42% of physicians used appropriate hand hygiene (random sampling by blinded observation of Units 7a, 2d, ED and Resp Therapy). 100% rooms cleaned properly at discharge.

6. MN State Statute
Section 15 [ ] Methicillin-Resistant Staphylococcus aureus control programs
In order to improve the prevention of hospital-associated infections due to MRSA, every hospital shall establish an MRSA control program that meets MDH MRSA recommendations as published Jan 15, In developing MRSA recommendations, the Department of Health shall consider the following infection control practices:

7. Cont..
1. identification of MRSA-colonized patients in all intensive care units, or other at risk patients identified by the hospital;
2. isolation of identified MRSA-colonized or MRSA-infected patients in an appropriate manner;
3. adherence to hand hygiene requirements, AND
4. monitor trends in the incidence of MRSA in the hospital over time and modify interventions if MRSA infection rates do not decrease.
MDH to review MRSA recommendations annually and revise as necessary.

8. MRSA Background MRSA: methacillin resistant Staphylococcus aureus
30% of humans colonized by S. aureus at any point and time, usually anterior nares
Other sites hands, skin (intact and non-intact), throat, urine, perineum, stool
MRSA discovered in 60’s and has increased since that time

9. MRSA vs MSSA
MRSA colonized more likely to have MRSA infection compared to MSSA colonized pts with MSSA infections
MRSA easier to transmit between patients and caregivers compared to MSSA transmission
Hospital acquired versus community acquired
Different strains, Comm. Acq.(CA) more virulent

10. Infection prevention and control strategies
Standard Precautions
Any blood, body fluid, secretion, excretion, non-intact skin and mucous membranes contain transmissible infectious agents
Hand hygiene, gloves
When exposure anticipated, gown, mask, eye protection or face shield
Transmission-Based Precautions:
Contact precautions (MRSA)
Direct and indirect contact
Droplet precautions
Airborne precautions

11. Specific IP/IC strategies
Private patient room or cohort strategy
Private room patient rooms/isolation may have higher anxiety and depression, less interaction with healthcare providers, have shorter direct examination times, are less likely to have vital signs recorded, fewer physician progress notes, more likely to complain and more likely to experience an adverse event (as compared to non-isolation patients)

12. Personal protective equipment
Before entering room, wear gloves and gown.
Gloves to prevent contaminating hands with MRSA from patient (direct) or patient environment (indirect)
Glove use positively associated with hand hygiene compliance
Gown use with glove use associated with increased compliance with all precautions
Compared to periodic/procedure based use when contact is anticipated type system.

13. Hand Hygiene If you care for MRSA patient, is there MRSA on you?
MRSA found on 65% of uniforms and gowns or healthcare workers caring for MRSA patients
42% of healthcare workers who ONLY had contact with patient environment had MRSA on their gloves
13% - 29% of healthcare workers’ hands were contaminated with same organism present on the outside of their gloves
How compliant are we with hand hygiene?
Not great with figures ranging between 5-81%, average 40%

14. What about visitors?
Instruction on basic precautions including hand hygiene, to reduce the risk of transmission
Visitors are not required to follow glove and gown recommendations UNLESS participating in direct care of patient
Institution specific policies

15. Environment MRSA can live on a surface for 1-56 days
Up to 25% of patients with MRSA found to have objects in environment (over-bed table, door handle, etc.) contaminated with MRSA
Proper facility cleaning
EQUIPMENT: dedicated patient only equipment including stethoscope, blood pressure cuff, tourniquet, computer, etc… or thorough cleaning between patients
How would you accomplish this in peri-operative setting?

16. Screening Optional Population Individual
If low risk hospital, then select high risk patients
ICU, long term care residents/skilled nursing facilities, history recent hospitalization, dialysis, correctional facilities with recent antibiotic use, chronic skin wounds, elderly
If high risk hospital, screen all admits
Screen these and identify those colonized
ACTIVE SURVEILLANCE CULTURES
Place in contact precautions
Monitor other patients to make sure no transmission to neighbors; monitoring compliance with IC/IP practices
Individual
Consider patient risk factors, history, procedure, etc..
Screen patient prior to procedure
Attempt to decolonize prior to procedure
Optional

17. Why screen populations?
ICU patients more prone to infections and MRSA infections
Many receiving antibiotics and have indwelling invasive medical devices
ICU patient colonized with MRSA 4X likely to get MRSA bacteremia compared to MSSA colonized patient
Prevent spread of MRSA to vulnerable patient population.

18. Why screen individual?
Identify with intent to decolonize prior to procedure.
Prevent surgical site infections
Cardiothoracic surgery
Orthopedic surgery with implants
Elective surgeries
Adherence to SSI prevention measures such as proper selection, timing and administration and discontinuation of antibiotics; skin preparation practices, etc… probably have bigger impact than screening and decolonizing patients
See for more information
If SSI rates do not decrease with SSI prevention measures, consider screening for MRSA and decolonizing strategy.

19. What about screening healthcare workers? BAD IDEA
Although healthcare workers can become colonized with MRSA, HCW are rarely the cause of MRSA outbreaks in acute care settings.
Transmission of MRSA from HCW (as primary source of MRSA) to patient is thought to be rare
Unless epidemiological evidence of HCW linked to epidemic, screening NOT recommended
HCW may have transient carriage
Disruption to staff routine, stigmatization, decolonization and furloughed, etc..
Don’t screen Healthcare Workers

20. How to decolonize for individual model of MRSA screening?
Several protocols in literature.
Most involve mupurocin ointment alone in combination with antimicrobial body washes
How effective are decolonization efforts and how long do they last?
Several studies:
Initial success 90%
After 90 days: 54-61%
Multiple colonized sites: 6%
What about resistance to mupurocin?
It is reported and increasing in frequency

21. Other strategies to reduce MRSA
Antibiotic stewardship
About 50% of antibiotic usage is inappropriate
Use narrow spectrum agent rather than broad
Do not use abx for viral infections
Clinically unnecessary doses and extended duration of treatment
Education and Training of Healthcare workers
Education, accountability, feedback with administrative support and participation of organization leadership with champions
Be a good role model for your co-workers

22. Apply these principles to Perioperative setting
How will you put some patients into “virtual isolation” ?
More space around them
Last case of the day?
Have them wait in room, not OR
How will you segregate equipment?
Special stethoscopes?
How will make sure hand hygiene is optimized?
Where does hand sanitizer get placed? Sinks?
How will you comply with gown portion of contact precautions in open room with multiple patients?
Do you need extra soiled hamper by bedside?
How to clean environment after patient taken to surgery or returned to room post surgery from recovery?
How much environment would be impacted compared to patient room?

23. Summary
MRSA Surveillance will usually identified small group of patients needing contact precautions, with intent to prevent infection to other patients by optimizing infection control and infection prevention practices
Optional individuals could be screened for MRSA with attempts to decolonize
Perioperative environment presents with unique challenges in complying with the usual contact precautions