Health Facilities

Protocol for Methicillin-Resistant Staphylococcus aureus (MRSA) Infection in Long Term Care Facilities

Developed by the Colorado Medical Directors Association and  the Colorado Department of Public Health and Environment

INTRODUCTION

This document addresses the need for a state wide standard for managing MRSA infections in long-term care facilities (LTC facilities). This document is the result of a meeting between medical directors of the LTC facilities in El Paso County and infectious disease physicians practicing in area acute care facilities.

This document is designed to set a standard for the care of LTC residents. However, it is not intended to mandate treatment. The coordination of this standard between the LTC facilities and acute care hospitals will provide a reasonable approach to the containment and treatment of MRSA and is intended to dispel the need for unwarranted isolation, expense and medication use.

MRSA are strains of Staphylococcus aureus (SA) which are resistant to methicillin and related drugs. The organism itself has the same virulence that community isolated SA strains have. It is found in areas where SA is found (skin, anterior nares, respiratory tract). It colonizes LTC residents at a given level which varies from facility to facility. Colonization itself is not detrimental to the health of an individual. This organism becomes clinically important when it infects wounds, the respiratory system or the urinary tract.

Most commonly MRSA is transmitted between individuals by direct contact. Therefore, hand washing between the care of residents is the most effective means to prevent the spread of this bacteria. Isolation protocol for infected individuals will be discussed below.

Standard precautions - changing gloves after each patient and good hand washing techniques - should be strictly adhered to. Treatment considerations of clinically significant conditions require simultaneous treatment of the skin and anterior nares.

PART I: CARE OF INDIVIDUALS WITH MRSA INFECTION

Remember: The presence of a MRSA positive culture does NOT mean infection. Infection is diagnosed by a CLINICAL evaluation. Sputum cultures are more confusing than helpful as most residents cannot cough up phlegm but usually produce saliva which contains mouth flora. When appropriately obtained by a respiratory therapist or by suctioning, sputum cultures may be useful in guiding therapy once an infection has been identified.

A. Respiratory infection with MRSA

1. Clinically significant respiratory infections with MRSA requires systemic treatment with antibiotics and isolation is advised. In addition, a daily total body bath with chlorhexidine (Hibiclens) and twice a day application of mupirocin (Bactroban) ointment to the anterior nares is strongly recommended for seven (7) days. Do not culture nose.
   
2. If clinical infection has resolved, followup cultures are not necessary. Infections are deemed cured if sputum production ceases and clinical illness resolves. If clinical infection is not resolved, cultures should be obtained 48 hours after the completion of antibiotics.
   
3. Isolation procedures would include private room as well as staff using gloves, hand washing, mask with eye protection, and gown. Cohort pairing (another individual known to have MRSA) is acceptable. Isolation can be discontinued when evidence of clinically significant infection is no longer present. Reculture is not necessary. The most effective means to prevent aerosolization of MRSA when a resident has a productive cough is for the resident to wear a mask. Applying a mask to the resident in their room can be frightening and should be avoided unless persistent coughing causes concern. A resident with productive cough may be transported to common areas (such as showers) if the resident wears a mask.

B. Care of individuals with MRSA infected wounds including skin infections and conjunctivitis.

Remember: Do NOT culture pressure sores or decubiti except in a surgical setting after deep debridement.

1. Pressure sores or decubiti are NOT cultured as cultures reflect skin flora rather than infecting organisms. Other wounds with pus laden exudate should be cultured. The exudate should be rinsed off and the bed of the wound cultured.
   
2. Wounds infected with MRSA need good wound care. If not responding, antibiotics may be needed. Vancomycin should be reserved for severe infections not responsive to other antibiotics based on clinical evaluation. Topical antibiotics can be used as indicated. Treatment with daily total body bathing with chlorhexidine (Hibiclens) and twice daily application of mupirocin (Bactroban) ointment to the anterior nares may also be used.
   
3. Antibiotic treatment should continue at least seven (7) days. If clinical infection has resolved, follow up cultures are not necessary.
   
4. Isolation in a private room is helpful but not necessary. Cohort pairing (another individual known to have MRSA) is acceptable. Gloves and good hand washing are mandatory. A gown should be used when wound contact is anticipated. (This is to prevent contamination of the caregiver's clothing which could then touch other residents and spread infection.) The resident may be transported to common areas (such as showers) provided the wound is covered. Isolation procedures can be terminated after clinical infection has resolved.
   
5. Exudative conjunctivitis not responding to usual treatment may be cultured. Good hand and face washing of resident several times a day is useful along with antibiotics if indicated.

C. Care of individuals with MRSA isolated from the urine

Note: A urine culture routinely obtained is of little therapeutic value in an asymptomatic resident.

1. A urine culture in an asymptomatic resident probably should not be obtained. If the resident is symptomatic, and MRSA is isolated from the urine, the resident should be evaluated for the possibility of sepsis. Cellulitis, pressure sores, carbuncles, and indwelling lines are possible etiologies for such sepsis. MRSA sepsis is generally treated with IV vancomycin, but in certain circumstances can be treated with trimethoprim/sulfa (Septra, Bactrim). Treatment should also include daily bathing with chlorhexidine (Hibiclens) and twice daily application of mupirocin (Bactroban) ointment to the anterior nares for seven (7) days. Standard precautions should be followed. Cultures should be obtained 48 hours after the completion of antibiotics.
2. MRSA isolated from the urine in residents with indwelling foley catheters is a complex clinical problem. This can represent either colonization of the foley catheter, cystitis, or MRSA-sepsis and requires medical scrutiny. Changing the foley catheter is necessary prior to obtaining a culture. The intensity of the medical work up depends upon the residents clinical presentation. If felt to be due to an infection, treatment includes steps listed above.

PART II: Workup for MRSA Epidemics in the LTC facilities

1. An outbreak of MRSA is defined as: three (3) or more cases of clinically significant, facility acquired MRSA occurring in the same general area within a period of seven (7) days.
2. The Medical Director should be notified.
3. If feasible, there should be cohorting of MRSA residents. Staff should not crossover to MRSA negative residents.
4. If there is clinical resolution of the infection after treatment, no reculture is needed to remove from cohort. If there is no clinical resolution of the infection after treatment, the physician (or Medical Director) should evaluate resident prior to release from cohort. Reculture may be needed if obtainable.
5. It is believed that an outbreak is caused by the transmission of infection by staff and a breakdown in the use of standard precautions. Therefore, an intense education program for staff should ensue with rigorous supervision of handwashing, glove use and linen collection. If after these procedures are done and there continues to be clinically significant MRSA infections, an epidemiologist in the state or local health department should be notified.

Part III: Transferring residents with MRSA infection to acute care facilities and their return to the LTC facilities

1. Colonization of an individual with MRSA should not prevent the transfer of that individual between facilities. However, prior notification is strongly recommended.
2. Transfer of an individual from a LTC facilities to the acute care or visa versa is based solely on the individual's clinical status.

Part IV: If a resident (or guardian) refuses treatment

1. It is the right of individuals in LTC facilities to refuse treatment of their particular medical problem.
2. If a resident (or guardian) refuses treatment, their wishes should be respected. It is then the responsibility of the facility to maintain appropriate containment (as mentioned above) to protect staff and other residents.

Part V: General principles and guidelines regarding MRSA

1. MRSA is no more virulent than methicillin-sensitive Staphylococcus aureus.
2. MRSA is transmitted primarily by hands; the role of contaminated objects is over stressed; airborne spread is rare. Persons with a draining lesion or purulent discharge are the most common sources of epidemic spread.
3. MRSA cannot be permanently eradicated from a nursing home. It will be intermittently introduced either from the community in newly admitted residents, employees and visitors or by transfer of residents from hospitals.
4. Treatment is important for the clinically ill person and should be undertaken by the resident's physician.
5. The goal of infection control efforts in the nursing home should be to prevent transmission.
6. Transmission is prevented by ongoing, strict attention to hygiene. In these circumstances, hygiene=hand washing and appropriate use of barriers to keep staff clothing from touching contaminated body fluids, sheets, or railings. Gloves are helpful but they must be removed after contact with each resident or infection will be transmitted by the gloves themselves. Hand washing must be performed after gloves are removed. They should be available in each resident's room. Standard precautions and hygiene present the long term solution to the problem.
7. Maintenance staff should service soap and towel dispensers daily.
8. Culturing asymptomatic residents and staff members or environmental surfaces is not helpful and is discouraged.

Revised August 18, 1997
Original was Approved May 10, 1995

Colorado Medical Directors Association
Colorado Department of Public Health and Environment
Colorado HealthCare Association
Colorado Medical Society
El Paso County Medical Society Long Term Care Committee
University of Colorado Center on Aging
Denver VA Medical Center - Department of Geriatrics
Larimer County Medical Society

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