APIC MRSA Elimination Guideline

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Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital SettingsContact Precautions for MRSACompliance with isolation precautions for patients colonized or infected with MRSA is essential toeliminate transmission of MRSA in the hospital setting. Many studies have documented the transmissionrisk of MRSA and other multidrug-resistant organisms from infected and/or colonized patients, and fromcontaminated equipment and supplies and the environment.Basic Components:The elements of Contact Precautions are well-established for hospital settings and are derived from theCDC Guideline for Isolation Precautions in Hospitals, 1996.In addition to standard precautions:• Place the patient in a private room. When a private room is not available, place the patient in a room with apatient(s) who has active MRSA infection but with no other infection (cohorting). Category IB• Wear clean, non-sterile gloves when entering the room. Change gloves after having contact with infective material(fecal material and wound drainage). Remove gloves before leaving the patient’s room and perform hand hygieneimmediately. After glove removal and hand washing, ensure that hands do not touch potentially contaminatedenvironmental surfaces or items in the patient’s room to avoid transfer of microorganisms to other patients orenvironments. Category IB• Wear a clean, non-sterile gown when entering the room to avoid contamination of clothing by contact with thepatient or environmental surfaces. Remove the gown before leaving the patient’s environment, and ensure thatclothing does not become contaminated by environmental surfaces to avoid transfer of microorganisms to otherpatients or environments. Category IB• Limit the movement and transport of the patient from the room to essential purposes only. If the patient istransported out of the room, take measure to prevent the risk of transmission of MRSA to other patients andenvironmental surfaces or equipment. Category IB• Use dedicated non-critical patient-care equipment while patient is on contact precautions. Adequately clean anddisinfect common equipment that is not dedicated to the patient before use with another patient. Category IBContact precautions are a routine (Tier 1) strategy of the CDC guidance document “Management ofMDRO in Healthcare Settings, 2006” for patients colonized or infected with MRSA. 4,5,6,7Note: The use of a mask for MRSA contact precautions remains controversial. Some hospitals require itfor all MRSA-related isolation (reduce healthcare worker risk of nasal colonization), while other facilitiesrequire it only if the MRSA-positive patient is known to have MRSA infection of the respiratory tract.24ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital SettingsSpecial Considerations: Contact Precautions and Active Surveillance Culture (ASC)The ideal situation for a hospital that is admitting a patient is to know the MRSA status of the patient atthe time of admission. Unfortunately, this is rarely possible unless there are current culture results availableat the time of admission.Hospitals must make decisions regarding room placements of patients who are in high risk groups orwho are candidates for ASC as identified by the MRSA risk assessment. Many factors will have to beconsidered when establishing criteria for the timing of contact precautions:• Are there identified high risk groups from endemic settings (patients from long-term care facilities,institutionalized living environments, etc)?• Are there identified high risk groups based on clinical presentation (e.g. skin and soft tissue infectionsin athletes, veterinary personnel, IV drug users, etc.)• Are ASC screens being done on admission to a clinical unit or service line?• Are ASC screen results available in 24 hours, 48 hours, or longer?• Are private rooms available on all or any units for patients identified by the MRSA risk assessment?Room Placement for Patients Who are Candidates for ASC:There is no “one-size-fits-all” solution for the question of who, how and when to use contact precautionsprior to culture results. When a patient who is not known to have MRSA is admitted to a hospital, thereis very little research regarding how long it takes before the lack of isolation leads to significant risk oftransmission of MRSA. Therefore, hospitals must start with a reasonable approach based on MRSAsurveillance and risk assessment, and adjust the approach if surveillance demonstrates MRSA transmissionproblems. The following are a few examples of possible options for patient placement on admission.1. Use private rooms and contact precautions for all patients from identified high risk groupsper MRSA risk assessment until ASC results are known. Additionally, use private rooms andcontact precautions for all patients who have history of MRSA (“flagged” on admission) andhave not met hospital-specific criteria for discontinuation of contact precautions. Discontinuecontact precautions when MRSA ASC is resulted as negative.2. Use routine room placement assignments for all patients who are candidates for ASC unlessthey have known history of MRSA (“flagged” on admission). Make MRSA culture tests apriority for the laboratory and have positive results alerted immediately to the clinical units.Implement contact precautions as soon as a positive result from ASC or clinical cultureis reported. If the positive patient has a roommate, obtain specimen for ASC from theroommate right away and at the time of discharge.Either of these options, or others that hospitals may develop, will result in patient, resource and staffingconsequences. Before implementation of new processes related to contact precautions for the purpose ofmanagement of MRSA and other MDRO, address any of the following considerations that will apply.ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY 25
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APIC MRSA Elimination Guideline

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