APIC MRSA Elimination Guideline

Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital SettingsIn Tier 2, when intensified MRSA control efforts are necessary, decolonization may be considered as partof a control program for a limited time and for select colonized patients or healthcare workers on a caseby-casebasis after consultation with infectious disease experts.If a decolonization strategy is implemented in a hospital, monitors must be put in place to detect emergingmupirocin. Laboratory protocols for detecting mupirocin resistance must be developed and used with allStaphylococcus aureus isolates.Infection Prevention and Control Strategy Related to Healthcare Worker DecolonizationHealthcare worker decolonization is indicated only as a prevention and control intervention when a healthcare worker is chronically colonized with MRSA and has been epidemiologically implicated in ongoingtransmission of MRSA to patients. See section V.B.9. “Decolonization” in CDC/HICPAC “Managementof Multidrug-Resistant Organisms in Healthcare Settings, 2006.”MRSA Decolonization RegimensIn a hospital setting, decolonization may be attempted when a patient will benefit clinically (as determinedby expert medical opinion), or as an intervention when there is an identified MRSA transmission problemin a patient unit or patient population. Therefore, a standardized regimen for decolonization should beestablished. Although optimal regimens have not yet been definitively established, expert opinion is that anMRSA decolonization regimen should include:• Nasal decolonization with intranasal topical mupirocin (BID for 5 days) and/or,• Oral antimicrobials (usually rifampin and trimethoprim-sulfamethoxazole or rifampin anddoxycycline or rifampin and minocycline)• Skin antisepsis (e.g., chlorhexidine baths) concurrently with the decolonization regimenNotes:1. Rifampin should never be used singly to treat MRSA infection or colonization.2. Recent studies from Sweden and Switzerland indicate that the throat may serve as a reservoirof MRSA and, therefore, may confound attempts to eradicate MRSA in any colonized patient.Surveillance During the Intervention PeriodDuring an intervention that includes decolonization, both MRSA transmission rates and Staphylococcusaureus mupirocin resistance must be monitored. The effectiveness of the decolonization intervention willdepend on the ability to eliminate MRSA transmission while avoiding mupirocin resistance.Discontinue the routine use of mupirocin nasal decolonization when MRSA transmission rates decreasesignificantly and consistently over time, or when mupirocin resistance and/or decolonization failuresincrease. Judicious use of mupirocin for decolonization will help to insure continued efficacy when it ismedically indicated for patient management.GuidelinesSiegel JD, Rhineheart E, Jackson M, Linda C; Healthcare Infection Control Practices AdvisoryCommittee. Management of multidrug-resistant organisms in healthcare settings, 2006.” Available athttp://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf. Accessed February 27, 2007.48ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY