Microbiological screening of patients on admission (including MRSA)

This guideline provides guidance on the microbiological screening of patients on admission (including MRSA) at Great Ormond Street Hospital (GOSH).

Note: While this guideline refers to the 'child' throughout, all activities are applicable to young people.

 
Admission screening
 

  • Patients should be screened for MRSA (nose and throat swab) within 24 hours of admission and every 30 days while inpatients.

  • Patients already alerted on PiMS for MRSA require a full screen which includes: nose, throat, hairline, axilla, groin/perineum and any skin lesions within 24 hours of admission and every 30 days while inpatients.

  • A stool sample has to be sent on admission for all patients and every 30 days while inpatients. The sample will be screened for gentamicin-resistant gram-negative organisms. 

Introduction

MRSA screening compliance statement

The Department of Health (DH) strategy for NHS Trusts regarding screening for MRSA (Meticillin resistant staphylococcus aureus) colonisation, identifies the need to screen all elective admissions either before or on admission, unless the patient falls into groups who should not be routinely screened. The recommended groups who should not be screened include children/paediatrics, unless they are already in a high-risk group. There is no additional guidance on children.

Great Ormond Street Hospital for Children NHS Foundation Trust recognises that MRSA, while relatively uncommon in children, may be found in those admitted in any speciality and introduced universal MRSA admission screening in the 1990s. The local policy is contained in the admission screening document and we are compliant with the standard. 

Screening of patients on admission is performed for two reasons:

1. To detect the carriage of potentially pathogenic micro-organisms which may subsequently give rise to infection in certain circumstances, for example prolonged ventilation on the Intensive Care Unit (ICU) or surgical wound infection. The collection of admission screening data aids:

  • antibiotic prophylaxis policy

  • subsequent empirical antibiotic therapy

  • discussion with the Infection Prevention & Control Team (IPCT) on the use of topical decolonisation therapy

2.To detect the carriage of MRSA and other antibiotic-resistant organisms. These organisms can be passed from patient to patient and the IPCT is committed to reducing the incidence of acquisition by children in this Trust. The Trust’s policy is to screen all children at pre-admission visits or on admission for these organisms to facilitate the initiation of infection prevention and control procedures. 

Background

Compliance with the NHS strategy for Screening for MRSA colonisation

The NHS strategy recommends universal screening of admissions except in children, unless they are in a high-risk group. National reporting of total admissions and total MRSA screens is reported monthly as required. 

However, GOSH will continue with its current universal screening policy of all elective and emergency admissions. If screened in a pre-admission clinic within 30 days of admission, repeat screening need not occur on admission unless the child has attended another healthcare setting. Note: any symptomatic illness must be investigated appropriately.

Previous Trust surveillance has shown a high-risk group for MRSA transmission to be in the ICU, where 100 per cent admission screening is the target. This is to be fed back monthly to the unit. Compliance for screening in other areas is monitored monthly for the whole Trust. For inpatient admissions the target is 80 per cent compliance.

Diagnostic samples 

Patients should be screened for MRSA (nose and throat swab) within 24 hours of admission and then every 30 days while inpatients. Patients already alerted on PIMS for MRSA require a full screen which includes: nose, throat, hairline, axilla, groin/perineum and any skin lesions on admission and every 30 days while inpatients.

Stool specimens should be collected as soon as possible after admission and every 30 days while inpatients.

If this is outside normal laboratory hours the specimens should be taken and sent the following morning. The on-call biomedical scientist should not be bleeped for routine screening samples.

For further guidance see our clinical guideline on specimen collection.

Any child with symptoms should receive an appropriate microbiological specimen. Please ensure the laboratory form contains relevant clinical details so that this is performed. Specimens without details may only be routine screened for antibiotic-resistant organisms. 

Routine screen

All nose and throat swabs will be screened for MRSA and all stools for antibiotic-resistant gram-negative organisms. 

Results:

  • nose/throat (N/T) swab – MRSA detected or not detected
  • stool screen: gentamicin resistant, coliform detected/not detected

Enhanced screening (1)

Will be performed on the N/T swab for beta haemolytic streptococci (BHS) (eg Group A strep) and any Staphylococcus aureus (S. aureus) on patients undergoing ENT, maxillofacial and plastic surgery. 

Results:

  • MRSA detected or not detected
  • beta haemolytic strep and S. aureus detected or not detected

Enhanced screening (2)

The presence of any potentially pathogenic micro-organisms will be performed on N/T swabs from admissions to the Intensive Care Units (PICU, CICU and NICU) and on any admission less than three months of age.

Results:

  • MRSA detected or not detected
  • plus additional results depending on culture

If detected, reports on other S. aureus, BHS, predominant coliforms, Pseudomonas aeruginosa, heavy growths of Haemophilus influenzae, Streptococcus pneumoniae and other species will be produced if in pure heavy growth.

Sensitivity data may be provided but this does not imply treatment is indicated.

Please remember if a throat swab is being sent for specific investigations, this must be indicated on the clinical details.

Communication of results

Current inpatients: the clinical team is informed by the microbiologist/IPCT. The clinical team must inform the parents/child immediately.

Patients discharged or outpatients: the clinical team is informed by the microbiologist/IPCT. The clinical team are responsible for informing the parents/child. The IPCT will send an email to the clinician requesting confirmation of the process.

Blood borne viruses (hepatitis B and C, HIV)

The following screening is performed:

  • children receiving renal dialysis – hepatitis B and C
  • pre-treatment of children with leukaemia – hepatitis B and C, HIV
  • children with haemophilia who go on treatment – hepatitis B and C, HIV
  • prior to transplantation (renal, heart, heart/lung, BMT) – hepatitis B and C, HIV
  • inoculation injury donor – hepatitis B and C, HIV 

PiMS biohazard alerts

The IPCT is responsible for alerting and removing the biohazard alerts on PiMS. 

Removal of the alert does not remove the red alert indicator on PiMS printed request forms. Therefore, please check that alert is current for all patients.

  • Aim: to alert all health care workers involved in the care of individual patients that important infection control information is available.

  • Method: a PiMS biohazard alert will be put on any child’s record who is found to be colonised with a significant antibiotic-resistant organism. 

  • Outcome: the presence of these organisms requires the initiation of specific infection prevention and control procedures. Any issues should be discussed with the IPCT.

Biohazard alerts are put on and taken off PiMS by the IPCT.

The following organisms are alerted: 

MRSA

  • All patients with MRSA must have an alert.
  • Comment on screen: 'Isolate and send full screen – nose, throat, hairline, axillae, groin/perineum, skin lesions'. 
  • For further information see the clinical guideline: Control of Methicillin-resistant Staphylococcus aureus
  • De-tagging – detailed in the above policy and then discuss with IPCT. 
  • Patients with particular identified transmissible MRSA strains will have additional comments regarding risk and environmental cleaning and screening.

Gram-negative resistant organisms

All patients with the following antibiotic-resistant patterns for isolates of coliforms (eg E.coli, Klebsiella, Enterobacter, Serratia) and Pseudomonas aeruginosa must have a 'Gram-negative antibiotic-resistant organism' alert:

  • Gentamicin R plus at least one other: 
    • Amikacin R 
    • Ciprofloxacin R
    • Ceftazidime R
    • Piptazobactam R 
  • Amikacin R coliforms and Pseudomonaus aeruginosa
  • transmissible carbapenemase-carrying organisms
  • Meropenem and Imipenem R coliforms 
  • other multi-resistant isolates may be alerted by IPCT

Note: Meropenem and Imipenem R not due to carbapenemase in Pseudomonas aeruginosa are not alerted.  

Comments on screen: 'Isolate and send stool on each admission'.

De-tagging: The clinical team responsible for the care of the patient should contact the IPCT once a patient meets the following criteria: 

  • The patient has not received antibiotics in the last six months (treatment or prophylaxis).
  • The patient has three negative stool specimens taken one week apart, the last sample must be in or after the fifth month of the period where no antibiotics were given. If the multi-drug resistant organism was isolated from another area or sample, such as urine or sputum, then three specimens of urine or sputum would need to be negative, as well as three stool samples.
  • not immunosuppressed.

If the above criteria are fulfilled, then the IPCT will remove the alert from PiMS.

Certain patients with gram-negative organisms carrying resistance genes will have additional comments eg patients colonised with carbapenemase-producing enterobacteriaceae will also have the comment: ‘Highly resistant’ followed by appropriate advice on cleaning and screening the environment.

Patients with cystic fibrosis that have Burkholderia cepacia will be alerted on PiMS with the comment that they require isolation form other cystic fibrosis patients.  

Vancomycin-resistant enterococci (VRE) 

All patients with VRE must be alerted on PiMS.
Comments on screen: 'Isolate and send stool or urine for VRE.' 

De-tagging: The clinical team responsible for the care of the patient should contact the IPCT once a patient has had three negative stool or urine samples taken at least a week apart and five to six months from the last positive sample and the child has also:

  • not received antibiotics in the last six months. 
  • not been an inpatient in (any) hospital during the last six months. 
  • not immunosuppressed.

If the above criteria are fulfilled, then the IPCT will remove the alert from PiMS. 

Patients who are alerted with individualised precautions 

These patients may have a series of clear specimen, but do not currently meet the criteria for removal of the PiMS alert as outlined above. The clinical team responsible for the care of the patient can contact the IPCT with the request to consider a modification of the isolation requirements for this patient. The risk assessment will be based on the age of the patient, mobility and screening results. The IPCT will ensure that a copy of the risk assessment is available in the patient’s notes and that an additional copy is given to the parents/carers of the patient.

Comments on screen: 'See risk assessment in patient notes or contact the IPCT'. 

References

Reference 1: 
DEPARTMENT OF HEALTH (DH) (2006) Saving lives: Screening for Meticillin-resistant Staphylococcus aureus colonisation; A Strategy for NHS Trusts: Summary of best practice. [Accessed 14 August 2013].

Reference 2:
DEPARTMENT OF HEALTH (DH) (2008) Screening for Meticillin-resistant Staphylococcus aureus. [Accessed 14 August 2013].

Reference 3: 
NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (NICE) (2011) PH36 Prevention and control of healthcare-associated infections: guidance. [Accessed 14 August 2013].

Document control information

Lead Author(s)

Helen Dunn, Lead Nurse, Infection Prevention & Control

Additional Author(s)

John Hartley, Consultant Microbiologist and Director of Infection Prevention and Control, Infection Prevention & Control Barbara Brekle, Deputy Lead Nurse, Infection Prevention & Control

Document owner(s)

Helen Dunn, Lead Nurse, Infection Prevention & Control

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
01 May 2002
Date approved: 
11 December 2014
Review schedule: 
Three years
Next review: 
11 December 2018
Document version: 
4.0
Previous version: 
3.1