The purpose of this document is to provide guidance about the control of MRSA at Great Ormond Street Hospital (GOSH).
Please note that this is a GOSH clinical guideline and may vary from other external hospital MRSA policies or guidelines.
It is GOSH Trust policy to take all reasonable steps to prevent both infection and the acquisition of potentially pathogenic microorganisms, including antibiotic-resistant microorganisms, such as MRSA, by patients/families or staff. This is undertaken while minimising the disruption of the care of the patients but it is recognised that the application of this policy may impact on the patient's stay in the hospital.
The Infection Prevention and Control (IPC) team is available to discuss patient care if conforming to these guidelines creates problems for any reason.
Note: While this guideline refers to the 'child' throughout, all activities are applicable to young people.
Staphylococcus aureus (S. aureus) is a major human pathogen, responsible for a range of infections including simple skin and soft tissue infection, vascular access and other indwelling device infection, pneumonia, blood stream infection, overwhelming sepsis and death. S. aureus carriage is common, especially in children (15 – 30%) and infection may occur from a strain a child already had before seen for health care, or from a strain acquired in hospital. The majority of S. aureus carriage or infection results from meticillin sensitive S. aureus but MRSA is especially important as a cause of health care associated infection (HCAI) because:
The strains are usually adapted to spread in the health care environment and frequently cause outbreaks if not controlled.
They are resistant to flucloxacillin, and often other commonly used antibiotics, so may not be covered by conventional empiric treatment.
Prevention and control of S. aureus infection relies initially on the implementation of standard infection prevention and control guidelines, especially good hand hygiene, care of vascular access devices and environmental cleanliness. However, because of the risk of treatment failure with unsuspected MRSA and the propensity for rapid cross infection in hospital, additional guidelines are advised for control.
The revised guidelines for the control and prevention of MRSA in healthcare facilities (Coia et al, 2006) clearly indicate that infection control measures do have an impact on controlling the spread of MRSA. These, and other evidence, show:
The key points are:
- Implementation of screening policy (including staff at start of employment) to identify MRSA carriage and cross-infection, including procedures to notify children/young people, their carers and staff of the MRSA results.
- Identification, and ‘alerting’, of MRSA-positive patients (who have been detected through screening patients on admission or at pre-admission clinics, or from routine diagnostic testing) followed by implementation of additional control steps shown below: -
- Implementation of isolation precautions, the wearing of protective clothing and thorough hand washing/sanitising before and after contact with patients and the use of cubicles where appropriate (with risk assessment for individual locations)
- Maintaining a clean environment – additional cleaning is required proportionate to the risk assessment of environmental contamination for each individual
- Investigation of MRSA acquisition to detect and eliminate hidden reservoirs.
- MRSA decolonisation in selected patients will help to reduce the spread of MRSA in the hospital and MRSA infections in those at increased risk of S. aureus infection.
- Modification of antibiotic prophylaxis to include cover for MRSA when given to cover S. aureus infection, with an efficient pre-operative MRSA screening programme.
- Maintaining correct ventilation to reduce airborne transmission
At GOSH, patients colonised/infected with antibiotic-resistant organisms (including MRSA) are alerted on PIMS by the IPC team (see GOSH clinical guideline Microbiological screening of patients on admission) to assist in the implementation of these actions.
- Infection with MRSA: harm resulting from the presence of MRSA or it’s toxins
- Carriage of MRSA: the presence of MRSA on a person without infection. Carriage may be transient, without multiplication e.g. on hands before washing or long term, when it is called colonisation.
- Colonisation of MRSA: the presence and multiplication of MRSA at a body site without infection.
Human reservoir – individuals with infection, transient carriage or colonisation with MRSA may serve as a reservoir for ongoing transmission.
MRSA control actions
MRSA screening of patients
When to undertake MRSA screening:
The rationale for the GOSH MRSA screening policy is detailed in the GOSH clinical guideline Microbiological screening of patients on admission, after consideration of national advice including the updated Department of Health policy (Department of Health expert advisory committee on Antimicrobial Resistance and Healthcare Associated Infection, 2014).
All inpatients should be screened (with a nose and throat swab) in the 30 days prior to admission or within the first 24 hours of admission and then at least every 30 days during admission (except in areas with local policy for more frequent screening e.g. NICU and PICU). Patients already known to be colonised with MRSA should have a full MRSA screen (nose, throat, hairline, axillae, groin/perineum, any skin lesions and sites of indwelling devices) taken on admission. The swabs need to be sent to the microbiology laboratory to be tested for MRSA (Department of Health, 2006 and 2014).
The reasons for taking MRSA swabs must be explained to the parents/carers and child/young person and verbal consent obtained. If permission is refused, this must be recorded in the patient’s medical/nursing records.
Patients with epidermolysis bullosa do not need to have a nose or throat swab taken as this may cause mucosal damage.
They should still be screened on non-mucosal sites such as hairline, axillae, groin/perineum and sites of indwelling devices.
How to take an MRSA screen:
Procedure for nose swab:
- Use ‘charcoal’ bacteriology swabs.
- If the nose is dry, moisten the swab with sterile 0.9% saline solution beforehand without touching the tip of the swab.
- Insert the swab into the anterior nares and direct it up into the tip of the nose and gently rotate. Both nares should be swabbed using the same swab to obtain adequate material.
- Return the swab to the container with the transport medium.
- The outside of the nostrils may be rubbed after the procedure to alleviate the unpleasant sensation of swabbing.
Procedure for throat swab:
- Use ‘charcoal’ bacteriology swabs.
- Place the child in a position with a good light source. This will ensure maximum visibility of the tonsillar bed.
- Either depress the tongue with a spatula or ask the child to say “aahh”. The procedure is likely to cause gagging and the tongue will move to the roof of the mouth. This can prevent accurate sampling, therefore it is important to quickly but gently rub the swab over the tonsillar fossa (tonsillar bed).
- Care should be taken not to contaminate the swab by contact with the tongue or the oral mucosa on removal.
- Return swab to the container with transport medium.
Action required following detection of a positive MRSA test:
If the result is MRSA positive a member of the IPC team will inform the clinical team in charge of the care of the patient. The team will be advised to isolate the patient in contact precautions and to take additional swabs as listed below:
- nose and throat
- umbilicus in neonates
- sites of indwelling devices (e.g. tracheostomy, gastrostomy, central venous catheter)
- skin lesions such as wounds, eczema, etc.
The IPC team will place an alert on PIMS with the following advice – ‘Isolate and send a full MRSA screen on admission/appointment’.
A repeat set of swabs should be taken on each admission to hospital.
If the patient is a long-term patient then repeat swabs should be taken monthly while in hospital, in order to monitor the degree of colonisation.
It is the responsibility of the clinical team to inform the patient and parents/carers of the screening result and to ensure they have received the ‘GOSH MRSA information leaflet’ (Appendix 1).
If the patient is not an inpatient at the time when the screening results becomes available, then a member of the IPC team will email the clinical team identified as responsible for the patient's care when the swab was taken. This includes the consultant named on the request form, ward sister or clinical nurse specialist depending on the department/specialty where the patient was seen.
The IPC team will also write to the parents/carers of the patient and forward the GOSH MRSA information leaflet to them for advice. A copy of the letter will also be sent to the patient’s GP. If the patient is scheduled to undergo elective surgery, it may be appropriate for the clinical team to contact the IPC team to discuss decolonisation of the patient (see Appendix 2 for the decolonisation protocol). Individual specialties should have a local policy of need for this.
The IPC team will place an alert on PIMS with the following advice – ‘Isolate and send a MRSA screen on admission/appointment’ – and the clinical team should follow the isolation policy on admission.
Sharing the information within the Trust and other healthcare facilities
It is important that the patient’s MRSA status is communicated on the discharge summary to the GP and other healthcare facilities. This must also be communicated to wards/departments at GOSH during intra-hospital transfers or transfers for investigations to other departments.
If the clinical team is made aware that patient who is admitted/transferred to a GOSH ward/department from another healthcare facility, and is known to be colonised with MRSA, the IPC team must be informed. The IPC team will then alert the patient on PIMS, ask the clinical team to take a full MRSA screen and to isolate the patient.
What does an MRSA positive result mean for the patient?
The patient should not have their clinical care compromised due to a positive MRSA result; the child’s/young person’s clinical care should take precedence.
Cancelling surgery or investigations for patients simply because they are MRSA positive is not acceptable. Individual cases should be discussed with the IPC team so that a risk assessment can be undertaken if necessary. Disruption of patient flow may occur if there are insufficient resources to accommodate all patients due to cleaning requirements, but allocation should be on clinical requirements.
In an attempt to reduce disruption to patient flow, Theatres, Angiography, Interventional Radiology, MRI, CT and Ultrasound have specific advice developed in conjunction with the IPC team to care for these patients in these departments, including specific advice on cleaning, which WILL differ from inpatient ward areas. This advice was developed to avoid or reduce the number of patients who had their procedures cancelled and may need explaining to patients/parents.
Information for parents/carers and those with parental responsibility
The child's nurse/doctor must inform parents of the colonisation/infection status of the child and ensure the parents or child/young person, if appropriate, is given the GOSH MRSA information leaflet which is available on the GOSHweb intranet, (Appendix 1).
Criteria for removing an MRSA alert on PIMS
The clinical team responsible for the care of the patient should contact the IPC team once a patient has had three complete sets (nose, throat, hairline, axillae, groin/perineum, any skin lesions and sites of indwelling devices) of swabs negative for MRSA, taken at least a week apart and the last five to six months from the last positive, 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
- no indwelling devices or skin lesions
- not immunosuppressed
If the above criteria are fulfilled, then the IPC team will remove the alert from PIMS.
Laboratory processing of MRSA screens and action on detecting a first isolate
The laboratory staff assess the clinical details and the request on the laboratory form, as these influence the laboratory investigation. The basic clinical condition and the reasons for the request should be recorded on the laboratory form.
The laboratory procedure for MRSA will exclude MRSA at 48 hours after receipt of the specimen (if negative), but confirmed positive cultures in new cases usually take between 72-96 hours. Preliminary results may be communicated earlier.
A new isolate will be sent to the Public Health England S. aureus reference laboratory for typing. The result of this may take some time, but will be compared to other first isolates to assist in determining source.
Investigation of a new MRSA cases
Case review and outbreak assessment – for all first MRSA detections
Instructions for screening patients, parents or staff following detection of a new case/during an outbreak situation are initiated by the IPC team.
Every acquisition of MRSA is assessed by the IPC team to determine the likely source. Where it is considered to be hospital acquired at GOSH, the following will be considered:
- the likely extent of the transmission
- the likely source and if it may still exist
- the risk to other patients and the need to close the ward to further admissions
Environmental or staff screening will be initiated by the IPC team on a case by case basis. If staff are considered a possible source, screening will be undertaken. Sites sampled are nose, throat and any skin lesions. These should be taken, where possible, on arrival at work. Actions to be taken should a staff member be found MRSA positive are given under the MRSA screening of staff section below.
Additional investigations for MRSA bacteraemia
Whether a first detection or not, all cases of MRSA bacteraemia are investigated in detail. Currently this will be performed by following the nationally mandated Post Infection Review (PIR) approach. A request will be sent out by the IPC team requesting the clinical team to arrange a PIR meeting, including the template to be followed. The IPC team must be invited to attend this RCA meeting.
The results of the PIR should be reported to the Director of Infection Prevention and Control (DIPC) within five days of the clinical team being informed of the case.
Isolation of MRSA positive patients
Patients who are colonised with MRSA will contaminate the environment and airborne particles carrying staphylococci may be widely disseminated. The aim is to isolate all patients with MRSA, but the degree of environmental contamination will vary from case to case, and precautions may be varied on risk assessment in individual cases. Please see Appendix 3 for an example of a nursing care plan for a patient with MRSA.
Isolation should consist of:
- Placement in a single cubicle (negative pressure, neutral pressure or positive pressure ventilated lobby source and protective isolation cubicle) with the door closed and en-suite bathroom. A red 'Contact Precautions' door sign must be placed outside the cubicle door.
- Where a single cubicle is not available, individual risk assessment should be performed and isolation may be undertaken in a ward bed space if environmental contamination outside the bed space is minimal and access still controlled.
- Hand-washing/hand-sanitising facilities should be available at the patient’s bedside.
- Staff must be familiar with the GOSH Standard and Isolation Precautions Policy.
- Personal protective equipment must be available and used.
- Patients colonised with MRSA, especially those who are skin shedders, should not be moved to other wards unless a risk assessment has been carried out, along with consultation with the IPC team.
- Where possible, the nurse/HCA caring for a patient with MRSA designated as high risk, e.g. known skin shedder, should not attend other high risk patients (e.g. immuno-suppressed, patients with non-intact skin, those in ICU or neonates) during the same shift.
Transfers to other hospitals/units/community settings
All healthcare facilities are responsible for informing the receiving hospital/unit if the child is MRSA positive. This is the responsibility of the lead clinician responsible for the patient. The IPC team at GOSH will liaise with the IPC team of the transferring hospital if appropriate.
The lead clinician must ensure the GP and parents are informed.
If the patient is discharged to a hospice or residential home, the appropriate staff should be informed in advance. Carriage of MRSA is not a contraindication for transfer to other units.
Deceased patients should be handled using standard infection control precautions.
Environmental cleaning in normal care and outbreak control
Instruments and equipment (e.g. stethoscopes, sphygmomanometers with cuffs, monitors, pens, scissors etc.) should be designated to the patient with MRSA and, on discharge or transfer, cleaned with sanitising wipes (e.g. Clinell® ) or according to manufacturer’s instructions.
Items such as IV trays, food trays, patient bedside testing equipment (e.g. glucometer, blood tracking device) and tablet computers (e.g. IPads) should be decontaminated with sanitising wipes (e.g. Clinell®) prior to be taken out of the room/bed space.
Items that cannot be cleaned (e.g. folders or paper charts) should not be taken into the room.
On discharge or transfer of the patient the cubicle will require a level 2 clean. If the patient is alerted on PIMS as ‘highly resistant’ or as a ‘skin shedder’ then a level four clean is required. Please refer to the ‘Infection Cleans Protocol’ on GOSHweb for further information. Specific policies have been designed for some areas, e.g. Safari outpatients, or Theatres/X-ray, and these should be followed.
Following a detected cross-transmission, additional environmental cleaning may be required and will be arranged during outbreak control meeting. There will be requirements for additional resources for the ward at this time.
Decolonisation of MRSA positive patient
Rational for choosing decolonisation
- Staphylococcus aureus is adapted for long-term carriage in humans (with around a third of us colonised at any one time) and is a dynamic state, with constant re-exposure. Eradication of the carriage of MRSA, especially at sites other than the nose, may fail, may have side effects and may have no benefit for the individual patient if not at increased risk of Staphylococcus aureus infection.
- While MRSA eradication may be difficult, MRSA load reduction may be achieved with timely use of the decolonisation protocol.
- A risk assessment should be made in consultation with the IPC team as to whether the benefits outweigh the risks. It may be appropriate to apply the protocol to children prior to surgery to reduce colonisation and therefore the risk of infection. This should be discussed with the child/young person and/or parents/carers.
- MRSA load reduction in specific surgical specialties:
It is recommended that individual surgical specialties should have their own protocols for the identification of patients that would benefit from decolonisation. National adult MRSA policy recommends decolonisation before surgery in all cases, however the benefit is likely to be low in those specialties where S. aureus infection is unlikely e.g. those surgeries where S. aureus infection is considered unlikely and controlled by normal surgical care pathway without the use of specific antibiotic prophylaxis. If surgeons consider MRSA decolonisation necessary they should also consider whether they wish to recommend decolonisation for MSSA. Regardless of application of decolonisation, if antibiotic prophylaxis is used to prevent S. aureus infection, it should be modified to cover MRSA in known colonised children, and pre-operative MRSA screening should be arranged.
- Caution must be taken when decolonising neonates or children with allergies. Other decolonisation agents may be used in consultation with pharmacy. If the child has indwelling devices or stomas then application may prove difficult.
- If systemic treatment is considered, then consultation with the consultant microbiologist must take place. Some systemic agents which may be used have severe side effects e.g. Rifampicin.
Agents used at different sites:
Mupirocin 2% (Bactroban Nasal®) in a paraffin base should be applied with a cotton wool bud to the inner surface of each nostril three times a day for five days.
Prolonged use of Mupirocin 2% (Bactroban Nasal®) (more than seven days) or repeated courses (more than two in the same hospital admission episode) should be avoided as this may increase resistance (Gemmell et al., 2006) however the IPC may advise in specific circumstances.
Patients carrying MRSA in any site should bathe/shower daily for five days with an antiseptic detergent such as:
- Chlorhexidine gluconate 4% – Hibiscrub® – GOSH first choice
- Octenidine hydrochloride – Octenisan® - first choice in neonates
- Povidone-iodine 7.5% – Betadine®
The skin should be moistened and the undiluted antiseptic solution applied thoroughly to all parts of the skin before rinsing in the bath or shower. Do NOT dilute in bath water as the concentration is insufficient. A disposable sponge or flannel should be used to apply the antiseptic solution.
Special attention should be paid to sites such as axillae, groin, perineum and buttock areas and other skin folds.
In neonates, the efficacy of this treatment is unknown.
The antiseptic solutions are drying to the skin and can cause allergic reactions.
Mupirocin 2% maybe used for seven to 10 days. It may be applied to small lesions but not large areas, such as burns or indwelling plastic devices. Treatment should not extend beyond 10 days as resistance to Mupirocin may occur (Gemmell et al, 2006).
Dressings containing povidone-iodine or chlorhexidine gluconate are unlikely to eradicate MRSA, but may reduce the numbers of organisms.
The hair should be washed daily for 5 days, if possible, with one of the antiseptic solutions. Ordinary shampoo/conditioner can be used after the treatment if desired, as the antiseptic solutions are drying to the hair.
Staphylococcus survives on skin scales which are trapped in clothing.
- Washable clothes should be changed daily and washed at 60◦C (if possible) with laundry detergent.
- Bedding, clothing, and towels should be changed daily (whilst in hospital).
Creams, lotions and other cosmetics may become contaminated with Staphylococcus and should be single patient use.
MRSA Re-screening after decolonisation protocol
- If assessment of immediate protocol efficacy is required the first screen should not be performed until at least 48 hours after completion of this regimen.
- A repeat set of swabs (nose, throat, axillae, perineum/groin, skin lesions and sites of indwelling devices) should be taken. Patients should then receive a full set of screening swabs on each admission to hospital to aid in the assessment of risk and removal of alert (in the future).
- For long-term hospitalised patients repeat monthly.
- To confirm eradication in staff, a further two sets of screens 48 hours apart, are required (see section on 'MRSA screening and management of MRSA positive staff' below)
Policy for failed topical decolonisation protocol (where evidence of de-colonisation is required)
- Attention should be paid to potential causes which may be treated, e.g. skin or sinus disease or specific colonised sites. These may require referral to the appropriate medical specialty.
- Review antibiotic sensitivities and if Mupirocin sensitive, repeat protocol and re-screen.
- If reduced antibiotic sensitivity to Mupirocin, attempt topical protocol with alternative anti-staphylococcal nasal agent and re-screen.
- If still positive after repeat topical protocol, discuss systemic protocols with Microbiology.
MRSA screening and management of MRSA positive staff
Staff may be found to be MRSA positive during pre-employment screening process, during investigation of a hospital transmission or from clinical investigation of infection. Management in these situations is described below.
Detection and management of staff who are found to be MRSA positive through the pre-employment health interview (Occupational Health Department – OHD)
All offers of employment are conditional upon completion of satisfactory pre-employment health-checks. As part of this process, all new recruits should be assessed according to the Occupational Health (OH) pre-employment health interview.
Those who have previously been colonised with MRSA should either provide evidence (see below – excerpt from the GOSH pre-employment questionnaire) that they are no longer carrying MRSA before starting employment or undergo MRSA screening at GOSH.
If a new recruit is found to be MRSA positive during this pre-employment screen or pre-employment checks, they must arrange to undergo decolonisation and screening (or re-screening) as per protocol before the offer of employment can be confirmed by GOSH or accepted by the new recruit. This decolonisation and screening can be arranged through their current OHD if employed elsewhere or through the GOSH OHD if not.
If, following treatment and screening (or re-screening), the new recruit is found to be MRSA positive and the ongoing risk of transmission remains, the conditional offer of employment may be withdrawn.
Management of staff who are found to be MRSA positive during employment
Staff who are found to be MRSA positive after screening during an outbreak or if identified during an investigation of an infection or otherwise, may be a reservoir for cross infection and a potential risk to patient wellbeing. However, they may also be an asymptomatic carrier not associated with any transmission. Further investigation is required and when found to be positive they will be informed and sent to Occupational Health where they will receive individual information.
An individual risk assessment will be carried out for each case, in consultation with IPC. This will be influenced by
- the patient group worked with
- any evidence of skin lesions or infection
- by subsequent MRSA typing results and evidence, or not, of the staff member acting as a reservoir.
If the staff member is considered a possible source for transmission, their manager must be informed. The staff member may be asked to either take authorised absence for infection control purposes or non-clinical contact duties may be recommended. They will be required to submit a full set of screening swabs and undergo the decolonisation protocol and re-screening as described below.
They must be cleared by OHD before returning to work.
Topical decolonisation protocol for staff
A full set of screening swabs should be taken prior to commencing the MRSA decolonisation protocol to estimate the extent of colonisation. See Appendix 2 for current the MRSA decolonisation protocol.
Following the protocol a full set of screening swabs should be taken 48 hours after completion and thereafter two further sets each 48 hours apart (three full sets in total post protocol).
Policy for failed topical decolonisation protocol for staff and potential re-deployment
- Attention should be paid to potential causes which may be treated e.g. skin or sinus disease or specific colonised sites. These may require referral to the appropriate medical specialty.
- Review antibiotic sensitivities and if Mupirocin sensitive – repeat protocol and re-screen.
- If reduced antibiotic sensitivity to Mupirocin attempt topical protocol with alternative anti-staphylococcal nasal agent and re-screen.
If still positive after repeat topical protocol, discuss systemic protocols with Microbiology. Staff member must give consent to treatment.
If still positive after systemic treatment a full risk assessment should be undertaken with IPC, the staff members manager, OH and the staff member. If ongoing risk of transmission remains and patient safety is compromised, the staff member would be referred to HR to consider re-deployment.
MRSA specific antimicrobial prophylaxis
MRSA prophylaxis may be considered in specific surgical specialties and individual specialties should have specific protocols. In those surgeries where S. aureus infection is considered unlikely and controlled by a normal surgical care pathway without the use of specific antibiotic prophylaxis, additional MRSA prophylaxis is not necessary. If surgeons consider S. aureus antibiotic prophylaxis is advised to prevent S. aureus infection, it should be modified to cover MRSA in known colonised children, and pre-operative MRSA screening should be arranged so this policy can be implemented.
See GOSHweb pharmacy website for the GOSH Antibiotic Policy and antibiotic prophylaxis protocols that have modified advice for MRSA positive patients.
COIA, J.E., DUCKWORTH, G.J., EDWARDS, D.I., FARRINGTON, M., FRY, C., Humphreys, H., Mallaghan, C., Tucker, D.R. (2006) Guidelines for the control and prevention of methicillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. Journal of Hospital Infection, 64(1): 97-98.
DEPARTMENT OF HEALTH EXPERT ADVISORY COMMITTEE ON ANTIMICROBIAL RESISTANCE AND HEALTHCARE ASSOCIATED INFECTION (ARHAI) (2014) Implementation of modified admission MRSA screening guidance for NHS. [Accessed 26 January 2016].
GEMMELL, C.G., EDWARDS, D.I., FRAISE, A.P., Gould, F.K., Ridgway, G.L., Warren, R. E. (2006) Guidelines for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the UK. J Antimicrob Chemother, 57 (4): 589 608.
DEPARTMENT OF HEALTH (2006) Screening for Methicillin-resistant Staphylococcus aureus (MRSA) colonisation: a strategy for NHS trusts – a summary of best practice. London: Department of Health.
NICE PUBLIC HEALTH GUIDANCE (2011) PH36: Prevention and control of healthcare-associated infections: Quality improvement guide [Accessed 26 January 2016].