Multi-resistant Staphylococcus aureus – MRSA€¦ · MRSA, short for methicillin- or multi-resistant Staphylococcus aureus, plays the most important role. The Scottish surgeon Sir

BODE–SCIENCE–COMPETENCE

Clinical importance, pathogenic profile,hygiene management

Multi-resistant Staphylococcus aureus

– MRSA

A company of the HARTMANN GROUP

2

Background

Contents:

Background 2

Economic Consequences 4

Glossary 5

Pathogenic Profile 6

Transmission Paths 10

Basic Hygiene 11

Hand Disinfection 12

Screening 13

MRSA Hygiene Management 14

Methicillin-resistant Staphylococcus aureus(MRSA) poses an increasing challenge to the infec-tion control community due to several reasons: thespread of nosocomial multi-resistant strains andthe emergence of less resistant PVL-positivestrains in the community which will eventually alsoaffect hospitalised patients. The major problem ofnosocomial MRSA is the restriction of therapeuticoptions – the major problem of community-acquired MRSA the increased invasiveness. Anypreventable infection triggered by MRSA causesunnecessary, potentially severe personal sufferingand increases treatment costs dramatically.

Hence, whenever possible the transfer of theseemerging pathogens in healthcare facilities shouldbe avoided. But what is necessary to control thespread of MRSA?

Appropriate hand hygiene using alcohol-basedhand rubs is probably the most important measureto control the spread of MRSA. Any initiative toimprove compliance with hand hygiene practiceswill also help reduce the transmission of MRSAbetween patients and consequently the incidenceof MRSA infection in hospitals. And – as outlined inthis brochure – there are many other measures thatcan contribute to control the spread of MRSA.

Less transmission of MRSA in hospitals will helppreserve the valuable antibiotics for a little bit longer – antibiotics that are desperately needed for all the unpreventable bacterial infections. Withefficient infection control strategies all of us canhave a share in maintaining antibiotics as long aspossible. In this respect MRSA is a good example.

Prof. Dr. Günter Kampf 1) 2), MD, PhDconsultant hospital epidemiologist1) BODE Chemie GmbH,

Scientific Affairs.2) Institut für Hygiene und

Umweltmedizin, Ernst-Moritz-Arndt Universität Greifswald.


3

MRSA – on the riseThe prevalence of infections with antibiotic-resistant microorganisms in healthcare facilities is assu-ming alarming proportions worldwide. MRSA, short for methicillin- or multi-resistant Staphylococcusaureus, plays the most important role.

The Scottish surgeon Sir Alexander Ogsten was thefirst to prove the link between pyogenic infections anda certain bacterium he identified as Staphylococcusaureus. But at that time, in 1880, he could not foreseethe worldwide risk that once would emanate from thisspherical, gram-positive bacterium.

Rates of more than 60 %But not only Europe is concerned: today, a good 125years after its discovery by the Aberdeen physician,MRSA is the most common elicitor of pyogenicinfection in- and outside the hospital and the reasonwhy the Word Health Organisation (WHO) talksabout a global health crisis.

Literature

The European Antimicrobial Resistance Surveillance System (EARSS):EARSS Annual Report 2008, National Institute for Public Health and the Environment (RIVM), Bilthoven. Available at:http://www.rivm.nl/earss/Images/EARSS%202008_final_tcm61-65020.pdf

Deaths involving MRSA, England and Wales, 1993-2009.Office for National Statistics, February 2007. Available at:http://www.statistics.gov.uk/StatBase/Product.asp?vlnk=13571 MRSA proportions of countries reporting to EARSS.

Arrows indicate significant trends.Source: EARSS Annual Report 2008

0 10 20 30 40 50 60

Netherlands (NL)Norway (NO)Sweden (SE)

Denmark (DK)Island (IS)

Finland (FI)Estonia (EE)Slovenia (SI)Austria (AT)

Luxemburg (LU)Switzerland (CH)

Lithuania (LT)Poland (PL)Latvia (LV)

Czech Republic (CZ)Germany (DE)Belgium (BE)

Bosnia and Herzegovina (BA)Hungary (HU)

France (FR)Bulgaria (BG)

Spain (ES)United Kingdom (UK)

Ireland (IE)Romania (RO)

Italy (IT)Croatia (HR)

Israel (IL)Turkey (TK)

Greece (GR)Cyprus (CY)

Portugal (PT)Malta (MT)

MRSA rates in Europe (2008)

2.500

2.000

1.500

1.000

500

01993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Number of death certificates mentioning Staphylococcus aureus by methicillin resistance. England and Wales.

MRSAS. aureus not specified as resistant Source: Office for National Statistics

Economic Consequences

A variety of attempts have been made to documentthe excessive costs associated with MRSA. Butseparating the true costs of MRSA infection and thecosts of the actual interventions to control and pre-vent MRSA from the consequences of colonisationand infection is very difficult. However, the trend isclear: Compared with MSSA (methicillin-susceptibleS. aureus) the expenses for MRSA infection areapproximately twice as high.

Even a MRSA colonisation alone increases costs dueto the additional measures that have to be taken. Incase a MRSA infection occurs these costs quicklyrise three and a half times and higher. Essential costdrivers are:■ Prolonged hospital stays■ Additional surgeries■ Stays on intensive care unit■ Additional diagnostics, e.g. x-ray and computer

tomography■ Systemic antibiotic therapies■ Additional pharmaceuticals

Each HAI infection – this includes MRSA infection –costs between £4,000 and £10,000.

So, HAI considerably impacts on a hospital’s financialposition. Under Payment by Results (PbR), the defi-ned tariff will not take account of additional costsincurred by the treatment of HAI, including MRSA.This means, if a hospital has 40 cases of MRSA bac-teraemia per year, these will incur additional costs of between £160,000 and £400,000 in excess of tariff

income. This of course does not take other HAIs intoaccount – this figure could quickly increase tenfold.

Major savingsIn order to reduce MRSA, one of England’s largestNHS foundation trusts – Guy’s and St. Thomas’ –implemented a trust-wide infection control program-me: It updated its infection control policies and monitored compliance through audit, feedback andperformance management.Although the number of patients admitted with MRSArose from around 40 % in 2003 to around 70 % in2005, the trust very successfully decreased the num-

Excessive costs and potential savingsHospital-acquired infection (HAI) including MRSA is linked to organisational efforts and is very staff-intensive. Moreover, HAI costs the UK health service around £ 1 billion per year.

4

Personnel costs 53 %

Drug costs 9 %Material costs

10 %

Medical and non-medical infrastructure* 28 %

A good portion of the expenses for MRSA infection isspent for personnel and infrastructures.

Source: Wilke MH, Fink C, Maerz A, Resch A., Berlin, 2007

* Costs of medical infrastructure: e.g., for central bed unit, medical typing. Costs ofnon-medical infrastructure: e.g., for power and water supply, cleaning services.

SEM picture of Staphylococcus aureus


ber of patients acquiring MRSA at the trust, the num-ber of patients giving positive MRSA results fromwound swabs and the MRSA bacteraemia rate –moving from having one of the worst MRSA bacte-raemia rates for specialist trusts to one of the best.

5

■ Antibiotic resistanceAbility to withstand the effect of certain antibiotics. Theserum levels reached by the patients do not suffice to killthe pathogen. Bacteria apply different strategies to inac-tivate antibiotics.

■ cMRSAMRSA that is called community-acquired due to a mis-sing link to medical facilities. cMRSA can trigger skin andsoft tissue infections without a route of entry (intact skin).

■ ComplianceIn general, compliance describes the adherence to regu-lations, recommendations or rules of action. In connecti-on with hand disinfection, compliance comprises twoaspects: Performing hand disinfection when indicatedand using the correct rub-in method.

■ Device-associated carePatient care using devices, such as catheters, probes,ventilation tubes. The associated routes of entry increa-se the risk of pathogens reaching the patient’s body andeliciting infections.

■ MRSA/ORSAMulti-resistant Staphylococcus aureus strains: Originally,‘MRSA’ means methicillin-resistant S. aureus. Methicillinwas the first penicillinase-resistant staphylococci penicil-lin and was replaced by Oxacillin (ORSA) later on. MRSAbecame increasingly resistant to other antibiotic classes,too. Hence, the term is primarily used for multi-resistantS. aureus today.

■ MRSA bacteraemiaBacteraemia occurs when bacteria get into the blood-stream. Bloodstream infection is also sometimes calledsepticaemia, which implies greater severity/clinical signi-ficance. A wide variety of bacteria can cause bacterae-mias, the two most common being Staphylococcusaureus and Escherichia coli.

■ MRSA colonisationAfter the colonisation, MRSA proliferates in different bodyareas without eliciting symptoms or immune reactions.

■ MRSA infectionAfter entering the body, MRSA divides and proliferates.The infection manifests itself for example through feverand pus formation or other clinical signs of infection.

■ MSSAMethicillin-susceptible or -sensitive Staphylococcusaureus strains.

■ Nosocomial infectionFollowing a definition of the Centers for Disease Controland Prevention (CDC), patients suffer from a nosocomialinfection, when they do not show any visible indication ofinfection at the moment of hospital admission, but 48hours later, and when the incubation period does notclearly indicate that this infection was not obtainedduring hospital stay.

■ PbR (Payment by Results)New funding system for the NHS in England. Paymentwill be linked to activity and adjusted for case mix. Theimplementation of this system began in 2003/2004.

■ PVL (Panton-Valentin leukocidin)PVL is a toxin which is produced by certain strains ofMRSA or MSSA. It is not a variation of MRSA and can beproduced by both methicillin-resistant S. aureus (MRSA) and methicillin-susceptible S. aureus (MSSA). PVL-producing MRSA is more virulent than other types ofMRSA, it can cause more serious infections, e.g. necro-tising pneumonia.

■ ScreeningExamination involving swabs taken from the anteriornares, the throat, skin lesions and other (clinically suspi-cious) sites.

Literature

Going further faster:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4134549. Accessed on June 21, 2008.

Wilke MH, Fink C, Maerz A, Resch A.Kosten von MRSA und ihre Abbildung im G-DRG - System. Eine multizentrische AnalyseIII. Innovationskongress der Deutschen Hochschulmedizin, Berlin, 12. Juli 2007

Glossary

But what is more:The reduction of MRSA infections from 2003 to 2006resulted in the following annual savings:■ Prevention of 100 bacteraemias and 360 surgical

site infections■ Savings of approx. 4,000 bed days and £1.4

million in hospital costs

6

Pathogenic Profile

Inappropriate or excessive antibiotic therapies set off S.aureus resistance. Experts estimate that approxi-mately one third of all hospitalised patients receiveantibiotics and that some of these are unnecessary.

The common practice of antibiotic therapy and prophylaxis results in so-called selection pressure.Frequently prescribed broad-spectrum antibioticsmodify the patient’s normal flora, which then cannotsufficiently compete against the resistant S. aureusstrains. Only the most robust, antibiotic-resistant

bacteria survive and pass their resistances on asgenetic information that is stored in the genes (DNA). These resistance genes cannot only be found in chromosomal DNA, but also in so-called plasmids – a small ring-like fragment of DNA, which can beexchanged between different bacteria species relati-vely easily and quickly. This gene transfer can cause atransmission of resistances. The plasmids act as agenetic information pool and jump back and forthbetween the individual isolates of S. aureus and alsoother species – antibiotic resistance spreads.

Resistance mechanismsInappropriate use of antibiotics has gradually increased the resistance of Staphylococcus aureus.Meanwhile the bacteria react to the antibiotics using a variety of strategies.

Antibiotic-inactivatingenzyme

Efflux pump

Antibiotic

Antibiotic

Antibiotic

difficult transport

Bacterial cell

CHROMOSOME

1

3

2

Resistance mechanismsBacteria develop different strategies for wardingantibiotics off:

1. An enzyme (penicillinase) decomposes the antibiotic and thus destroys it.

2. A membrane pump of the bacterium is altered sothat the antibiotic can be channelled out imme-diately.

3. Modifications in the cell wall considerably impedethe transport of the antibiotic inside the bacterium.


Multiple resistance mechanismsThe development of resistances is by no means anew phenomenon. When Sir Alexander Flemingheralded the era of antibiotics by discovering penicil-lin in 1928, he already knew that penicillin could not cure all diseases and that there was the risk thatbacteria could develop resistance to this drug.

As early as 1944, the first resistance to penicillindeveloped. Staphylococcus aureus indeed was thefirst bacterium that was killed by the new drug, but it was also the first pathogen that successfully defen-ded itself against the drug. And already Fleming described its strategy: The staphylococci formed anenzyme – the penicillinase – which decomposed thepenicillin ring of the antibiotic. Without this ring theantibiotic is ineffective.

Staphylococcus aureus that take action against beta-lactam antibiotics with the beta-lactamase enzymeuse the same principle, which is the most known ofthree resistance mechanisms resulting in the so-called methicillin-resistance.

Methicillin- and multi-resistanceConventionally, the abbreviation ‘MRSA’ stands formethicillin-resistant Staphylococcus aureus; by definition it stands for a resistance to all antibioticswith beta-lactam structure, for example penicillins,cephalosporins, carbapenems and monobactams.Where the resistance includes different additionalantibiotic classes one speaks about multi-resistance.As most MRSA in the meanwhile are resistant to up to20 different antibiotics, multi- and methicillin-resi-stance are used synonymously. In many cases glyco-peptides such as vancomycin are the only effectivetherapeutic agents – but also here resistance hasalready emerged.

Literature

Fleming, A. (Hrsg.), Penicillin. Its practical application. Science, Volume 104, Issue2710, 12/1946, pp. 558

Kramer A, Daeschlein G, Eikmann T et al.Task force MRSA zur Intensivierung der Präventionsstrategien für die Eindämmungvon MRSA Stellungnahme der DGKH. Hyg Med (30) 2005-Heft 1/2: 29-31

Janata O.Staphylokokken – heute ein Problem?Wien, 2005, Antibiotika Monitor XXI, 6/2005: 121-123.

7

1944 1951 1952 1954 1956 1958 1961 1962 1981 1985 1987 2001 2002

Penic

illin G

Stre

ptom

ycin

Tetra

cycli

ne

Eryt

hrom

ycin

Chlor

amph

enico

lNo

vobi

ocin

Met

hicillin

Pr

istina

myc

inTr

imet

hopr

im

Quinolo

neRi

fam

picin

Linez

olid

Vanc

omyc

in

Development of S. aureus resistances

Source: Janata O. Staphylokokken – heute ein Problem? Wien, 2005, Antibiotika Monitor XXI, 6/2005: 121-123.

Pathogenic Profile

The pathogenic characteristics of resistant Staphylo-coccus aureus do not differ from the ones of antibiotic-susceptible S. aureus. However, a recent meta-analy-sis on bacteraemias showed that the risk of dyingfrom a MRSA sepsis is 42 percent higher in compari-son to a sepsis with susceptible Staphylococcusaureus strains. Diseases triggered by S. aureus aredivided into pyogenic, invasive infections and disea-ses caused by toxins.

■ Pyogenic, invasive infectionPyogenic, invasive infection (inflammation with pusformation) can occur as local (superficial), deep andsystematic infection. In the majority of cases, localinfections affect the skin and its adnexa, for examplein the form of furuncles, carbuncles and abscesses.Deep infections include acute parotitis (inflammationof the parotid gland) and osteomyelitis (bacterialinflammation of bone) of exogenous or hematogenicorigin. Emanating from a local infection S. aureus cancolonise other organ systems and cause empyema. Ifthe bacteria pass into the bloodstream, there is therisk of endocarditis (inflammation of the inner layer ofthe heart) or life-threatening sepsis.

■ Toxin-mediated diseasesS. aureus strains can form certain cytotoxins, theexfoliative toxins A and B (ETA and ETB). The toxinsresult in so-called staphylococcal scalded skin syndrome (SSSS) and staphylococcal toxic epidermal necrolysis (TEN) respectively. SSSS canoccur locally or systemically: widespread erythemaswith epidermal peeling develop. This syndrome pre-dominantly affects infants and adults over 80 years.

Toxic shock syndrome (TSS) is a life-threateninginfection that can result in multiple organ failure. For adiagnosis of TSS three or more of the following organsystems have to be involved: gastrointestinal tract(vomiting, nausea or diarrhoea), muscular system(strong myalgias), mucous membranes (hyperaemia),kidneys (increase of urea or creatinine in the serum),liver (e.g., increase of transaminases), CNS (disorien-tation, impaired consciousness).

PVL-induced skin and soft-tissue infections cMRSA (community acquired MRSA) is particularlydangerous. It forms the Panton-Valentin leukocidin(PVL) toxin. Although there is no evidence that PVL-producing MRSA is more virulent than other types ofMRSA it can cause more serious infections and usu-ally affects previously healthy young children andyoung adults. PVL generates pores in the membraneof white blood cells which are part of the immunesystem defending the body and thus causes therelease of inflammation messengers. The clinical picture is a deep, recurrent and necrotising skin andsoft-tissue infection, which can be life-threatening, forexample by resulting in necrotising pneumonia. TheHealth Protection Agency (HPA) is aware of 7 deathsrelated to this organism in England and Wales in 2005and 2006.

Food intoxicationsFood intoxications caused by S. aureus are elicited by the intake of enterotoxin. After the contaminationof food the staphylococci must proliferate.As S. aureus enterotoxin is highly heat-resistant, it isnot killed during food preparation.

Manifold clinical outcomesAmong all staphylococci Staphylococcus aureus possesses the strongest pathogenicity. Hence, thisbacterium is a very persistent enemy that causes diseases with manifold clinical outcomes.

8


S. aureus particularly colonises the anterior nares.Approximately 60 percent of all individuals in thedeveloped countries are colonised occasionally bythe bacterium, about 20 percent are colonised permanently and 20 percent never.

Risk area ICUThe MRSA colonisation itself does not possess aharmful character – but vulnerable patients, particu-larly those in intensive care units (ICUs), might be atrisk of getting a MRSA infection. It has been knownfor a long time that a weak immune system, continu-ous use of antibiotics and invasive therapies promotethe spread of antibiotic-resistant pathogens. Intensi-ve device-associated care, e.g. central venous cathe-ters (CVC), mechanical ventilation and urinary cathe-ters, provides pathogens with routes of entry. In addi-tion, the numerous necessary contacts with theemployees’ hands increase the risk of spreadingmicroorganisms.

Hence, it is no wonder that MRSA prevalence ratesare high on ICUs: in 27 out of 30 countries reportingdata to EARSS the 2006 MRSA proportions in ICUwere higher than the overall MRSA proportions, inthirteen countries this difference was significant,including UK. In some countries – Croatia, Greece,Ireland, Malta and Turkey – the proportion of MRSAfound among ICU patients was even over 60%.

Risk factor antibiosisBroad spectrum antibiotics and drug classes that arenot effective play a decisive role in the spread ofMRSA. Current or past systemic antibiotic therapycreates one of the most important risk factors for sus-ceptibility to MRSA. The authors of a study with12,072 newly admitted patients identified the follo-wing 9 independent risk factors: ■ Male gender■ Age > 75 years■ Fluoroquinolones within the past 6 months■ Cephalosporins within the past 6 months■ Carbapenems within the past 6 months■ Hospital stay within the past 12 months■ IV therapy within the past 12 months■ Urinary drainage at hospital admission■ Transfer within the hospital

Affected patients can be colonised by MRSA for a lon-ger time and repeatedly. The medical personnel canalso be colonised. The normal flora of healthy peopleusually protects against a colonisation. The MRSA rateamong medical personnel can increase during out-breaks and is dependent on the characteristics of theindividual MRSA isolates.

Literature

RKI-Ratgeber Infektionskrankheiten – Merkblätter für Ärzte. Staphylokokken-Erkrankungen, insbesondere Infektionen durch MRSA. Erstveröffentlichung im Epid.Bull. 08/2000; ergänzt und aktualisiert: November 2003.

Cosgrove SE, Sakoulas G, Perencevich.Comparison of mortality associated with methicillin-resistant and methicillin-susceptibleStaphylococcus aureus bacteremia: a meta-analysis.Clin Infect Dis 2003; 36: 53–59.

PVL-associated Staphylococcus aureus – Frequently Asked QuestionsHealth Protection Agency. Last review: April 2008. Available at:http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1207208304493?p=1192454969657. Accessed on June 21, 2008.

EARSS Annual Report 2006. loc. cit.

Kappstein I. Prävention von MRSA-Übertragungen.In: Krankenhaushygiene up2date, Georg Thieme Verlag, Stuttgart, 2006, 1: 9-20.

Harbarth S et al. Methicillin-resistant S. aureus infections among patients in theemergency department. Am. J. Med., 2006,119:275e15-275e23.

9

Source: Kappstein I. Prävention von MRSA-Übertragungen. Krankenhaushygieneup to date, Georg Thieme Verlag, Stuttgart, 2006, 1: 9-20.

S. aureus-colonisation rates

The human as reservoirToday, Staphylococcus aureus is not only one, but the most common elicitor of pyogenic infection.Independent from antibiotic-sensitivity or –resistance, one of its natural reservoirs is the human.

Anterior nares

Axillae

Breast / Back

Wound / Skin fold

Groin

Genitalia / Perineum

Pharynx

Scalp / Hair

Forehead/hair boundary

Normal population

Hospital staff

Patients at admission

Hospitalised patients

Insulin-dependent diabetics

Neonates after birth

Neonates after two-week hospital stay

0 10 20 30 40 50 60 70 80 90 100

19-55 %17-56 %

10-85 %

14-55 %

24-76 %

2 %

80-100 %

Transmission Paths

Among all staphylococci, S. aureus not only posses-ses the strongest pathogenicity, it is also characteri-sed by a particular durability:S. aureus■ grows in nearly all simple culture media at tempe-

ratures between 18 °C and 40 °C – best at tempe-ratures between 30 °C and 37 °C

■ can persist on inanimate surfaces (e.g. bedsidetables, doorknobs, etc.) for up to 7 months

■ survives contact with up to 10 percent NaCl solution

■ survives in dust and can be passed on from there■ dies only after 1 hour in dry heat at a temperature

of 80 °C■ is able to survive in ice for 66 days■ possesses an affinity to hydrophobic materials

such as synthetics and stainless steel

Transmission pathsMRSA colonisation alone does not have a clinicalsignificance. Normally, Staphylococcus aureus needsroutes of entry to trigger an infection. In this connec-tion, the bacteria are relocated from the patient’scolonised skin or mucous membrane to usuallymicroorganism-free body areas or to wounds.MRSA can be transmitted endogenously (patient-own flora) or exogenously by employees, inanimatesurfaces or other patients.

■ Endogenous patient floraThe nose is a common origin of infection – in factvia the patients themselves. This self-infection canoccur surreptitiously e.g. by touching the nose, ormore directly via a wound or catheter insertion.

■ HandsTransmission of microorganisms from patient topatient is relatively rare, but the hands of the medical staff play a decisive role in spreadingMRSA – they can become contaminated when theycome into contact with nasopharynx/secretions orcolonised/infected wounds. If the hands are notdisinfected, e.g. when leaving the room, it is possi-ble that MRSA is passed on to other patients.

■ Inanimate surfacesIts high survivability of up to 7 months suggeststhat MRSA is also transmitted through contamina-ted objects. It has been shown, for instance, thatMRSA remains capable of surviving on a sterilepackage for more than 38 weeks. And hands can be contaminated over and over by inanimatesurfaces: A study demonstrated that during onesingle direct contact between hand and inanimatesurface approximately 4 to 16 percent of the handtouches the surface – after 12 contacts evenaround 40 percent.

■ AirborneIn principle, airborne transmission of MRSA is possible, e.g. through large droplets in case of veryclose contact. But it only plays a minor role. Airbor-ne transmission can rarely be clearly identified as transmission path, because direct or indirectcontact (staff, contaminated objects) duringpatient care cannot be ruled out completely.

Literature

Kramer A, Schwebke I, Kampf G.How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect. Dis. 2006; 6: 130.

Kampf G.Mikrobielle Besiedelung der Hände und ihre epidemiologische Bedeutung. In: KampfG (Hrsg.). Hände-Hygiene im Gesundheitswesen. Springer-Verlag Berlin Heidelberg, 2003: 29-64.

Kappstein I.Prävention von MRSA-Übertragungen. In: Krankenhaushygiene up2date, GeorgThieme Verlag, Stuttgart, 2006, 1: 9-20.

Most important origins of infectionStaphylococcus aureus is extremely resistant to environmental impacts and can survive for a longtime – even on inanimate surfaces. So, the medical personnel’s hands play a major role.

10


■ Hand disinfectionHygienic hand disinfection is generally carried outwhen entering a patient room, when moving from acontaminated to a clean body site, after removingdisposable gloves and before leaving the patientroom. Also visitors should be informed of accuratelyperforming hand disinfection after leaving the patientroom.

■ Disposable glovesDisposable gloves serve as protection against con-taminated materials, objects, devices and instru-ments. They are to be donned while entering thepatient room after having performed hygienic handdisinfection. After glove removal in the room, thehands are always disinfected.To prevent a contamination there are additional mea-sures that have to be carried out when entering theroom of a MRSA colonised/infected patient. If appli-cable, these have to be explained to staff from otherwards.

■ Protective gownsWhen entering the patient room a protective gown isput on and closed at the back. Disposable gownsare thrown into the hospital trash. Reusable gowns(one per patient) remain in the room and are dispo-sed in a closed laundry bag after shift.

■ Mouth/nose protectionDonning a mouth/nose protection when entering thepatient room keeps medical and caregiving person-nel from becoming colonised by MRSA. Themouth/nose protection is thrown into the hospitaltrash before leaving the room. In residential and nur-sing homes mouth/nose protections are alwaysnecessary, when there is a risk of contamination viaaerosols – e.g. when suctioning tracheostomies.

■ Surface disinfectionMRSA and MSSA can remain infectious on inanima-te surfaces for up to 7 months. Hence, in case ofMRSA, the Robert Koch-Institute recommends

- disinfecting surfaces (wipe disinfection) close topatients (bedframes, bedside tables, wet areas,doorknobs, etc.). If necessary, surface disinfection isto be extended to additional surfaces that are at riskof contamination.

- disinfecting surfaces of all contact areas of devicesused on the patient (e.g. ultrasound heads, ECGelectrodes and cables) – after each use and beforeremoval from room.

- dedicating stethoscopes, thermometers and the likefor use by only one patient and disinfecting themimmediately after use.

11

Basic HygieneThe measure of choiceAdherence to basic hygiene is of major importance in MRSA prevention. In particular, correct hand disinfection is the most effective measure to prevent transmission.

Basic hygiene

Hand disinfection

Protective gown

Surface disinfection

Mouth/nose protectionDisposable gloves

12

The key factorIt is generally accepted that hand disinfection is the most important preventive measure, even againstantibiotic-resistant microorganisms. However, hand disinfection remains a challenge, as compliancerates average only 40%.

Hygienic hand disinfection is a key factor in preven-ting nosocomial infection – also with MRSA. Expertsestimate that up to 90 percent of all hospital-acquiredinfections are transmitted by hands. One third of these is considered to be avoidable. This fact is sufficiently known. Nevertheless, only one in two indi-cated hand disinfections is carried out.

As an essential part of standard hygiene, it is vital to perform hand disinfection before and after each directpatient contact.

This means in detail:■ when entering the patient room■ after handling blood and body fluids and items

contaminated with blood and body fluids■ prior to aseptic technique■ before donning and after removing protective

clothing/gloves■ before handling invasive devices■ prior to and following bed making■ before handling food■ before leaving the patient room

Efficacy in case of MRSAHand disinfectants that possess a proven bactericidalactivity in accordance with the European standardsshould be used to reliably inactivate MRSA.But besides using an effective product when indica-ted, this product should also be used properly. Gapsin coverage have to be avoided by paying particularattention to fingertips, nail folds and the thumbs.

In addition, the basic principles of hand hygieneshould be followed: Well-groomed hands (regularmoisturising), short, clean, polish-free natural nailsand no jewellery including wedding ring and watch.

Training promotes complianceStudies have shown that compliance with hand disin-fection increases in case of a MRSA outbreak. As it isimportant to prevent a spread of pathogens beforethe occurrence of outbreaks, raising the compliance

rate is of major importance in hand hygiene. In thisconnection, staff training is a crucial measure. Butalso skin compatibility plays a major role: Hand disin-fectants applied should possess a good skin tolerabi-lity to support compliance.

Better accessibility of hand disinfectants throughgood availability of disinfectant dispensers or by pro-viding employees with pocket bottles also results inan increase in compliance with hand disinfection –and a decrease in the rate of nosocomial infection.

Typical weak pointsKnowing typical weak points of hand disinfection is avital aspect of compliance: non-compliance is higherwhen employees wear gowns and gloves, performactivities with increased risk of cross contaminationand when they are entrusted with tasks that requirefrequent hand disinfection during patient care. All the-se facts apply to the care of MRSA colonised/infectedpatients.And there is an additional aspect when caring forMRSA carriers: The unconscious hand-face contact.As MRSA often colonises the anterior nares,employees, who unconsciously touch their face withthe contaminated hand, are at risk of being colonisedor transmitting MRSA. In addition to hand disinfecti-on, the mouth/nose protection is therefore a reasona-ble barrier.

Literature

Empfehlungen Händehygiene.Mitteilung der Kommission für Krankenhaushygiene und Infektionsprävention amRobert Koch-Institut. Bundesgesundheitsblatt – Gesundheitsforschung – Gesund-heitsschutz, 2000, 43: 230-233

Guidance for Nursing Staff; Methicillin-resistant Staphylococcus aureus (MRSA)Royal College of Nursing. April 2004. Available at:http://www.rcn.org.uk/__data/assets/pdf_file/0011/78653/002740.pdf. Accessed on June 21, 2008.

Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften(AWMF): Leitlinie Händedesinfektion und Händehygiene, Hyg Med 2003; 4; 129-133

Benzer H. et al:Barrieren gegenüber der hygienischen Händedesinfektion, Hyg Med 1994; 19: 327-335

Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programmeto improve compliance with hand hygiene, Lancet 2000; 356:1307-1312

Hand Disinfection


Screening serves as early identification of patientswho are colonized with MRSA either before or onadmission. This swab test is not a control measure initself. Hence, its results need to be linked to a targe-ted approach to the appropriate measures (seepages 14 and 15).

Patient screeningExperts have repeatedly called for widespread MRSAscreening to reduce the high MRSA rates in hospitals,but whether endemic MRSA can be reduced throughuniversal screenings remains subject to great contro-versy.

As the local epidemiology of MRSA greatly differsfrom one healthcare facility to the next, the fine detailregarding which patients are screened should bedetermined by the infection control team and needsto be discussed with the clinical teams and endorsedby the hospital management. However, certain high-risk patients should be screened routinely, this inclu-des those who are:■ known to have been infected or colonised with

MRSA in the past■ frequent re-admissions to any healthcare facility■ recent inpatients at hospitals abroad or hospitals in

the UK which are known or likely to have a highprevalence of MRSA, and

■ residents of residential care facilities where there is aknown or likely high prevalence of MRSA carriage.

In addition, patients on certain high-risk units – inclu-ding intensive care, neonatal intensive care, burns,transplantation, cardiothoracic, orthopaedic, trauma,

vascular surgery, renal, regional, national and interna-tional referral centres – may be screened at leastintermittently as the patients on these units are oftenseriously ill and particularly susceptible to an MRSAinfection.

When screening patients without clinical signs ofinfection, the following sites should be considered forsampling: anterior nares and throat, groin, perineum,wounds, catheter insertion sites, and tracheostomy.

Staff screeningIn terms of type and extent, screening of staff shouldbe aligned with already established patient screeningpolicies. However, as a general rule it should be car-ried out in outbreak situations. In these cases it maybe advantageous to limit the group of employees tobe screened, e.g. to persons with allergies, skin orrespiratory diseases. Appropriate sampling sites forstaff screening are: anterior nares, throat and any are-as of abnormal or broken skin.

Literature

Coia JE, Duckwoth GJ, Edwards DI et al.Guidelines for the control and prevention of methicillin-resistant Staphylococcusaureus (MRSA) in healthcare facilities. J Hosp Infect 2006; 63S:1-44

Harbarth S, Fankhauser C, Schrenzel J et al.Universal Screening of Methicillin-Resistant Staphylococcus aureus at HospitalAdmission and Nosocomial Infection in Surgical Patients. JAMA 2008;299(10):1149-1157

von Baum H, Dettenkofer M, Föll M, Heeg P, Sernetz S, Wendt C Consensus Empfehlung Baden-Würtemberg: Umgang mit MRSA-positivem Perso-nal. Hyg. Med. 2008; 33: 25-29

Rodríguez-Baño J. et al: Long-Term Control of Endemic Hospital-Wide Methicillin-Resistant Staphylococcusaureus (MRSA): The Impact of Targeted Active Surveillance for MRSA in Patients andHealthcare Workers, Infect Control Hosp Epidemiol 2010; 31(8):786-795

13

Identifying at risk patientsIn addition to basic hygiene, so-called screening can help define adequate risk-related measures toprevent the spread of MRSA in medical facilities.

Screening

14

MRSA Hygiene ManagementDecolonisationA decrease of MRSA carriage can reduce the risk of transmission in healthcare settings and of inocu-lation to the patient’s own surgical wound during surgery. The so-called decolonisation mainly refersto the use of topical agents.

MRSA colonisation increases the risk of spread andinfection. To suppress MRSA carriage a decolonisati-on regimen should be carried out – under the adviceand supervision of the hospital infection control team.The Guidelines for the Control and Prevention ofMRSA in Healthcare Facilities recommend the follo-wing approach:

■ Nasal decolonisation In an outbreak situation and as prophylaxis for anoperative procedure, patients should undergonasal decolonisation by applying a nasal ointment(mupirocin 2 %) to the anterior nares three timesdaily for five days. Mupirocin should not be usedfor prolonged periods or repeatedly as this mightencourage resistance.

■ Oral hygiene Systemic treatment of throat carriage should onlybe considered in exceptional circumstances, e.g.when there is evidence for a transmission from athroat carrier, and if required, be restricted to onecourse.

For oral hygiene single-use toothbrushes and antiseptic mouth rinses are recommended. Thetooth mug should be disinfected daily.

Decolonisation

Skin decolonisation including hair wash

Single use or disinfected equipment for personal hygiene

Daily fresh bed linen

■ Skin decolonisationColonised patients should be decolonised daily forfive days with an antiseptic detergent. After moistening hair and skin the antiseptic body washis thoroughly applied to all areas including hair. Indoing so, special attention has to be paid to knowncarriage sites, for example the axilla, groin andperineal area. Afterwards the detergent is rinsed off. The antiseptic body wash should bealso used for bed bathing of immobile patients.

To prevent re-colonisation clean clothing, beddingand towels should be provided after each bath andhair wash. Any further equipment for personel use,e.g. comb, glasses, drinking vessel, should bereplaced or disinfected in the meantime while thepatient is decolonised.

Skin decolonisation with an antiseptic body wash/shampoo is useful in eradicating or suppres-sing skin colonisation for short times.

Wash lotions that possess good skin tolerabilityeven with long-term use and are effective withinshort exposure times, e.g. 30 seconds, increasethe comfort for the patient and thus the willingnessto carry out decolonising measures consistently.

Skin decolonisationimmobile patient

Nasal decolonisation


15

Risk-related measuresThe proper management and placement of patients is one of the fundamentals of minimising theimpact and potential transmission of any infectious condition, including MRSA.

Based on the known routes and risks of transmission,hygiene experts and commissions develop conceptsfor the prevention and decolonisation of MRSA inhospitals and other healthcare settings. In addition to basic hygiene (see page 11), the following proce-dures are recommended in case MRSA screeningresults are positive:

■ Duty of notificationIn case vancomycin-intermediate and -resistant S. aureus (VISA and VRSA) are identified, the rele-vant national surveillance organisation, e.g. HealthProtection Agency (HPA) in England and Wales,should be notified. In addition, all cases of MRSAbacteraemia need to be reported to the HPA aspart of Mandatory Surveillance directed by theDepartment of Health.

■ Single-room/cohort isolationPatient isolation for those infected or coloniseddepends on the facilities available and the associa-ted level of risk. The most effective form of isolati-on is a single-room and should be the first choiceof placement. However, rooms, bays and areasused for isolated patients should have dedicatedhand hygiene and toileting facilities.

■ Cleaning and decontaminationManagement of the patient environment andequipment (occupied facility and after discharge ofthe patient) is important in minimising the risk ofspread.- Equipment should preferably be single-patient

use. Multiple-patient use items must be decon-taminated before use on another patient.

- All waste should be categorised as hazardous waste and disposed according to local policy.

- All linen, including bedding and adjacent curtain, should be treated as infected in line with hospital policy.

■ Patient movementTransfer and movement should be kept to a mini-mum to reduce the risk of infection spreading. If atransfer is necessary, the following should beobserved:- The receiving area/facility must be informed so

that effective infection control measures can be put into place.

- Hand hygiene and personal protective equip-ment (gloves, gown, etc.) procedures should beclosely followed. Gloves and gowns should be disposed as clinical waste after contact with thepatient.

- Lesions should be covered with an impermeabledressing.

- Equipment used to transport the patient (e.g., trolley, chair) should be decontaminated in accordance with local policy.

- Staff should decontaminate their hands tho-roughly after dealing with the patient and cleaning the trolley or chair.

■ Surgical/invasive proceduresPrior to any planned invasive procedure, effortsshould be made to decrease the risk of infection.Good infection control practices that should be inplace between all patients should reduce the riskof cross-transmission.

■ Discharge Generally, MRSA-colonised patients do not needto continue with extended eradication protocolsafter discharge. However, patients, their relativesand carers should be fully informed about MRSA.

Literature

Coia JE, Duckwoth GJ, Edwards DI et al.Guidelines for the control and prevention of methicillin-resistant Staphylococcusaureus (MRSA) in healthcare facilities. J Hosp Infect 2006; 63S:1-44

The Health Act 2006: Code of Practice for the Prevention and Control of HealthcareAssociated Infections. Revised January 2008. Department of Health. Available at:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081927. Accessed on June 21, 2008.

Isolating patients with healthcare-associated infection.Department of Health. Available at: http://www.clean-safe-care.nhs.uk/toolfiles/116_283198IP_isolating_patients.pdfAccessed on June 21, 2008.

16

MRSA Hygiene ManagementCare plan immobile patient

Nursing staff Before enteringpatient room

Basic hygieneSterillium®

Sterillium® Gel30 sec exposure time, hygienic hand disinfection.

Nursing staff As ordered Swabs

Nursing staff Change of dressing,if applicable

Cover wound with impermeable dressing.

Nursing staff /Patient

Daily Oral hygieneEnsure that enough single-use toothbrushes are available. Disinfect tooth mug.

Staff Daily


Daily for five daysin line with deco-lonisation

Antiseptic whole-body wash

Stellisept® med foamStellisept® med tissues

Dispose hospital linen in laundry bag.

Apply foam on dry single-use washcloth or useready made soaked tissues. Thoroughly spreadon respective body part. No rinsing required, letproduct dry naturally.

In case rinsing with wet cloth is desired the exposure time of minimum 60 seconds must beadhered to.

Nursing staff Daily Change of beddingPart I

Leave unused bedding in room.

Nursing staff Daily Change of beddingPart II

Leave unused bedding in room.

(30 sec)(30 sec)

Cleaning staff Daily Disinfection ofenvironment andfloor near topatient

Mikrobac® forteBODE X-Wipes

5ml/l – 0.5 % – 1h

Nursing staff Before leavingpatient room

Basic hygienebefore leaving the room

Sterillium®

Sterillium® GelObserve 30 sec exposure time (hygienic hand disinfection).

Staff

Who When WhatWith what Please notice

Sterillium®

Sterillium® Gel

Nursing staff Daily Skin care, clean clothes, if applicable

Nursing staff Daily Continuation ofwhole-body wash

Stellisept® med foamStellisept® med tissues

Leave-on products! No washing up, please let air dry.

3 times daily for 5days in line withdecolonisation

Application ofnasal ointment

Mupirocin, in case ofresistance alternative

Don disposable gloves. Perform hygienic hand disinfection after removal and disposal.

Change of dres-sing, if applicable



17

■ Hygienic hand disinfection ■ Don mouth/nose protection ■ Don protective gown ■ Don disposable gloves

Take necessary swabs (anterior nares, throat, skin lesions, wounds, sites, sputum in acc. with local policy).

Prior to whole-body wash in case of strong secretion.

Oral hygiene with single-use toothbrush and antiseptic mouth rinse.

Use clean washcloth after eachstep and in between to assurehair and skin is moistenedthroughout the whole wash procedure.

Beware! Area near eyes applywith care and make sure, no product gets into the eyes.

1. Step:■ Hair■ Place head on clean towel■ Forehead■ Face■ Closed eyes■ Ears■ Neck: front and sides

2. Step:■ Upper part of body, front■ Upper extremities■ Axillae■ Lower extremities, front■ Groin / Genitalia

3. Step:Turn patient to the side, use clean washcloth.■ Neck: nape and sides■ Back■ Flank facing staff■ Lower extremities, back ■ Anal area

■ Spread clean bed sheet, rollup lengthwise to centre andput on mattress

■ Lay patient on the other side(over sheet role)

■ Immediately dispose usedbedding in laundry bag

■ Remove disposable glovesand throw into trash

■ Dispose mouth/nose protection

■ Remove disposable protective gown and dispose it

■ Reusable gowns are left inthe room and disposed inlaundry bag after shift; dispose immediately, if visiblysoiled

■ Perform hygienic hand disinfection

How

4. Step:■ Don disposable gloves

■ Use clean washcloth andwash flank

■ Remove disposable gloves ■ Perform hygienic hand disinfection

■ Put clean pillow sheet on

Apply ointment to both anterior nares with cotton swab.

After whole-body wash in case of dry, not infected wounds.

18

MRSA Hygiene ManagementCare plan mobile patient

Nursing staff Before enteringpatient room

Basic hygieneSterillium®

Sterillium® Gel30 sec Exposure time, hygienic hand disinfection.

Nursing staff As ordered

Nursing staff Daily ■ Change bedding ■ Disinfection of

mattress cover■ Disinfection of

furniture andcontact surfaces

Mikrobac® forteBacillol® AF

Bacillol® AFBacillol® TissuesMikrobac® Tissues

Immediately dispose bedding in laundry bag.

5 ml - 0.5% - 1 hConc. - 30 sec


Daily Disinfection of personal objects of patient.

Afterwards: discard disposablegloves and performhand disinfection.

Use single-use materials, e.g. toothbrush, comb, nailbrush.

Conc. - 30 secConc. - 30 secConc. - 60 sec

Nursing staff Daily Put on clean bed sheetsLeave unused bedding in room.

Application ofnasal ointment

Skin care, clean clothes, if applicable

Swabs

Antiseptic whole-body wash

Stellisept® med

■ Dispose hospital linen in laundry bag

■ Use single-use washcloth

■ Exposure time: at least 30 sec

Nursing staff Daily Oral hygieneEnsure that enough single-use toothbrushes are available. Disinfect tooth mug.

Staff Daily


Daily for five daysin line with deco-lonisation

Staff 3 times daily for 5days in line withdecolonisation

Mupirocin, in case of resistance alternative

Nursing staff Before leavingpatient room

Basic hygienebefore leaving theroom

Sterillium®

Sterillium® GelObserve 30 sec exposure time (hygienic hand disinfection).



Patient Daily

Change of dressing, if applicable

Nursing staff When necessary Change of dressing, if applicable

Cover wound with impermeable dressing.

Who When WhatWith what Please notice

Cleaning staff Daily Disinfection of environ-ment and floor near topatient

5 ml/l - 0.5% - 1hMikrobac® forteBODE X-Wipes


19

■ Hygienic hand disinfection ■ Don mouth/nose protection ■ Don protective gown ■ Don disposable gloves

Take necessary swabs (anterior nares, throat, skin lesions, wounds, sites, sputum in acc. with local policy).

■ Strip off bedding

■ Wipe disinfection

e.g. table, bedside table, bed-frame, chair surfaces, handles,doorknobs, handrails, light switches, trapeze bar

■ Wipe disinfection

e.g. visual aids, hearing aid,jewellery, thermometer, hairbrush, hairdryer

■ Shower: Wet hair and body,apply wash lotion towashcloth (switch off shower)

Order of washing:■ Hair■ Forehead, face, ears, neck■ Upper part of body, upper

extremities, axillae■ Back■ Groin, genitalia, anal area

Wet clean washcloth andapply antiseptic detergent:

■ Lower extremities■ Shower hair and body after

exposure time

Prior to whole-body wash in case of strong secretion.

After whole-body wash in case of dry, not infected wounds.

Oral hygiene with single-use toothbrush and antiseptic mouth rinse.

Apply ointment to both anterior nares with cotton swab.

■ Remove disposable glovesand throw into trash

■ Dispose mouth/nose protection

■ Remove disposable protective gown and dispose it

■ Reusable gowns are left inthe room and disposed inlaundry bag after shift; dispose immediately, if visiblysoiled

■ Perform hygienic hand disinfection

How


BODE Chemie GmbH . GermanyMelanchthonstr. 27 . 22525 HamburgTel. +49 40 54006-0 . Fax -200www.bode-chemie.com . [email protected]

PAUL HARTMANN AGwww.hartmann.info

A company of the HARTMANN GROUP

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