final copy nov 2 ebp paper

Running head: MRSA Prevention 1

MRSA Prevention in the Healthcare Setting

Ferris State University

Debby Boyle, Nicole Cory, Anne Hendricks, Linda Hansen, Suzette Ploughman

Running head: MRSA Prevention2

Abstract

Emergence of antibiotic-resistant bacteria has added new and challenging issues in healthcare.

An analysis of multiple research articles was performed to find the best practice for prevention of

the spread of methicillin-resistant staphyloccocus aureus (MRSA) in health care settings.

Importance to nursing includes: protecting critical medical resources, decreasing morbidity and

mortality, and decreasing over-all health burden. Certain patients are at higher risk for

contracting MRSA and avenues must be explored to prevent transmission. These include: early

identification, isolation precautions, antibiotic therapy, and hand washing. This paper will serve

to show the best evidence for the prevention of the spread of this potentially lethal bacterium.


MRSA in the Healthcare Setting

Aim of the Paper

What does the literature show is the best way to control the spread of MRSA in the

health-care setting? The aim of this paper is to analyze the best evidence to control the spread of

antibiotic-resistant bacteria. It is imperative to implement strategies for prevention in the

hospital setting to protect critical medical resources, to decrease morbidity and mortality, to

protect both patients and health care workers, and to decrease the over-all health burden created

by MRSA.

Support for Relevance

MRSA was first reported in the United Kingdom in 1961, when it was found that Staph

aureus infections were becoming resistant to beta-lactum inhibitors such as methicillin (Romero,

Treston, & O’Sullivan, 2006). MRSA ranks “among the most prevalent pathogens in hospitals

worldwide” (Diekema & Climo 2008, p.1192). Infections caused by multidrug-resistant gram-

positive bacteria represent a major public health burden in terms of morbidity and mortality,

increased expense in patient management, and implementation of infection control measures

(Woodford & Livermore, 2009). Staphylococcus aureus is an established pathogen in the

hospital environment and when it becomes multidrug resistant, it complicates therapy (Woodford

& Livermore, 2009). The "superbug", MRSA, regularly attracts media interest and there is

political pressure to reduce MRSA infection rates (Woodford & Livermore, 2009).

According to the article Invasive MRSA infections in the United States by Klevins et al,

2007), 126,000 patients hospitalized develop MRSA and 5,000 of those patients die each year

and today’s numbers state that 46 out of 1,000 patients have MRSA. Klevins et al (2007) reports

nearly 9,000 cases of invasive MRSA were reported from July 2004 through December 2005.


Of these cases, 26.6% or 2,389 cases were hospital acquired MRSA (HA-MRSA). HA-MRSA

patients have an increased length of stay up to nine and one-tenth days and incur costs of roughly

$30,000 per episode (Richmond et al, 2007). The numbers of HA-MRSA are rising and hospitals

need to enforce infection control measures.

Certain patients are at higher risk for contracting MRSA which include: patients with

known previous MRSA infection, patients who have been hospitalized three or more times in

one year, residents of long-term care facilities, and patients with chronic wounds (Kucina et al.,

2008). Through the screening of high-risk patients for the infection, appropriate isolation

precautions can be put into place so transmission to other patients or caregivers may be avoided

(Kucina et al., 2008).

Isolation and antibiotic therapy alone are not sufficient to stop the transmission of MRSA

from one patient to another. According to the CDC, “The main mode of transmission to other

patients is through human hands, especially healthcare workers' hands” (Siegel et al, 2007).

According to both hand washing studies, hand washing has been shown to be a key factor in

reducing the spread of microorganisms (Laustsen et al., 2009; Thomas et al., 2005). However,

these studies show that many healthcare workers still do not practice effective hand hygiene

when taking care of patients (Laustsen et al., 2009; Thomas et al., 2005).

Summary of the Evidence

According to Mertz et al., (2007), “approximately 30% of the healthy population carries

S. aureus in their anterior nares” (p.475). This carriage of S. aureus is associated with increased

risk of infection post surgery (Mertz et al., 2007). “Approximately 80% of invasive nosocomial

infections are of endogenous origin in nasal carriers (Mertz et al., 2007, p. 475).”

Early detection of carriers is important in prevention of the spread. Most screening


programs include a swab of the anterior nares (Mertz et al., 2007). Swabbing the throat is not

standard because of increased discomfort, costs, and limited research (Mertz et al., 2007). This

article suggests that selective colonization of the throat may be more common than presently

acknowledged (Mertz et al., 2007). Unrecognized carriers render infection control programs

futile, therefore evaluation of the benefit of screening both the nares and throat was examined in

four study populations (Mertz et al., 2007).

In the Mertz et al., (2007) study, there were 5,041 participants in different roles of the

healthcare organization and each were swabbed in different manners for the bacteria. In groups

one though three, 2,966 people were screened for carriage of S. aureus (Mertz et al., 2007). A

fourth group consisted of 2,075 people who had nasal and throat swabs pooled in the laboratory

(Mertz et al., 2007). Fifty and four tenths percent of the subjects were female with the average

age of 50 + 21 years (Mertz et al., 2007). Group one included health care workers and patients

screened after exposure to MRSA during 2000-2005 (Mertz et al., 2007). Group two consisted

of healthcare workers who participated in a prevalence survey of S. aureus carriage among Swiss

population in 2004 (Mertz et al., 2007). The third group was healthy blood donors screened for

S. aureus in 2005 (Mertz et al., 2007). Group four consisted of nasal and throat swabs pooled in

the lab from patients and healthcare workers exposed to MRSA (Mertz et al., 2007).

In 2007, the US Food and Drug Administration (FDA) approved the first rapid blood test

for MRSA, the BD GeneOhm Staph SR assay (Kucina et al, 2008). This test is able to identify

whether it is MRSA or a less dangerous staph that can still be treated with Methicillin. Clinical

trials were 100% correct in identifying MRSA and 98% positive of identifying the less

dangerous strain (Overby, 2008).


MRSA can exist on environmental surfaces and lead to the transmission between patients as

shown in an article by Hardy, Oppenheim, Gossain, Gao, & Hawkey, (2006) which studied

environmental contamination. Multiple sites in a nine bed intensive care unit (ICU) were

swabbed including under the bed, the workstation, the control buttons on the monitors, and a

ledge that was behind each bed as well as samples from nose, perineum, and wound sites of the

patient’s admitted to this unit (Hardy et al, 2006). Compliance for cleaning the environment of

the ICU was followed according to the standards of the National Health Service (Hardy et al.,

2006) yet sites still tested positive for MRSA.

Hand washing has been shown to help prevent the transmission of many infection

producing organisms, but compliance with hand washing has been shown to be less than optimal

in many situations (Laustsen et al., 2009; Thomas et al., 2005). In the focus group study

(Thomas et al., 2005), initial compliance was deemed to be 20% in the one unit where baseline

compliance was measured (during direct but random observations). This study indicates that a

belief is held that overall compliance rate estimates are actually a little higher, in the 30%-50%

range.

In the cohort study conducted by Laustsen et al., (2009), the compliance rate was

measured before and after care was rendered to patients with both the patients and staff aware of

the study. The compliance rate was significantly higher (in the 60%-70% range) for this group

(Laustsen et al., 2009). According to the article Listen Up MRSA: The Bug Stops Here, hand

hygiene is the single most effective way to prevent the spread of healthcare related infections

(Yamamoto & Marten, 2007).


Health care workers are the principal mode of transmission for MRSA infections,

therefore proper hand hygiene is imperative to decrease the spread of disease (Yamamoto &

Marten, 2007).

In the past, a culture of wound or sputum has been the standard method of detection,

which could take up to 72 hours (Kucina et al, 2008). A rapid MRSA assay has been instituted in

some hospitals which detect the bacteria utilizing nasal, throat, and skin swabs, and some sets

contained only nasal and skin swabs (Kucina et al, 2008). This rapid screening test requires a

maximum of 3hours 40 minutes to complete (Kucina et al, 2008). It has been demonstrated to be

most accurate when all three swabs are pooled and tested (Kucina et al, 2008).

By identifying patients with MRSA or other potential hospital acquired infections,

contact precautions can be used to avoid disease spread. According to the CDC (Siegel et al,

2007), isolation precautions, or contact precautions, are one category of Transmission-Based

Precautions aimed at preventing transmission of infectious diseases that spread by direct or

indirect contact with an infected patient or the patient’s environment.

The CDC outlines several procedures based on the assessed risk beginning with private

rooms for high-risk patients, three feet of separation in multi-patient rooms, and placing patients

with the same pathogen in the same room. In rooms designated for contact precautions, cleaning

and disinfecting should be done daily focusing on frequently-touched surfaces (Siegel et al,

2007).

For health care professionals and staff, protective attire (gowns, masks, gloves) must be

changed and hand hygiene performed between patient contacts. Furthermore, patient equipment

should be handled using standard precautions, but disposable or dedicated equipment, is

recommended. Equipment for patients in isolation should be disposed of in waterproof


containers, while reusable equipment should be placed and transported in plastic bags for

disinfection (Siegel et al, 2007).

In the article Methicillin-Resistant Stapholococcus Aureus: The modern day challenge,

several factors are listed as contributory to the increased and persistent nature of MRSA in the

healthcare setting (Barnes & Jinks, 2008). These include:

Longstanding inappropriate prescribing practice (compounded by the use of antimicrobial

agents in veterinary and agricultural practices)

Poor and inconsistent infection control measures such as hand washing

Lack of adequate surveillance together with inadequate isolation resources for colonized

or infected individuals (Kelly, 2001)

In addition nurses’ lack of knowledge and understanding of epidemiology, microbiology,

pharmacology and infection control have also been singled out (Gould, 2003)

Contact transmission is probably the most important factor in its dissemination as MRSA is

readily spread in this way, usually via the hands of healthcare workers (Barnes & Jinks, 2008).

According to Capprioti (2003), the average rate of compliance with MRSA precautions was

28%. “There was a general lack of awareness regarding the likelihood of MRSA contamination

during superficial contacts with an infected patient” (Afif et al., 2002). Surfaces of inanimate

objects utilized in care of the patient have also been implicated as sources of MRSA

contamination. Many investigators contend that limiting the spread of MRSA depends on health

care personnel using proper hand hygiene practices, contact isolation, and barrier precautions in

the clinical setting (Afif et al., 2002; Boyce, 2001; Pittet, 2001; Simor, 2001).

The following is a list of interventions to aid in preventing the spread of infection in the

hospital setting:


Wash hands after contact with patient fluids and contaminated items, whether or not

gloves are worn.

Wash hands immediately after gloves are removed between patient contacts.

Wash hands between tasks and procedures on the same patient to prevent cross-

contamination of different body sites.

Use gloves (clean, non-sterile are adequate) when in contact with patient or patient items.

Use clean gloves when touching patient mucous membranes and non-intact skin.

Wear masks and eye protection during procedures that are likely to generate splashes or

sprays of patient body fluids.

Use single-use disposable, equipment; discard in biohazard waste container.

Ensure that reusable equipment is not used in the care of another patient until it has been

appropriately decontaminated.

Assure that patient environment is cleaned daily with antiseptic solution.

Isolate patient in a private room or in room with other patients on MRSA precautions.

If possible, divide patient assignments so that health care personnel are not required to

care for both (Capriotti, 2003).

Critical Appraisal of the Evidence

One study regarding rapid MRSA testing utilizing nasal, throat, and skin swabs had a

limited sample size of only 292 samples (Kucina et al., 2008). Some of the participants were

tested using both throat and nasal swabs (Kucina, 2005). There are a few drawbacks to this

study, the test was performed over a period of only one year, and a new method of culture

utilizing the three swabs had to be formulated for this study to be completed (Kucina et al.,


2008). Earlier batches of samples were found to be less sensitive and specific, and during the

testing period the methods were modified (Kucina et al., 2008). After testing was modified,

results became more sensitive and specific for MRSA, further research may demonstrate an even

higher rate of success now that the testing process has been perfected (Kucina et al., 2008).

In the Mertz, et al (2007) study, groups 1-3, 49.9% tested positive for S. aureus and a

total of 37.1% had nasal carriage of S. aureus with/without positive throat cultures while a total

of 25.7% of the carriers were colonized in the throat solely. Among the third group, the throat

swab yielded more positives than the nasal swab (Mertz et al., 2007). In group 4 the carriage

rate was 52.1% which is similar to the combined results of groups 1-3 both nasal and throat

swabs (Mertz et al., 2007).

The addition of throat swab cultures increased the sensitivity by 25.7% (Mertz et al.,

2007). Group 4, the combined nasal and throat pooled specimens yielded a S. aureus carriage

result of 52.1% (Mertz et al., 2007). These results suggest that pooling combined results from

both nares and throat may be the most effective method of analysis.

Admission screening to identify and control MRSA focuses on the nares alone in many

institutions, and this data confirms that the nares is the most prevalent site for colonization

(except in group 3) (Mertz et al., 2007). The addition of throat cultures to cultures from the

nares increased the sensitivity by 25.7%, and 12.8% had positive throat cultures alone;

suggesting that both nares and throat cultures should be pooled to attain greatest sensitivity

(Mertz et al., 2007).

The environmental study results indicate that MRSA can live on surfaces for long periods

of time and was isolated from surfaces in this ICU at every screening (Hardy et al., 2006).


According to Yamamoto, MRSA can survive on surfaces anywhere from hours up to 3-5 days

(2007). In addition to this, “the environmental strains were more often identical to those

colonizing another patient elsewhere in the ward, possibly indicating the spread of bacteria”

(Hardy et al., 2006, p. 130). This study showed that the highest area (81 of 216 sites) of MRSA

contamination was obtained in the samples from under the beds which led the researchers to

speculate as to possible reasons for this finding (Hardy et al., 2006). Speculation included this

area being closest to the floor or the accumulation of dust. Other surfaces were also

contaminated “although workstations and monitors have lower levels of contamination than do

the areas under the bed, the consequences of contamination of the workstations and monitors are

potentially greater, in terms of transmission of MRSA to patients” (Hardy et al., 2006, p. 129).

This studied showed that even if the bed space was not occupied with a patient colonized with

MRSA, the space still tested positive for MRSA 20.2% of the time (Hardy et al., 2006).

Data from the focus group study indicated posters were updated four times over the

period of the study and made a difference in improving hand washing from 20% at baseline to

37% overall at the end of the twelve month campaign (Thomas et al., 2005). This study

employed techniques of using incentives to increase compliance. Focus groups met to develop

the posters as well as brainstorm a reward system for compliance. The group felt that physicians

were the most non-compliant but were least impacted by the rewards or the posters. The group

felt that the posters gave educational information and increased the knowledge of the reader to

the importance of hand hygiene.

Integration of the Evidence

Most healthcare workers have encountered more than one undiagnosed MRSA infection

in their practice. A rapid test with results obtained in a 3 to 4 hour period could prevent this


unseemly event. Furthermore, patients in high-risk categories will not need to be placed in

isolation for three days only to find they are negative for the bacteria. This practice is costly and

time-consuming.

The rapid testing for MRSA is performed utilizing swabs, which is a fairly non-invasive

and inexpensive procedure (Kucina et al., 2008). Patients may prefer to have this testing done to

avoid being placed in tentative isolation, or to avoid potentially exposing other patients. Many

patients, in years of practice, will warn health care workers upon entering the patient room, to

don gloves due to communicable illnesses that they are aware they have.

Patients have expressed anger and resentment at contracting the infections and express

dismay at missing work, costs of travel and time/duration of the treatment. Patients are now

understandably fearful of the possible consequences of healthcare interventions or a stay in the

hospital (Barnes & Jinks, 2008). MRSA has occurred, on several occasions, in post-operative

patients. When one patient is diagnosed with MRSA, others soon follow which leads one to

wonder about a hypothesis of environmental contamination versus spread from healthcare

workers. Some insurance companies do not cover home IV antibiotics which can be a dilemma

for further treatment. Non-compliance with hand hygiene has been personally observed on

multiple occasions and it seems that physicians are frequent offenders.

Recommendations to Utilize the Evidence

The evidence that appropriate and early detection could prevent or even eliminate the

spread of antibiotic-resistant bacteria is impressive. “Approximately 80% of invasive

nosocomial infections are of endogenous origin in nasal carriers” (Mertz et al., 2007, p. 475). To

save critical medical resources, decrease morbidity and mortality, and decrease over-all health

burden should be the goal of healthcare. The evidence demonstrates the rapid assay culture to be


highly accurate for testing patients at high-risk for MRSA (Kucina et al., 2008).

The rapid culture may be implemented using specific criteria. Performing an initial

assessment for MRSA prior to admission or transfer of a hospitalized patient can prevent

transmission between patients and healthcare workers. If the patient has a chronic wound, has

been hospitalized three or more times in the last year, or is a resident of a long-term care facility

they must be tested according to the research (Kucina et al., 2008). If the patient is found to be

at high risk, swabs should be obtained and sent for analysis to the lab. The patient should remain

in isolation in a private room until culture results are obtained. As always, with every patient,

standard precautions should be maintained.


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final copy nov 2 ebp paper

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