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Infection Prevention, and Control Guidelines for Primary Care Physicians

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Patient Management of MRSA and VRE

Introduction:

Antibiotic resistant organisms (AROs) are a growing problem impacting health outcomes, quality of care, duration of hospitalization and other issues across the continuum of care. The use of evidence-based practices to prevent transmission will not only protect clients, service providers and staff in the community, but will reduce associated costs to the health care system. Infection prevention and control emphasizes the early identification of colonized patients and the use of additional precautions where necessary for prevention and transmission of spread of AROs such as MRSA and VRE.

Policy Statement:

Patients should not be excluded from receiving care from employees of the Family Health Teams because of colonization or infection with an ARO.  Routine practices are fundamental to the prevention of transmission and must be utilized by all staff and physicians at all times. These include hand hygiene and use of protective barriers.  In addition to routine practices, additional precautions specific to ARO management are required.

Definitions:

Antibiotic Resistant Organism (ARO) – A microorganism that has developed resistance to the action of several antimicrobial agents and that is of special clinical or epidemiological significance.

Colonization – The presence and growth of a microorganism in or on a body with growth and multiplication but without tissue invasion or cellular injury. The patient will be asymptomatic.

Infection – The entry and multiplication of an infectious agent in the tissues of the host. Asymptomatic or subclinical infection is an infectious process running a course similar to that of clinical disease but below the threshold of clinical symptoms. Symptomatic or clinical infection is one resulting in clinical signs and symptoms (disease).

Methicillin Resistant Staphylococcus aureus (MRSA) - a bacterium that periodically lives on the skin and mucous membranes of healthy people. Occasionally S. aureus can cause an infection. When S. aureus develops resistance to the beta lactam class of antibiotics, it is called methicillin-resistant Staphylococcus aureus, or MRSA.

Vancomycin Resistant Enterococci (VRE) are bacteria that live in the gastrointestinal tract of most individuals and generally do not cause harm (colonization). Vancomycin-resistant enterococci (VRE) are strains of enterococci that are resistant to the antibiotic vancomycin, and can cause urinary tract or blood stream infections that may be more difficult to treat.

Best Practices:

1. Acknowledge risk factors for MRSA and VRE   

The following clients/patients are at increased risk for both MRSA and VRE and employees should be aware of potential MRSA and VRE colonization or infection:

• those who have previously been colonized or infected with MRSA or VRE

• those who have spent time in a health care facility outside of Canada in the last 12 months
  
  
• those who have been admitted to, or who have spent more than 12 continuous hours as a client/patient/resident in, any health care facility in the past 12 months
  
  
• those who have recently been exposed to a unit/area of a health care facility with an MRSA or VRE outbreak
  
  
• those receiving home health care services in the past year
  
  
• those receiving treatment with an indwelling medical device
  
  
• those living in a communal setting (e.g. shelter, halfway home, correctional facility)
  
  
• those with a history of injection drug use
  
  
• those who are household contacts of people with MRSA
  
  
• individuals from populations where community-associated MRSA is known to be a problem (e.g. organized sports teams)

2. Specimens for detection of MRSA and VRE should include:

For MRSA:

• a swab from the anterior nares; AND

• a swab from the perianal area (a perineal or groin swab is also acceptable) AND
  
  
• a swab from skin lesions, wounds, incisions, ulcers and exit sites of indwelling devices, if present, using aseptic technique where indicated
  
  
• for newborn infants, a swab from the umbilicus should also be taken

For  VRE:

• must include stool or a swab from the rectum or anus. Stool specimens are preferred as they provide a higher yield. If a client/patient has a colostomy, the specimen for VRE should be taken from this site.

3. Follow-up Screening for MRSA and VRE:  

• Every effort should be made to try to determine the source of new cases of MRSA or VRE. Every new case should warrant an investigation.

• All affected health care settings (e.g. hospital) should be notified following the identification of a new case of MRSA or VRE or the identification of a new contact of a case
  
  
• Swab MRSA positive patient every 6 months to determine status
  
  
• If MRSA decolonization is attempted: 3 sets of negative swabs each week 1 week apart, started after 48 hours have passed since completion of treatment. If all sets are negative, discontinue use of contact precautions, continue to monitor every 6 months.
  
  
• Swab VRE positive patients every 6 months to asses for natural clearance. If negative results obtained, re-swab weekly for two weeks, if negative discontinue the use of contact precautions, continue to swab every 6 months.

4. Prevention and Control Measures for MRSA and VRE

• Hand Hygiene and Routine Practices

• Hand hygiene must be performed before and after each contact with a client/patient or contact with environmental surfaces near the client/patient
  
  
• Clients should be encouraged to perform hand hygiene upon arrival and before leaving office setting
  
  
• Additional Precautions for MRSA and VRE
  
  
• Additional Precautions are necessary to prevent and control MRSA and VRE
  
  
• Signage indicating the required contact precautions should be posted at the entrance to the patient assessment room
  
  
• Patient Placement
  
  
• It is strongly recommended that patients known to be colonized or infected with MRSA or VRE be assessed at the end of the day
  
  
• Place the patient in an appropriate assessment room as soon as possible
  
  
• Personal Protective Equipment
  
  
• Gloves and long-sleeved gown should be worn when providing direct care to a patient who has/suspected of having infection/colonization with MRSA or VRE
  
  
• All personal protective equipment is to be removed, discarded and hand hygiene performed immediately on leaving the room of a patient who has/suspected of having colonization/infection with MRSA or VRE

5. Environmental Cleaning

• Dedicate equipment to a single client/patient on contact  precautions

• Upon discharge of the client/patient with MRSA, rooms and dedicated equipment must be thoroughly cleaned and then disinfected using a disinfectant
  
  
• Stringent protocols are required for the cleaning of rooms contaminated with VRE
  
  
• Routine health care cleaning practices for laundering linens/laundry are adequate for eliminating MRSA and VRE

6. Flagging of Patient Charts

• Flagging/unflagging of client/patient charts for MRSA and VRE will be the responsibility of the individual responsible for infection prevention and control of the practice setting
  
  
• A tracking system and database of flagged patients will be in place to help identify them upon return to the office

7. Education

• Staff must receive education in the correct and consistent use of routine practices with emphasis on hand hygiene and appropriate use of personal protective equipment

• Staff must have an understanding of MRSA and VRE
  
  
• Patients should receive education and training in correct hand hygiene procedures
  
  
• Patients should receive education regarding MRSA and VRE (refer to Section V b)

8. Decolonization

• Current evidence does not recommend widespread or prolonged MRSA decolonization therapy as this may promote antibiotic resistance, long-term efficacy is poor and systematic therapy may lead to adverse events. Routine decolonization therapy of MRSA patients is not currently recommended.

• Decolonization therapy with topical antibiotics alone is not effective
  
  
• If decolonization is used, attention must be given to scrupulously clean the patient environment in order to decrease the risk of recolonization, as the environment can play a role in transmission
  
  
• Efforts at VRE decolonization are not effective and this is not recommended
  
  
• In situations where a patient colonized with MRSA is implicated in an outbreak, decolonization may be considered in consultation with an Infectious Disease Physician.

Reference:

PIDAC Best Practices For Infection Prevention and Control of Resistant Staphylococcus aureus and Enterococci. March 2007

Procedure for Collecting Specimens for MRSA and VRE

Check with your laboratory regarding appropriate specimens for detection of MRSA and VRE

Note: Specimens may show a false negative result if the patient is on an antibiotic to which the microorganism is sensitive. MRSA may not show up on specimens taken from patients who have recently had an antimicrobial bath. Surveillance specimens should be taken once the antibiotic has been discontinued for 48 hours.

MRSA Screening Procedure for Cultures/Molecular Detection:

• Pre-moisten all swabs with sterile normal saline or with transport medium prior to taking a specimen

• Swab anterior nares (use the same swab for both nostrils). Use a circular motion to touch as much mucous membrane as possible.
  
  
• Swab perianal/perineal skin or groin with a new swab
  
  
• Swab wounds/skin lesions/incisions/ulcers if present with separate swabs
  
  
• Swab exit sites of indwelling devices if present
  
  
• Label the individual specimens appropriately

VRE Screening Procedure for Cultures/Molecular Detection:

• Stool or a rectal or anal swab may be used for VRE screening. Stool specimens are preferred as the yield is higher.

• If a swab is used, pre-moisten the swab with sterile normal saline or with transport medium prior to taking a specimen
  
  
• Swab around the external rectal orifice. If visible stool is not obtained on the swab, insert it a few millimeters into the rectum until visible stool is obtained
  
  
• Label the individual specimens appropriately

Information for Patients

• MRSA Fact Sheet for Patients

• VRE Fact Sheet for Patients