AWARENESS AND ADHERENCE TO METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) GUIDELINES, AS PER THE WORLD HEALTH ORGANIZATION, AT ALEXANDRIA UNIVERSITY HOSPITALS

G.S. Soliman1*, R.M. Abu-Youssef1*, B.F. Saleib1, A.M. El-Moughazi1, A. Zaki2

1Alexandria University, Faculty of Medicine; 2Alexandria University, Department of Bioinformatics and Medical Statistics, Medical Research Institute. *Co-first authors.

AbstractAbstract

IntroductionIntroduction

ObjectivesObjectives ResultsResults

ConclusionsConclusions

RecommendationsRecommendations

Problem Statement : MRSA is believed to be the result of decades of antibiotic misuse. A study done at Alexandria Main University Hospital in 2009 reported that 71 out of 100 S. aureus isolates were MRSA. Clinicians must be aware of the potential danger of MRSA infection.Objectives : Assess the awareness and adherence to MRSA control guidelines among the medical staff and unveil the reasons, if any, for non-adherence.Design : Descriptive cross-sectional study.Setting : Local level; examines the public sector healthcare staff at Alexandria Main University Hospital & Pediatrics/Obstetrics Hospital.Study population : The data collection was conducted from September 2010 to November 2010. A sample of 158 physicians and 47 nurses were randomly selected from among medical staff working in the departments of Anesthesiology, Cardiothoracic Surgery, Coronary Care Unit (CCU), General Intensive Care Unit (ICU), Neonatal ICU, Pediatric ICU, and Pulmonology Medicine. Data was collected using a pre-tested self-administered questionnaire covering detailed questions about the magnitude of the problem of MRSA, awareness about the routes of transmission, available guidelines, and the rate of adherence to the guideline recommendations.Results : Overall awareness of MRSA control guidelines was 67.3%. The highest rate of awareness of MRSA guidelines was found among medical staff in the Neonatal ICU (85.7 %), while the lowest was among Anesthesiology staff (45%), (p<0.05). Medical staff with more than 3 years of experience were significantly more aware of MRSA guidelines as compared to less experienced staff (p<0.01). The three main reasons for lack of awareness were a lack of infection control teaching program (72%), unavailable guidelines on department walls (49%), and work overload (34%). 55% knew the correct MRSA transmission routes. 86% were aware that washing hands after removing gloves is obligatory, while 70% supported screening of high-risk patients to help early detection. 70% acknowledged the use of new gloves with each procedure done on the patient. Regarding guideline implementation, 31.2% of the medical staff believed that the guidelines are implemented. Non-adherence to recommendations was mostly stated with regards to isolation measures (56%), hand-washing compliance (35%), and screening of high-risk patients (33.3%). The three main reasons for poor adherence to guideline recommendations were unavailability of resources (58%), lack of awareness (33%), and negligence (20%). 98% (p>0.05) of interviewees agreed on the importance of the guidelines, while 91% (p<0.05) believed that they adhere to them.Conclusions : The study showed low levels of awareness and poor adherence to MRSA-related guidelines. Efforts should be exerted to maintain an influential infection control team whose responsibility is the reinforcement of guideline implementation as well as the undertaking of periodic health education programs.Funding : Self-funded.

MRSA is believed to be the result of decades of antibiotic misuse. In a Mediterranean study published in August 2007, the highest proportions of MRSA were reported by Jordan, Egypt and Cyprus. The prevalence of MRSA in Egypt was 52%, in comparison to other Mediterranean countries such as Lebanon, Morocco, Algeria, Tunisia and Malta, which reported rates of 12, 19, 45, 18 and 50%, respectively; while countries such as Jordan and Cyprus reported higher rates of 56 and 55%, respectively. In 2009, a local study performed at Alexandria Main University Hospital reported that 71 out of 100 S. aureus isolates were MRSA.

Descriptive cross-sectional study conducted from September to November 2010 at a local level, examining the public healthcare staff at Alexandria Main University Hospital & Pediatrics/Obstetrics Hospital of Alexandria, Egypt. A sample of 158 physicians and 47 nurses were randomly selected from among medical staff working in the departments of Anesthesiology, Cardiothoracic Surgery, Coronary Care Unit (CCU), General Intensive Care Unit (ICU), Neonatal ICU, Pediatric ICU, and Pulmonology Medicine.

Data was collected using a pre-tested self-administered questionnaire covering detailed questions about the magnitude of the problem of MRSA, awareness about routes of transmission, available guideline recommendations, and the rate of adherence to these recommendations.

Overall, the level of awareness of MRSA guidelines was 67.3%. The highest rate of MRSA control guideline awareness was found among medical staff in the Neonatal ICU (85.7 %), while the lowest was among Anesthesiology staff (45%), (p<0.05) (Graph 1). 55% identified the correct transmission routes (p>0.05), (Graph 2), while 21% knew the most important MRSA risk factor, namely open skin wounds.The number of years of experience partially affected the level of awareness, as medical staff with more than 3 years of experience were significantly more aware of MRSA guideline recommendations (77.8%) as compared to less

Posters to be available on department walls, informing about MRSA, its routes of transmission, and the guideline recommendations that should be followed when caring for a patient. Easy equipment accessibility of gloves, gowns, face masks, hand disinfectant and hand-washing stations to help prevent MRSA spread. Isolation measures and screening of high-risk patients to be firmly executed.

The study showed low levels of awareness and

poor adherence to MRSA-related guidelines. Efforts

should be exerted to maintain an influential infection

control team whose responsibility is the

reinforcement of guideline implementation as well as

the undertaking of periodic health education

programs.

MethodsMethods

Clinicians must be aware of the potential danger of MRSA infection. Countries that did not implement early MRSA surveillance and control measures have struggled to control MRSA epidemics. Our Aim: Assess the awareness and adherence to MRSA control guideline recommendations among the medical staff at Alexandria University Hospitals and unveil the reasons, if any, for non-adherence.

ResultsResults

Graph 1: AWARENESS OF MRSA GUIDELINE RECOMMENDATIONS

PER UNIT

0%10%20%30%40%50%60%70%80%90%

Ane

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Car

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Surg

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C.C

.U.

I.C

.U.

N.I

.C.U

./P.I

.C.U

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Pulm

onol

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Percentage of awareness

experienced staff, who portrayed a level of awareness of 60.5%, (p<0.01). Overall:86% were aware that washing hands after removing gloves is obligatory. 70% advocated screening high-risk patients to help early detection.However, 30% did not recognize the necessity of using new gloves with each procedure performed on the patient at hand, (p<0.05).

Graph 3: Reasons of lack of guideline awareness

0%

10%

20%

30%

40%

50%

60%

70%

80%

Lack of infectioncontrol

program/team

Unavailableguideline copies ondepartment walls

Lack ofprioritization/work

overload

Inadequateimplementation by

senior staff &improper follow-up

Reasons of lack of guideline awareness

Graph 4: MOST COMMON NON-IMPLEMENTED GUIDELINE

RECOMENDATIONS

0%10%20%30%40%50%60%

Ade

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mea

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Han

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Scre

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h-ris

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Cle

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Physician/Nurse ResponseRate

Graph 5: MOST COMMON REASONS FOR GUIDELINE NON-

IMPLEMENTATION

0%20%40%60%80%

100%

Lack

of

reso

urce

s

Lack

of

awar

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s

Neg

ligen

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Lack

of

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Wor

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Reasons for guideline non-implementation(according to physicians/nurses)

31.2% of the medical staff believed that the guidelines are implemented. 98.4% (p>0.05) of interviewees recognized the importance of the role of guidelines, while 91.2% (p<0.05) of them believed that they correctly follow them. There was a large discrepancy in the ICU, where 100% believed in the importance of guidelines, while only 89.2% believed that they implemented them, as well as the Anesthesiology unit, where 87.5% believed in their importance, while only 75% believed that they adhere to them.

Graph 6: COMMON GUIDELINE SOURCES FOR MEDICAL STAFF

0% 5% 10% 15% 20% 25%

Others

Tutors

Pharmaceutical Pamphlets

Medscape

Journals

Books

Peers

UptoDate

Internet

Table 1: SUGGESTIONS FROM PHYSICIANS/NURSES TO IMPROVE MRSA CONTROL GUIDELINE AWARENESS & IMPLEMENTATION

Physicians/Nurses

N %

Infection control programs to teach staff; continuous medical education; adding infection control as a curriculum subject for students/staff 26 33.3%

Written treatment algorithms/guideline copies in every unit 10 12.8%

Active surveillance by infection control supervisors for guideline implementation; reward/punishment system to ensure strict adherence 14 17.9%

Improve availability of resources e.g. alcohol, isolation with individually assigned doctor/nurse for infected patient 26 33.3%

Others e.g. administrative infrastructure changes 2 2.6%

Total 78 100.0%

Graph 2: AWARENESS OF MRSA TRANSMISSION ACCORDING

TO YEARS OF EXPERIENCE

0%10%20%30%40%50%60%

<=3 years >3 yearsCorrect MRSA transmissionroutesMost important MRSA risk factor