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

Aim of the PaperThe 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 so that we may:

protect critical medical resources

decrease morbidity and mortality

protect both patients and health care workers

decrease the over-all health burden created by MRSA

Support for Relevance

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).

MRSA, regularly attracts media interest and there is

political pressure to reduce MRSA infection rates (Woodford

& Livermore, 2009).

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).

Healthcare Acquired-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).

MRSA Prevention/Early DetectionThrough 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).

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).

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).

There were 5,041 participants in different roles of the healthcare organization and each were

swabbed in different manners for the bacteria.

In three groups, 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). Group one included health care workers and patients screened

after exposure to MRSA during 2000-2005 (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 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).

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 detects 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 three hours and forty minutes to complete (Kucina et al, 2008).

It has been demonstrated to be most accuratewhen all three swabs are pooled and tested (Kucina et al, 2008).

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

Nurses’ lack of knowledge and

understanding of epidemiology, microbiology, pharmacology and infection

control have also been singled out

Several factors are listed as contributory to the increased and persistent nature of MRSA in the healthcare setting (Barnes & Jinks, 2008). These include:

A Study of the Relationship Between Environmental Contamination with Methicillin-Resistant Staphylococcus Aureus(MRSA) and Patients’ Acquisition of MRSA

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).

“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).

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).

This study 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).

Critical Appraisal of the EvidenceOne 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).

Drawbacks to this study: the test was performed over a period of only one year 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 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).

Critical Appraisal ContinuedIn 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 naresand throat cultures should be pooled to attain greatest sensitivity (Mertz et al., 2007).

Critical Appraisal ContinuedThe 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). “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). The highest area (81 of 216 sites) of MRSA contamination was obtained in the samples from under the beds (Hardy et al., 2006). 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).

Integration of the Evidence

Rapid testing for MRSA is performed utilizing swabs, which is a fairly non-

invasive and inexpensive procedure (Kucina et al., 2008).

Patients have expressed anger and resentment at contracting the infections and

express dismay at missing work, needing a driver (in many cases), costs of travel

and time/duration of the treatment.

Many 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 Recommendations include strict compliance with hand washing, and the implementation of screening for patients being transferred between nursing floors.

• Wash hands after contact with patient s, bodily fluids, and contaminated items, and after gloves are removed between patient contact

• Use gloves (clean, non-sterile are adequate) when contacting patient or patient items.

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

Hand Hygiene

• Always wear gloves; wear masks and eye protection during procedures that are likely to generate splashes• Ensure that reusable equipment is not used in the care of another

patient until it has been appropriately decontaminated.• 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).

Isolation Precautions

• Assure that patient environment is cleaned daily with antiseptic solution.

• 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.

Surfaces

The rapid culture may be implemented using the follow criteria and protocol.

Assess for the following risk

factors: presence of a chronic wound,

has been hospitalized three or more times in

the last year, or is a resident of a long-term care facility.

If the patient is found to be at high

risk, the 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 .

If positive for MRSA the patient

will require a private room.

Contact isolation precautions should

be utilized

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