strategies to prevent transmission of methicillin

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Strategies to Prevent Transmission of Methicillin‐Resistant

Staphylococcus aureus in Acute Care Hospitals

David P. Calfee , MD, MS; Cassandra D. Salgado , MD, MS; David Classen , MD, MS;Kathleen M. Arias , MS, CIC; Kelly Podgorny , RN, MS, CPHQ;

Deveri! ". Anderson , MD, MPH; Helen #$rstin , MD; S$san %. Coffin , MD, MPH;

%ri! R. D$&&er!e , MD; 'itoria (raser , MD; Dale N. )erding , MD;(ranes A. )riffin , RR*, MPA; Peter )ross , MD; Keith S. Kaye , MD; Mihael Klo+as , MD;

%velyn -o , MD; "onas Marshall , MD; -eonard A. Mer+el , D, SM; -indsay Niolle , MD;

David A. Peg$es , MD; *rish M. Perl , MD; San/ay Saint , MD; Ro&ert A. 0einstein , MD;Ro&ert 0ise , MD; De&orah S. 1o!oe , MD, MPH

(ro+ the Mo$nt Sinai Shool of Mediine, Ne2 1or!, Ne2 1or! 3D.P.C.4; the Medial

5niversity of So$th Carolina, Charleston 3C.D.S.4; the 5niversity of 5tah, Salt -a!e City 3D.C.4;

the Assoiation for Professionals in Infetion Control and %ide+iology 3K.M.A.4 and the National Q$ality (or$+ 3H.#.4, 0ashington, D.C.; the "oint Co++ission, a!&roo! *errae

3K.P., R.0.4, the -oyola 5niversity Chiago Strith Shool of Mediine 3D.N.).4 and the Stroger

3Coo! Co$nty4 Hosital and R$sh 5niversity Medial Center 3R.A.0.4, Chiago, and the Hines'eterans Affairs Medial Center, Hines 3D.N.).4, Illinois; the D$!e 5niversity Medial Center,

D$rha+, North Carolina 3D.".A., K.S.K.4; the Children6s Hosital of Philadelhia and 5niversity

of Pennsylvania Shool of Mediine, Philadelhia, Pennsylvania 3S.%.C.4; the 0ashington

5niversity Shool of Mediine, St. -o$is, Misso$ri 3%.R.D., '.(., ".M.4; the Instit$te forHealthare I+rove+ent, Ca+&ridge 3(.A.).4, and #righa+ and 0o+en6s Hosital and Harvard

Medial Shool, #oston 3D.S.1., M.K.4, Massah$setts; the Ha!ensa! 5niversity Medial

Center, Ha!ensa! 3P.).4, and the 5niversity of Mediine and Dentistry7Ne2 "ersey Medial

Shool, Ne2ar! 3P.).4, Ne2 "ersey; the 0arren Alert Medial Shool of #ro2n 5niversity andRhode Island Hosital, Providene, Rhode Island 3-.A.M.4; the David )effen Shool of

Mediine at the 5niversity of California, -os Angeles 3D.A.P.4; the "ohns Ho!ins MedialInstit$tions and 5niversity, #alti+ore, Maryland 3*.M.P.4; the Ann Ar&or 'eterans Affairs

Medial Center and the 5niversity of Mihigan Medial Shool, Ann Ar&or, Mihigan 3S.S.4;

and the 5niversity of Manito&a, 0innieg, Canada 3%.-., -.N.4.

Address rerint re8$ests to the Rerints Coordinator, 5niversity of Chiago Press, 9:< %. =>thSt., Chiago, I- =>=?< 3rerints@ress.$hiago.ed$4 or ontat the /o$rnal offie

3ihe@ress.$hiago.ed$4.

Aeted "$ne :, >>; eletronially $&lished Sete+&er 9=, >>.

Purpose

"$+ *o Setion...

Previo$sly $&lished g$idelines are availa&le that rovide o+rehensive reo++endations for

deteting and reventing healthare‐assoiated infetions 3HAIs4. $r intent in this do$+ent is


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to highlight ratial reo++endations in a onise for+at to assist a$te are hositals in their

efforts to revent trans+ission of +ethiillin‐resistant Staphylococcus aureus 3MRSA4. Refer to

the Soiety for Healthare %ide+iology of A+eriaBInfetio$s Diseases Soiety of A+eriaCo+endi$+ of Strategies to Prevent Healthare‐Assoiated Infetions %Ee$tive S$++ary,

Introd$tion, and ao+anying editorial for additional dis$ssion.

Section 1: Rationale and Statements of Concern

"$+ *o Setion...

9. #$rden of HAIs a$sed &y MRSA in a$te are failities

a. In the 5nited States, the roortion of hosital‐assoiated S. aureus infetions

that are a$sed &y strains resistant to +ethiillin has steadily inreased. In >>:,MRSA ao$nted for =?F of S. aureus infetions in hositals.9

&.

Altho$gh the roortion of S. aureus 7assoiated HAIs a+ong intensive are $nit3IC54 atients that are d$e to +ethiillin‐resistant strains has inreased 3a

relative +eas$re of the MRSA ro&le+4, reent data s$ggest that the inidene

of entral line7assoiated &loodstrea+ infetion a$sed &y MRSA 3an a&sol$te

+eas$re of the ro&le+4 has dereased in several tyes of IC5s sine >>9.

Altho$gh these findings s$ggest that there has &een so+e s$ess in reventingnosoo+ial MRSA trans+ission and infetion, +any atient gro$s ontin$e to

&e at ris! for s$h trans+ission.

. MRSA has also &een do$+ented in other areas of the hosital and in other

tyes of healthare failities, inl$ding those that rovide long‐ter+ are.

. $to+es assoiated 2ith MRSA HAIs

MRSA HAIs are assoiated 2ith signifiant +or&idity and +ortality.?‐G

a.

Co+ared 2ith atients 2ith &atere+ia a$sed &y +ethiillin‐s$seti&le S.

aureus, those 2ith MRSA &atere+ia have nearly t2ie the +ortality rate,?

signifiantly longer hosital stays,G and signifiantly higher +edian hosital

osts.=

&. Co+ared 2ith atients 2ith a s$rgial site infetion a$sed &y +ethiillin‐

s$seti&le S. aureus, those 2ith a s$rgial site infetion a$sed &y MRSA have

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a ?.: ti+es higher ris! of death and al+ost ti+es greater +edian hosital

osts.:

.

*he higher +or&idity and +ortality rates assoiated 2ith MRSA are notneessarily d$e to inreased vir$lene of resistant strains &$t rather +ay &e d$e

to other fators, s$h as delays in the initiation of effetive anti+iro&ialtheray, less‐effetive anti+iro&ial theray for infetion d$e to resistant strains,

and higher severity of $nderlying illness a+ong ersons 2ith infetion d$e to

resistant strains.

?. Ris! of MRSA HAI a+ong MRSA‐olonied atients

A s$&stantial roortion of MRSA‐olonied atients 2ill s$&se8$ently develo an

MRSA infetion.‐9

.

*rans+ission of o++$nity‐assoiated MRSA an and does o$r in hositals.

ne reent st$dy fo$nd that 9G.


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2ere a$sed &y 5SA?>>,9? the strain tye +ost fre8$ently assoiated 2ith

o++$nity‐assoiated MRSA.

G.

Reservoir for MRSA trans+ission in a$te are failities

In healthare failities, anti+iro&ial $se rovides a seletive advantage for MRSA to

s$rvive, and trans+ission o$rs largely thro$gh atient‐to‐ atient sread.

a.

MRSA‐olonied and ‐infeted atients readily onta+inate their environ+ent,

and healthare ersonnel o+ing into ontat 2ith atients or their environ+ent

readily onta+inate their hands,9: lothing, and e8$i+ent.9G‐9

Section 2: Strategies to Detect MRSA

"$+ *o Setion...

9.

S$rveillane definitions

a. Standardied definitions sho$ld &e $sed to lassify eah atient6s first MRSA

isolate as either hosital or o++$nity onset. Altho$gh no lassifiation syste+

rovides o+lete a$ray, for $roses of MRSA s$rveillane,

reo++endations for lassifying eah atient6s first MRSA isolate 3regardless of

2hether the isolate reresents linial infetion or asy+to+ati oloniation4have &een +ade &y the Soiety for Healthare %ide+iology of A+eria, $sing

the follo2ing ti+e‐ &ased definitionsJ>

i.

Hosital‐onset MRSAJ A atient6s first MRSA isolate is lassified as a

ne2 ase of hosital‐onset MRSA if it is identified fro+ a sei+en

o&tained after the third alendar day of hositaliation, 2ith the day of

ad+ission &eing o$nted as alendar day n$+&er 9. 3*he ad+ission

date is defined as the date that the atient o$ies a roo+ for

overnight stay, not the date of o$tatient or e+ergeny deart+entvisit.4 (or eEa+le, if a atient 2ho 2as not revio$sly !no2n to &e

olonied or infeted 2ith MRSA is ad+itted on Monday, an MRSA

isolate 2o$ld &e onsidered to &e hosital onset if the sei+en 2aso&tained fro+ the atient on or after *h$rsday.

ii.

Co++$nity‐onset MRSAJ A atient6s first MRSA isolate is lassified

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as o++$nity‐onset MRSA if it is identified fro+ a sei+en

o&tained on or &efore the third alendar day of a atient6s

hositaliation, 2ith the day of ad+ission &eing o$nted as alendar

day n$+&er 9. 3(or MRSA s$rveillane $roses, the ter+

o++$nity onset is $sed to indiate that the MRSA isolate does not+eet the s$rveillane definition for indiating hosital‐onset MRSA.

*he MRSA isolate +ay &e attri&$ta&le to the o++$nity or to another

healthare faility.4

&. Clinial definitions an also &e $sed to lassify MRSA isolates andBor eisodes

of MRSA infetion as healthare assoiated or o++$nity assoiated.> 5nli!ethe ti+e‐ &ased definitions desri&ed a&ove, 2hih ta!e into ao$nt only the

ti+e of sei+en olletion in relation to the ti+e of hosital ad+ission, these

linial definitions re8$ire eval$ation of the atient6s linial history and rior

healthare eEos$res.

. Methods for detetion of atients 2ith MRSA oloniation or infetion

*he reservoir for trans+ission of MRSA is largely o+osed of gro$s of atients those 2ith linial MRSA infetion and a +$h larger gro$ of atients 2ho are +erely

olonied. 'ario$s detetion +ethods an &e $sed to identify one or &oth of these gro$s.

a.

Ro$tine revie2 of data fro+ linial sei+ensJ Clinially infeted atients and

so+e asy+to+atially olonied atients an &e deteted 2hen MRSA isisolated fro+ a linial sei+en sent to the +iro&iology la&oratory.

&.

Revie2 of ative s$rveillane testing dataJ Ative s$rveillane testing for MRSA

is defined as erfor+ing diagnosti testing for the $rose of deteting

asy+to+ati MRSA oloniation.

Section : Strategies to Prevent MRSA Transmission

"$+ *o Setion...

9.

%Eisting g$idelines and reo++endations

a.

Several govern+ental, $&li health, and rofessional organiations have

$&lished evidene‐ &ased g$idelines andBor oliies for revention and ontrol

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of MRSA trans+ission.9‐: *hese g$idelines inl$de si+ilar reo++endations,

differing ri+arily 2ith regard to the ro$tine $se of ative s$rveillane testing to

identify atients asy+to+atially olonied 2ith MRSA.

&. *he +a/or reo++endations of eah of these g$idelines are s$++aried in

*a&le 9. Altho$gh these g$idelines seifially reo++end a n$+&er of revention +eas$res, g$idane as to the i+le+entation of these +eas$res

2ithin hositals is not rovided.

.

*he Instit$te for Healthare I+rove+ent and the Assoiation for Professionals

in Infetion Control and %ide+iology have develoed ratial s$ggestions for

i+le+entation and +onitoring of several of the revention +eas$res seifiedin evidene‐ &ased g$idelines.G,=

. Infrastr$t$re re8$ire+ents

a. Infrastr$t$re re8$ire+ents of an MRSA trans+ission revention rogra+

inl$de the follo2ingJ

i.

An ative infetion revention and ontrol rogra+ staffed &y as$ffiient n$+&er of trained ersonnel to allo2 i+le+entation and

ontin$ation of MRSA s$rveillane and infetion revention efforts

2itho$t o+ro+ising other infetion revention and ontrolativities.

ii.

Infor+ation tehnology syste+s to allo2 raid notifiation of linial ersonnel and infetion revention and ontrol ersonnel of ne2

MRSA isolates, olletion of data needed for MRSA s$rveillane and

rate al$lations, and identifiation of MRSA‐olonied atients on

read+ission.

iii.

S$ffiient s$lies for hand hygiene and ontat rea$tions 3eg,go2ns and gloves4

iv.

Reso$res to rovide aroriate ed$ation and training to healthare

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ersonnel, atients, and visitors

v.

Ade8$ate la&oratory s$ort

*a&le 9. S$++ary of Reo++endations (ro+ P$&lished )$idelines for Prevention andControl of Methiillin‐Resistant Staphylococcus aureus 3MRSA4 andBor ther M$ltidr$g‐

Resistant rganis+s

Section !: Recommendations for "mplementing Prevention and Monitoring

Strategies

"$+ *o Setion...

Reo++endations for reventing and +onitoring MRSA trans+ission are s$++aried in thefollo2ing setion 3also see (ig$re4. *hey are designed to assist a$te are hositals in rioritiing

and i+le+enting their MRSA trans+ission revention efforts. Criteria for grading of the

strength of reo++endations and 8$ality of evidene are desri&ed in *a&le . *hese

reo++endations are ri+arily intended for the ontrol of MRSA trans+ission in the setting ofende+iity; ho2ever, they +ay also &e aroriate for eide+i MRSA, 2ith the eEetion of

an aelerated ti+e fra+e for i+le+entation and the fre8$eny at 2hih o$to+es are assessed.*hese reo++endations are +eant to &e o+le+entary to other general infetion revention+eas$res, s$h as entral line7assoiated &loodstrea+ infetion and ventilator ‐assoiated

ne$+onia &$ndles.

3G: K#4

(ig$re. Aroah to ontrol and revention of +ethiillin‐resistant Staphylococcus aureus

3MRSA4 trans+ission. IC, infetion ontrol.

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*a&le . Strength of Reo++endation and Q$ality of %videne

I. #asi raties for revention of MRSA trans+issionJ reo++ended for all a$te are

hositals

A. Co+onents of an MRSA trans+ission revention rogra+

9.

Cond$t an MRSA ris! assess+ent 3#‐III4.

a. Cond$t an MRSA ris! assess+ent. *his ris! assess+ent rovides a &aseline

for s$&se8$ent assess+ents and other data o+arisons.

&. *yes of data that an &e $sef$l in erfor+ing an MRSA ris! assess+ent

inl$de the follo2ingJ

i.

*he roortion of S. aureus isolates resistant to +ethiillin

ii. *he n$+&er of ne2 ases of MRSA oloniation or infetion over a

given eriod of ti+e 3inidene4

iii.

*he n$+&er of ne2 ases of 9 or +ore seifi tyes of MRSA

infetion 3s$h as &atere+ia4 over a given eriod of ti+e

3inidene4

iv. Point revalene s$rvey3s4 of MRSA oloniation or infetion

NoteJ *hese and other MRSA +etris are dis$ssed in greater detail

&elo2 in the Perfor+ane Meas$res setion of this do$+ent.

.

5se findings fro+ the ris! assess+ent to develo the hosital6s s$rveillane,

revention, and ontrol lan and to develo goals to red$e MRSA a8$isition

and trans+ission.


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.

I+le+ent an MRSA +onitoring rogra+ 3A‐III4.

a.

A rogra+ sho$ld &e in lae to identify and tra! atients fro+ 2ho+ MRSA

has &een isolated fro+ any linial or ative s$rveillane testing sei+en.

&.

A o++on detetion strategy $sed &y infetion ontrol rogra+s inl$des a

daily revie2 of la&oratory res$lts to identify atients fro+ 2ho+ MRSA has

&een isolated.

. A o++on +ethod of tra!ing MRSA is a line list or ase o$nt. *he line list

inl$des the first MRSA isolate, regardless of &ody site, er atient andinl$des isolates identified &y linial $lt$re and ative s$rveillane testing,

2hen availa&le. *hese isolates sho$ld &e lassified as either hosital‐ or

o++$nity‐onset MRSA &y $se of reseified definitions, as desri&ed a&ove.

In addition, atients !no2n to &e MRSA olonied or infeted on the &asis of

testing erfor+ed at another healthare faility +ay &e inl$ded in the line list.Additional infor+ation ontained in the line list +ay inl$de atient

identifiation, date of olletion of sei+en fro+ 2hih MRSA 2as isolated,

site fro+ 2hih sei+en 2as o&tained, and hosital loation at ti+e of

olletion. S$&se8$ent MRSA isolates fro+ an individ$al atient +ay also &einl$ded in the line list &$t sho$ld &e la&eled to avoid &eing o$nted as

additional ne2 ases. *he line list 2ill allo2 MRSA isolates to &e +onitored

and eval$ated at the $nitB2ard and organiational levels.

d. $to+e +eas$res related to MRSA in hositals are dis$ssed in +ore detail

&elo2 in this do$+ent.

?.

Pro+ote o+liane 2ith Centers for Disease Control and Prevention or 0orld Health

rganiation hand‐hygiene reo++endations 3A‐II4.

a.

I+le+ent a hand‐hygiene o+liane rogra+.

&.

Patient‐to‐ atient trans+ission of MRSA o++only o$rs thro$gh transient

oloniation of the hands of healthare ersonnel, and so+e investigators have

attri&$ted red$ed rates of MRSA a+ong hosital inatients to efforts +ade toi+rove hand‐hygiene raties.,

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.

Hand‐hygiene raties o+liant 2ith Centers for Disease Control and

Prevention or 0orld Health rganiation g$idelines are ritial to MRSA

trans+ission ontrol and revention. %videne‐ &ased reo++endations for

i+le+entation and assess+ent of hand‐hygiene rogra+s in healthare

settings have &een $&lished.?>

*he >>G 0orld Health rganiation)$idelines on Hand Hygiene in Health Care are availa&le online.?9

d. Infor+ation on ro+oting o+liane 2ith hand hygiene an &e fo$nd in +any

$&lished +aterials, s$h as the Instit$te for Healthare I+rove+ent6s Ho2‐

*o )$ideJ I+roving Hand Hygiene.?

:.

5se ontat rea$tions for MRSA‐olonied or ‐infeted atients 3A‐II4.

a. Plae atients 2ith MRSA oloniation or infetion $nder ontat rea$tions

to hel red$e atient‐to‐ atient sread of the organis+ 2ithin the hosital.,??

i.

Plae atients in a single or rivate roo+ 2hen availa&le. Cohorting

of atients 2ith MRSA oloniation or infetion is aeta&le 2hen

a single or rivate roo+ is not availa&le. Cohorting does noteli+inate the need for o+liane 2ith hand‐hygiene g$idelines and

other infetion revention +eas$res.

ii.

0ear a go2n and gloves on entry into the atient6s roo+.

iii.

Re+ove the go2n and gloves &efore eEiting the roo+.

iv.

5se aroriate hand hygiene on entering and eEiting the atient6s

roo+. 0earing gloves does not eli+inate the need for hand hygiene.

&. Address otential adverse events assoiated 2ith ontat rea$tions.

i.

%d$ate healthare ersonnel a&o$t isolation rea$tions, inl$ding

the &enefits and otential adverse effets assoiated 2ith ontat

rea$tions.

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ii.

Several $nontrolled st$dies have reorted that atients in isolation

are eEa+ined less fre8$ently and for shorter eriods, o+ared 2ith

those not in isolation.?:‐?= So+e st$dies have reorted signifiantly

inreased rates of deression and anEiety a+ong these atients.?<

iii. Patients isolated seifially for MRSA oloniation or infetion

2ere +ore li!ely to eEeriene reventa&le adverse events, s$h as ress$re $lers, falls, or eletrolyte i+&alanes, o+ared 2ith

nonisolated atients 2itho$t MRSA oloniation or infetion.?

iv.

A$thors of these st$dies e+hasied that additional st$dies are

needed to onfir+ their findings. So+e have also s$ggested that

hositals +onitor adverse events otentially attri&$ta&le to ontat

rea$tions.?

v.

*hese otential adverse events sho$ld not &e onsidered /$stifiation

to avoid the $se of ontat rea$tions &$t rather sho$ld serve as a

re+inder to ens$re that atients $nder ontat rea$tions reeiveade8$ate are.

vi.

%ns$re that hosital $lt$re and leadershi s$ort the roer $se of

and enfore adherene to ontat rea$tions for MRSA.

vii.

%d$ate atients, fa+ilies, and visitors a&o$t isolation rea$tions.

.

Criteria for disontin$ation of ontat rea$tions

i.

*he d$ration of ontat rea$tions neessary for atients olonied

or infeted 2ith MRSA re+ains an $nresolved iss$e.

ii.

St$dies have s$ggested that atients +ay have ersistent arriage of

MRSA for rolonged eriods 3+edian d$ration, .G +onths in onest$dy:>4 and that MRSA shedding an &e inter+ittent and th$s +ay

&e +issed if only a single s$rveillane $lt$re is erfor+ed.

http://www.jstor.org/stable/10.1086/591061#rf34http://www.jstor.org/stable/10.1086/591061#rf34http://www.jstor.org/stable/10.1086/591061#rf34http://www.jstor.org/stable/10.1086/591061#rf36http://www.jstor.org/stable/10.1086/591061#rf37http://www.jstor.org/stable/10.1086/591061#rf38http://www.jstor.org/stable/10.1086/591061#rf39http://www.jstor.org/stable/10.1086/591061#rf39http://www.jstor.org/stable/10.1086/591061#rf40http://www.jstor.org/stable/10.1086/591061#rf34http://www.jstor.org/stable/10.1086/591061#rf36http://www.jstor.org/stable/10.1086/591061#rf37http://www.jstor.org/stable/10.1086/591061#rf38http://www.jstor.org/stable/10.1086/591061#rf39http://www.jstor.org/stable/10.1086/591061#rf40


12/39

iii.

0ith regard to the d$ration of ontat rea$tions, Healthare

Infetion Control Praties Advisory Co++ittee g$idelines

reo++end the follo2ingJ

3a4 0hen ative s$rveillane testing is $sed to identify

MRSA‐olonied atients, ontat rea$tions are to &e

ontin$ed thro$gho$t the d$ration of hosital stay; a

reasona&le aroah to s$&se8$ent disontin$ation 2o$ld

&e to do$+ent learane of the organis+ 2ith ? or +ore

s$rveillane tests in the a&sene of anti+iro&ialeEos$re. 0hen to onsider retesting atients to

do$+ent learane is de&ata&le, &$t ?‐: +onths after the

last ositive test res$lt is o++only $sed as the ti+e

fra+e. So+e hositals +ay hoose to onsider MRSA‐

olonied atients to &e olonied indefinitely.

G.

%ns$re leaning and disinfetion of e8$i+ent and the environ+ent 3#‐III4.

a. MRSA onta+inates the atient6s environ+ent 3eg, over ‐ &ed ta&les, &ed rails,

f$rnit$re, sin!s, and floors4:9‐:= and atient are e8$i+ent 3eg, stethosoes

and &lood ress$re $ffs4.9G,9=,:

&.

Develo and i+le+ent rotools for leaning and disinfeting environ+ental

s$rfaes.

i. Selet aroriate leaning and disinfeting agents for environ+ental

s$rfaes. Reent g$idelines have o$tlined environ+ental disinfetion rotools.G9 Ro$tine leaning and disinfetion of the atient

environ+ent 2ith 5S %nviron+ental Protetion Ageny7registered

hosital disinfetants 3eg, 8$aternary a++oni$+ o+o$nds, sodi$+hyohlorite, iodohors, and henolis4 $sed in aordane 2ith the

+an$fat$rers6 diretions is ade8$ate to red$e MRSA onta+ination.

ii.

Develo 2ritten rotools for daily and ter+inal leaning and

disinfetion of atient roo+s.

http://www.jstor.org/stable/10.1086/591061#rf22http://www.jstor.org/stable/10.1086/591061#rf41http://www.jstor.org/stable/10.1086/591061#rf46http://www.jstor.org/stable/10.1086/591061#rf46http://www.jstor.org/stable/10.1086/591061#rf46http://www.jstor.org/stable/10.1086/591061#rf15http://www.jstor.org/stable/10.1086/591061#rf16http://www.jstor.org/stable/10.1086/591061#rf16http://www.jstor.org/stable/10.1086/591061#rf16http://www.jstor.org/stable/10.1086/591061#rf47http://www.jstor.org/stable/10.1086/591061#rf47http://www.jstor.org/stable/10.1086/591061#rf49http://www.jstor.org/stable/10.1086/591061#rf50http://www.jstor.org/stable/10.1086/591061#rf51http://www.jstor.org/stable/10.1086/591061#rf51http://www.jstor.org/stable/10.1086/591061#rf22http://www.jstor.org/stable/10.1086/591061#rf41http://www.jstor.org/stable/10.1086/591061#rf46http://www.jstor.org/stable/10.1086/591061#rf15http://www.jstor.org/stable/10.1086/591061#rf16http://www.jstor.org/stable/10.1086/591061#rf47http://www.jstor.org/stable/10.1086/591061#rf49http://www.jstor.org/stable/10.1086/591061#rf50http://www.jstor.org/stable/10.1086/591061#rf51


13/39

.

Pay lose attention to leaning and disinfetion of fre8$ently to$hed 3high‐

to$h4 s$rfaes in atient‐are areas 3eg, &ed rails, arts, &edside o++odes,

door!no&s, and fa$et handles4.

i. (or ter+inal leaning of roo+s of atients olonied or infeted 2ith

MRSA, ay seial attention to ens$ring ade8$ate overage of

environ+ental s$rfaes 2ith aroved disinfetants at aroriate

dil$tions for the aroriate a+o$nt of ontat ti+e.

ii.

A syste+ for +onitoring adherene to environ+ental leaning anddisinfetion rotools is desira&le.

iii.

Develo and i+le+ent rotools for leaning and disinfeting atient are e8$i+ent.

iv.

*o red$e MRSA onta+ination, disinfet orta&le healthare

e8$i+ent, s$h as stethosoes and otosoes, 2ith a F

isoroyl alohol s2a& or other disinfetant after eah $se.

d.

Dediate nonritial atient are ite+s, s$h as &lood ress$re $ffs andstethosoes, to a single atient 2hen they are !no2n to &e olonied or

infeted 2ith MRSA. 0hen this is not ossi&le, ens$re ade8$ate leaning and

disinfetion of ite+s &et2een atient eno$nters.

e. Provide aroriate training for ersonnel resonsi&le for leaning and

disinfeting the environ+ent and atient are e8$i+ent.

=.

%d$ate healthare ersonnel a&o$t MRSA, inl$ding ris! fators, ro$tes of

trans+ission, o$to+es assoiated 2ith infetion, revention +eas$res, and loal

eide+iology 3#‐

III4.

a.

Modify healthare ersonnel &ehaviorJ Several !ey o+onents of an effetive

MRSA trans+ission revention rogra+ involve +odifiation of healthare

ersonnel &ehavior 3eg, o+liane 2ith hand hygiene, ontat rea$tions,environ+ental disinfetion, and ative s$rveillane testing rotools4.


14/39

&.

Provide an ed$ational rogra+ to foster desired &ehavior hangesG and

inl$de a dis$ssion of MRSA ris! fators, ro$tes of trans+ission, o$to+es

assoiated 2ith infetion, revention +eas$res, loal MRSA eide+iology3MRSA infetion rates, et.4 and $rrent data regarding healthare ersonnel

o+liane 2ith infetion revention and ontrol +eas$res.

.

*arget ed$ational rogra+s on the &asis of healthare ersonnel needs 3eg,

rofessional or nonrofessional4. )iven the 2ide range of ed$ational

&a!gro$nds a+ong hosital ersonnel, several ed$ational rogra+s 2ill &eneeded to rovide the infor+ation neessary at the aroriate level for all

relevant ersonnel. S$&se8$ent ed$ational sessions and 2ritten

o++$niations +ay &e of +ore li+ited soe and +ay inl$de data related toMRSA roess and o$to+e +eas$res.

d. Inl$ding oinion leaders and role +odels in the ed$ational and &ehavioral

+odifiation rogra+ +ay &e $sef$l.


15/39

&.

Infor+ation +ay o+e fro+ rior testing &y the hosital syste+ or fro+

infor+ation s$lied &y a referring faility. *his infor+ation +ay &e integrated

into the o+$teried data&ase $sed d$ring ad+ission and registration or +ayeEist as a searate eletroni or aer ‐ &ased data&ase.

. *he alert sho$ld re+ain in effet $ntil learane of MRSA has &een

do$+ented &y s$&se8$ent $lt$re or other for+s of testing. 3See the

dis$ssion regarding the d$ration of ontat rea$tions.4

d.

I+le+ent a syste+ for o++$niating the MRSA stat$s of a atient 2hen

transferring hi+Bher to another hosital, so that aroriate rea$tions an &e

i+le+ented at the aeting faility.

.

Provide MRSA data and o$to+e +eas$res to !ey sta!eholders, inl$ding seniorleadershi, hysiians, and n$rsing staff 3#‐III4.

a. *he roess and o$to+e +eas$res o$tlined in the Perfor+ane Meas$res

setion of this do$+ent sho$ld &e rovided to aroriate hosital staff and

ad+inistrators on a reg$lar &asis. *he fre8$eny 2ith 2hih these data are

rovided 2ill deend on the hosital6s eEisting reorting str$t$re and the tye

of data olleted. *hese data an &e added to ro$tine 8$ality assess+ent and erfor+ane i+rove+ent reorts.

9>.

%d$ate atients and their fa+ilies a&o$t MRSA, as aroriate 3#‐III4.

a.

%d$ation of the atient and the atient6s fa+ily +ay hel to alleviate atientfears regarding &eing laed into isolation.G?

i.

Inl$de infor+ation a&o$t antiiated 8$estionsJ )eneral infor+ation

a&o$t MRSA, oloniation vers$s infetion, the hosital6s MRSAtrans+ission revention rogra+, the o+onents of and rationale for

ontat rea$tions, and the ris! of trans+ission to fa+ily and visitors2hile in the hosital and after disharge. Helf$l +ethods +ight

inl$de atient ed$ation sheets in aroriate lang$ages, atient

ed$ation hannels, 0e& sites, or video resentations.



16/39

#. Ao$nta&ility

9.

*he hosital6s hief eEe$tive offier and senior +anage+ent are resonsi&le for

roviding a healthare syste+ that s$orts an infetion revention and ontrol rogra+

that effetively revents healthare‐assoiated infetions and the trans+ission of

eide+iologially signifiant athogens.

. Senior +anage+ent is ao$nta&le for ens$ring that trained ersonnel are assigned to the

infetion revention and ontrol rogra+.

?.

Senior +anage+ent is ao$nta&le for ens$ring that healthare ersonnel, inl$dingliensed and nonliensed ersonnel, are o+etent to erfor+ their /o& resonsi&ilities.

:. Diret healthare roviders 3s$h as hysiians, n$rses, aides, and theraists4 and

anillary ersonnel 3s$h as ho$se!eeing and e8$i+ent‐ roessing ersonnel4 are

resonsi&le for ens$ring that aroriate infetion revention and ontrol raties are

$sed at all ti+es 3inl$ding hand hygiene, standard and isolation rea$tions, andleaning and disinfetion of e8$i+ent and the environ+ent4.

G.

Hosital and $nit leaders are resonsi&le for holding ersonnel ao$nta&le for their

ations.

=.

*he erson 2ho +anages the infetion revention and ontrol rogra+ is resonsi&le for

ens$ring that an ative rogra+ for identifying MRSA is i+le+ented, that data on

MRSA are analyed and reg$larly rovided to those 2ho an $se the infor+ation toi+rove the 8$ality of are 3eg, $nit staff, liniians, and hosital ad+inistrators4, and

that evidene‐ &ased raties are inororated into the rogra+.


17/39

II. Seial aroahes for the revention of MRSA trans+ission

Seial aroahes are reo++ended for $se in loations andBor o$lations 2ithin the hosital

that have $naeta&ly high MRSA rates desite i+le+entation of the &asi MRSAtrans+ission revention strategies listed a&ove. *here are several ontroversial iss$es regarding

revention of MRSA trans+ission. As a res$lt, i+le+entation of the reo++endations &eyondthe &asi raties to revent MRSA trans+ission sho$ld &e individ$alied at eah healthare

faility. (ailities +ay onsider a tiered aroah in 2hih reo++endations are instit$tedindivid$ally or in gro$s; additional tiers are added if MRSA rates do not i+rove, 2ith

i+le+entation of &asi raties as the first tier.

A. Ative s$rveillane testingJ MRSA sreening rogra+ for atients

Ative s$rveillane testing is &ased on the re+ise that linial $lt$res identify only as+all roortion of hosital atients 2ho are olonied 2ith MRSA and that

asy+to+atially olonied MRSA arriers serve as a s$&stantial reservoir for erson‐

to‐

erson trans+ission of MRSA in the a$te are hosital setting. St$dies have sho2n that

ro$tine $se of linial $lt$res alone does not identify the f$ll reservoir of

asy+to+atially olonied atients, $nderesti+ating the overall hosital‐2ide

revalene of MRSA &y as +$h as GFG: and $nderesti+ating the +onthly average revalene of MRSA in IC5s &y 9.=F‐=?.GF.GG In addition, ative s$rveillane testing

an red$e +islassifiation of MRSA isolates &y identifying atients 2ho are already

olonied at the ti+e of ad+ission, so that s$&se8$ent MRSA isolates are not falsely

attri&$ted to intrafaility a8$isition.GG

*he effetiveness of ative s$rveillane testing in the revention of MRSA trans+ission

is $rrently an area of ontroversy, and oti+al i+le+entation strategies 3inl$dingti+ing and target o$lations4 are $nresolved. Several $&lished st$dies of high‐ris! or

high‐ revalene o$lations 3inl$ding those in o$t&rea! sit$ations4 have sho2n an

assoiation &et2een the $se of ative s$rveillane testing to identify and isolate MRSA‐

olonied atients and the effetive ontrol of MRSA trans+ission andBor infetion.G=‐G

*2o reent st$dies eval$ated the i+at of $niversal ative s$rveillane testing

erfor+ed at the ti+e of hosital ad+ission o+&ined 2ith ad+inistration of

deoloniation theray to MRSA arriers and a+e to onfliting onl$sions. ne st$dy$sed an o&servational ohort design and reorted a signifiant red$tion in hosital‐

assoiated MRSA disease after the introd$tion of ative s$rveillane testing of all

atients and deoloniation of MRSA arriers.=> *he other st$dy $sed a rossover ohort

design and fo$nd no signifiant hanges in the inidene of nosoo+ial MRSA infetiona+ong s$rgial atients.=9 *here are several ossi&le eElanations for the differenes in

o$to+e o&served in these st$dies, inl$ding differenes in st$dy design, atient

o$lation, adherene to ro$tine infetion ontrol +eas$res, and adherene todeoloniation theray rotools. f note, a +$ltienter, l$ster ‐rando+ied trial

investigating the i+at of ative s$rveillane testing on MRSA in IC5s has &een erfor+ed, &$t the res$lts have not yet &een $&lished 3Clinial*rials.gov identifier

http://www.jstor.org/stable/10.1086/591061#rf54http://www.jstor.org/stable/10.1086/591061#rf55http://www.jstor.org/stable/10.1086/591061#rf55http://www.jstor.org/stable/10.1086/591061#rf55http://www.jstor.org/stable/10.1086/591061#rf56http://www.jstor.org/stable/10.1086/591061#rf56http://www.jstor.org/stable/10.1086/591061#rf56http://www.jstor.org/stable/10.1086/591061#rf59http://www.jstor.org/stable/10.1086/591061#rf60http://www.jstor.org/stable/10.1086/591061#rf61http://www.jstor.org/stable/10.1086/591061#rf61http://www.jstor.org/stable/10.1086/591061#rf54http://www.jstor.org/stable/10.1086/591061#rf55http://www.jstor.org/stable/10.1086/591061#rf55http://www.jstor.org/stable/10.1086/591061#rf56http://www.jstor.org/stable/10.1086/591061#rf59http://www.jstor.org/stable/10.1086/591061#rf60http://www.jstor.org/stable/10.1086/591061#rf61


18/39

NC*>>9>>?= 4.

*his 2as a very o+leE st$dy. Preli+inary analysis did not de+onstrate a &enefit fro+

ative s$rveillane testing d$ring the =‐+onth st$dy eriod $nder the seifi st$dy

rotool. *he a$thors have stated that those reli+inary res$lts sho$ld not &e $sed toonl$de that ative s$rveillane testing is $seless or that efforts to ontrol MRSA aref$tile.= *he final analysis and eer revie2 of st$dy +ethods, res$lts, and onl$sions are

ending.

#ea$se of onfliting res$lts fro+ these st$dies and the differenes a+ong a$te are

hositals and their assoiated atient o$lations, a seifi reo++endation regarding$niversal sreening for MRSA annot &e +ade. Ho2ever, ative s$rveillane testing as a

single intervention in the a&sene of a +$ltifaeted aroah to MRSA trans+ission

revention 3eg, the &asi +eas$res desri&ed a&ove4 is $nli!ely to &e $nifor+ly effetiveaross healthare instit$tions. Ative s$rveillane testing +ay, ho2ever, &e $sef$l in

failities that have i+le+ented and oti+ied adherene to &asi MRSA trans+ission revention raties &$t ontin$e to eEeriene $naeta&ly high MRSA rates.

9. I+le+ent an MRSA ative s$rveillane testing rogra+ as art of a +$ltifaeted

strategy to ontrol and revent MRSA trans+ission 2hen evidene s$ggests that there isongoing trans+ission of MRSA desite effetive i+le+entation of &asi raties 3#‐

II4.

Assess MRSA trans+ission as the &asis for deter+ining if, 2hen, and 2here ative

s$rveillane testing is to &e $sed at an individ$al hosital. In general, ative s$rveillane

testing is onsidered aroriate in a faility 2here there is diret or indiret evidene ofongoing MRSA trans+ission desite ade8$ate i+le+entation of and adherene to &asi

raties. Altho$gh the $se of serial ative s$rveillane testing of hosital atients

rovides the +ost a$rate +eas$re+ent of MRSA trans+ission, other +etris +ay &e$sed as s$rrogate +ar!ers for trans+ission 2hen o+rehensive ative s$rveillane

testing data are not availa&le. %Ea+les inl$de the follo2ingJ

L A high or inreasing revalene or inidene of hosital‐onset MRSA infetion

or oloniation

L An inidene of hosital‐onset MRSA infetion or oloniation that is not

dereasing desite the $se of &asi raties

L An inreasing roortion of hosital‐onset S. aureus isolates that are resistant to

+ethiillin

http://www.clinicaltrials.gov/ct2/show/NCT00100386?term=NCT00100386%5Bamp%20%5Drank=1http://www.jstor.org/stable/10.1086/591061#rf62http://www.clinicaltrials.gov/ct2/show/NCT00100386?term=NCT00100386%5Bamp%20%5Drank=1http://www.jstor.org/stable/10.1086/591061#rf62


19/39

L Identifiation of seifi hosital $nits in 2hih the oloniation ress$re 3ie,

the revalene rate of MRSA4 is a&ove the level assoiated 2ith an inreased ris!

of trans+ission 3S$h $nits +ay &e identified 2ith the $se of oint revalenes$rveys.4

L Identifiation of seifi atient o$lations at high ris! for MRSA oloniationor infetion

a.

Convene a +$ltidisilinary tea+ to revie2 the MRSA ris! assess+ent and to

lan and oversee the ative s$rveillane testing rogra+.

i.

#ea$se of the +$ltidisilinary nat$re of an ative s$rveillane

rogra+, reresentatives fro+ the +iro&iology la&oratory, infetion revention and ontrol ersonnel, n$rsing staff, +edial staff,

+aterials +anage+ent, environ+ental servies, and hosital

ad+inistration sho$ld &e involved in rogra+ develo+ent,i+le+entation, and reso$re alloation. Caref$l onsideration of the

reso$res neessary for an ative s$rveillane testing rogra+ is

essential to ens$re that the ative s$rveillane testing rogra+ is

i+le+ented roerly and that other i+ortant o+onents of thehosital6s infetion ontrol rogra+ are not disr$ted.

ii.

Cons$ltation 2ith a trained individ$al 2ho has eEertise in MRSAtrans+ission ontrol and revention +ay &e $sef$l for rogra+

develo+ent and assess+ent if s$h a erson is not availa&le 2ithinthe hosital.

iii.

Pilot the rogra+ in one loation &efore eEanding to other loations.Selet the ilot $nit on the &asis of the ris! or revalene of MRSA on

the $nit or the resene of +otivated leadershi and front‐line

ersonnel.

iv.

%Eand the rogra+ to additional $nits one the ilot rogra+ has

&een eval$ated and ad/$sted and initial goals have &een +et 3eg, +ore

than >F o+liane 2ith sei+en a8$isition4.

&.

Selet and identify the atient o$lation3s4 to &e sreened.



20/39

i.

Deter+ine 2hih atients to sreen 3eg, all atients vers$s high‐ris!

atients or atients on high‐ris! $nits4.

3a4

5se the MRSA ris! assess+ent to deter+ine 2hether all atients, atients ad+itted to seifi high‐ris! $nits 3eg,

the IC54, or high‐ris! atient o$lations 3regardless of

loation4 2ill &e inl$ded in the sreening rogra+.

3&4

Patient‐level ris! fators for MRSA oloniation 3eg, reent

ad+ission to a hosital or s!illed n$rsing faility, long‐ter+

he+odialysis, and reent anti+iro&ial theray4 +ay also &e $sed to deter+ine inl$sion in the sreening rogra+.=?

34

Consider availa&le infrastr$t$re and hosital‐seifi

harateristis 3sie; staffing for infetion revention and

ontrol, la&oratory, and n$rsing; atient o$lation; and

infor+ation tehnology s$ort4 2hen seleting the atient o$lation3s4 to &e sreened.

ii.

Develo and i+le+ent a syste+ to identify and sreen atients 2ho

+eet the sreening rogra+ riteria.

3a4

A relia&le syste+ for identifiation of all atients +eeting

the riteria for inl$sion in the sreening rogra+ is

neessary for the s$ess of the rogra+.

3&4

Identifiation of atients 2ho +eet riteria for MRSAsreening +ay &e +ore diffi$lt 2hen atient‐level ris!

fators, rather than atient are $nit, are $sed to deter+ine

inl$sion in the s$rveillane rogra+. *a!e this into

onsideration d$ring the lanning stages of the sreening rogra+. Hositals 2ith 2ell‐develoed eletroni +edial

reords and other o+$ter data&ases +ay &e a&le to

identify s$h atients &y $se of a o+$ter algorith+.



21/39

34

Consider develoing and i+le+enting a he!list to &e

o+leted at ad+ission to assist in identifying atients to

&e sreened for MRSA.

3d4 Deter+ine ho2 sreening sei+ens 2ill &e ordered 3eg,

rotool ad+ission order set or individ$al atient order4,2ho 2ill initiate the order 3eg, hysiian or n$rse4 and 2ho

2ill o&tain the sei+ens 3eg, $nit‐ &ased n$rsing ersonnel

or designated MRSA +onitoring rogra+ ersonnel4.

*hese deisions 2ill need to ta!e into ao$nt relevanthosital oliies, staffing, and infrastr$t$re.

.

Deter+ine 2hen to erfor+ sreening tests.

i.

At a +ini+$+, MRSA s$rveillane sho$ld &e erfor+ed at ad+ission

to the hosital or to the seifi $nit in 2hih s$rveillane is &eing

erfor+ed.

ii. *o detet trans+ission 2hile in the hosital, additional testing of

atients 2ith initial negative s$rveillane test res$lts an &e doneeither at reg$lar intervals 3eg, 2ee!ly4 or at disharge fro+ the

hosital or $nit.

iii.

*esting at reg$lar intervals has the otential to detet atients 2ho

have a8$ired MRSA d$ring their hositaliation earlier than testingonly at disharge and th$s allo2s i+le+entation of ontat

rea$tions to revent f$rther trans+ission.

iv.

0hen testing is to &e erfor+ed at reg$lar intervals, deter+ine a

seifi day of the 2ee! 2hen sei+ens 2ill &e olleted. *his 2ill

si+lify the roess and allo2 the +iro&iology la&oratory toantiiate the inreased vol$+e of sei+ens and lan staffing and

s$lies aordingly.

d.

Deter+ine the anato+i sites to inl$de in sreening rogra+.


22/39

i.

Identify the anato+i site3s4 to &e tested.

3a4

Anterior naresJ *he sensitivity of s$rveillane sei+ens

o&tained fro+ a variety of sites has &een eval$ated inseveral settings and atient o$lations. Altho$gh testing of

no single site 2ill detet all MRSA‐olonied ersons, the

anterior nares aear to &e the +ost fre8$ently ositive site,

2ith sensitivity ranging fro+


23/39

referene la&oratory4 that 2ill &e roviding the servie

3d4

N$+&er of sei+ens that 2ill &e roessed

3e4

(aility‐seifi ost‐ &enefit al$lations

iii. A detailed dis$ssion of the vario$s la&oratory +ethods for MRSA

detetion is &eyond the soe of this do$+ent, &$t so+e of the !eyfeat$res of the +ost o++on +ethods are dis$ssed &elo2.

3a4

C$lt$re‐ &ased +ethodsJ C$lt$re‐ &ased tehni8$es have

&een $sed in the +a/ority of MRSA sreening rogra+s.

N$+ero$s +iro&iologial +edia and tehni8$es have

&een desri&ed for $se in the detetion of MRSAoloniation. ne of the +ore o++only $sed seletive

+edia is +annitol salt agar 2ith or 2itho$t anti+iro&ial

3eg, oEaillin or efoEitin4 s$le+entation to inrease

seifiity for +ethiillin‐resistant organis+s. Additional

enrih+ent stes, s$h as overnight in$&ation intrytiase soy &roth, an f$rther inrease the yield of

standard $lt$re‐ &ased +ethods.


24/39

advantage of this tehnology is its a&ility to rovide a

res$lt less than ho$rs fro+ the ti+e of sei+en

olletion, altho$gh in at$al ratie the t$rnaro$nd ti+e

+ay &e longer &ea$se of &athing of sa+les. Altho$gh at

least 9 $nontrolled st$dy=

and a +athe+atial +odel<

have s$ggested that raid testing +ay allo2 for +ore

effetive $se of isolation rea$tions and enhaned revention of MRSA trans+ission, a reently $&lished

l$ster ‐rando+ied rossover trial of $niversal sreening

in general 2ards failed to identify a differene in MRSA

a8$isition rates 2ith the $se of raid testing, o+ared2ith the $se of a $lt$re‐ &ased +ethod. *hese data

s$ggest that the linial and eono+i &enefits of raid

testing +ay vary a+ong individ$al hositals and settings.

f. Clarify ho2 to +anage atients 2hile a2aiting the res$lts of sreening tests.

i.

#efore i+le+enting a sreening rogra+, a deision sho$ld &e +ade

as to ho2 a atient 2ill &e +anaged 2hile 2aiting for the res$lt of thead+ission MRSA sreening test. *here are o++on aroahesJ

3a4

A2ait the sreening test res$lt and i+le+ent ontat rea$tions only if the test res$lt is ositive.

3&4

Plae the atient $nder e+irial ontat rea$tions $ntil a

negative ad+ission sreening test res$lt is do$+ented.

ii.

I+le+enting ontat rea$tions at the ti+e of reeit of a ositive

sreening test res$lt is a reasona&le initial aroah. Altho$ghe+irial ontat rea$tions +ini+ie the ris! of MRSA trans+ission

fro+ $nreognied so$res and have &een sho2n to ontri&$te to

effetive ontrol of MRSA,G logistial diffi$lties are assoiated 2ith

this aroah. %+irial $se of ontat rea$tions s$&stantiallyinreases the need for single roo+s and the a+o$nt of s$lies needed

to ratie ontat rea$tions. 0hen only a s+all roortion of

sreened atients are olonied 2ith MRSA and single roo+s are ofli+ited 8$antity, a large n$+&er of atients 2hose sreening test

res$lts are negative 2ill need to &e +oved so that their single roo+ an

&e $sed for another atient. *hese roo+ reassign+ents and the

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neessary leaning &efore the vaated roo+ an &e reo$ied an

slo2 do2n atient flo2 2ithin the hosital. *he e+irial $se of

ontat rea$tions for all tested atients 2hile a2aiting test res$lts+ay &e +ost feasi&le in hositals in 2hih a relatively large roortion

of atient roo+s are single roo+s and in individ$al hosital $nits, s$has +any IC5s, in 2hih eah atient is in an individ$al roo+ or &ay.Desite its otential logistial diffi$lties, this aroah sho$ld &e

onsidered if trans+ission ontin$es desite introd$tion of a

sreening rogra+ in 2hih ontat rea$tions are i+le+ented only

after a ositive MRSA sreening test res$lt is o&tained.

g.

Assess the availa&ility of single roo+s and, if needed, lan for ohortingolonied or infeted atients.

i. 0hen develoing a sreening rogra+, address the availa&ility of

single roo+s for MRSA‐ ositive atients, inl$ding ohorting ersons

olonied or infeted 2ith the sa+e organis+, 2hen single roo+s are

not availa&le. Consider the follo2ingJ

3a4 Prioritie MRSA‐ ositive atients 2ho are at greater ris!

for trans+ission 3eg, those 2ith draining 2o$nds4 for a

single roo+.

3&4 %ns$re that atients 2ho are !no2n or s$seted to have

other indiations for isolation rea$tions 3eg, oloniation

or infetion 2ith other +$ltidr$g‐resistant organis+s,

infl$ena, or t$&er$losis4 are not ohorted 2ith MRSA‐

ositive atients.

34

Cohorting does not eli+inate the need for f$ll o+liane

2ith hand hygiene and other &asi revention

reo++endations.

h.

Assess the availa&ility of ersonal rotetive e8$i+ent and other s$lies.

i. %ns$re that go2ns, gloves, and hand‐hygiene rod$ts 3eg, alohol‐

&ased hand r$&s, soa, and aer to2els4 are onsistently availa&le to


26/39

healthare ersonnel. *he sreening rogra+ 2ill not &e effetive if

healthare ersonnel are not a&le to o+ly 2ith ontat rea$tions

&ea$se of a la! of s$lies.

3a4 Cooeration a+ong the $rhasing deart+ent,

la$ndryBlinen servie 3if re$sa&le go2ns are seleted4, and$nit‐ &ased ersonnel is i+erative.

3&4

Infetion revention and ontrol eEerts, arti$larly thosefa+iliar 2ith the $se of ative s$rveillane, an serve as a

reso$re to hel hositals esti+ate the n$+&er of atients

li!ely to &e fo$nd to &e olonied 2ith MRSA and, th$s, thea+o$nt of s$lies needed.

i.

Assess o+liane 2ith the sreening rotool.

i.

Monitor o+liane 2ith the sreening and ontat rea$tions

rotools, &ea$se s$&oti+al o+liane 2ill revent the s$rveillane

rogra+ fro+ roviding its +aEi+al &enefit. *he +onitoring rogra+

sho$ld ens$re that the follo2ing +eas$res are ta!enJ

3a4

Sreening tests are olleted and roessed aording to

rotool.

3&4

Infetion revention and ontrol ersonnel are notified of

ositive res$lts 2ithin the roer ti+e fra+e.

34

*he linial ersonnel aring for the atient are notified of

ositive res$lts 2ithin the roer ti+e fra+e.

#. Ative s$rveillane testing for MRSA a+ong healthare ersonnel

Sreening of healthare ersonnel for MRSA is not ro$tinely reo++ended in settings of ende+iity $nless they have &een eide+iologially lin!ed to ne2 MRSA ases.


27/39

Sreening of healthare ersonnel for MRSA sho$ld &e onsidered in an o$t&rea! setting.

9.

Sreen healthare ersonnel for MRSA infetion or oloniation only if they are

eide+iologially lin!ed to a l$ster of MRSA infetions 3#‐III4.

a.

Healthare ersonnel an &eo+e transiently or ersistently olonied 2ith

MRSA, and this has &een deter+ined to &e the so$re of several o$t&rea!s in

hositals. Mole$lar testing 3eg, $lse‐field gel eletrohoresis4 to esta&lish

lonality of MRSA isolates has &een $sef$l in s$h sit$ations.‐?

C. Ro$tine &athing 2ith hlorheEidine

Reent st$dies have de+onstrated that the $se of hlorheEidine for ro$tine leansing of

ad$lt IC5 atients +ay derease the inidene of atient a8$isition of MRSA: and

vano+yin‐resistant EnterococcusG and +ay red$e the inidene of atheter ‐

assoiated &loodstrea+ infetions.= *he effet of hlorheEidine on trans+ission of &aterial athogens is li!ely d$e to a red$tion in the &$rden of organis+s on the s!in of

olonied or infeted atients, 2ith a s$&se8$ent red$tion in onta+ination of

environ+ental s$rfaes and the hands of healthare 2or!ers.G *he $se of hlorheEidine

for ro$tine atient leansing o$tside of the ad$lt IC5 setting has not &een st$died.

9.

Ro$tinely &athe ad$lt IC5 atients 2ith hlorheEidine 3#‐III4.

a.

5se hlorheEidine rather than reg$lar soa and 2ater or other non+ediated

leansing regi+ens for ro$tine atient leansing.

&. A variety of hlorheEidine rod$ts that o$ld &e $sed for atient &athing are

availa&le. *hese inl$de single‐$se &ottles of a8$eo$s hlorheEidine that an &e

added to a &asin of 2ater and F hlorheEidine‐i+regnated loths. It sho$ld &e

noted that the $se of $ndil$ted :F a8$eo$s hlorheEidine sol$tion for s!inleansing has &een assoiated 2ith a relatively high rate of reversi&le adverse

s!in effets 3eg, s!in fiss$res, ithing, and &$rning of the s!in4.<

.

0hen $sing hlorheEidine, the +an$fat$rer6s reo++endations sho$ld &e

follo2ed. Care +$st &e ta!en to avoid ontat 2ith the eyes and +iddle ear 3eg,

in atients 2ith erforated ty+ani +e+&ranes4. ChlorheEidine is in 5S (ood

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and Dr$g Ad+inistration Pregnany Category C.

D. MRSA deoloniation theray for MRSA‐olonied ersons

MRSA deoloniation theray an &e defined as the ad+inistration of toialanti+iro&ial or antiseti agents, 2ith or 2itho$t syste+i anti+iro&ial theray, to

MRSA‐olonied ersons for the $rose of eradiating or s$ressing the arrier state.

*he $se of MRSA deoloniation theray in on/$ntion 2ith ative s$rveillane testing

+ay &e a $sef$l ad/$ntive +eas$re for revention of MRSA trans+ission 2ithin a

hosital. (or eEa+le, one gro$ of investigators o&served a GF red$tion in inidentases of MRSA oloniation or infetion a+ong ad$lt IC5 atients after the introd$tion

of a deoloniation regi+en for all MRSA‐olonied atients. Deoloniation theray

has also &een a o+onent of several s$essf$l MRSA o$t&rea! ontrol rogra+s.‐9>9

Deoloniation theray has also &een $sed in ertain atient o$lations in an atte+t to

red$e the ris! of s$&se8$ent S. aureus infetion a+ong olonied ersons. *hese

o$lations have inl$ded atients $ndergoing dialysis,9> atients 2ith re$rrent S.aureus infetions, and atients $ndergoing ertain s$rgial roed$res.9>? ($rther

dis$ssion of this toi is &eyond the soe of this do$+ent.

9.

Provide deoloniation theray to MRSA‐olonied atients in on/$ntion 2ith an

ative s$rveillane testing rogra+ 3#‐III4.

a. *he oti+al deoloniation theray regi+en has not &een deter+ined. Most

eEeriene has &een 2ith the $se of F +$iroin ad+inistered intranasally

2ith or 2itho$t hlorheEidine &athing. In the revio$sly +entioned st$dy that

o&served a red$tion in inident ases of MRSA oloniation or infetion afterthe introd$tion of deoloniation theray, the deoloniation regi+en onsisted

of intranasal ad+inistration of F +$iroin t2ie daily for G days and

hlorheEidine &aths for < days. In that st$dy, &ed &aths 2ere erfor+ed afteradding a :‐o &ottle of :F hlorheEidine gl$onate to a =‐8t &asin of 2ar+

2ater.

&. Co+liations of deoloniation theray are relatively $no++on; ho2ever,

hosital ersonnel involved in the deoloniation theray rogra+ sho$ld &e

fa+iliar 2ith otential adverse effets, s$h as develo+ent of resistane to the

agents $sed 3eg, +$iroin4 and dr$g‐related toEiities.

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III. 5nresolved Iss$es

*here are a n$+&er of $nresolved iss$es related to MRSA and its trans+ission. A f$ll dis$ssion

of these iss$es is &eyond the soe of this do$+ent, &$t a &rief +ention of so+e of thesei+ortant tois is 2orth2hile. (or eEa+le, the i+at of anti+iro&ial ste2ardshi efforts on

the ris! of MRSA infetion and trans+ission has not &een learly defined. Also, f$rther st$dy ofthe eide+iology and revention of MRSA trans+ission a+ong fa+ily +e+&ers and other lose

ontats of ersons olonied or infeted 2ith MRSA is needed. Additionally, the e+ergene ofo++$nity‐assoiated MRSA has f$rther o+liated the eide+iology of MRSA in healthare

failities and has generated ne2 8$estions related to MRSA trans+ission revention in hositals.

ne s$h toi that re8$ires f$rther st$dy is the aroah to detetion of arriers of o++$nity‐

assoiated MRSA. C$rrent aroahes that are largely &ased on the eide+iology of hosital‐

assoiated MRSA +ay &e s$&oti+al, given differenes in ris! fators for oloniation and the

resene of so+e evidene that s$ggests that there are differenes in the redo+inant sites ofoloniation, o+ared 2ith hosital‐assoiated MRSA. Differenes in anti+iro&ial

s$seti&ility and vir$lene &et2een tyial hosital‐assoiated MRSA and o++$nity‐

assoiated MRSA s$ggest that the henotyi harateristis 3eg, anti+iro&ial s$seti&ility4 ofMRSA isolates fro+ individ$al atients +ay need to &e onsidered 2hen it &eo+es neessary to

ohort atients 2ith MRSA oloniation or infetion. *hese and other asets of MRSAtrans+ission and ontrol re8$ire f$rther investigation.

Section #: Performance Measures

"$+ *o Setion...

I. Internal reorting

*hese erfor+ane +eas$res are intended to s$ort internal hosital 8$ality i+rove+entefforts and do not neessarily address eEternal reorting needs. *he roess and o$to+e

+eas$res s$ggested here are derived fro+ $&lished g$idelines>‐,?> and other relevant

literat$re.G Additional infor+ation regarding the rationale for and signifiane of so+e of these

+eas$res is rovided in the AendiE. A +ore detailed desrition of these and other o$to+e+eas$res that +ay &e $sef$l for MRSA trans+ission revention rogra+s is rovided in the

Soiety for Healthare %ide+iology of A+eriaBHealthare Infetion Control Praties

Advisory Co++ittee osition aer on +eas$re+ent of +$ltidr$g‐resistant organis+s in

healthare settings.> Proess and o$to+e +eas$res sho$ld &e reorted to senior hositalleadershi, n$rsing leadershi, and liniians 2ho are for atients at ris! for MRSA infetion or

oloniation.

A. Proess +eas$res i+ortant for all a$te are hositals

9.

Co+liane 2ith hand‐hygiene g$idelines

a.

Monitor healthare ersonnel o+liane 2ith hand‐hygiene g$idelines &oth

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&efore and after ontat 2ith the atient or environ+ent.

&.

Preferred +eas$re of hand‐hygiene o+liane

i.

N$+eratorJ n$+&er of o&served ade8$ate hand‐hygiene eisodes

erfor+ed &y healthare ersonnel.

ii. Deno+inatorJ n$+&er of o&served oort$nities for hand hygiene.

iii.

M$ltily &y 9>> so that the +eas$re is eEressed as a erentage.

. Co+liane 2ith ontat rea$tions

a.

*his assess+ent sho$ld &e erfor+ed only as an internal +eas$re in instit$tions

that $se ontat rea$tions as art of a MRSA trans+ission revention rogra+. *his +etri has not &een validated for, and sho$ld not &e $sed for,

interhosital o+arisons.

&.

Preferred +eas$re of ontat rea$tions o+liane

i.

N$+eratorJ n$+&er of o&served atient are eisodes in 2hih

ontat rea$tions are aroriately i+le+ented.

ii. Deno+inatorJ n$+&er of o&served atient are eisodes in 2hih

ontat rea$tions are indiated.

iii.


#. Proess +eas$res for settings 2here ative s$rveillane testing for MRSA has &eeni+le+ented

9.

Co+liane 2ith the MRSA ative s$rveillane testing rogra+


31/39

a.


that $se ative s$rveillane testing as art of a MRSA trans+ission revention rogra+. *his +etri has not &een validated for, and sho$ld not &e $sed for,


&.

Preferred +eas$re of o+liane 2ith the ative s$rveillane testing rogra+J

Deter+ine the erentage of ersons fro+ 2ho+ sreening test sei+ens 2ere

aroriately olleted.

i.

N$+eratorJ n$+&er of ersons fro+ 2ho+ s$rveillane sei+ens

2ere aroriately olleted.

ii.

Deno+inatorJ n$+&er of ersons +eeting the seleted riteria for

s$rveillane testing.

iii.


C. $to+e +eas$res i+ortant for all a$te are hositals

9.

Methiillin resistane a+ong S. aureus isolates

a.

*he Clinial and -a&oratory Standards Instit$te has iss$ed a onsens$s

do$+ent to assist linial la&oratories in the rearation of this tye of

infor+ation.9>:

&.

*he roortion of inatient S. aureus isolates resistant to +ethiillin isal$lated as 9 +in$s the roortion of isolates s$seti&le to +ethiillin. *he

roortion of inatient isolates s$seti&le to +ethiillin is al$lated as

follo2sJ

i.

N$+eratorJ n$+&er of nond$liate S. aureus isolates s$seti&le to

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+ethiillin reovered fro+ inatients.

ii.

Deno+inatorJ total n$+&er of S. aureus isolates reovered fro+

inatients.

iii.


.

Inidene or inidene density of hosital‐onset MRSA &atere+ia

a.

Ho2 to al$late the inidene of hosital‐onset MRSA &atere+ia

i.

N$+eratorJ n$+&er of first &loodstrea+ MRSA isolates er infetion

for eah $nit or faility that o$r +ore than ? alendar days afterad+ission to the $nit or faility d$ring the s$rveillane eriod 3eg, 9

+onth4.

ii.

Deno+inatorJ n$+&er of atient ad+issions for that $nit or faility

d$ring the s$rveillane eriod 3eg, 9 +onth4.

iii. M$ltily &y 9>> so that the +eas$re is eEressed as ases er 9>>

atient ad+issions.

&.

Ho2 to al$late the inidene density of hosital‐onset MRSA &atere+ia

i.

N$+eratorJ n$+&er of first &loodstrea+ MRSA isolates er infetion

for eah $nit or faility that o$r +ore than ? alendar days afterad+ission to the $nit or faility d$ring the s$rveillane eriod 3eg, 9

+onth4.

ii.

Deno+inatorJ n$+&er of atient‐days for that $nit or faility d$ring

the s$rveillane eriod 3eg, 9 +onth4.

iii.

M$ltily &y 9,>>> so that the +eas$re is eEressed as ases er 9,>>>


33/39

atient‐days.

. 0ith regard to the n$+erator $sed in the al$lation of hosital‐onset MRSA

&atere+ia inidene and inidene density, a single atient o$ld &e o$nted+ore than one in a s$rveillane eriod 3eg, 9 +onth4 if the ositive &lood

$lt$re res$lts are fro+ sa+les olleted at least 9: days aart. Si+ilarly,

+$ltile &loodstrea+ MRSA isolates fro+ the sa+e atient sho$ld not &eo$nted as $ni8$e infetions if the sa+les are olleted 2ithin 9: days after a

revio$s ositive $lt$re sa+le, even if it sans s$rveillane eriods. Note

that this +etri inl$des &oth ri+ary and seondary &loodstrea+ infetions as

defined &y the National Healthare Safety Net2or!, Centers for Disease Controland Prevention.

?.

Inidene or inidene density of hosital‐onset MRSA 3See setion .9, S$rveillane

Definitions, for the definition of hosital‐onset MRSA.4

a. Ho2 to al$late the inidene of hosital‐onset MRSA

i.

N$+eratorJ n$+&er of first MRSA isolates 3fro+ oloniation or

infetion4, regardless of so$re, er atient for eah $nit or faility

fro+ sei+ens o&tained +ore than ? alendar days after ad+ission tothe $nit or faility deteted d$ring the s$rveillane eriod 3eg, 9

+onth4. *his inl$des MRSA identified fro+ linial $lt$re and

ative s$rveillane testing, if erfor+ed. *his eEl$des historiallyMRSA‐ ositive atients 3ie, atients 2ith a !no2n history of MRSA

ositivity4.

ii.

Deno+inatorJ n$+&er of atient ad+issions for that $nit or faility


iii.

M$ltily &y 9>> so that the +eas$re is eEressed as ases er 9>> atients.

&. Ho2 to al$late the inidene density of hosital‐onset MRSA

i.



34/39

infetion4, regardless of so$re, er atient for eah $nit or faility

fro+ sei+ens o&tained +ore than ? alendar days after ad+ission to

the $nit or faility deteted d$ring the s$rveillane eriod 3eg, 9+onth4. *his inl$des MRSA identified fro+ linial $lt$re and

ative s$rveillane testing, if erfor+ed4. *his eEl$des historiallyMRSA‐ ositive atients 3ie, atients 2ith a !no2n history of MRSA

ositivity4.

ii.

Deno+inatorJ n$+&er of atient‐days for that $nit or faility d$ring

the s$rveillane eriod 3eg, 9 +onth4.

iii.

M$ltily &y 9,>>> so that the +eas$re is eEressed as ases er 9,>>>

atient‐days.

D. SeialBadvaned o$to+e +eas$res

*he &asi o$to+e +eas$res inl$ded in the revio$s setion are designed to rovide

esti+ates of those o$to+es 3eg, atients 2ith ne2 a8$isition of MRSA4 that +ay &e

+ost raidly infl$ened &y an effetive MRSA trans+ission revention rogra+. *he revalene +eas$res listed here rovide esti+ates of the overall &$rden of MRSA

oloniation and infetion in a hosital, inl$ding those atients already !no2n to &e

olonied 2ith MRSA. *his +ay allo2 a hosital to esti+ate the a+o$nt of eEos$re that

atients in that hosital have to other atients 2ho are either olonied or infeted 2ithMRSA and 2ho o$ld therefore otentially trans+it MRSA. S$h infor+ation +ay &e

$sef$l in deter+ining the need for and designing ertain o+onents of an MRSAtrans+ission revention rogra+, s$h as an ative s$rveillane testing rogra+.

9.

verall revalene or revalene density of MRSA oloniation andBor infetion

a.

Ho2 to al$late the overall revalene of MRSA oloniation andBor infetion

i.

N$+eratorJ total n$+&er of atients d$ring a given s$rveillane eriod3eg, +onth4 2ho 2ere !no2n to &e olonied or infeted 2ith MRSA

3inl$des all atients 2ith MRSA as deter+ined &y +edial history,

revio$s linial $lt$res, and, if availa&le, ative s$rveillanetesting4.


35/39

ii.

Deno+inatorJ n$+&er of atient ad+issions d$ring s$rveillane

eriod 3eg, 9 +onth4.

iii.


.

Ad+ission revalene of MRSA oloniation andBor infetion

a.

Ho2 to al$late ad+ission revalene of MRSA oloniation andBor infetion

i.


infetion4, regardless of so$re, er atient for eah $nit or failityfro+ sei+ens o&tained less than ? alendar days after ad+ission to

the $nit or faility, deteted d$ring the s$rveillane eriod 3eg, 9

+onth4. *his inl$des MRSA identified fro+ linial $lt$re and, if

availa&le, ative s$rveillane testing l$s the n$+&er of historiallyMRSA‐ ositive atients 3ie, atients 2ith a !no2n history of MRSA

ositivity4.

ii.

Deno+inatorJ n$+&er of atient ad+issions for that $nit or failityd$ring the s$rveillane eriod 3eg, 9 +onth4.

iii.


?.

Point revalene of MRSA oloniation andBor infetion

a.

Point revalene s$rveys tyially involve erfor+ing ative s$rveillane testing

on all atients in the o$lation of interest 3eg, all atients 2ith a seifi ris!

fator, all atients in a seifi hosital $nit or $nits, or all atients in the

hosital4 at a seifi oint in ti+e. In the a&sene of an ongoing MRSA atives$rveillane testing rogra+, oint revalene s$rveys +ay &e $sef$l in

identifying o$lations or loations in 2hih there is a high level of ende+iMRSA or, 2hen erfor+ed serially, in +onitoring the i+at of MRSA

trans+ission revention ativities.

&.

Ho2 to al$late the oint revalene of MRSA oloniation andBor infetion


36/39

i.

N$+eratorJ total n$+&er of MRSA isolates 3fro+ oloniation or

infetion4, regardless of sei+en so$re 3eg, linial $lt$re or atives$rveillane testing4, er atient for eah $nit or faility at the ti+e of

the s$rvey.

ii.

Deno+inatorJ total n$+&er of atients on the $nit or in the faility at

the ti+e of the s$rvey.

iii. M$ltily &y 9>> so that the +eas$re is eEressed as a erentage.

:. Inidene or inidene density of MRSA infetion3s4

a.

S$rveillane for hosital‐assoiated MRSA infetions 3eg, devie‐assoiated or

roed$re‐assoiated infetions4 +ay &e $sef$l to assess the &$rden of seifi

MRSA infetions and to +onitor the i+at of revention ativities 2ithin a

faility or o$lation. ($rther dis$ssion of this tye of s$rveillane is &eyondthe soe of this do$+ent. Additional infor+ation and g$idane related to

erfor+ing this tye of s$rveillane is availa&le fro+ the National Healthare

Safety Net2or!.9>G

%. $to+e +eas$res for settings 2here ative s$rveillane testing for MRSA has &eeni+le+ented

9.

MRSA trans+ission inidene

a.


that $se ative s$rveillane testing as art of a MRSA trans+ission revention rogra+. *his +etri has not &een validated for, and sho$ld not &e $sed for,


&. Ho2 to al$late MRSA trans+ission inidene



37/39

i.

N$+eratorJ n$+&er of atients 2itho$t a history of MRSA

oloniation or infetion and 2ith a revio$sly negative MRSA

s$rveillane test res$lt 2ho s$&se8$ently have a ositive MRSAs$rveillane test res$lt or linial $lt$re res$lt d$ring the s$rveillane

eriod 3eg, 9 +onth4.

ii.

Deno+inatorJ total n$+&er of atients or n$+&er of atients 2itho$t a

history of MRSA 2ith a negative MRSA s$rveillane test res$lt


iii. M$ltily &y 9,>>> so that the +eas$re is eEressed as trans+issions

er 9,>>> atients.

II. %Eternal reorting

Many hallenges eEist in roviding $sef$l infor+ation to ons$+ers and other sta!eholders and

in reventing $nintended onse8$enes of $&li reorting of HAIs. 9>= Reo++endations for

$&li reorting of HAIs have &een rovided &y the Hosital Infetion Control PratiesAdvisory Co++ittee,9>


38/39

Ac$no%ledgments

"$+ *o Setion...

(or Potential Conflits of Interest state+ents and infor+ation on finanial s$ort, lease see the

A!no2ledg+ents in the %Ee$tive S$++ary, on age S> of this s$le+ent.

Appendi&

Performance Measures Rationale

"$+ *o Setion...

Process Measures

"$+ *o Setion...

Co+liane 0ith Hand Hygiene

Altho$gh several +eas$re+ents of o+liane 2ith hand hygiene have &een desri&ed, there is$rrently no standardied +ethod of +eas$re+ent, and eah +ethod is assoiated 2ith ertain

advantages and disadvantages.99> )$idelines for hand hygiene in healthare settings desri&e

indiators for $se in +eas$ring i+rove+ents in hand hygiene a+ong healthare ersonnel.?>

*he first is a diret +eas$re+ent of adherene, al$lated as the n$+&er of hand‐hygiene

eisodes erfor+ed &y healthare ersonnel divided &y the n$+&er of o&served oort$nities for

hand hygiene. *he res$lt is then +$ltilied &y 9>> to deter+ine the erentage of oort$nities

in 2hih hand hygiene is erfor+ed. Ideally, the goal for o+liane sho$ld &e 9>>F. *hese

data sho$ld &e olleted on a reg$lar &asis &y $se of a standardied data olletion for+.Colletion and analysis of o&servation data at the $nit‐seifi and /o& ategory7seifi 3eg,

hysiian, n$rse, or resiratory theraist4 level sho$ld &e onsidered, eseially in larger

hositals, so that ed$ation and enfore+ent reso$res an &e alloated aroriately. *he other

s$ggested erfor+ane indiator for hand hygiene al$lates the vol$+e of alohol‐ &ased hand

r$& 3or soa for hand 2ashing4 $sed er atient day. ($rther dividing this &y the average vol$+eof hand‐hygiene rod$t $sed er hand‐hygiene eisode rovides an esti+ate of the n$+&er of

hand‐hygiene eisodes erfor+ed er atient day. Altho$gh this seond indiator an &e a $sef$l

and, in +any instanes, +$h less reso$re‐intensive +ethod for +onitoring trends over ti+e,

the data +ay not &e as +eaningf$l to healthare ersonnel and do not rovide the detail andoort$nity for i++ediate feed&a! that diret o&servation rovides.

Co+liane 0ith Contat Prea$tions

Hositals sho$ld eriodially +onitor healthare ersonnel adherene to ontat rea$tions 3ie,

roer $se and re+oval of go2n and gloves4 2hen roviding are to atients olonied orinfeted 2ith MRSA 3or to other atients for 2ho+ ontat rea$tions have &een i+le+ented4.

Adherene to ontat rea$tions is a diret +eas$re+ent, al$lated as the n$+&er of o&served

atient are eisodes in 2hih ontat rea$tions are aroriately i+le+ented divided &y the

http://www.jstor.org/stable/10.1086/591061#rf110http://www.jstor.org/stable/10.1086/591061#rf30http://www.jstor.org/stable/10.1086/591061#rf110http://www.jstor.org/stable/10.1086/591061#rf30


39/39

n$+&er of o&served atient are eisodes in 2hih ontat rea$tions are indiated. *he res$lt

is then +$ltilied &y 9>> to give the erentage of oort$nities in 2hih ontat rea$tions are

aroriately i+le+ented. *he fre8$eny of o&servation and the n$+&er of oort$nities thatsho$ld &e o&served 2ill vary a+ong hositals &$t +$st &e s$ffiient to allo2 +eaningf$l

interretation of the data. *hese data sho$ld &e olleted on a reg$lar &asis &y $se of a

standardied data olletion for+. As 2ith hand hygiene, olletion and analysis of data at the$nitB2ard‐ and /o& ategory7seifi level is reo++ended, eseially in larger hositals, so that

ed$ation and enfore+ent an &e targeted aroriately. Ideally, the goal for o+liane sho$ld

&e 9>>F.

Co+liane 0ith Ative S$rveillane *esting

0hen ative s$rveillane testing is inl$ded in MRSA trans+ission revention ativities,o+liane 2ith the sreening rotool sho$ld &e +onitored. *his is al$lated as the n$+&er of

ersons fro+ 2ho+ s$rveillane sei+ens 2ere o&tained divided &y the n$+&er of ersons

+eeting the seleted riteria for s$rveillane. Ideally, this statisti sho$ld &e al$lated at the

level of the individ$al $nit, so that identifiation of &arriers to sei+en olletion an &edeter+ined and aroriate interventions an &e +ade. *his is eseially i+ortant if different

individ$als are resonsi&le for ordering andBor olleting sei+ens on different $nits. It is

$nli!ely that 9>>F o+liane 2o$ld &e ro$tinely ahieva&le, &ea$se of $nontrolla&le eventss$h as the transfer of a atient to another loation 3eg, an oerating roo+ or IC54, the death of a

atient 2itho$t s$ffiient ti+e for sa+ling, or a atient6s ref$sal to $ndergo testing. A goal of

>F or greater +ay &e +ore reasona&le.

'utcome Measures

"$+ *o Setion...

0hen o+aring trends in o$to+e +eas$res over ti+e, one +$st &e a2are of hanges indetetion tehni8$es 3eg, hange to a +ore sensitive detetion +ethod or addition or eEansion

of a sreening rogra+4 so that data an &e interreted aroriately. (or instane, the addition

of a sreening rogra+ for MRSA 2ill +ost li!ely res$lt in a nota&le inrease in the n$+&er of

ne2 MRSA ases identified. If this hange in s$rveillane tehni8$es is not onsidered d$ringdata analysis, an inrease in identified ases o$ld &e inorretly interreted as evidene of

inreased trans+ission. A +ore detailed desrition of o$to+e +eas$res that +ay &e $sef$l for

MRSA trans+ission revention rogra+s is rovided in the Soiety for Healthare%ide+iology of A+eriaBHealthare Infetion Control Praties Advisory Co++ittee osition

aer on +etris for +$ltidr$g‐resistant organis+s in healthare settings.>

strategies to prevent transmission of methicillin

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