Download MRSA Policy Template for General Practice

Meticillin Resistant Staphylococcus Aureus
(MRSA) Policy Template for General Practice Use
Provided by
Community Infection Prevention & Control Team
Mansfield & Ashfield CCG
Birch House
Ransom Wood Business Park
Southwell Road West
Mansfield
Nottinghamshire
NG210HJ
Direct dial: 01623 673081
March 2017
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Contents
Section
Page Number
1.Introduction
3
2.Scope
3
3. Purpose
3
4. Definitions
3
5. Responsibilities
4
6. Delivery of Care
5
7. Control of MRSA
8
8. Monitoring and Review
9
9. Equality and Diversity Statement
9
10. Protocol
11
11. How to apply Chlorhexidine / Octenisan bodywash and Mupiricin
(Bactroban) ointment
12
12. References
13
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3
1. Introduction
The aim of this policy is to provide information to staff working within Primary Care
organisations within Nottinghamshire Clinical Commissioning Groups (CCG) (excluding
Bassetlaw) to ensure that people with MRSA (Meticillin Resistant Staphylococcus Aureus)
are managed appropriately and effectively in order to limit the spread within primary care.
The Department of Health have stated that all Organisations are directly accountable for
reducing the rate of MRSA bacteraemia in their local population. Each organisation has been
given a zero tolerance target for avoidable MRSA bacteraemia infections
2. Scope
This policy has been written for all staff working within Primary Care to:

Explain what MRSA is and to highlight the standard infection prevention and control
principles that should be applied by staff to minimise the spread.

Ensure that patients who are found to be MRSA positive are informed of their
diagnosis, given the correct information about MRSA, its treatment and any follow up
required.

Ensure that patients who are found to be positive for MRSA are offered
decolonisation treatment in accordance with this policy.

Ensure that all patients who require screening for MRSA are screened according to
this policy
3. Purpose
The Health and Social Care Act 2008, states the need for health and social care providers to
have policies in place that will help to prevent and control infections. The purpose of this
policy is to ensure that staff, working within Primary Care in Nottinghamshire CCGs, have
sufficient information to effectively care for and manage patients with MRSA.
4. Definitions
4.1 MRSA - Staphylococcus aureus (SA) is a common bacteria, which may be found on the
skin of around one third of healthy adults. Meticillin Resistant Staphylococcus aureus
(MRSA) is a strain of SA that is resistant to many antibiotics, in particular flucloxacillin, which
is the standard treatment for many staphylococcal infections. Although MRSA is no more
likely to cause an infection than sensitive SA, the infection can be more difficult to treat due
to a limited choice of antibiotics. It can be carried on the skin or in the nose of healthy people
(colonisation) without causing any adverse effects. However, colonisation is considered to
be a major risk factor for infections, which may range from mild to life threatening.
4.2 Panton Valentine Leukocidin (PVL) - Staphylococcus aureus (SA) is a bacterium that
commonly lives on healthy skin. About one third of healthy people carry it quite harmlessly,
usually on moist surfaces such as the nostrils, armpits and groin. Some types of SA produce
a toxin called Panton Valentine Leukocidin and they are known as PVL-SAs. (Panton and
Valentine were the two doctors who first found the toxin which can kill white blood cells
called leukocytes – hence leukocidin).
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PVL-SAs can cause skin and soft tissue infections e.g. boils and abscesses. They can also
cause invasive infections affecting the lungs, blood, joints and bones.
The PVL toxin can be produced by both meticillin-sensitive Staphylococcus aureus (MSSA)
and meticillin-resistant Staphylococcus aureus (MRSA). (Refer to the CityCare Policy for
Managing and Treating Patients in Primary Care available on the POD).
If patients attends with recurrent boils or skin abscesses please consider additional testing
for PVL infection. This will need to be specifically requested on the laboratory form
4.3 Colonisation- occurs when a microbe establishes itself in a particular environment such
as a body surface, without producing disease or symptoms. This is sometimes referred to as
asymptomatic carriage and can be identified by screening. Around 30% of the general
population are colonised with Staphylococcus aureus. It may be present on the skin, in the
nose, axillae, groin or perineum. It can also colonise wounds and other areas of non-intact
skin without causing harm.
4.4 Decolonisation – refers to the application of antimicrobial products to body surfaces
cavities in order to eradicate colonising micro-organisms (e.g. MRSA)
4.5 Infection - occurs when the bacteria gain access to the body tissues and multiply,
causing a host reaction and clinical signs of infection, which may include redness, swelling,
pain or discharge in a wound or invasive device site. Depending on the properties of the
infecting micro-organism and the capacity for resistance of the infected host, there may be
other effects in the body, including toxin production and spread to other sites.
4.6 Bacteraemia – occurs when there is evidence of spread of infection into the blood
stream.
5. Responsibilities
5.1 Infection Control Lead in the practice Insert Name____________________________
The Infection Control Lead has overall responsibility for ensuring that there are effective
arrangements for infection prevention and control within the practice and for meeting all
statutory requirements.
5.2 The Practice Manager Insert Name______________________________
The Practice Manager is responsible for ensuring that there are the necessary policies and
training to reduce the risk of infections being transmitted and for ensuring that appropriate
governance arrangements are in place to provide effective care and management of patients
with MRSA in accordance with this policy.
5.3 The infection Prevention and Control Team (IPC):
Receive laboratory reports which provide information about the positive MRSA screens and
samples from primary care and receive discharge information on patients requiring further
follow up and treatment interventions from hospital
The Infection Prevention and Control team will receive the results from the source laboratory
and will provide clinical expertise and advice and support clinicians with the choice of
treatment and management appropriate for the patient.
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The IPC team provide support and leadership for providers in implementing the Post
Infection Review process (PIR) for all pre-48 hour MRSA bacteraemia cases in line with the
criteria in the NHS England PIR process and policy for serious incidents.
https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/04/seriousincidnt-framwrk-upd2.pdf
http://www.england.nhs.uk/wp-content/uploads/2014/04/mrsa-pir-guid-april14.pdf
The team will disseminate the findings to the clinicians involved and the wider lessons for all
clinicians
5.4 Line managers
Line Managers have responsibility to ensure staff are aware of this policy, have read
and signed to say they have read it and for ensuring their staff adhere to the policy
5.5 All staff
 Ensure all staff that have contact with a patient with MRSA adhere to the relevant
this policy and guidelines

Take screens in accordance with the policy and communicate screen results to the
patients

Inform the patient of their diagnosis and document this within the patients’ medical
/care records.

Explain and document treatment regimens.

Implement standard infection prevention and control principles (see section 7
Control of MRSA).

Ensure when care is transferred to another provider, that the diagnosis is
communicated to the provider after consultation with the patient.
6. Delivery of Care
6.1 Transmission
MRSA infections occur in all types of healthcare settings, however it is well known that
controlling the spread of MRSA outside of the acute hospital environment has often been
overlooked or deemed to be unnecessary. The recent trends towards earlier discharge from
hospital, day surgery, minor surgery and interventions in community settings, along with the
increased need for the use of indwelling devices significantly increases the risk of patients
developing infections in the community. The often continuous and repeated movement of
patients between different healthcare settings also increases the risks of HCAI to patients,
as well as the emergence of Community Associated strains of MRSA e.g. Panton- Valentine
Leukocidin (PVL) which is also a significant factor.
6.2 Routes of Transmission
MRSA can be transmitted either:

Endogenously - this occurs when a person already colonised with MRSA spreads the
organism from one part of their body to another.
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
Exogenously - this occurs when MRSA is spread from one person to another. This
can happen in a variety of ways including:

Direct spread via the hands of healthcare workers

Indirect spread through equipment that has not been appropriately decontaminated

Via transfer of micro-organisms from the environment, where contamination is highly
significant, as staphylococci can survive for long periods in dust
6.3 Screening

A new diagnosis of MRSA is often made from a clinical specimen (e.g. wound swab)
and not from an MRSA screen. In this instance, please contact the Infection
Prevention and Control team for advice on the correct management of the patient.
A screen consists of swabs / samples being taken from the following sites:
Nose swab– one swab from both nostrils, pre-moisten the swab with saline if needed
and roll around both nostrils

Perineum or groin swab

Wound swab- swab all wounds and other lesions or breaks in the skin

Swabs from manipulated sites- lines, cannulae, drains, PEG sites etc

Urine specimen from patients with a catheter in situ only or mid-stream urine (MSU) if
MRSA has been isolated in a urine specimen previously. If the patient has a supra
pubic catheter in situ then the entry site should also be swabbed

Sputum sample if patient has a productive cough

Swabs from invasive medical devices such as PEG tubes, tracheostomies and
supra-pubic catheter sites.

The laboratory request form should be clearly request an MRSA screen and give
details of why the screen is being performed, the clinician requesting the screen
should ensure the site of the screen is documented on each individual swab and on
the laboratory request form.

The clinician should ensure that the individual is fully aware of the screens to be
taken and ensure consent to the procedure, documenting in their records.
6.4 Rescreening
A patient should be re screened one month after completion of decolonisation treatment. A
negative screen will suggest that the decolonisation treatment has been effective. If the
screen results identify a positive MRSA result a second decolonisation treatment can be
offered.
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Sometimes a third might be attempted if the patient has increased risk factors, but this will
need to be reviewed with the Infection Prevention and Control Team (after discussion with
Infection control doctor/medical microbiologist) and assessed on an individual patient basis.
Further re screening is not recommended
Some patients in primary care will remain colonised with MRSA, it is important that this is
documented in the patient’s records and communicated effectively to the patient and when
transferring care to another provider or out of hours provider
Further advice should be sought from the Infection Prevention and Control Team.
6.5 Treatment
Decolonisation

MRSA decolonisation refers to the use of topical agents such as nasal ointment and
body wash/shampoo to eradicate or reduce nasal and skin carriage.

Complete eradication is not always possible but a decrease of carriage may reduce
the risk of transmission into the healthcare setting and therefore the risk to other
patients. It will also reduce the risk of transmission into any wounds or indwelling
devices that the patient may have.

Compliance with the treatment is important and once commenced should be
completed for the full 5 days.

Decolonisation treatment should not be implemented for prolonged periods or
repeatedly i.e. more than 2 courses for 5 days, as resistance may be encouraged.

In cases of repeated colonisation the advice of a medical microbiologist should be
sought.

For patients with eczema, dermatitis or other skin conditions, attempts should be
made to treat the underlying skin condition. Advice on suitable eradication protocols
for these individuals should be sought from the consultant
Dermatologist/Microbiologist
Nasal decolonisation


Currently the treatment is 2% Mupiricin (bactroban) nasal ointment (or other
Microbiological approved product) which should be applied to the inner surface of
each nostril (anterior nares) three times daily for five days. Nasal decolonisation
should always be used in conjunction with skin decolonisation.
Whilst Mupiricin (bactroban) nasal ointment is the treatment of choice, Naseseptin
cream can be prescribed and applied to both nostrils four times daily in the event of
a supply problem with Mupiricin (bactroban) treatment period is between 5-10 days.
This should be prescribed with caution as it contains arachis oil so should be
avoided in those with peanut allergies
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Skin decolonisation

Skin decolonisation is useful for eradicating or suppressing skin colonisation for short
periods, particularly pre-operatively. Patients should bathe/shower daily for five days
using the prescribed antiseptic detergent as below

The current recommended agents are either Chlorhexadine 4% or Octenisan. For
neonates and children under 5 Octenisan should be used. The body wash should be
applied neat to wet skin and left on the skin for 3 minutes (refer to product
instructions). Applying a diluted solution to the skin will affect its efficacy. Special
attention should be paid to all carriage sites, such as the axilla, groin and perineal
area. The patient should be advised not to use normal soap or shower gels following
the treatment being applied.

Hair should also be washed on days 2 and 4 within the five-day treatment using the
same product. Clean clothing, bedding, wash cloths and towels should be provided
after each bath/shower/bed bath and hair wash.
Peg Sites


If Peg site is positive on screening, and site is dry, 2% Mupiricin (bactroban)
nasal ointment should be prescribed and applied around the site three times daily
for five days.
If Peg site is positive on screening and site is moist or sticky seek advice from
Nutrition team or Tissue Viability team.
Antibiotic Therapy

As antimicrobial use is a recognised risk factor for MRSA acquisition, all patients with
MRSA should have their current antibiotic therapy reviewed. Any unnecessary
agent should be stopped.

Antibiotics are not indicated unless there are clinical signs suggestive of infection.
Prescribers should refer to the Antimicrobial Prescribing Guidelines (2015) and
discuss with the duty Microbiologist for further advice if needed.
www.nottsapc.nhs.uk

If antibiotics are required they should be in line with the given sensitivities and
antimicrobial prescribing guidance. If uncertain then contact the Medical
Microbiologist for advice
NUH - 0115 9249924 ext. 61163
SFHT – 01623 622515
Consider the temporary use of an antimicrobial dressing for wounds where there are
signs of clinical infection, refer to the Wound Care Formulary for wound care products or
the Tissue Viability team on 01623 784759.
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7. Control of MRSA
7.1 Basic Principles
Standard IPC precautions must be implemented at all times in all settings to reduce the risks
and should include all of the following:
Hand Hygiene –Compliance with hand hygiene is essential and will significantly
reduce the risk of transmission and cross infection. Decontamination of hands should
be carried out before and after every episode of direct patient care or contact with the
patient’s environment and equipment. Effective hand hygiene can be achieved using
soap and water or alcohol gel (on visibly clean hands), using the National Patient
Safety Agency (NPSA) recommended technique.(NPSA 2008)
http://www.npsa.nhs.uk/corporate/news/cleaning-up-at-the-awards/

The Correct use of Personal Protective Equipment (PPE)

Decontamination of Equipment according to manufacturer’s guidance. Single Use
equipment should always be considered where possible.
7.2 Advice for Patients in their own Home

MRSA does not present a risk to other healthy individuals and colonisation should
not prevent an individual from continuing with normal unrestricted activities

Wherever possible, patients with a known MRSA infection should be seen at the end
of the healthcare professionals visiting list.

Good hand hygiene and standard basic precautions should be employed by all staff
involved in the care of a patient at home

Avoid taking non-essential equipment in to the home.

Encourage patients and carers to undertake good hand washing.

Family members should be advised to cover any skin lesions they may have with an
impermeable dressing and to maintain good hand hygiene.

Advise the patient/family that regular environmental cleaning using detergent and
water is an effective method of reducing levels of MRSA.

Patients should be advised that their laundry should be washed at the hottest
temperature suitable for the fabric and that it can be washed with other household
laundry. Laundered garments should be dried thoroughly before re-use. Drying in a
hot air dryer or ironing will help further reduce the amount of MRSA present.

Patients should be encouraged to continue with their normal activities/routines.
7.3 Advice to parents about school aged children

Children should not normally be excluded from school as a result of MRSA
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
Wounds must be kept covered to reduce the risks of transmission.

Encourage and promote good hand washing and the use of liquid soap, rather than
bar soap which will reduce to risk of transmission

An alert should be added to the patient’s records to highlight that the patient is at risk
of acquiring MRSA again in the future
8. Monitoring and Review

Infection prevention and control principles are monitored through a rolling programme
of peer reviews

This procedure will be reviewed in 3 years or in light of organisational or legislative
changes
9. Equality and Diversity Statement
The organisation aims to design and implement services, policies and measures that meet
the diverse needs of our service, population and workforce, ensuring that none are placed at
a disadvantage over others.
All policies and procedures should be developed in line with the CCGs Equality and diversity
policy and need to take into account the diverse needs of the community that is served. The
Equality Impact Assessment tool is designed to help consider the needs and assess the
impact of the procedure being developed. An Equality and Diversity Assessment has been
completed for this procedure.
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10. MRSA protocol for screening and decolonisation
MRSA positive swab
Previous history of MRSA
Has the patient been treated before?
Yes – ring Infection
Prevention and Control
team
Check history
No history
Is the wound expected
to heal?


Yes
Add alert to record
Send Special Note to OOH
Does the patient have an existing wound?
No - Decolonise using 2% Nasal
Mupirocin, Octenisan or
Chlorhexadine
No
Yes
No
A
Rescreen in 1 month –
nose/perineum, and any
invasive devices
Decolonise after wound
has healed. using 2%
Nasal Mupirocin,
Octenisan or
Chlorhexadine
Consider referral to
Tissue Viability and
decolonise using 2%
Nasal Mupirocin,
Octenisan or
Chlorhexadine
Decolonise using 2% Nasal
Mupirocin, Octenisan or
Chlorhexadine
Give advice/leaflet on hygiene
whilst using decolonisation
Rescreen in 1 month –
wound, nose,
perineum and any
invasive devices
Rescreen in 1 month –
nose/perineum, wound
and any invasive devices
Rescreen in 1 month
– nose/perineum, and
any invasive devices
If positive – prescribe 2nd
course of decolonisation
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using 2% Nasal Mupirocin,
Octenisan or
Chlorhexadine
Reinforce hygiene
measures
If negative – no further
action required unless 3
negative screens
requested by acute trust action one week apart
11. How to apply Chlorhexidine / Octenisan bodywash and Mupiricin (Bactroban) ointment
1.
2.
3.
Ensure that your hair and body
are wet
Put the lotion onto a damp
washcloth
4.
5.
Apply all over body paying
particular attention to the areas
highlighted in red. Hair must be
washed on day 2 and 4.
6.
Rinse off thoroughly
Dry with a clean, dry towel
Put on clean underwear and
nightwear every day
Mupiricin (Bactroban) ointment application
Apply a matchstick head sized amount (less for
a small child) on the end of cotton bud to inner
surface of each nostril and massage gently
upwards for 3 times a day for 5 days
Night clothes and bedding must be changed daily throughout the treatment and vacuuming and damp
dusting completed daily during treatment.
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12. References
Department of Health (2008) The Health and Social Care Act 2008 –code of practice for health and
adult social care on the prevention and control of infections and related guidance Crown copyright
2009 London UK.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_
115045.pdf
Department of Health (2010) MRSA Screening Operational Guidance 3 Gateway Reference
Number 13482 Department of Health Crown Copyright.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_
115045.pdf
NHS England (2014) Guidance on the reporting and monitoring arrangements and post infection
review process for MRSA bloodstream infections from April
2014 (version 2)http://www.england.nhs.uk/wp-content/uploads/2014/04/mrsa-pir-guid-april14.pdf
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