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By Linda Yamamoto, RN, PHN, BSN, MBA/HCA, and Molly Marten, BA, MPH

Nursing2007, DecemberEarn 2.0 ANCC/AACN contact hoursOnline: http://www.nursing2007.com

© 2007 Lippincott Williams & Wilkins

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1. Discuss the transmission of methicillin-resistant Staphylococcus aureus (MRSA) infections.

2. Identify ways to prevent MRSA infections.

3. Identify ways to treat MRSA infections.

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Six interventions:1. Deploy rapid response teams.2. Prevent ventilator-associated pneumonia

(VAP).3. Prevent adverse drug events.4. Prevent central line infections.5. Prevent surgical site infections (SSIs).6. Deliver evidence-based care to treat acute

myocardial infarction (MI).

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Goal is to prevent 5 million incidents of medical harm in a 2-year period (12/06 to 12/08)

Six additional interventions: Reduce surgical complications. Prevent harm from high-alert medications Prevent pressure ulcers Reduce methicillin-resistant Staphylococcus

aureus (MRSA) infection Deliver reliable, evidence-based care for heart failure Get boards on board by defining and spreading the

best-known leveraged processes for boards of directors

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Easily transmitted and drug resistant, MRSA can survive on hands, clothing, environmental surfaces, and equipment.

About 126,000 hospitalized patients develop MRSA infections each year.

Over 5,000 of those patients die.

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Improve hand hygiene. Make fastidious environmental cleaning

and disinfection a priority. Consider performing active surveillance

cultures. Identify colonized patients and

implement contact precautions. Implement and perform all interventions

from the central line bundle and the ventilator bundle.

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Staphylococcus aureus is commonly carried on healthy people’s skin, nares, and perineum.

It may cause superficial skin infections treatable with beta-lactam inhibitors (such as methicillin).

Over time, some strains have become resistant.

First cases of MRSA in the United States occurred in the 1960s.

Today, 46 out of 1,000 patients have MRSA.

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Using antibiotics appropriately is key. Encourage cultures before antibiotics are started,

and, if necessary, narrow the spectrum of antibiotics based on culture results.

Review all culture reports to ensure that bacteria are sensitive to the prescribed antibiotics.

Teach the patient how to use antibiotics: Take as prescribed Finish the course of treatment Don’t take someone else’s prescribed medication

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Community-associated MRSA (CA-MRSA) Causes skin and soft-tissue infections, such as boils,

blisters, abscesses, folliculitis, and carbuncles Also, fever and local warmth, swelling, pain, and

purulent drainage Health care-associated MRSA

More highly drug resistant Causes more invasive infections, such as surgical site

infection, endocarditis, osteomyelitis, bacteremia, pneumonia

“According to the Centers for Disease Control and Prevention definition, a diagnosis of CA-MRSA requires that the patient have

no medical history of MRSA or colonization and no risk factors associated with

health care–associated MRSA.”

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CA-MRSA Person-to-person by sharing personal items

(clothing and towels) Close contact

Health care-associated MRSA Contaminated environmental surfaces Staff members

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Patients weakened by disease or injury

Recent hospitalization or surgery

An invasive device Surgical wound or

pressure ulcer Prolonged

hospitalization Severe underlying

illness Immunocompromise

d status

Undergoing dialysis I.V. drug abuse Diabetes Burns Dermatitis Previous exposure to

broad-spectrum antibiotics

Proximity to patient colonized or infected with MRSA

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Incision and drainage, followed by routine wound care

Broad-spectrum antibiotic, changed as indicated based on susceptibility testing

Local antibiograms should be used to guide antibiotic therapy

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1. Perform hand hygiene.2. Make sure patient rooms are cleaned

well and often.3. Actively look for MRSA.4. Implement contact precautions to

prevent transmission.5. Bundle up best practices.

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After each glove change and when entering and exiting any patient’s room

Alcohol-based sanitizers are a suitable substitute as long as hands aren’t visibly soiled or grossly contaminated.

Use appropriate technique Focus on fingernails, nail beds, between

fingers, and around thumbs Keep jewelry to a minimum; clean under your

rings and watch

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MRSA survives for hours or days in the environment.

Surfaces and equipment must be cleaned, especially between patients.

Make sure that every item that comes out of a MRSA patient’s room is cleaned.

If patient is on contact precautions, housekeeping should clean the room daily.

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Active surveillance refers to taking cultures of a group of people to see if they’re colonized with MRSA.

Each infection-control program should evaluate the benefit of active surveillance cultures.

Some facilities culture all patients on admission; others culture certain groups, such as ICU patients or those being admitted from long-term care facilities.

A person colonized with MRSA carries the bacteria; although he has no signs or symptoms, he can transmit it to others.

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Reservoirs for MRSA Anterior nares (most common) Skin of the axillae, perineum, hands, arms Gastrointestinal tract Ostomy sites Pressure ulcers and other wounds Sputum

Drug susceptibility testing can differentiate MRSA from S. aureus

Active surveillance cultures of the anterior nares will identify 80% of colonized adults. Cultures of clinical specimens identify

patients infected but won’t detect up to 85% of colonized patients.

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Active surveillance is controversial and challenging.

If used, it must be combined with other control efforts, such as contact precautions.

Be aware of facility transmission rates–it helps reinforce what works well to stop transmission.

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Anatomic location – make sure the area from which the specimen was taken is correct.

Gram stain report – look for the presence of white blood cells (indicates infection).

Antibiogram – identifies susceptible and resistant antibiotics.

Organisms – know the epidemiology of the isolated organism. Source Potential for multiple-drug resistance Mode of transmission

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Always wear a gown and gloves when caring for infected or colonized patients.

Always perform hand hygiene between patients and as you leave each room and after removing gloves.

Follow contact precautions for those infected or colonized.

Remember that a patient on contact precautions requires the same level of care and attention as any other patient.

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Private room for those infected or colonized (if not possible, use visual cues, such as signs or a line on the floor to remind everyone).

Cohort patients with MRSA, if necessary. Gloves and gowns for caregivers and visitors

(keep a supply handy). Use dedicated patient-care equipment or

disposable equipment. Clean equipment upon removal from room. Discontinue precautions when appropriate (at

least three negative cultures on separate days).

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A colonized patient is more likely to develop a MRSA infection because he already has the bacteria as part of his normal flora.

Central line bundle and ventilator bundle implemented to reduce or eliminate device-related infections.

Review these bundles in detail at http://www.ihi.org.