The purpose of this guideline is to provide guidance for the prevention and control of Meticillin resistant Staphylococcus aureus bacteria within the Trust healthcare environment and to promote effective and evidence-based patient care.

Staphylococcus aureus (S. aureus) is a common skin bacterium (asymptomatically colonising approximately 30% of the human population), but can also be a major human pathogen, responsible for a range of infections including:

• simple skin and soft tissue infection

• vascular access and other indwelling device infection

• pneumonia

• blood stream infection/ bacteraemia

• overwhelming sepsis and death

Infection may occur from a strain an individual already has prior to receiving healthcare, or from a strain acquired through healthcare. The majority of S. aureus carriage or infection results from meticillin-sensitive Staph. aureus (MSSA) but meticillin-resistant Staph. aureus (MRSA) is especially important as a cause of healthcare-associated infection (HCAI) because:

• The strains are usually adapted to spread in the healthcare environment and frequently cause outbreaks if not controlled. So far 16 epidemic strains of MRSA have been identified (clones EMRSA-15 and -16 remain the main strains in bacteraemia in the UK). (Ellington et al., 2010)

• MRSA have a gene mecA coding for a penicillin-binding protein (PBP-2A) with a reduced affinity for beta-lactam antibiotics. As a result of this, antibiotics are not able to attach to the bacterium or lyse it. MRSA is resistant to flucloxacillin, and often other commonly used antibiotics, so may not be covered by conventional empiric treatment.

Prevention and control of MRSA relies initially on the implementation of standard infection prevention and control guidelines, especially good hand hygiene, care of vascular access devices and wounds, and environmental cleanliness. However, because of the risk of treatment failure and risk to some vulnerable groups of patients, additional guidelines are advised for control, including:

• MRSA screening

• MRSA suppression therapy

• Source isolation in acute care environments.

• Appropriate communication.

The aim of MRSA screening is to identify MRSA-colonised patients within the acute Trust, to allow targeting of inpatient isolation facilities, minimising the risk of onward transmission to other vulnerable patients and to also ensure that any necessary antibiotic treatment is appropriate to that patient. (DH ,2014).

Since January 2015, staff at Frimley Health Foundation Trust (FHFT) have followed the guidance in the Department of Health’s Implementation of modified admission MRSA screening guidance for NHS (DH 2014). This guidance recommends the screening of patients for whom, if they were to acquire a MRSA infection, the outcome could be worse.

3.1 Who to Screen

In line with a risk assessment of MRSA infections identified at FHFT in the past five years, the following patients must be screened for MRSA:

1) Admissions requiring an overnight stay on, or undergoing high-risk surgery (such as insertion of prosthetic material) within:

• Critical Care

• Neonatal Unit

• Trauma & Orthopaedics

• General Surgery (including Vascular, Breast, & Urology)

• Haematology/ Oncology (including Paediatric Oncology beds)

• Haematology/ Oncology patients admitted to non- Haematology/Oncology wards

• Cardiology

• Renal (including patients requiring dialysis admitted to non-Renal wards)

2) Un-planned/ Emergency admissions requiring an overnight stay on:

• Critical Care

• Neonatal Unit

• Trauma & Orthopaedics

• General Surgery (including Vascular, Breast, & Urology)

• Haematology/ Oncology (including Paediatric Oncology beds)

• Haematology/ Oncology patients admitted to non- Haematology/Oncology wards

• Cardiology

• Renal (including patients requiring dialysis admitted to non-Renal wards)

3) Patients (both adult and child) flagged as previous MRSA-positive (as highlighted on Epic, or by the patient themselves)

4) All inter-hospital transfers (both adult and child) from secondary or tertiary care in the UK or abroad.

5) Any patient admitted with wounds or invasive devices (eg. PEG sites, IV devices) MUST have these screened for MRSA. This is because MRSA colonising wounds or invasive devices will significantly increase the risk of a systemic infection with MRSA.

6) Any patient planned to have a long-term urinary catheter inserted.

If a patient is screened for MRSA, who does not meet the criteria above but is assessed to be at high risk from a MRSA infection, the rationale for screening should be documented in the medical notes.

• It is the ward/ department nurses’ responsibility for ensuring all patients meeting the criteria are screened for MRSA.

• The healthcare worker obtaining the specimen for testing is responsible for the appropriate collection following Trust protocol, and the timely delivery of the specimen to the laboratory.

• The pathology laboratory and Consultant Microbiologist are responsible for the accurate and timely processing of the specimen.

• It is the ward/ department nurses’ responsibility for checking MRSA screening results on Epic®

• It is the ward/ department nurses’ responsibility for communicating a positive result to both the patient, referring to the leaflet given on consent for screening and the patient’s clinician.

• It is the clinician’s responsibility to act on receipt of a positive result, prescribing MRSA suppression therapy and review of any antibiotic treatment.

• It is the clinician’s responsibility to inform the patient’s GP of an MRSA positive result, via the summary on the patient’s discharge letter.

MRSA screens should be requested via Orders on EPIC®. A trained and competent healthcare worker (HCW) must take the specimens for the MRSA screen in a timely manner:

• for elective patients, screen within 16 weeks of planned admission (normally taken at pre-operative assessment).

• within 48 hours of admission for Emergency patients.

• every 7 days for patients in Critical Care, Renal or Neonatal units.

• at any time during admission if repeat screen is required or infection is suspected.

Inter-hospital transfers (both adult and child) should be isolated in a single room until admission screening results are available. If these are negative, the patient can be de-escalated.

5.1 How to screen

The MRSA screening procedure must be explained to the patient prior to specimens being taken and consent gained. The MRSA information leaflet MRSA leaflet should be provided to the patient to aid explanation.

To determine the extent of MRSA carriage swabs must be taken from the following sites:

Routine:

• Nose - 1 swab used for both nostrils (anterior nares).

• Groin – 1 swab used in the moist skin folds.

In addition:

• Wounds/ breaks in skin. Including:

• Chronic wounds – diabetic foot ulcers, leg ulcers, pressure sores

• Recent surgical wounds

• Traumatic wounds

• Burns

• Invasive devices, e.g.:

• Long-term urinary catheters – collect a CSU.

• IV devices – swab insertion site (at next required dressing change)

• Tracheostomies – swab site

• PEG tubes – swab site

• Surgical drains – swab site

• Sputum (if patient has a productive cough)

• Umbilicus – in neonates.

5.2 Validity of MRSA screen (for patients with no past history of MRSA)

• Patients who have screened negative in pre-op assessment within the past 16 weeks and who have not had an intervening inpatient stay do not require repeat admission screening. This validity can be extended to six months where agreed by the Consultant surgeon.

• Patients in ITU/Critical Care and Neonatal units should be screened on admission and weekly thereafter.

Negative results

MRSA-negative results should be available to view on Epic® within 48 hours of the specimen being sent and should be checked by the ward/department nurse sending the specimen.

Positive results

MRSA-positive results should be available and flagged on Epic® between 48 hours and 5 days of the specimen being sent. Epic® will generate a MRSA care plan for a positive result. Nursing staff must ensure that all interventions on the care plan are completed.

Clinicians must ensure any antibiotic treatment is reviewed and MRSA suppression therapy is prescribed in line with the Trust’s Eolas.

If inpatients with MRSA are unable to be nursed in single rooms, the Infection Prevention & Control Team must be informed so they can then advise on placement of patients. The reason for not isolating the patient must be recorded on their MRSA care pathway.

If a patient has a positive result from another healthcare provider, the Infection Prevention and Control team must be informed, to add an infection flag to EPIC®.

A positive MRSA screening result should not be a reason to delay or defer necessary medical interventions or diagnostic procedures. The receiving ward/department should be informed of the patient’s MRSA status prior to transfer.

Clinicians need to include the MRSA positive result in the patients discharge/transfer documentation.

7.1 Treatment of MRSA-positive in-patients (ADULT)

MRSA suppression treatment must be prescribed on EPIC® without delay and should be commenced for adult in-patients within 24 hours of receipt of a positive result.

Please refer to the Trust Eolas for MRSA suppression therapy.

If there is a record of previous complete MRSA suppression therapy (i.e. completed the 5-day course of treatment detailed below) in the past 3-6 months, please contact the Infection Prevention & Control Team for advice. Suppression therapy should not be used for prolonged periods or used repeatedly (ie. more than two courses of five days treatment), as resistance to Mupirocin may occur.

MRSA suppression therapy products are provided by pharmacy. It is the nursing staff responsibility to advise patients on how to use the products.

If patient has eczema, dermatitis or other skin condition, dermatologist advice must be sought for treatment of the underlying skin condition.

7.2 Treatment of MRSA-positive pre-admission patients (ADULT)

A positive screen should not delay surgery for elective patients. It is preferable for elective surgery to take place on day FIVE of topical suppression therapy (prescribed as per Eolas) to ensure the maximum reduction of MRSA present on the patient’s skin is achieved. If there are fewer than 5 days prior to surgery, commence MRSA suppression therapy as soon as possible and continue until all 5 days have been completed (either at home or in the hospital).

Maternity cases screening positive for MRSA should commence the 5-days course of suppression therapy at 37 weeks. Clearance screening is not required prior to admission.

When prescribing antimicrobial treatments (such as perioperative antimicrobial prophylaxis) for known MRSA-positive patients, Eolas must be referred to for the appropriate MRSA protocol.

7.3 Treatment of MRSA-positive patients under care of Community Care Teams (ADULT)

MRSA suppression therapy is not indicated as a matter of routine for patients being cared for in their own homes. If infection is suspected, MRSA-positive results must be considered when prescribing antimicrobials.

7.4 Treatment of MRSA-positive in-patient CHILDREN/ BABIES

Please contact the on-call Consultant Microbiologist for advice. MRSA suppression therapy for neonates should only occur after risk assessment and discussion with the Consultant Neonatologist, (paediatric surgeon, as appropriate), Consultant Microbiologist and Infection Prevention & Control Team, to determine whether the benefits outweigh the risks. It may be appropriate to apply the protocol to neonates prior to high-risk procedures (e.g. surgery, long term indwelling catheter insertion, and tracheostomy) or term babies. This should also be discussed with parents.

Re-screening after MRSA suppression therapy is not required, unless the patient is in Critical Care/ITU, Neonatal Units and Renal Units, where admission and weekly screens are carried out.

Clinical samples should be sent as indicated/required to check for successful treatment of infection (e.g. blood cultures, tissue samples)

Regardless of whether a patient has several negative MRSA screens after a positive one, the patient will still be considered as colonised with MRSA when managing inpatient admissions or antimicrobial therapy. This is because MRSA screening will not always detect colonisation, and because treatment with broad spectrum antibiotics will sometimes select MRSA out as a predominant skin flora within healthcare.

9.1 MRSA Bacteraemia

MRSA bacteraemia cases are apportioned to the acute Trust if the infection is identified on or after Day 3 of admission to the Trust (day of admission being Day 1). If a patient has MRSA isolated from a blood culture, a Post-Infection Review (PIR) will be undertaken with all relevant healthcare provider services, ideally within five days of the result being reported. The resulting information including the potential root cause of the infection are uploaded onto the UK Health Security Agency Data Capture System (DCS). Formal reviews are completed for healthcare-associated MRSA bacteraemia cases, to understand the system-factors that contributed to the infection, in line with the Patient Safety Incident Framework and identify learning and areas for meaningful improvement for the Trust.

9.2 Outbreak

An outbreak is defined as two or more related cases of MRSA infection (with the same sensitivity/ typing pattern) in one clinical area. The Outbreak Control Team will be established as per the Trust’s Outbreak Management Plan (IPC 26).

9.3 New cases of MRSA on Elective Orthopaedic wards

If a patient has a new positive MRSA result (who is currently nursed in a ring-fenced orthopaedic ward bay):

• Isolate patient in a single room or escalate to operational team for isolation.

• Close the bay to admissions and re-screen all other patients in the bay.

It is desirable that all inpatients who are colonised or infected with MRSA are nursed in a single room as per Trust’s guideline for the isolation of patients (IPC 04). All patient care will follow the Standard Infection Control Precautions (SICPs) and Transmission-based Precautions (TBPs) stated in the National Infection Prevention and Control manual (NHSE, 2024)

Following patient discharge/transfer, the patient’s room will require terminal cleaning (see IPC31), using a combined detergent/chlorine releasing solution with a concentration of 1,000ppm available chlorine.

If any patient or visitors have any concerns or queries that staff feel they are unable to answer, please contact a member of the IPC Team who will come to speak to them.

Visitors who only have social contact with the patient do not need to wear gloves or aprons, they will be encouraged to clean their hands on entering and leaving the room.

As antibiotic therapy encourages the persistence of carriage, all patients with MRSA should have their antimicrobial therapy reviewed, with a view to discontinue at the earliest possible time. Please refer to the Trust’s Eolas. Please contact the on-call Consultant Microbiologist for advice on complex cases, or when prolonged antibiotic courses are required.

In mechanically filtered operating theatres, the number of air exchanges should make it unnecessary to place MRSA positive patients at the end of a theatre list. Cleaning procedures, minimising staff movement, and allowing only essential equipment in theatre, should be in place for every patient, not just exclusively for MRSA.

Refer to Trust’s guidelines for transfer of infectious patients (IPC 10)

Adherence to this guideline is monitored via IPC Annual Audit & Surveillance programme.

Ellington, M.J. et al. (2010) ‘Decline of EMRSA-16 amongst methicillin-resistant Staphylococcus aureus causing bacteraemias in the UK between 2001 and 2007’, Journal of Antimicrobial Chemotherapy, 65(3), pp. 446-448. Available at: https://academic.oup.com/jac/article/65/3/446/745017

Department of Health (2014). Implementation of modified admission MRSA screening guidance for NHS. Department of Health, London. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/345144/Implementation_of_modified_admission_MRSA_screening_guidance_for_NHS.pdf

NHSE (2024) National infection prevention and control manual (NIPCM) for England. Available at: NHS England » National infection prevention and control manual (NIPCM) for England https://www.england.nhs.uk/national-infection-prevention-and-control-manual-nipcm-for-england/

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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