Kingdom of Saudi Arabia Ministry of Health Al Zulfi General Hospital

Infection control policy

Title / Description: MANAGEMENT OF SUSPECTED MRSA COLONISED PATIENT PREPARED DATE 07/02/2011 REVIEW DATE 07/02/2013 Applies to All Doctors and nursing staff Index no 38.5 Page no

DEFINITION
This policy describes the steps needed to prevent the spread of Methicillin Resistant staphylococcus Aureus (MRSA ) to patient staff & visitors

Screen all patients who are :

Admitted to the ICU

Transfers from other hospitals or patients treated in another hospital or clinic with in the past six months Continuous ambulatory peritoneal dialysis (CAPD Known to be previously MRSA positive Room mates of positive patients not on precautions Additional populations of patients as designated at the individual facility (direction to come from IC):

Sites to screen are

Anterior nares

Title / Description: Management of suspected MRSAcolonised patient

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Any indwelling catheter sites Open skin areas (e.g . tracheostomy ,pressure sores or surgical wounds ) Neonates & patients for liver transplant should also have groins & both axilla screened

Specimen collection
Use sterile swab stick with transport medium Moisten swab in transport medium before swabbing the site Use same swab for identical sites :one swab for both nares ,one swab for both axilla & one swab for both inguinal areas Use separate swabs to screen other sites NB :The accompanying requisition should request MRSA SCREEN

Patient placement
Initiate empiric contact isolation precautions during the screening process

Request single room for contact isolation from bed co ordination .Two or more MRSA patient for screening may be corhorted if needed , after consultation with infection control

Observe contact isolation precautions in addition to standard precautions Place contact isolation sign on the outside of isolation room door

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Ensure that all staff understand & compare with the isolation precautions & hand hygiene policy Cohort non critical items such as stethoscope & pressure cuff with the patient Store minimum amount of ( daily ) supplies in patient room Limit pt activities out side of the ward Notify receiving departments /wards ( eg . radiology ,endoscopy , clinics ,O.R ) of pts isolation status when pt must be transported for treatments / tests If pt is positive refer to management of MRSA positive pts below

MICROBIOLOGY LABORATORY MUST Notify the ward of positive MRSA cultures Notify ICP of all new positive MRSA cultures MANAGEMENT OF PATIENTS CONFIRMED POSITIVE MRSA : NURSING Request a single room for contact isolation from bed coordination Two or more MRSA positive pts can be cohered if needed after consultation with infection control. Notify infection control staff that patient is placed in contact isolation

Maintain standard precautions with all patient care activities Place pt in a single room . only neutral room air pressure is indicated Put contact isolation sign on door

Title / Description: Management of suspected MRSAcolonised patient Supplies needed :

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PPE must be readily available for use Wear gown and gloves when anticipating contact with pt or before entering pt environment Cohort non critical items such as stethoscopes and pressure cuffs with the patients Store minimum amount of supplies in a pt room Use an isolation cart for extra needed supplies ( keep outside the room ) Strict hand hygiene is the most important means of preventing or reducing contact transmission of micro organisms Screen all pts for MRSA who have shared a room with the MRSA positive pts for more than 48 hrs ( nares & all open sites ) Encourage the patient to observe strict hand hygiene with the personal hygiene Restrict internal and external movement of patient When transferring patient the receiving department / facility ( eg . x ray ) must be informed of patient isolation status to permit implementation of proper precautions Patients body fluids must be contained & wound covered etc . Equipement ( wheel chairs , stretchers ) used must be cleaned before use on other patients

Explain the purpose of precautions to the patients & visitors in the order to solicit their cooperation

Handle / discard contaminated items as per standard precautions

Title / Description: Management of suspected MRSAcolonised patient

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Maintain control isolation until a consultation with infection control regarding de colonization oor dis continuation of isolation is made Initiate the flagging system for MRSA positive patients

MEDICAL Restrict antibiotic use

( especially broad spectrum )& invasive devices where possible

Discharge patient when medical condition allowes Use broad spectrum systemic antimicrobials only when there is evidence of active infection Seek infectious diseases consultants / ICPs advise regarding possible decolonization

DECOLONIZATION PROTOCOL
Infection control staff assess if pt is suitable for decolonization protocol

Treat nares topically for periods not exceeding 7 days with bactroban ( mupirocin ) cream only if organism is mupirocin sensitive . Restrict use as resistance to this agent is well documented

Use 4 % chlorhexidine wash ( suppressive therapy ) to reduce or inhibit MRSA skin colonization , assess pts on an individual basis in consultation with infection control staff Apply this protocol to those who are for organ transplant , cardiac , orthopedic surgery and to those who regularly attend other departments for therapy such as dialysis pts or those requiring physiotherapy

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DISCONTINUATION OF CONTACT ISOLATION

Discontinue isolation of MRSA positive patient in consultation with ICP or ICMO Criteria to discontinue isolation Antibiotic therapy is completed atleast 3 days prior to screening Vancomysin level should be ZERO prior to rescreening Three consecutive cultures ( taken 3 days apart ) from NARES and all previously positive sites are negative Patient should not be receiving antibiotic therapy throughout the screening process

LINEN
Keep a linen hamper in the isolation area

CLEANING OF PATIENTS ROOM

Regular cleaning as per housekeeping protocol with hospital approved disinfectant Once cleaning is completed the room should be available for new admission

AMBULATION
Patient with infected body fluids If pt can contain his / her body fluids ( secretions , urin , stool ) walking in the coridoors is permissible but not allowed to visit other pt care areas If unable to contain body fluids pt must be encourage to stay in the room

VISITORS & SITTERS

Provide information about MRSA as required Hand hygiene must be emphasized as pt contact

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Barriers may be required if providing direct pt care SCREENING OF HEALTH CARE WORKERS (HCW s ) & THE ENVIRONMENT Do not culture HCWs or environment since it is not indicated and incurs unnecessary costs Consult ICP before such measures are taken

OUTBREAK MANAGEMENT
Will be coordinated by the ICP & will require the cooperation of medical , nursing , laboratory and other department s

MRSA DECOLONIZATION
Assessment for decolonization will be done by the IC practioner in consultation with the attending physician & infectious disease consultant . Maintain contact isolation during decolonization treatment

SUPPLIES: Chlorhexidine 4% soap

Mupirocin / Bactroban per MD order Clean linen for bed & pt

PPE

Title / Description: Management of suspected MRSAcolonised patient

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IC 38.5

Spread full strength chlorhexidine 4% solution from neck to toes ensuring you get underarms ,groin , and between fingers & toes Cover pt with a sheet & wait for 10 minutes Rinse with warm water

Change bed linen & pt clothing completely after bath Repeat this process twice a day Shampoo hair with the chlorhexidine solution on the first ,3rd & 7th day of Treatment , make sure pts hair is thoroughly dried Apply mupirocin or Bactroban ointment to anterior nares ( inside nose ) after chlorhexidine treatment and pt is dried & dressed as ordered by the MD

NB: mupirocin should not be applied for the open wounds

These treatment must be given to 7 consecutive days Stop treatment & wait for 3 days ( days 8, 9, & 10 ) On day 11 , start screening the process Do a complete set of swabs from nares & originally positive sites every 3 days ( day 11 , 14 , & 17 )

Three negative culture sites are required before pt is cleared of MRSA & can be taken out of the isolation Title / Description: Management of suspected MRSAcolonised patient

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NB : This will be assessed by IC practitioner

NOTES : The pt must be on antibiotic at the time of screening Vancomysin level must be ZERO before screening

If any swab is positive , stop screening process until further assessment Please complete all documentation of this form . ICP will collect form when complet MRSA DECOLONISATION RECORD START DATE : ----------------------------------

Treatment time Day 1 AM PM Day 2 AM PM Day 3 AM PM Day 4 AM PM Day 5 AM PM Day 6 AM PM Day 7 AM PM

Chlorhexidine 4% Wash & shampoo

Mupirocin /Bactroban ointment

Initials

SCREENING 1 /DAY 11 SCREENING 2 /DAY 14 SCREENING 3/DAY 17 --

DATE DUE : ---------------------

DONE:------------------

DATE DUE :------------------------DONE:-------------------DATE DUE :-----------------------DONE :--------------------

COMMENTS : ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Title / Description: Management of suspected MRSAcolonised Index no Page patient IC 38.5

Prepared by: Nirmala Philip -Infection control practitioner

Reviewed by : Dr .R.N.ThakurInfection control Medical officer

Reviewed by: Dr. Ammar Al Amri Q.M. Director Approved by: Dr. Mohd Alwan Al Shamrani Hospital Director