MANAGEMENT OF INPATIENTS WITH MRSA

• Check for IC alert
• if IC alert not available, check previous 12 months of microbiology reports
• Presumptive or confirmed MRSA report in last 6 months without 3 consecutive clear screens since last MRSA, treat as tagged for MRSA
• All inpatients colonised with MRSA on screening. See screening for MRSA/SA and MGNB/ESBL/CPE

Emergency admission

• If the patient has any of:
• history of MRSA in previous 6 months
• red MRSA infection prevention alert in IC alert
• age >65 yr AND transferred from a care home or other hospital
• Immediately after taking samples for MRSA screening, start INITIAL MANAGEMENT
• if all MRSA screening reports state ‘MRSA not detected’, stop decolonisation immediately

• Use standard infection prevention precautions

Isolation

• If patient has any of:
• exfoliating skin condition
• productive sputum
• extensive wound areas/skin ulcers
• multiple MRSA positive sites
• Nurse in single room
• If patient has none of:
• exfoliating skin condition
• productive sputum
• extensive wound areas/skin ulcers
• multiple MRSA positive sites
• Nurse in single room or cohort nurse with other patients with recent positive MRSA report

Signs of clinical infection

• If patient has a wound or ulcer infected with MRSA (not just colonised), treat infection
• Once infection has improved, move to decolonisation of the patient

Decolonisation

• Once any infection clear, start 5-day decolonisation regimen
• If there is a medical device in situ that breaches skin or mucous membranes (central venous catheter, tracheal cannula, drain, external pacemaker), or a urinary catheter, decolonise while device in situ
• and again, after all devices have been removed

Patient safe not to decolonise

• About to be discharged home
• Unlikely to be re-admitted within 12 months and
• At low risk of aureus (SA) infection
• skin intact, no diabetes
• no malignancy and not on immunosuppressive treatment

• Nasal mupirocin 2% 8-hrly for 5 days
• For mupirocin-high level resistant MRSA, use chlorhexidine 0.1% with neomycin 5% (Naseptin^®) nasal cream topically to each nostril 6-hrly for 10 days
• Wash body once daily for 5 days, and hair twice in 5 days
• with chlorhexidine gluconate solution 4% (Hibiscrub^®)
• alternative product (e.g. Octenisan® or Triclosan®)
• if chlorhexidine gluconate solution 4% not tolerated or patient not self-caring, use octenidine (Octenisan^®)

Repeat Screening

Patient safe not to re-screen

• About to be discharged home
• Unlikely to be re-admitted within 12 months and
• At low risk of aureus (SA) infection
• skin intact, no diabetes
• no malignancy and not on immunosuppressive treatment

Patients for re-screening

• After any systemic and/or topical antimicrobial treatment stopped for 48 hr, re-screen
• Screen weekly in MRSA infection high risk areas:
• Critical care unit/PICU/SCBU
• Burns and plastics
• Vascular surgery
• Renal unit
• Cardiothoracic wards
• Orthopaedic wards
• Neurosurgical wards
• Oncology/haematology wards

Outcome

• If 3 clear screens, patient may come out of single room or cohort
• no longer requires barrier nursing
• do not admit to MRSA-screened ward
• If eradication has failed, do not repeat decolonisation until all indwelling lines/medical devices removed
• Do not attempt to eradicate more than twice during any one admission