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13.1.3.5 Ward environment
1. All shared communal services such as lavatories, bathrooms, etc. should be cleaned daily and kept dry.
2. In general, environment disinfectants are not required; detergent and hot water are adequate.
3. Sink traps inevitably harbor organisms, which cannot be removed by disinfectants.
4. The taps and sinks should be designed so that ther is minimal splashing from the sink area.
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13.2 Methicillin Resistant Staphylococcus Aureus
13.2.1 Introduction
MethicillinResistant Staphylococcus Aureus MRSA have been a major cause of health care-associated infections HCAI worldwide. Detection of MRSA within hospitals and
long term care facilities has increased dramatically and a great deal has been written regarding its management and control.
Concern about MRSA is related to the potential for health care and community transmission and the limited number of antibiotics available to treat infections caused by this organism.
13.2.2 Epidemiology
The current prevalence rate of MRSA in United States hospitals is now believed to exceed 50. Canada reported a 6 rate, while Japan’s rate exceeded 80. Most European
countries had a greater than 6 rate of S. aureus strains be MRSA in 1999, but the Netherlands reported less than 1.
In Malaysia, the rate of MRSA isolate was 0.5 per 100 admissions in 2005 and 0.3 2007. The epidemiology of MRSA has changed with the apparent emergence of MRSA in
the community with clinical, epidemiologic and bacteriologic characteristics distinct from health care-associated MRSA.
13.2.3 Methicillin-Resistant Staphylococcus Aureus
• Staphylococcus aureus is a facultative anaerobe, non-motile, catalase positive, gram-
positive cocci which predominantly arranged in grape-like clusters. •
It is the most important human pathogen among the staphylococci. •
S. aureus that is resistant to the synthetic penicillins methicillin, oxacillin, nafcillin is referred to as MRSA.
• They colonises the skin, particularly the anterior nares, skin folds, hairline, axillae,
perineum and umbilicus. They may also colonise chronic wounds, for example in eczema, varicose and decubitus ulcer.
• MRSA is transmitted primarily through direct person-to-person contact, commonly
through the hands of health care workers. However, It can also be transmitted through contact with inanimate objects such as linen, clothing and dust, although these do
not represent significant sources for transmission.
• Nasal carriage of MRSA is very common and due to hand to nose transmission.
• A nasal carrier often contaminates hisher own hands by hand to nose contact, then
transmits the organism in the course of routine activities. •
Since skin to skin contact is the most significant mode of transmission, hand hygiene is of primary importance in preventing its spread.
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• Because of its resistance to antibiotics, management of MRSA infections requires
more toxic and expensive treatment. •
MRSA colonization and infections have a significant impact on individual patients and institutions.
• Many patients with MRSA remain colonized indefinitely, and the majority of hospital and
nursing homes that have endemic MRSA never eradicates MRSA from the institution.
13.2.4 Clinical Manifestation
• Infections caused by MRSA are wound infections, bacteremia, ventilator-associated
pneumonia and less commonly endocarditis and osteomyelitis •
It also produces toxins which can cause necrotising entero-colitis among newborns.
13.2.5 Laboratory Diagnosis
• Screening for MRSA colonization can be detected by culture of the nares or wound swabs
• Clinical infection caused by MRSA can be identified by cultures of blood, broncho-
alveolar lavage, sputum, urine or surgically obtained specimens. •
Oxacillin susceptibility testing by the Kirby Bauer technique is the preferred method of identifying MRSA. Resistance to oxacillin also defines resistance to all penicillins,
cephalosporins, cephamycins and other classes of antibiotics including aminoglycosides, macrolides and quinolones.
• Methicillin resistance in MRSA is conferred by the mecA gene, which encodes an
altered penicillin binding protein PBP2a.
13.2.6 Treatment
Treatment of MRSA falls into two areas, one is the antimicrobial treatment of clinical invasive infection and the other is topical to eradicate skin and nasopharyngeal colonization.
Eradication of colonized patients is recommended as these patients provide a reservoir for subsequent spread of MRSA.
1. Hygiene
• Bath daily and wash hair twice weekly with an antiseptic body wash such as 4
chlorhexidine gluconate scrub or 2 triclosan . •
Use a disinfectant dusting powder hexachlorophene 0.33 after bathing and drying. Apply to axilla, groin and any skin folds.
2. Nasal carrier
The usual treatment for nasal carriage is mupirocin, which is an effective topical agent •
Apply mupirocin nasal ointment three times per day for a period of five days. A ‘match head’ size of ointment should be applied to the inner side of the nostril.
• After the five-day treatment course, cease eradication therapy for two days and
repeat the swabs.
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• Use an antibacterial chlorhexidine gluconate 0.2 mouth wash two times per day.
• If after two courses of mupirocin treatment the nasal carriage is not eradicated, it
is important that mupirocin is stopped because the risk of resistance will develop. 3.
Wound treatment Colonisation or infection caused by MRSA may delay wound healing. These general
principles can be applied: •
Clean wound with sterile water. •
Use povidone-iodine or silver sulphadiazine preparations where possible. •
Cover wound with an appropriate dressing. •
DO NOT USE TOPICAL ANTIBIOTICS FOR LOCALISED WOUND INFECTION
4. Systemic infection
• With the emergence of resistance to the penicillinase-resistant penicillins, the
glycopeptides agent vancomycin became the treatment of choice for infections cause by MRSA.
• Vancomycin can have serious side effects, include ototoxicity, nephrotoxicity,
‘red man syndrome’ and allergic reactions •
Alternative antibiotics to treat MRSA include linezolid, rifampicin, fucidic acid, tigecycline, quinopristindalfopristin and teicoplanin
•
Avoid using rifampicin or fucidic acid as single agent because of rapid development of resistance.
13.2.7 Infection Control And Prevention
• The preventive measures of infection control for MRSA follows the contact based
precautions which includes hand hygiene, isolation, gloving, linen handling and environmental cleaning.
• Hand hygiene is the single most important factor in preventing the spread of MRSA,
therefore the 5 moments shall be adhered to at all times. •
Gloves should be worn for any contact with bloodbody fluids, secretions and excretions wounds, invasive site, or mucous membrane of a patient
• Gowns may be worn if splashing or extensive soiling is likely.
• Masks and eye protection are indicated if exposure to aerosols generated by coughing
patient is likely or when irrigating wounds. •
Daily routine cleaning of formites must be done with a disinfectant 70 alcohol and performed in a sanitary manner as is done in all rooms regardless of the presence
of MRSA. Terminal cleaning shall be performed upon patient discharge. Equipment should be routinely cleaned, disinfected or sterilized per institution policy.
• The MRSA colonized or infected patient should be isolated in single room if available
or cohort with other known MRSA patient. •
Contact based precaution should be strictly adhered to at all times, irrespectively of isolation.
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