Antimicrobial Resistance in Ireland - Health Service Executive

1 The Control and Prevention of MRSA inHospitals and in the Community SARI Infection Control SubcommitteeA Strategy for the Control ofAntimicrobial Resistance in IrelandSARI- 1 -Guidelines for the Control of MRSA in Ireland SARIThe Control and Prevention of MRSA inHospitals and in the CommunitySARI Infection Control Subcommittee Published on behalf of SARI by HSE, Health Protection Surveillance CentreISBN: 0-9540177-7-3 The Infection Control Subcommittee has produced these guidelines as part of its remit under theStrategy for the Control of Antimicrobial Resistance in Ireland (SARI). The membership of theSubcommittee is:Dr Mary Crowe, representing the Irish Society of Clinical Robert Cunney,representing the Health Protection Surveillance Centre (formerly the NationalDisease Surveillance Centre), Honorary Eleanor Devitt, representing the Infection Control Nurses AssociationMs Mary Durcan, representing Bord Patricia Garry, representing the Institute of Community Health Bl naid Hayes, representing the Faculty of Occupational Medicine, Royal College ofPhysicians of Ireland .

2 Professor Hilary Humphreys, representing the Faculty of Pathology, Royal College ofPhysicians of Ireland , M ire O Connor,representing the Faculty of Public Health Medicine, Royal College ofPhysicians of draft version of this document was circulated for consultation to a wide range of professional andother bodies. Thirty-seven written or electronic submissions were received in response to theconsultation request, many of which were very comprehensive in their review of the draft document, andthese were considered in the preparation of the final draft of the guidelines. The Subcommittee wouldlike to thank all of those who took the time to respond to the consultation request. A list of organisations,infection control teams and individuals who submitted comments is included in Appendix 2 -Guidelines for the Control of MRSA in Ireland SARI- 3 -Guidelines for the Control of MRSA in Ireland SARITABLE OF CONTENTSFOREWORD4 Executive Summary5A BACKGROUND AND JUSTIFICATIONS FOR Why control MRSA?

3 Of MRSA in hospitals in in the clinical and financial impact of of antibiotic control and cohorting of patients with of MRSA carriage (decolonisation) Nasal Decolonisation of non-nasal Decolonisation of throat and for revised MRSA guidelines and strength of and control in Infection control Antibiotic measures to control and prevent Surveillance and screening of Surveillance and screening of Patient isolation and Eradication of MRSA Recommendations for control of glycopeptide-intermidiate and glycopeptide-resistant strains of Staphylococcus aurues(GISA/GRSA) of MRSA in the Recommendations for care of patients with MRSA in the Recommendations for care in community Patients with MRSA and skin ulceration or indwelling urinary Course of action if there is spread of MRSA infection in a community of measures and their research and developments23 DREFERENCES25 APPENDIX 1: SUMMARY OF GUIDELINES FOR HAND HYGIENE IN IRISH Health CARE SETTINGS31 APPENDIX 2: LABORATORY METHODS OF DETECTION35 APPENDIX 3: CONTACT PRECAUTIONS36 APPENDIX 4: SUMMARY OF RECOMMENDATIONS FROM THE SARI HOSPITAL ANTIBIOTIC STEWARDSHIP SUBCOMMITTEE38 APPENDIX 5.

4 RESPONSES TO CONSULTATION REQUEST40- 4 -Guidelines for the Control of MRSA in Ireland SARIF orewordThis document represents the expert opinion of the SARI Infection Control Subcommittee, following a reviewof the scientific literature and an extensive consultation exercise. Responsibility for the implementation ofthese guidelines rests with individuals, hospital executives and, ultimately, the Health Services we accept that some aspects of the recommendations may be difficult to implement initially due to alack of facilities or insufficient personnel, we strongly believe that these guidelines represent best there are difficulties, these should be highlighted locally and elsewhere so that measures are taken toensure implementation. We have endeavoured to ensure that the recommendations are as up-to-date aspossible, however we acknowledge that new evidence may emerge that may overtake some of theserecommendations.

5 Consequently, the Subcommittee undertakes to review and revise as and whenappropriate, and to review the recommendations at a minimum of three years from the publication date. - 5 -Guidelines for the Control of MRSA in Ireland SARIE xecutive SummaryBackground Methicillin resistant Staphylococcus aureus (MRSA) is widespread in many Irish hospitals and isincreasingly seen in community Health care units such as nursing homes. The impact of MRSA isconsiderable; in Ireland approximately 40-50% of isolates of Staphylococcus aureus recovered frombloodstream infections are methicillin resistant, and this is significantly higher than in some Europeancountries such as the Netherlands and the Scandinavian countries (data from the European AntimicrobialResistance Surveillance System (EARSS)). Measures to control the emergence and spread of MRSA are justified because there are fewer optionsavailable for the treatment of MRSA infections and because these strains spread amongst vulnerable at-risk patients.

6 Patients with MRSA bloodstream infection are twice as likely to die from their infection,compared to patients with bloodstream infection caused by methicillin-sensitive S. aureus. Furthermore,isolates with reduced susceptibility or isolates that are completely resistant to glycopeptide antibioticshave been described in other countries such as the USA and France, and will probably appear in Irelandeventually. The prudent use of antibiotics underpins any approach to the control of antibiotic resistant bacteria,including MRSA. This, together with good professional practice and routine infection controlprecautions, such as hand hygiene, constitute the major measures in controlling and preventinghealthcare-associated infection, including that caused by MRSA, both in hospital and in communityhealth care units. The Infection Control Subcommittee of the Strategy for the Control of Antimicrobial Resistance in Ireland (SARI) has reviewed the literature and revised the 1995 Irish guidelines.

7 The Subcommittee has utilisedguidelines produced in other countries, including the United Kingdom, the United States of America, NewZealand and the Netherlands. In drafting a set of recommendations for Ireland , the Subcommittee hasgraded these in accordance with the strength of evidence. The Subcommittee acknowledges that many Irish healthcare facilities will have difficulties implementingall of the recommendations included in this guideline document, due to inadequate infection controlresources. Where this is so, this should be communicated to senior management and these guidelinesshould be used as a basis for the provision of appropriate resources. *Main Recommendations Hand hygiene before and after each patient contact is essential. Grade ARecommendation The physical environment of any Health care institution must be clean and theChief Executive Officer must take corporate responsibility for this.

8 Every hospital and Health -care institution must take steps to prevent patientovercrowding and ensure adequate space between adjacent ARecommendationGrade DRecommendationGrade BRecommendation- 6 -Guidelines for the Control of MRSA in Ireland SARI Hospitals should have a sufficient number of isolation rooms to assist in thecontrol of infection, including MRSA, in addition to single rooms required forother purposes. Hospitals should also provide appropriate hand hygiene andbathroom facilities to facilitate infection control and phase out large multi-bedded wards wherever possible. Healtcare facilities should ensure that patients who are found to carry MRSAare informed of this and provided with appropriate information. Informationleaflets on MRSA should also be available for all patients, carers and familymembers, as well as visitors to the healthcare facility.

9 Patients with MRSA in high-risk units, intensive care units must beisolated. Patients with MRSA in other units should be isolated whereverpossible. Health care institutions should institute antibiotic stewardship programmes inline with the recommendations of the SARI Hospital Antibiotic StewardshipSubcommittee, and in particular, limit the use of broad-spectrum antibiotics. Early detection of MRSA through surveillance is fundamental to preventingspread. Patients who should be screened for MRSA include those knownpreviously to be positive and who are re-admitted to hospital, patientsadmitted from a hospital or Health -care facilities known or suspected to haveMRSA, and patients during an outbreak as determined by the infection controlteam. Other patients may be included in routine screening, as deemedappropriate by the local infection control team.

10 Although staff may carry MRSA, such carriage is often transient and is notbelieved to contribute significantly to the spread of MRSA. Therefore thescreening of staff on a routine basis is generally not indicated. Staff screeningmay be considered for institutions without endemic MRSA, or for specifichigh-risk units, as determined by the local infection control team. Patients colonised with MRSA who meet any of the following criteria shouldundergo nasal and general body decolonisation: Patients due to undergo an elective operative procedure Patients who have a prosthesis in-situ Patients who are in a clinical area where there is a high risk ofcolonisation leading to invasive infection, intensive care unit. All laboratories should ensure that MRSA isolates that are non susceptible orare fully resistant to vancomycin are detected rapidly and that this iscommunicated to infection control teams and the relevant authorities.