MRSA

What Is It

MRSA is now an everyday problem within healthcare organisations including those in the community. For Infection Control teams it can be their biggest challenge, particularly those in hospital, as it remains a significant cause of hospital - acquired infection. This article will describe MRSA, its microbiology and epidemiology, and how within the perioperative environment, practitioners can adopt evidence based practices to minimise and prevent the spread of MRSA to patients and colleagues. The article will also examine the wide variations in incidence within areas of Europe.

What is MRSA?
S. Aureus is a common pathogenic commensal bacterium found in warm, moist areas of the body, particularly the nose, axilla and perineum. Approximately 30% of the population are colonised with the bacterium – that is they carry S. Aureus but it does not cause them harm and they do not require treatment. However, within the hospital environment this means that potentially both patients and staff can act as a reservoir and source for the spread of infection to susceptible individuals.


Why is MRSA dangerous?
MRSA can only be treated with the glycopeptide group of antibiotics such as vancomycin, which are expensive, can only be given intravenously and are associated with renal impairment. In 2002 the latest figures from the PHLS revealed that MRSA infection rates have reached a plateau but that new strains of vancomycin resistant S. Aureus (VRSA) are emerging. The first known case of VRSA was reported in Japan in 1997 and although still rare in incidence it must not be ignored. The PHLS reported the first case of intermediate resistance to vancomycin in England and Wales in 2002. This development is potentially hazardous with disastrous consequences as it reduces the treatment options for those patients with MRSA.

MRSA is a common isolated organism in postoperative wound infections, but can also be isolated from intravenous catheter tips, chest drains and burn wounds. MRSA was identified as the cause of surgical site infection in almost 25% of all wounds examined, and the commonest staphylococci in large bowel surgery, vascular and limb surgery, open reduction of long bone fracture and hepato-biliary surgery. The majority of wound infections arise from the patients’ own skin flora (endogenous) although some come from the Operating Theatre and its staff.

How do we control it?
It has been advocated that an active programme of controlling MRSA and its spread is essential to reducing the impact on the organisation as well as the financial burden.

Each healthcare organisation must have a policy for the management of patient(s) infected with MRSA. The primary aim of any infection control policy is to prevent the acquisition and spread of MRSA by patients and staff. Guidelines were produced to address the problems encountered with the wide and varied management of these patients in different organisations.
Screening of all patients for MRSA as part of the pre-operative assessment process may be impractical and costly, but for selected groups may be beneficial. For the patient undergoing major joint surgery, screening for MRSA prior to surgery will allow all precautions to be taken to prevent prolonged hospital stay, breakdown of the wound, the potential for infection of the joint and breakdown of the prosthesis.


Following the review by Brown & Cumberland,the practices outlined below have now been suggested:

1. MRSA positive patients are operated on at the end of the list. Such patients are likely to disperse micro-organisms into the atmosphere and potentially are a risk to other patients. However operating lists can be delayed and the MRSA positive patient may not receive their surgery on that designated day.

2. All non-essential equipment should be removed to prevent contamination for subsequent patients.

3. Minimal staff should be present in the theatre to prevent cross-contamination between staff and patients.

4. The Operating Theatre and associated equipment should be cleaned with a hypochlorite solution once the wound is closed and the theatre rested between patients. The transmission of infection between successive patients is probably airborne on items of equipment or surfaces that have been in contact with the infected patient. MRSA can survive in dry conditions and for some considerable time so it is essential that the appropriate cleaning solution be used.

5. If no further surgery is to follow then theatre personnel need only change their scrub suits and theatre greens.

6. Patients will be recovered within the Operating Theatre.

The single most effective method of preventing and controlling the spread of MRSA is by the effective decontamination of hands after every patient episode of contact. It was identified that hand hygiene is not performed adequately nor often enough (frequency and quality are poor) but recognised that facilities may be insufficient, with ineffective hand solutions, no mixer taps and rough paper towels.

As practitioners we should question our own knowledge and practices for the management of the patient with MRSA. Does the Department have an Infection Control Policy and were theatre staff involved in writing it? One could question theatre practitioner’s ability to wash their hands as we are excellent at knowing how to "scrub up" but between patients, after any patient contact do we always wash our hands? And what do we wash them with? Excessive use of chlorhexidine or iodine solutions could be detrimental to the condition of the hands but do the scrub sinks or sluices have soap dispensers?

MRSA clearly warrants the name "super bug" dont be complacent

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