PURPOSE:

To provide guidance for personnel to prevent the spread of Methicillin Resistant Staphylococcus Aureus (MRSA) among individuals, personnel, and environment.

APPLICABILITY:

This advisory applies to individuals served by the department who receive day and/or residential supports or services regardless of the facility or region in which they are served.

The department recognizes the special need to work with facilities which it does not fund or license to ensure the thorough understanding and implementation of medical advisories.

DEFINITIONS:

Cohort: Placement of two or more individuals with Methicillin Resistant Staphylococcus Aureus (MRSA) in the same room or separation of individuals with MRSA from others who have not acquired MRSA.

Colonized individual (carrier): Any person who is found to be culture-positive for MRSA, but has no signs or symptoms of infection caused by the organism (asymptomatic).

Decolonize: To administer topical and/or systemic antimicrobial agents for the purpose of eradicating MRSA carriage by an individual.

Endemic: The usual (baseline) frequency of MRSA infection in a given facility. This frequency varies from one facility to another.

Epidemic: An increase in the incidence of MRSA infection above its expected endemic level of occurrence in a given facility.

Infected person: Any individual who has laboratory and clinical evidence of disease caused by MRSA (symptomatic).

Methicillin Resistant Staphylococcus Aureus (MRSA): A strain of Staphylococcus aureus resistant to methicillin, nafcillin, or oxacillin. Such strains are often resistant to many other antibiotics.

Nosocomial Infection: An infection acquired in a hospital.

Outbreak: An increase in the incidence of MRSA above its expected endemic level. An outbreak is suggested if there are three or more nosocomially-acquired cases that are linked by person (e.g., same health care provider), place (e.g. same wing, room) or time (onsets within 10 days of one another) of occurrence in a given facility.

Universal Body Substance Precautions: A system of precautions that assumes that all body substances may contain potentially infectious material. It requires good handwashing technique and appropriate use of barriers such as gloves, gowns, masks and eye protection to prevent transmission of microorganisms. (Different from Universal Precautions which apply only to blood or other body fluids containing visible blood)

DISCUSSION:

Staphylococci aureus is a type of bacteria (germ) that is commonly found on the skin and mucous membranes (such as inside the nose). These same bacteria may cause disease when

• an open wound or nick in the skin allows them to enter the body;

• there is a place they can accumulate and multiply, e.g. along side a catheter or any plastic prosthesis;

• the body's resistance to infection is diminished; and/or

• other helpful bacteria have been destroyed by antibiotics.

MRSA is distinguished from most other bacteria because it is particularly resistant to antibiotics. MRSA strains are not more virulent (more likely to cause disease/infection) than methicillin susceptible strains.

Transmission:

MRSA is transmitted by direct person to person contact, usually on the hands of care givers. Transmission is not likely via airborne route or from environmental surfaces including bed linens.  If a person has no signs of infection, there is no need to test individuals for the presence of the bacteria.

Masks are not recommended for routine use to prevent transmission of MRSA from patient to housemates or caregivers.  Use masks according to standard precautions when performing splash-generating procedures, caring for individuals with open tracheostomies with potential projectile secretions, and when there is evidence for transmission from heavily colonized sources.

PROCEDURE:

I. Management of Infected Individual

When an individual is diagnosed with MRSA, the following shall occur:

1. The person's physician shall determine whether the MRSA represents a colonization or an active infection, complete required reporting to the DPH, and shall order treatment as necessary. Consultation with an infectious disease specialist may occur as indicated.
   1. Treatment regimens of topical and/or systemic antibiotics may be ordered as indicated for infected or colonized persons by their physicians.
   2. Management of severe infection usually requires hospitalization for treatment with IV vancomycin.
   3. Cultures of infected/colonized sites may be recommended by the person's physician or an infectious disease specialist.
2. The facility/agency nurse shall be notified immediately and the DDS regional Health Service Director/Director of Nursing Public Programs shall be notified as soon as possible.
3. The facility/agency nurse with the person's IDT, including the physician shall review the health issues specific to the individual and make recommendations and/or decisions regarding home, work, and other activities as appropriate. Consideration shall be given to the fact that transmission of MRSA from roommate to roommate in other than acute care (hospital) settings occurs rarely. Participation in normal living activities shall be encouraged as appropriate for the individual. In making such decisions, the IDT shall consider:
   1. the body sites from which MRSA has been cultured and whether drainage from such sites can be contained;
   2. whether invasive devices are present (e.g. G-tubes, catheters);
   3. the person's competence regarding personal hygiene and whether these factors relate to the potential spread of MRSA;
   4. the type of direct care the person requires; and
   5. the characteristics of "housemates" and/or "coworkers" in relationship to the potential for spread of MRSA.
4. IDT recommendations/decisions regarding the individual's living and day situations shall be based upon the following considerations:
   1. MRSA positive individuals may share a bedroom with a low-risk individual (i.e. one who does not have tubes, catheters, wounds or decubiti, intravascular lines and/or is not immuno-compromised), or with another MRSA positive individual (cohorting).
   2. MRSA positive individuals should be considered for a private room if the person
      1. has a respiratory colonization and has a productive cough or other oral/nasal secretions (e.g., excessive drooling, runny nose, sneezing, etc.);
      2. has a draining wound that cannot be contained;
      3. does not understand or cannot cooperate with basic hygiene, has a skin condition that may facilitate transmission of MRSA (e.g. eczema) and/or may soil the room with body substances such that a roommate would be likely to have inadvertent contact; and/or
      4. as determined by the nurse, physician, or facility or regional infection control committee needs his/her own room.
   3. Decisions regarding placement and treatment shall be documented in IDT minutes and nursing notes per nursing documentation standards.
   4. Individuals with MRSA infection or colonization shall not be refused placement/services solely on the basis of his or her MRSA status.
5. The agency/facility nurse or other appropriate manager shall ensure that staff receive inservice training regarding MRSA infection including issues and concerns specific to the individual with MRSA.

II. Communication and Confidentiality

1. Information regarding the individual's infection or colonization with MRSA shall be handled in the same manner as any other medical information.
   1. As with all medical information, diagnosis and treatment of MRSA shall be released to the individual's health providers. Standard medical consent to release information shall be maintained in the individual's record (health or master file).
   2. Information regarding MRSA infection shall be released to others on a need to know basis and only after obtaining the consent of the individual or his or her guardian.
   3. If information cannot be shared due to lack of consent and concerns include potential risk to other individuals, the DDS Health Service Director/Director of Nursing Public Programs shall notify the central office director of health and clinical services who shall seek the advice of the Office of the Attorney General.
2. When the person is being transferred to another setting, advance notification shall be given to ensure appropriate planning.

III. Precautions:

1. Universal Body Substance Precautions
   Handwashing and adherence to universal body substance precautions remain the most important measures in controlling the spread of disease, including the spread of MRSA. Practice of universal body substance precautions includes:
   1. Thorough handwashing before donning gloves and immediately after gloves are removed.
   2. Thorough handwashing between caring for individuals.
   3. Use of gloves when caring for individuals whenever contact with wounds, sores, mucous membranes, or other body substances is anticipated. (See facility or agency universal precautions policies and procedures.)
   4. Use of gowns, masks and eye protections as appropriate.
2. Cleaning equipment
   1. Equipment should be dedicated for the person infected with MRSA whenever possible (.e.g., thermometers, commodes, etc.), especially when use of disposable equipment is not feasible.
   2. Non-dedicated or non-disposable equipment shall be disinfected with a tuberculocide agent prior to use by another individual.
3. Housekeeping and Laundry
   1. Standard housekeeping measures that include the use of tuberculocide cleaning agents shall be employed per agency infection control procedures.
   2. Linens and personal clothing should not be sorted in common house areas but do not have to be washed separately.

IV. Surveillance:

1. DDS Operated Facilities/Programs
   1. DDS regional infection control committees shall determine region specific infection control practices. Such committees shall identify a responsible person(s) who shall:
      1. determine baseline incidence rates for MRSA in DDS campus facilities and other settings as deemed appropriate by the committee;.
      2. monitor new cases of MRSA infection/colonization, identify increased incidences of infection above the expected endemic (baseline) level, and report to, or seek advice from the DPH Epidemiology unit or infectious disease specialists as appropriate;
      3. determine if additional incidences of MRSA constitute an outbreak as previously defined and ensure appropriate responses such as DPH notification, re-inservicing of infection control procedures, and other appropriate actions.
      4. monitor infection control practices.
   2. The DDS regional Health Service Director/Director of Nursing Public Programs shall ensure that appropriate measures are taken including placement decisions, inservice training, infection control practices.
2. Private Agencies Funded by DDS
   1. Private agency policies and procedures shall address infection control issues including MRSA infections, as appropriate.
   2. Private agencies shall report each new occurrence of MRSA infection or colonization to the DDS regional Health Service Director.
3. The DDS regional Health Service Director shall notify the central office director of health and clinical services as appropriate.
4. The central office director of health and clinical services shall notify the Commissioner and other individuals as appropriate.

NOTE: The State of Connecticut Department of Public Health (DPH) Guidelines for Management of Patients with Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals and Long Term Care Facilities is available upon request from the DPH, DDS regional Health Service Director/Director of Nursing Public Programs, or DDS central office director of health and clinical services.

for additional information on this disease, visit the following websites:

www.cdc.gov (Centers for Disease Control and Prevention)
www.ct.gov/dph (State of Connecticut Department of Public Health