Meticillin Resistant Staphylococcus aureus ( MRSA ) guideline (includes Panton-Valentine Leukocidin (PVL) positive S. aureus)
|Publication: 05/01/2010 --|
|Last review: 30/11/2017|
|Next review: 23/07/2021|
|INTERIM REVIEW DATE|
|Approved By: SMT|
|Copyright© Leeds Teaching Hospitals NHS Trust 2017|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Meticillin Resistant Staphylococcus aureus (MRSA) guideline (includes Panton-Valentine Leukocidin (PVL) positive S. aureus)
- For patients who need screening for MRSA please see Standard Protocol No. 1.
Patients who are MRSA-positive must be managed in source isolation as outlined in the
LTHT Isolation Guideline
- Patients who have previously been MRSA-positive must be managed in source isolation until they have had three full sets of negative MRSA screens since their last MRSA positive result – details of this process are outlined in the Repeat Screening section
- If MRSA-positive patients are discharged from or transferred within LTHT, the receiving area must be notified and a transfer form must be completed in line with LTHT policy.
- All ‘high risk’ patients (see definition) should receive surgical peri-operative antibiotic prophylaxis with an agent with activity against MRSA if they undergo a surgical procedure or other intervention (see definition) for which prophylaxis is indicated.
- All MRSA-positive patients (or their carers) should be provided with an MRSA patient information leaflet.
- In- patients to be screened monthly for the duration of their hospital stay.- irrespective if screened on admission.
- Patients being admitted for elective/day case procedures do not normally require negative screening swabs prior to the procedure being performed. However, it should be checked that they have taken appropriate decolonisation - both in respect of agent and timing. If the patient has not taken/completed appropriate decolonisation, a risk assessment should be made as to whether the procedure should be deferred until the appropriate decolonisation has been completed or the procedure undertaken as planned, with completion of decolonisation subsequently.
- CSUs may have local protocols in addition, or supplementary, to this Trust-wide guidance, which have been agreed with Infection Prevention and Control (IPC), such as when to give “decolonisation”; which should also be consulted as appropriate.
- There are 4 specific patient pathways with respect to MRSA: Adult Acute, Adult Elective, Womens and Children. Every patient being admitted should the appropriate pathway completed.
- Panton-Valentine Leukocidin (PVL) positive Staphylococcus aureus which produces PVL toxin is a specific and emerging infection prevention hazard. PVL can be produced both by meticillin sensitive and meticillin resistant strains of Staphylococcus aureus and is also covered within this document - see Standard Protocol No. 7.
Pre-admission MRSA screen positive
Source isolation is required - may be discontinued when there have been three negative sets of MRSA screens as described in the Repeat Screening section
Previous MRSA-positive identified on PPM+/ Order Comms (ICE) or from patient at admission
Source isolation is required unless the patient has had three sets of negative screens (see the Repeat Screening section) since the MRSA was identified
Inpatient found MRSA positive on screening (pre admission, on admission or post admission)
Source isolation is required - may be discontinued when there have been three negative sets of MRSA screens as described in the Repeat Screening section
Patients found MRSA positive in clinical sample(s).
Source isolation is required. This may be discontinued when there have been three negative sets of MRSA screens as described in the Repeat Screening section; but the decision will also depend on the type of clinical sample(s) that were positive; and whether further samples from same site(s) can be obtained and if clinical symptoms and signs of infection at those site(s) have resolved. Normally discuss with IPC prior to discontinuation of source isolation.
|Patients admitted for implant surgery - see definitions below||
Decolonisation is required in all cases irrespective of MRSA status. Decolonisation should be timed to finish on the day of surgery.
Pre-admission MRSA screen positive
Decolonisation is required in all cases. unless they have completed 3 separate appropriate decolonisation courses, in which case contact IPC. NB if due to have surgery, a further decolonisation course will be indicated.
Admission MRSA screen positive
Decolonisation course is required in all cases,
Previous MRSA-positive identified on PPM+/ Order Comms (ICE) at admission
Decolonisation is required for all patients (irrespective of anticipated length of admission) unless the patient has had a course of decolonisation within the last 14 days or they have completed 3 separate appropriate decolonisation courses, in which case start a further decolonisation course, and contact IPC.
Resident of nursing home or similar long-term care facility without a previous history of MRSA
MRSA decolonisation is required for all patients, unless had a course of decolonisation within the last 14 days
Patient >65 without a previous history of MRSA
MRSA decolonisation is required for all patients. unless had a course of decolonisation within the last 14 days
MRSA positive inpatient screen
Decolonisation is required in all cases unless they have completed 3 separate appropriate decolonisation courses, in which case start a further decolonisation course, and contact IPC
|Intensive care admission||MRSA decolonisation is required for all patients unless had a course of decolonisation within the last 14 days.|
Intravascular access device insertion /other procedures.
Patients (adults or children) having a long term vascular access device inserted, i.e. planned to be in for 30 days or more should receive decolonisation prior to line insertion, if possible, irrespective of MRSA status. The decolonisation should be timed to finish on the day of procedure.
Table 3: Summary of specific MRSA decolonisation agents - NB: All persons administering decolonisation MUST understand the importance of completing the course correctly.
|Details of patient requiring decolonisation||
Nasal decolonisation agent
Hair and body decolonisation agent
Bactroban® (mupirocin) nasal ointment/cream
Chlorhexidine 4% bodywash †§
Naseptin® (neomycin)* nasal cream
Prontoderm® nasal cream/ointment
*If peanut, chlorhexidine or neomycin allergy: use Prontoderm® (see standard protocol No. 5)
† For children under one: use octenisan® instead
§ If otherwise can’t use chlorhexidine: use octenisan® or Prontoderm®
Detailed information can be found in standard protocol No. 5.
To help prevent and control the spread of MRSA within LTHT and to provide a safe environment for all patients, staff and visitors.
- Acute admission – patients admitted directly i.e. in the absence of any planned waiting period; including e.g. from own home; via GP; via Emergency Department(ED); from out-patient clinic; transfer from another healthcare facility, where an overnight stay (i.e. period of at least 12 hours) is anticipated.
- Bacteraemia – isolation of a bacterium (e.g. MRSA) from a patient’s blood.
- Carriage – the presence of a micro-organism at a body site on, or in, a patient (either colonisation, or infection).
- Colonisation – the presence of a micro-organism at a body site on, or in, a patient, not causing “infection”.
- Decolonisation – the application of antimicrobial substances (e.g. antiseptics +/- antibiotics) in an attempt to reduce MRSA to a safe level Decolonisation is also used in patients who are considered at higher risk of being MRSA-positive and/or of more severe consequence of an MRSA infection.
- “Discharge screening – screening carried out in some institutions (not LTHT) within the three days prior to discharge from that institution.
- Elective admission – a patient admitted following a planned period of waiting, where an overnight stay (i.e. period of at least 12 hours) is anticipated. Admission may be from a waiting list or from being ‘booked’ (i.e. given a date at the time the decision to admit was made).
- ‘High risk’ patient - ‘High risk’ patients are those who have a history of MRSA colonisation or infection at any time, patients who are resident in a nursing home or similar long-term care facility, or lived/had healthcare abroad in the last 12 months.
- Implant – any non-human foreign body that is placed permanently in a patient during a surgical procedure, which is not routinely manipulated for diagnostic or therapeutic purposes. Examples are joint prostheses, prosthetic heart valves, gastrostomies, screws, wires or meshes that are left permanently in situ. Individual CSUs may have more specific lists of what is, or is not, an “implant” for the purposes of this guideline.
- Infection – symptoms and signs caused by pathogenic (harmful) micro-organisms. These include local evidence of inflammation (e.g. pain, redness, tenderness, swelling, heat), systemic effects (e.g. fever, low blood pressure and shock) and raised inflammatory markers (e.g. white blood cell count and CRP).
- Intervention - a diagnostic and/or therapeutic event that causes a break in the skin or mucous membrane.
- MRSA Acquisition: An individual gaining MRSA. This may be detected on screening swabs or from clinical samples. The likely timing of the acquisition may be suggested if a site which was previously negative for MRSA then becomes positive on repeat sampling.
- MRSA-positive – MRSA has been detected in or on a patient, whether infected or colonised,
- MRSA screening – the process of identifying patients who are MRSA carriers by bacteriological testing
- Set (of MRSA screening swabs) – MRSA swabs sent on the same day from nose, groin, axilla and any other appropriate sites (see standard protocol No 2 & 3, screening ).
MRSA is meticillin-resistant Staphylococcus aureus. This is a bacterium that is resistant to virtually all β-lactam antibiotics (e.g. flucloxacillin, co-amoxiclav, piperacillin-tazobactam; cephalosporins such as cefuroxime; and carbapenems such as meropenem). MRSA is not normally a significant risk to healthy people including health care workers and visitors, but can cause serious infection in vulnerable patients.
Like other S. aureus strains, MRSA colonises moist or broken skin, in particular the axillae and groin areas. The most common carriage site is the anterior nares (nostrils). MRSA is spread from person to person either by direct or indirect contact. In hospital, MRSA is most commonly spread on the hands of health care workers. Hospital equipment can also be a route of spread if not adequately decontaminated between patients. Patients with MRSA are likely to contaminate objects and the hospital environment in their vicinity. Subsequently this contamination can be transferred to other patients.
The two main risks associated with MRSA-positive patients are:
- They may be a source of MRSA cross-infection to other patients
- They are at increased risk of MRSA infection if they undergo invasive procedures
Screening helps identify these patients so that measures can be put in place to reduce these risks. These measures are:
- Reinforcement of Standard Precautions for Infection Prevention and Control
- Source Isolation
- Suppression of MRSA numbers with ‘decolonisation’ (see definitions)
- The risk of MRSA infection is reduced not only by decolonisation but also by including an anti-MRSA agent in any peri-operative antibiotic prophylaxis when prophylaxis is appropriate.
However, the overall yield of “universal” screening is low (for LTHT, from over 110,000 MRSA screening sets collected in year 2014-15, less than 3% were positive). Therefore, following revised national guidance issued in 2014, coupled with local consultation, a targeted approach is being introduced in LTHT. This strategy is designed so that only patients most likely to be positive for MRSA and/or to have a more severe outcome if infected will be screened.
All LTHT patients must be risk-assessed for MRSA - using the appropriate MRSA pathway.
All ’high risk’ patients should be managed as shown in the Summary tables for Patient Placement and MRSA Decolonisation above. Requirements for peri-operative prophylaxis in High Risk patients are shown in the Leeds Health Pathways Antimicrobial Guidelines
Paediatric patients are NOT routinely screened for MRSA, with the exception of;
- cardiac surgical, renal/liverintensive care unit, neonatal patients.
- previous positive MRSA.
- if they have lived and/or had healthcare abroad in the previous 12 months.
The definition of an implant is provided above. However, this is not an exhaustive list. The responsibility for determining whether an implant is involved in any specific procedure or if MRSA screening is otherwise required, resides with the relevant CSU management team (see standard protocol No 1 of patient categories to be screened for MRSA). Relevant members of the IPC team can be consulted for advice if required.
Advice regarding appropriate placement of MRSA-positive and other patients assessed as ‘high-risk’ within out-patient, day-case and other similar settings can be obtained from the IPC team. Also check if there are any specific infection prevention and/or microbiology infection advice notes on patient’s electronic care record (PPM+).
Characteristics of the Groups of patients to be screened for MRSA:
(See specific MRSA pathways).
- All Adult Acute Admissions
- All adults and children if previously resided or had healthcare abroad in the past 12 months
- All adults and children known to be MRSA positive in past
- All adult elective patients admitted to the following areas (with an anticipated overnight stay): Vascular, Renal, Neurosurgery, Cardiothoracic Surgery, Trauma and Orthopaedics, Haemato-Oncology, Critical Care, or for solid organ transplant.
- All paediatric patients admitted to the following areas: Cardiac Surgical, Renal, PICU and Neonatal Unit.
In addition to the above:
|Adult Critical Care||“Any” admission if not previously screened pre/at current admission|
|Chapel Allerton Hospital||See standard protocol 4 for patients on the CHOC pathway|
|Head & Neck||Follow agreed pathway on Order Comms|
|Trauma & Related Services||Plastics: follow agreed pathway on Order Comms|
|Women’s||Maternity: only if baby likely to need Neonatal Unit
C. section: all electives (NB screening set is nasal, axillae and self-taken vaginal swab)
Outpatients with long term vascular access devices
Screened pre-insertion and then at 3-monthly intervals
- All patients should be given a Patient Information Leaflet, outlining the MRSA screening process and treatment options [WNA1007], and asked for verbal consent to being screened.
- When indicated, MRSA screening should take place at the earliest appropriate opportunity after a decision has been made to admit a patient. This may be before admission (pre-admission screening) or at the time of admission (admission screening) if not practical at pre-admission. Other appropriate sites (see below) should normally be done within 48 hours of admission. Clearly document reason if not swabbed.
- MRSA screening should not delay urgent treatment; where immediate intervention is required (e.g. emergency Caesarean section). MRSA screening should be carried out at the earliest safe opportunity, which may be after the intervention. This should, however, ideally take place during the same shift that the patient is admitted.
- MRSA screening swabs should be taken from anterior nares, groin, axilla; umbilicus (in children <1 month old only); and, if practicable, any other sites that would be likely to be colonised in MRSA carriers (e.g. exit sites of lines in situ >30 days, CSU from urinary catheter, PEG sites, stoma sites, wounds (whether discharging or dry) and other areas of broken skin. For planned Caesarean sections - nose, axilla and self-collected vaginal swabs. Details of how to take screening swabs are given in Standard Protocol No. 3.
- All MRSA screening swabs should be put in the eSwab tube(s) (see Standard Protocol No. 3) in a single specimen bag and submitted correctly labelled with the screening location and requesting ‘MRSA screening‘. The completed request form must comply with the requirements of the Pathology Labelling Policy. The screening swabs will be processed in the laboratory as a single specimen. Catheter urine should be sent separately. Submission of MRSA screening specimens should be documented on each patient’s MRSA pathway.
- For sites considered to be clinically infected (e.g. erythematous wounds or inflamed sites) additional swabs should be sent to Microbiology on separate request forms, with appropriate clinical details and a request for culture and sensitivity testing.
- Patients have the right to refuse MRSA screening. In this situation they should be reminded that screening is in the best interests of themselves and other patients. If the patient continues to refuse, this should be documented in the nursing or clinical notes and the IPC Team should be consulted.
A note should be made in the patient’s medical and nursing notes as to whether there is a history of allergy to any products used in MRSA decolonisation (this includes arachis/peanut oil, which is a component of Naseptin®).
For elective admissions, where required, it is carried out at pre-operative assessment clinics.
- A negative result is valid up to three months before the planned admission date. If it is three months or more since the last MRSA screen it will need to be repeated at or before admission, assuming the patient continues to meet one or more criterion for screening. A positive result will remain “valid” until three subsequent negative screens are obtained.
- CSUs should have in place a system for informing patients that MRSA has been detected at pre-admission screening (if performed) and that decolonisation is required. This will usually be prescribed by the patient’s GP.
- If the patient clearly states that they were MRSA-positive in another organisation, they should be managed as if they had been found MRSA-positive within LTHT.
- Screening results are available 24 - 48 hrs after the sample is received in the laboratory, and released to PPM+/ Order Comms (ICE) as soon as the test is complete.
- It is the responsibility of the requestor to check results; they will not normally be telephoned.
- Results must be documented on the each patient’s MRSA pathway. Please refer to summary tables for actions to be taken with a positive result.
- Positive results are usually reported with a comment recommending which agent to use. Most isolates are mupirocin sensitive. Where resistance to mupirocin is reported an alternative agent should be used - see Table 3. NB if patient is MRSA positive it is imperative to check sensitivity results and manage accordingly.
- All patients with positive MRSA screens should be given the relevant Patient Information Leaflet, which gives information about the implications of MRSA and how they will be treated [WNA1007].
- Patients who are MRSA positive on screening need to have 3 consecutive negative screening sets after completing decolonisation. The patient should remain in source isolation until three complete sets of negative MRSA screens have been received.
- If a patient is MRSA-positive from a “clinical” site such as sputum, wound or urine, then the risk assessment also needs to take into account additional factors such as the site(s) that were positive and if they are “hard to decolonise” successfully, whether repeat specimens are obtainable and if there is on-going clinical evidence of infection. Normally IPC agreement is appropriate before stopping source isolation. Check if any relevant advice is recorded on PPM+.
- MRSA-positive patients have to be re-screened to confirm effective decolonisation.
- Post-decolonisation screening requirements are as follows:
- There must be a gap of at least two days between completing MRSA decolonisation and submitting the first post-decolonisation sample set.
- Three consecutive sets of MRSA screens must be taken from all appropriate sites as described above. There must be a gap of two days between each set of MRSA screens.
- If a patient was positive from a clinical sample, repeat sample(s) from the same site(s) should also be sent whenever possible.
- MRSA screens are counted as negative only if antibiotics with activity against MRSA and/or topical decolonisation agents have not been administered during post-decolonisation period. Medical staff should be consulted if it is unclear whether or not anti-MRSA antibiotics have been in use. If a patient is on such agent(s), clearance screening needs to be deferred until the patient is no longer on such agent(s).
- If three consecutive sets of decolonisation screens are negative the patient may be removed from source isolation provided there is no evidence of on-going infection/colonisation of a clinical site.
- Patients should be screened monthly for the duration of their hospital stay – irrespective whether they were screened pre- / on admission. This should be done when due regardless of whether the patient is receiving topical or systemic anti-MRSA agent(s).
- If at any time a re-screen is positive, or a patient becomes MRSA-positive in a clinical sample, they should be managed in source isolation and decolonised and re-screened as described above.
- There is no requirement to screen any patients who have been in the same bay as a patient subsequently identified to be MRSA-positive. However, should a patient become newly MRSA-positive during a hospital admission (either on screening or in a clinical sample) when previously classified as MRSA-negative, then a DATIX form should be completed for this event. If two or more such acquisitions occur within one month, then the incidents should be managed as a Level 1 outbreak [see Outbreak guidelines]
Procedure for taking MRSA Screening Swabs
Following the introduction of a new automated platform in the Microbiology Laboratory, new swabs have been introduced for use for MRSA screening, as detailed below.
The pink swabs do not have a breaking point. They should be used to swab one site and then are rotated in the liquid before discarding into a clinical waste bin. The white swab is then used for the last site and then broken into the liquid medium. The white swab contains preservatives so it is important it is this swab that remains in the tube.
One pink swab would be used for axilla, one for groin and then the third white swab for the nose. If screening additional areas that hard to decolonise e.g. such as wounds, lacerations, pressure ulcers, indwelling vascular access devices. Please use additional pack(s) with the requsite number of swabs.For neonates, one pink swab can be used for both the axilla and the umbilicus provided there is no evidence of infection.
If an infected site is to be screened then a separate pack should be used with a further screen request.
For Caesarean section, nose/axilla and one pink swab for a self-taken vaginal swab.
Patients who require MRSA decolonisation - see summary information at start of guideline.
- The MRSA decolonisation regimen should be prescribed as detailed on the prescription chart ( eMeds). In most cases this will consist of mupirocin nasal ointment (Bactroban®) three times per day for five days; and 4% chlorhexidine body wash daily with hair wash on days1 & 5.
- If the patient, or a carer, is administering, it is important that they understand and adhere to the application instructions and complete the course.
- In cases of mupirocin resistance and/or allergy or intolerance to Bactroban®, Naseptin® nasal ointment is usually used. Note that a course of Naseptin® lasts for 10 days, and it is administered four times daily.
- Skin decolonisation with chlorhexidine should take place on the same days as nasal decolonisation with Bactroban®, If Naseptin® is being used then the course is for 10 days, with hair washing days 1,5 and 10. If nasal decolonisation is repeated, skin decolonisation should also be repeated.
- In cases where it is not possible to use either Bactroban® or Naseptin®, Prontoderm® should be used. Prontoderm® is administered to the anterior nares three times daily for five days.
- In cases where it is not possible to use chlorhexidine bodywash e.g. due to skin irritation or allergy, Octenisan® or Prontoderm® should be used instead.
- MRSA decolonisation is repeated whenever follow-up MRSA screens are positive again or if the patient becomes MRSA-positive in a subsequent clinical sample, irrespective of the time after the previous course was completed.
- Some patients will remain MRSA-positive despite multiple courses of decolonisation. Patients who are still MRSA-positive after three complete decolonisation regimens using the appropriate agents should not normally receive further decolonisation unless undergoing a surgical procedure (NB: specialty-specific policies may differ from this, e.g. Renal Dialysis, Neonatal and Haemato-Oncology).
- The effectiveness of vaginal MRSA decolonisation has not been established and it is not recommended at LTHT. If MRSA is isolated from a vaginal swab during pregnancy, the mother should be decolonised as soon as possible. After delivery, the baby should be screened and both baby and mother (again) decolonised as soon as possible irrespective of result. Both mother and baby will require source isolation during their hospital stay. N.B. An MRSA positive patient having a Caesarean section should receive peri-operative antibiotic prophylaxis which includes an anti-MRSA agent - see guideline on Leeds Health Pathways.
- If an operation is delayed but takes place within 14 days of completing decolonisation, decolonisation should not be repeated. However, if the delay is 14 days or more, decolonisation should be repeated.
- If an MRSA-positive surgical patient is found at admission not to have started decolonisation, it should be started as early as possible prior to an operation. The operation can usually still go ahead.
- If a positive MRSA result becomes known after discharge, this should be communicated to the patient’s GP with a recommendation that the patient commences a full MRSA decolonisation regimen. It has been agreed with primary care (within the Leeds Health Economy) that decolonisation will be prescribed by the GP. It is ultimately the responsibility of the patient’s named consultant at the time of sampling to ensure that the patient’s GP has been informed of the positive result. Post-decolonisation screening is not normally required unless the patient is re-admitted (see CHOC pathway standard protocol 4).
MEASURES REQUIRED ON TRANSFER OR DISCHARGE
Colonisation/infection with MRSA is not a contraindication to discharge to nursing home/residential care, or transfer within LTHT or to other hospitals/healthcare providers.
Nursing Home If a patient who has been found to be positive for MRSA is discharged to the care of a nursing or residential home or a district nurse then his/her MRSA status must be communicated prior to the transfer/ discharge, and documented clearly in the patient’s discharge sheet. The information must also be communicated to the ambulance crew transferring the patient. A transfer form should be completed as specified in the LTHT Transfer Policy, which must include information on MRSA status.
Within LTHT: If a patient with current or previous MRSA is transferred within LTHT the receiving ward must be informed of MRSA status, the LTHT Transfer and hand over of care procedure should be followed, and the patient should be isolated unless he/she has previously had three sets of negative screens and the current admission screen and/or most recent inpatient screen is negative.
If a patient is being transferred to another hospital trust or healthcare provider the MRSA status must be communicated to the receiving facility prior to the transfer occurring. A transfer form should be completed as specified in the LTHT Transfer and ahnd over of care procedure which must include information on MRSA status.
On occasions other hospital trusts may require evidence of MRSA clearance or past screening results. If this is requested please check PPM+/ORDER COMMS (ICE).
If a patient is discharged whilst he/she is being decolonised, either as a result of a positive MRSA screen or because he/she is in a ‘High Risk Group’, decolonisation should be completed.
Staff found incidentally to be colonised with MRSA
Staff may be found positive through being screened for MRSA as part of the LTHT elective or acute admission screening pathways.
- The staff member should be referred immediately to the Occupational Health Service (OHS). He/she will need to be assessed for the presence of possible MRSA-disseminating lesions (e.g. wounds, eczematous lesions etc.). If present these will be investigated and treated accordingly.
- Assuming no such lesions, the staff member should commence a course of appropriate MRSA decolonisation regimen, and the need to observe good standards of hand hygiene will be reiterated. There is no requirement for the staff member to take time off work. However, following decolonisation, they will need to be rescreened as outlined in the Repeat Screening section above.
- If the staff member was scheduled for elective surgery, follow the appropriate guidance.
Staff found to be colonised with MRSA through Occupational Health screening
Staff may be found positive through being screened for MRSA as part of the OHS requirements of other employers (e.g. following job offers or prior to work placements). Actions taken will be the same as in the section above. Any additional actions required should be arranged by the organisation that requested the MRSA screening.
Staff found to be positive for MRSA during an outbreak investigation
A decision may be made to screen staff for MRSA as part of an investigation into a possible MRSA outbreak, following unusually high levels of MRSA in a clinical area, or, rarely, following known contact with MRSA. In most situations screening samples will be taken from anterior nares and any areas of broken skin:
- In this situation it is compulsory for staff to be screened, as an unscreened staff member may continue to act as a source of MRSA infection in patients.
- The Outbreak Control Team should ensure that the clinical and non-clinical leads responsible for the clinical area(s) act as positive role models and take on the responsibility of providing their staff with information regarding the screening process (with IPC Team and OHS support), communicate to staff why the screening is essential, the need for all staff to positively comply with screening and the process for supporting staff who test MRSA-positive
- A list of staff requiring screening must be agreed by the Outbreak Control Team and supplied to OHS in a secure form - see form below.
- The screening process is co-ordinated by OHS, and carried out jointly by the IPC Team and OHS. It may include peer-testing and/or self-testing. If screening is carried out at the workplace it should be done at start-of-shift, to avoid detecting transient carriage.
- Request forms must be filled in with the location specified as OHS, so that results are returned to OHS only and not the clinical area, and do not appear on PPM+/Order Comms (ICE).
- OHS will maintain a secure database of results, which will be shared only with the Chair of the Outbreak Control Team.
- All Staff found positive will be assessed for the presence of possible MRSA-disseminating lesions (e.g. wounds, eczematous lesions etc.). If present these will be investigated and treated accordingly. The presence of hand lesions may require a longer period off work than for colonisation “alone”.
- Assuming no such lesions, the staff member will receive a complete course of the appropriate MRSA decolonisation regimen, and the need to observe good standards of hand hygiene will be reiterated.
- The staff member will refrain from work that involves contact with patients or their environment for the first 48 hrs of decolonisation. This may require absence from work.
- Staff will be re-screened as outlined in the Repeat Screening section above. If negative after three re-screens they will be considered to be clear of MRSA.
- If a re-screen is positive for MRSA staff will receive a further course of appropriate decolonisation, again avoiding clinical work for the first 48 hours. Rescreening will again follow the process outlined in the Repeat Screening section above. If they remain MRSA-positive at this stage an individual plan will be agreed following discussion between an OHS consultant, the staff member and the Lead IPC Doctor (or deputy) on a case-by-case basis.
Staff found to be positive for MRSA during investigation of an infected lesion
Staff may be found to be positive for MRSA during investigation of an infected lesion (usually a skin lesion), either by their own doctor or OHS.
- If the staff member becomes aware of this through medical care other than OHS, he/she should report this to OHS.
- OHS will contribute to the staff member’s investigation and treatment, liaising with other medical staff as appropriate.
- Decisions relating to decolonisation, screening and removal from clinical contact will depend on individual circumstances and will be made in consultation with the Lead IPCD (or deputy).
OHS should inform the IPC Team of the name and work location of any MRSA-positive staff member so that recent MRSA data from his/her clinical area can be checked to see if there might be associated MRSA cases that had not been flagged as a possible outbreak. Subsequent IPC actions will depend on the results of this investigation.
7. Standard Protocol for the Management of Panton-Valentine Leukocidin Stapylococcus aureus (PVL-SA)Infections
What is PVL - SA
Stapylococcus aureus is a common bacterium found on the skin and mucous membranes. It is usually associated with skin and wound infections.
Staphyloccus aureus (SA) is the most common pathogen responsible for skin and soft tissue infections (SSTIs), however PVL-SA can cause more serious infections in wounds, joints and also invasive pneumonias.
Panton-Valentine Leukocidin (PVL) is a toxin that destroys white blood cells and is excreted by some strains of Staphyloccus aureus including both Meticillin Resistant (MRSA) and Meticillin Sensitive Staphyloccus aureus (MSSA)producing a new pattern of infection.
PVL-SA is most commonly associated with
- Infections in previously healthy individuals in the community
- Under 40 year olds
However anyone is susceptible
High risk groups for transmission for PVL-SA
PVL-SA infections are highly transmissible and tend to spread in settings where individuals are in close physical contact or may share personal items eg towels, gym equipment etc.
These groups include
- Educational settings - including nurseries
- Military personnel/barracks
- Close contact sports e.g. rugby, judo, wrestling
- Care homes
- Prison settings
Contact - especially inadequate decontaminated hands and shared equipment
Airborne - much less important mode of transmission. Airborne transmission of PVL-SA may be on skin scales but this is only a significant risk if the patient/member of staff has an excessive exfoliating skin condition such as eczema or psoriasis. Also droplet spread in PVL - SA necrotising pneumonia
Signs and symptoms
PVL- SA infection should be suspected if a patient has:
- pus- producing skin infections (boils and abscesses) which vary in severity and may be recurrent
- cellulitis - inflammation /blistering of skin
- pain that is out of proportion to severity of cutaneous findings
- necrotising pneumonia+/- leukopenia on full blood count
or there is a clustering of SSI’s within a household or social group.
Is PVL-SA suspected?
- Are there signs and symptoms of PVL-SA? - recurrence of symptoms
- Is there a previous clinical history of PVL-SA?
- Is there a history or suspicion PVL-SA within close contacts - household/social within the past 12 months
If suspecting PVL-SA please indicate on request form
For guidance on treatment refer to: Leeds Health Pathways; additional advice
Patients who are known or suspected PVL-SA should be source isolated for the duration of their hospital stay and source isolation guidelines followed.
Decolonisation should be offered to all primary cases - the decolonisation regimen is the same as for MRSA - (see main body of guideline) except that the recommendation is that hair is washed with the decolonisation body wash/shampoo on day 1, 3 and 5. Suppression of PVL-SA is ineffective if skin lesions are leaking
A decision will be made as to the appropriateness of contact screening - this will often be a joint agreement with Public Health England and community IPNs for community acquired PVL-SA and LTHT IPC team for hospital acquired PVL-SA.
Close contacts that are likely to be colonised should undergo decolonisation (which is the same as for MRSA) without prior screening. Repeat screening of positive contacts is not recommended unless they are particularly vulnerable to infection.
Who to inform about a case of PVL
- Inform IPC team
- Inform Public Health England local centre
- Inform other healthcare settings of admissions - transfers
To provide evidence-based recommendations for appropriate interventions to prevent and control the spread of MRSA within LTHT
Meticillin Resistant Staphylococcus Aureus (MRSA)
|Target patient group:||All patients at LTHT|
|Target professional group(s):||Secondary Care Doctors
Secondary Care Nurses
Allied Health Professionals
Bode LG, Kluytmans JA, Wertheim HF, et al. A randomized trial of admission screening and decolonization of Staphylococcus aureus carriers to prevent nosocomial S. aureus infections. In: Proceedings of the 48th Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology; 2008:25–28. Abstract K‐1711.
Buehlmann M et al. Highly effective regimen for decolonization of methicillin-resistant Staphylococcus aureus carriers. Infection Control and Hospital Epidemiology (2008): 29; 510-6
Coia J et al. Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. Journal of Hospital Infection, Volume 63, Supplement 1, May 2006, Pages 1-44 The Joint Working Party of the British Society of Antimicrobial Chemotherapy, the Hospital Infection Society, and the Infection Control Nurses Association
Cooper BS et al. Systematic review of isolation policies in the hospital management of methicillin-resistant Staphylococcus aureus: a review of the literature with epidemiological and economic modelling. Health Technology Assessment (2003); 7: No. 39
Department of Health (1995) Hospital Infection Control: Guidance on the Control of Infection in Hospitals, prepared by the Hospital Infection Working Group of the Department of Health and PHLS, London, Department of Health.
Department of Health. Winning Ways: Working together to reduce healthcare associated infection in England. Report from the Chief Medical Officer. 2003.
Department of Health expert advisory committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI). Implementation of modified admission MRSA screening guidance for NHS (2014). Department of Health.
Department of Health. Screening Emergency Admissions for MRSA - FAQs (April 2010)
Gemmell CG et al. Guidelines for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the UK. J Antimicrob Chemother (2006) 57(4):589-608
Loveday H. P. et al. epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 2014: 86: S1–S70
Karki S. and Cheng A.C. Impact of non-rinse skin cleansing with chlorhexidine gluconate on prevention of healthcare-associated infections and colonization with multi-resistant organisms: a systematic review Journal of Hospital Infection, 2012; 82:71-84
Kluytmans, J and Harbarth S. Methicillin-resistant Staphylococcus aureus decolonization: ‘Yes, we can,’ but will it help? Infect Control Hosp Epidemiol (2009);30:633–635
Merrer J et al. Prevalence of methicillin-resistant Staphylococcus aureus nasal carriage among patients with femoral neck fractures: implication for antibiotic prophylaxis. Infect Control Hosp Epidemiol (2004) 25(6):515-7
Health Protection Agency. Guidance on the diagnosis and management of PVL-associated Staphyococcus aureus infections (PVL-SA) in England 2008
Royal College of Nursing. Panton-Valentine Leukocidin positive Staphylococcus aureus (PVL-SA
LHP version 1.0
Equity and Diversity
The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.