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Joint Healthcare Infection Society (HIS) and Infection Prevention Society (IPS) guidelines for the prevention and control of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities

Published:October 28, 2021DOI:https://doi.org/10.1016/j.jhin.2021.09.022
      Meticillin-resistant Staphylococcus aureus (MRSA) infections remain a serious cause of healthcare-associated infection (HCAI) in many countries. MRSA is easily spread by multiple routes and can persist in the environment for long periods. In health and care settings, transmission via staff hands remains the most important route for patient MRSA acquisition. Infection prevention and control (IPC) measures and control of the use of antimicrobials are effective in reducing prevalence of MRSA. There have been many publications related to MRSA since the last guideline was published in 2006 and this update contains further measures that are clinically effective for preventing transmission when used by healthcare workers (Table I).
      Table ISummary of the changes to the recommendations from previous guidelines
      Previous recommendations Changes to recommendations
      Patient screening
      Active screening of patients for MRSA carriage should be performed and the results should be linked to a targeted approach to the use of isolation and cohorting facilities Rephrased recommendation:

      1. Targeted or universal patient MRSA screening must be performed and must be linked to a specific point of action such as decolonisation or isolation (or both).
      Certain high-risk patients should be screened routinely, and certain high-risk units should be screened at least intermittently in all hospitals. The fine detail regarding which patients are screened should be determined locally by the infection control team and must be discussed with the appropriate clinical teams and endorsed by the relevant hospital management structure. They will be influenced by the local prevalence of MRSA in the hospital and unit concerned, the reason for admission of the patient, the risk status of the unit to which they are admitted, and the likelihood that the patient is carrying MRSA. Patients at high risk of carriage of MRSA include those who are: (description follows) Rephrased recommendation:

      1.2 Use at least a targeted approach but consider using universal screening as appropriate depending on local facilities.
      Rephrased recommendation:

      1.3 If a targeted approach is used, define risk factors for MRSA carriage as appropriate for your area.
      In addition, screening all patients (regardless of their risk-group status) should be considered on admission to high-risk units Removed recommendation

      Refer to recommendations 1.1, 1.2 and 1.3
      The following sites should be sampled for patients (Category 1b): anterior nares, skin lesions and wounds and sites of catheters, catheter urine, groin/perineum, tracheostomy, and other skin breaks in all patients, and sputum from patients with a productive cough. Rephrased Good Practice Point:

      GPP 1.1 Establish documented local protocols for how swabs should be taken. The swabs should include a minimum of two sites from the following: nose, perineum, device entry sites, wounds, urine, and sputum, as appropriate depending on clinical presentation.
      The umbilicus should be sampled in all neonates. One should also consider sampling the throat. Removed recommendation

      We found no evidence that this is necessary
      Regular (e.g., weekly, or monthly, according to local prevalence) screening of all patients on high-risk units should be performed routinely Rephrased recommendation:

      2.1 Do not perform repeat MRSA screening for patients who screen positive at admission unless the patient undergoes decolonisation therapy.
      Rephrased recommendation:

      2.2 If the patient undergoes decolonisation therapy, consider repeat MRSA screening two to three days following the therapy, to determine whether decolonisation was successful or not. Do not delay a surgical procedure if the patient still tests positive.
      No recommendation is made about performance of ‘discharge screening’. Rephrased recommendation:

      2.3 Do not perform repeat MRSA screening routinely.
      2.4 Consider re-screening patients who previously screened negative if there is a significant MRSA exposure risk (e.g. contact with a confirmed MRSA case) or where there is a locally-assessed risk of late acquisition.
      In general, detection of patients colonized or infected with MRSA on a ward should be an indication for increased screening Removed recommendation
      There is always a delay between MRSA acquisition by a patient and its presence being detectable by screening samples, so it is recommended that at least three screens at weekly intervals should be performed before a patient can be considered to be at low risk of having acquired MRSA if they have been nursed in proximity to unknown and un-isolated MRSA-positive patients or by the same staff Removed recommendation
      No previous recommendation New recommendation:

      3.1 Use either PCR or traditional culture methods for MRSA screening as you consider appropriate depending on the local laboratory facilities.
      No previous recommendation New Good Practice Point:

      GPP 3.1 If using PCR methods, maintain access to culture methodology for specific circumstances such as outbreak investigation or sensitivity testing, and to support molecular technologies.
      Performance of active screening for MRSA in each unit within a hospital must be the subject of regular audit, with the results reviewed and minuted by the hospital's infection control committee and made available to the appropriate hospital management structure Removed recommendation
      Units with highly prevalent, endemic MRSA should consider focusing screening, control measures and other resources on high-risk units at first, with the intention of rolling them out to lower-risk areas after the position has improved Removed recommendation
      Geographically adjacent healthcare facilities, and those exchanging large numbers of patients because of clinical links, should liaise to agree common and efficient screening measures that should be linked to common and efficient control measures Removed recommendation
      Results of screening cultures should be made available promptly to the clinical and infection control teams of other healthcare facilities to whom a patient is to be, or has recently been, transferred Removed recommendation
      Staff screening and management
      Screening of staff is not recommended routinely, but if new MRSA carriers are found among the patients on a ward, staff should be asked about skin lesions. Staff with such lesions should be referred for screening and for consideration of dermatological treatment by the relevant occupational health department Rephrased recommendation:

      4.1 Do not routinely screen staff for MRSA.
      Staff screening is indicated if transmission continues on a unit despite active control measures, if epidemiological aspects of an outbreak are unusual, or if they suggest persistent MRSA carriage by staff Rephrased recommendation:

      4.2 Consider screening staff for MRSA if there is an epidemiological reason for suspecting a staff member as a source of MRSA, e.g. if transmission continues on a unit despite active control measures, if epidemiological aspects of an outbreak are unusual, or if they suggest persistent MRSA carriage by staff.
      Appropriate sampling sites for staff screening include anterior nares, throat and any areas of abnormal or broken skin New Good Practice Point:

      GPP 4.1 Screen staff at the beginning of their shift to avoid mistaking transient carriage for persistent carriage. Appropriate sampling sites for staff screening include anterior nares and any areas of abnormal or broken skin.
      New Good Practice Point:

      GPP 4.2 For staff who test positive, consider additionally screening throat, hairline, and groin/perineum as these if positive, increase the risk of shedding into the environment and transmission.
      New Good Practice Point:

      GPP 4.3 If possible, involve the Occupational Health Team in the process of staff screening and management.
      Staff with persistent carriage at sites other than the nose should be considered for referral for appropriate specialist management (e.g. ear, nose and throat; dermatology) who should arrange follow-up screening according to local protocols Rephrased recommendation:

      5.1 Consider excluding staff from work, reducing their interaction with patients, or offering decolonisation therapy as deemed appropriate.
      Rephrased recommendation:

      5.2 Consider investigating the risk factors for staff MRSA carriage. Investigate staff members with persistent carriage in a multi-disciplinary setting to determine any associated factors.
      Care is needed to distinguish between transient carriage (i.e. nasal carriage which is lost within a day or so of removal from contact with MRSA-positive patients and carries little risk of onward transmission) and prolonged carriage (especially associated with skin lesions) Removed recommendation
      Nurses, doctors, physiotherapists, other allied health professionals and non-clinical support staff (e.g., porters) should be considered for screening, and the implications for onward spread by staff working on other wards should also be considered Removed recommendation
      The special difficulties and risks posed by agency and locum staff should be considered Removed recommendation
      It is recommended that a minimum of three screens at weekly intervals, while not receiving antimicrobial therapy, should be performed before a previously positive staff member can be considered to be clear of MRSA New Good Practice Point:

      GPP 5.1 For staff members with nasal carriage only: offer decolonisation therapy, exclusion is not required. For staff with infected lesion/skin rash: offer decolonisation therapy AND carry out a risk assessment to consider re-deploying them to low-risk areas or excluding them from work.
      Local policies should be developed to guide post-clearance sampling of staff
      New Good Practice Point:

      GPP 5.2 2 Develop local policies to guide the decision of when staff should be excluded from work and when they should return, taking into consideration the individual's risk of transmission to patients (e.g. a staff member colonised with MRSA who is working in an ICU or neonatal unit represents a greater potential risk to patients than a staff member with MRSA working in an outpatients' department).
      Decolonisation therapy
      Patients receiving prophylaxis for an operative procedure and in an outbreak situation under the advice of the infection control team should undergo nasal decolonization. This should be achieved by applying mupirocin 2% in a paraffin base to the inner surface of each nostril (anterior nares) three times daily for five days. The patient should be able to taste mupirocin at the back of the throat after application Rephrased recommendation:

      6.1 Use mupirocin for nasal decolonisation, either selectively (i.e., for those who are colonised) or universally (i.e., for all high-risk patients).
      Skin decolonization using 4% chlorhexidine bodywash/shampoo, 7.5% povidone iodine or 2% triclosan is useful in eradicating or suppressing skin colonization for short times, particularly preoperatively to reduce the risk of surgical site infections Rephrased recommendation:

      6.2 Use chlorhexidine, either selectively or universally, for body decolonisation to reduce MRSA carriage.
      For patients with eczema, dermatitis or other skin conditions, attempts should be made to treat the underlying skin condition. Advice on suitable eradication protocols for these individuals should be sought from a consultant dermatologist. Oilatum bath additive or Oilatum plus (with added benzalkonium chloride 6% and triclosan 2%) may be used with these patients; these should only be prescribed on the advice of a dermatologist (Category 2). Rephrased recommendation:

      6.3 Consider alternatives (e.g. octenidine) where mupirocin and chlorhexidine are not feasible.
      Mupirocin should not be used for prolonged periods or used repeatedly (i.e. for more than two courses for five days) as resistance may be encouraged Rephrased recommendation:

      6.4 Monitor the emergence of resistance, especially to mupirocin and chlorhexidine, if used extensively.
      Nasal decolonization using topical nasal mupirocin should be used with other forms of intervention such as skin decolonization with 4% chlorhexidine gluconate aqueous solution Removed recommendation
      Systemic treatment should only be prescribed on the advice of the consultant microbiologist in the hospital, with appropriate monitoring [e.g. regular liver function tests (LFTs) to monitor effects of the drugs on the liver]. If treatment is required, this should be restricted to one course of treatment, the course should not be repeated and the possible side-effects should be explained to the patient Removed recommendation
      Systemic treatment should be given in conjunction with nasal mupirocin and skin decolonization Removed recommendation
      Local treatment for throat carriage such as antiseptic gargles or sprays may be used to reduce the organism load (no recommendation Removed recommendation
      Patients should bathe daily for five days with the chosen antiseptic detergent. The skin should be moistened and the antiseptic detergent should be applied thoroughly to all areas before rinsing in the bath or shower. Special attention should be paid to known carriage sites such as the axilla, groin and perineal area. The antiseptic should also be used for all other washing procedures and for bed bathing. Hair should be washed with an antiseptic detergent New Good Practice Point:

      GPP 6.1 Follow manufacturers' guidance when using decolonisation products.
      New Good Practice Point:

      GPP 6. For skin decolonisation, if 4% chlorhexidine wash is used, moisten the skin, apply the wash, and leave for 1–3min before rinsing off; if 2% chlorhexidine wipes are used, do not rinse off.
      New Good Practice Point:

      GPP 6.3 For skin decolonisation, pay special attention to known carriage sites such as the axilla, groin, and perineal area.
      After satisfactory completion of a course of treatment, i.e. each bath and hairwash, clean clothing, bedding and towels should be provided New Good Practice Point:

      GPP 6.4 After each bath and wash, provide clean clothing, bedding, and towels.
      New Good Practice Point:

      GPP 6.5 Consider using chlorhexidine in neonates only if there is no alternative and there is no broken skin present (for evidence on CHG safety in neonates, see Appendix 5).
      New Good Practice Point:

      GPP 6.6 Make healthcare workers and patients aware that decolonisation therapy does not necessarily result in complete eradication but that achieving temporary suppression is sufficient in many circumstances.
      Environmental sampling and cleaning/disinfection
      Cleaning regimens and their performance should be audited regularly. New recommendation:

      7.1 Do not screen/sample the environment routinely.
      New recommendation:

      7.2 Consider using environmental screening/sampling as part of targeted investigation of an outbreak.
      Cleaning regimens for isolation facilities should focus on the minimization of dust and the removal of fomites from contact areas. This should be a two-fold approach; firstly, the management of the occupied facility, and then the terminal clean of the facility after discharge of the patient. Removed recommendation
      Cleaning regimens and products should be in accordance with local policy, but should include the removal of organic material with a general purpose detergent Rephrased recommendation:

      8.1 Continue using currently utilised products approved for use in healthcare.
      No previous recommendation New recommendation:

      8.2 Consider hydrogen peroxide vapour (HPV) or ultraviolet (UV-C, PX-UV) devices as an adjunct to terminal cleaning as a part of a wider IPC strategy.
      Surveillance
      Surveillance must be undertaken routinely as part of the hospital's infection control programme and must be a recognized element of the clinical governance process. As such, there should be clear arrangements identifying those responsible for acting on the results in individual hospital directorates Rephrased recommendation:

      9.1 Undertake surveillance routinely as part of the hospital's infection prevention and control strategy and to comply with mandatory national requirements.
      MRSA surveillance should include:

      - any mandatory requirements

      - results of microbiological investigations for clinical purposes and - results of microbiological investigations undertaken for screening purposes
      Removed recommendation
      For benchmarking purposes, surveillance data should be collected and reported in a consistent way, to agreed case definitions and using agreed specialty activity denominators, with stratification according to case mix Removed recommendation
      Surveillance data should be fed back to hospital staff routinely, readily intelligible to most hospital staff, considered regularly at hospital senior management committees, and used in local infection control training. Rephrased recommendation:

      10.1 No recommendation (for the use of surveillance to drive system improvements). Good practice point set instead.

      New Good Practice Point:

      GPP 10.1 Consider using local surveillance of MRSA acquisition (colonisation and infection) as a component of local strategies to prevent and control MRSA and to drive improvement where needed.
      Standard vs. contact precautions and the use of isolation/cohorting
      The general principles of infection control should be adopted for the management of patients with MRSA. Good infection control practice should be placed at the centre of clinical practice, and requires the explicit support of the organizational executive to ensure that it is seen as having an appropriate position within the organization and can be enforced as a matter of clinical governance Rephrased recommendation:

      11.1 Use standard infection prevention and control precautions in the care of all patients to minimise the risk of MRSA transmission.
      New recommendation:

      11.2 For patients known to be colonised/infected with MRSA, consider using contact precautions for direct contact with the patient or their immediate environment. If contact precautions are used, gloves and aprons must be changed between care procedures and hand hygiene must be performed after glove removal.
      A standard approach to isolation precautions should be adopted in accordance with the general principles of infection control, rather than introducing specific guidance for the management of MRSA that may lead to differing standards Rephrased recommendation:

      11.3 Consider placing patients colonised or infected with MRSA in a single room. The decision to use a single room should be based on a risk assessment that considers the risk of transmission associated with the patient's condition and the extent of colonisation or infection (e.g. sputum, exfoliating skin condition, large open wounds) and the risk of transmission to other patients in the specific care setting e.g. in burns units.
      Patients should be managed in accordance with the type of facility in which they receive care, the resources available, and the level of risk that is posed to them and to others. Patients (and the facilities that may house them) classified as being at high risk of contracting MRSA or for whom the consequence of infection may have a high impact will require a rigorous approach to screening, placement and treatment.
      Patients identified with MRSA infection or colonization should be informed of their condition, and local arrangements should be made to ensure ease of identification if re-admission to the facility occurs New recommendation:

      11.4 Where isolation is deemed necessary, isolate patients for the shortest possible time to minimise feelings of stigma, loneliness, and low mood.
      Rephrased recommendation:

      11.5 Provide clear information to patients about the need for the use of protective equipment to reduce feelings of stigma.
      The procedures for isolation should be clearly stated, and where necessary explained, to staff, patients, and visitors. Hospital staff entering isolation facilities should be required to adopt the prescribed isolation precautions rigorously and these should be audited regularly. Non-staff visitors should be requested to adopt the necessary level of precautions to minimize the risk of spread of MRSA to other areas of the facility. Rephrased recommendation:

      11.6 Be consistent in the use of protective equipment to ensure that patients have confidence in the decision to place them in isolation.
      No previous recommendation New Good Practice Point:

      GPP 11.1 Advise visitors about the need and available facilities for hand hygiene.
      No previous recommendation New Good Practice Point:

      GPP 11.2 Where applicable, advise visitors about the use gloves and aprons.
      Patient isolation for those infected or colonized with MRSA will be dependent on the facilities available and the associated level of risk. Where new buildings or refurbishment are planned, published guidelines should be adopted to provide the most appropriate facilities for patient care. Isolation should be in a designated closed area that should be clearly defined; in most facilities, this will be either single-room accommodation or cohort areas/bays with clinical handwashing facilities. Consideration should be given to the provision of isolation wards to contain MRSA spread. New Good Practice Point:

      GPP 11.3 When considering the need to isolate a patient with MRSA in a single room, other demands on single-room use may take priority and alternative strategies such as nurse cohorting may be appropriate.
      New Good Practice Point:

      GPP 11.4 If isolation or cohorting of MRSA patients is not possible, use decolonisation therapy to temporarily suppress MRSA and prevent transmission to other patients.
      New Good Practice Point:

      GPP 11.5 Prioritise room cleaning and disinfection for MRSA patients placed in isolation or on contact precautions.
      Patient transfer and transport
      No previous recommendation New recommendation:

      12.1 Do not transfer patients between wards, units, hospitals, or other clinical settings unless it is clinically necessary.
      Arrangements for transfer to other healthcare facilities, e.g. hospitals, residential care homes, etc., should include notification of the individual's MRSA status, as appropriate New recommendation:

      12.2 Inform the receiving ward/unit/care home and the ambulance/transport service that the patient is colonised/infected with MRSA.
      New Good Practice Point:

      GPP 12.1 MRSA colonisation is not a barrier to discharging patients to another health care setting, their home or residential care.
      It may be considered desirable to place the individual at the end of a procedure list. However, in mechanically filtered environments such as operating theatre suites, the number of air exchanges should render this unnecessary. Good infection control practices, which should be in place between all patients, should reduce the risk of cross-infection Removed recommendation
      The risk of cross-infection from an MRSA-colonized or -infected patient to other patients in an ambulance is minimal. Good infection control practices and routine cleaning should suffice to prevent cross-infection Removed recommendation
      Shared equipment
      Patient equipment, e.g. wheelchairs, hoists, slings, sphygmomanometer cuffs, etc., should either be capable of being decontaminated and be decontaminated before use with other patients, or should be single-patient use and discarded as clinical waste at the end of a period of usage Rephrased recommendation:

      13.1 Clean and disinfect shared pieces of equipment used in the delivery of patient care after each use, utilising products as specified in a local protocol.
      No previous recommendation New Good Practice Point:

      GPP 13.1 Make all healthcare workers aware of the importance of maintaining a clean and safe care environment for patients. Every healthcare worker needs to know their specific responsibilities for cleaning and decontaminating the clinical environment and the equipment used in patient care.
      No previous recommendation New Good Practice Point:

      GPP 13.2 Introduce policies for staff, patients, and visitors to clean their hands before and after they use the shared equipment.
      Patient information
      No previous recommendation New recommendation:

      14.1 Make patients aware of the reasons for MRSA screening and decolonisation.
      Trusts should develop local protocols for informing patients, carers, relatives and staff members of their MRSA status with due regard for confidentiality Rephrased recommendation:

      14.2 Inform patients of their screening result as soon as it is available.
      Patients and their appropriate contacts should be fully briefed and given relevant information on MRSA, its implications and significance prior to discharge in order to reduce unnecessary anxiety and concern when returning to the home environment Rephrased recommendation:

      14.3 For patients who are identified as MRSA positive, provide consistent and appropriate information about:
      • The difference between colonisation and infection
      • The microorganism
      • How MRSA is acquired and transmitted
      • How MRSA is treated
      • The reasons for contact precautions or isolation.
      Rephrased recommendation:

      14.4 On discharge provide consistent and appropriate information about:
      • The risks to household members, friends, and family.
      • The implications for future health and health care.
      • Persons who need to be notified about their MRSA colonisation status.
      • If applicable, instructions on decolonisation regimen with the information that the results may not be permanent.
      No previous recommendation New recommendation:

      14.5 Provide information in a format and language that the patient and their family is able to understand.
      No previous recommendation New Good Practice Point:

      GPP 14.1 Use patient leaflets provided in the Supplementary Materials of this guideline.
      No previous recommendation New Good Practice Point:

      GPP 14.2 Inform patients about the possibility of re-colonisation and the importance of changing linen, towels, and clothes daily.
      Handling the deceased
      No previous recommendation New recommendation:

      15.1 Follow national guidance for managing infection risks when handling the deceased.
      Antibiotic stewardship
      This section has been covered in a separate publication with focus on MRSA antimicrobial stewardship and treatment. [
      • Brown N.M.
      • Goodman A.L.
      • Horner C.
      • Jenkins A.
      • Brown E.M.
      Treatment of meticillin-resistant Staphylococcus aureus (MRSA): updated guidelines from the UK.
      ]
      Staffing
      This topic was not included in the updated guidelines
      Control of VISA/VRSA/GISA
      This topic was not included in the updated guidelines

      Keywords

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      Abbreviations

      AOR
      adjusted odds ratio
      ATP
      adenosine triphosphate
      BSI
      bloodstream infection
      CBA
      controlled before/after (study)
      cfu
      colony forming units
      CHG
      chlorhexidine gluconate
      CI
      confidence intervals
      CLABSI
      central line-associated bloodstream infection
      CP
      contact precautions
      DAS
      diagnostic accuracy study
      ELOS
      estimated length of stay
      GP
      general practitioner
      HCAI
      healthcare-associated infection
      HES
      Hospital Episode Statistics
      HPV
      hydrogen peroxide vapour
      HR
      hazard ratio
      ICU
      intensive care unit
      IPC
      infection prevention and control
      IRR
      incidence rate ratio
      ITS
      interrupted time series (study)
      LOS
      length of stay
      MDRO
      multidrug-resistant organism
      MIC
      minimum inhibitory concentration
      MRSA
      Meticilin-resistant Staphylococcus aureus
      MSSA
      Meticilin-sensitive Staphylococcus aureus
      NICE
      National Institute for Health and Care Excellence
      NR
      not reported
      OR
      odds ratio
      PCR
      polymerase chain reaction
      pd
      patient days
      PICO
      Population-Intervention-Comparator-Outcome (framework)
      PPE
      personal protective equipment
      PVL
      Panton-Valentine leucocidin
      PVP
      povidone-iodine
      PX-UV
      pulsed-xenon ultraviolet
      QAC
      quaternary ammonium compound
      RCT
      randomised controlled trial (RCT)
      RR
      risk ratio
      SIGN
      Scottish Intercollegiate Guidelines Network
      SPC
      statistical process control (chart)
      SSI
      surgical site infections
      TAT
      turnaround time
      UBA
      uncontrolled before/after (study)
      UV-C
      ultraviolet-C
      WGS
      whole genome sequencing

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