Keywords
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Executive summary
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:
|
| Rephrased recommendation: 14.4 On discharge provide consistent and appropriate information about:
| |
| 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. [ [2] ] | |
| Staffing | |
| This topic was not included in the updated guidelines | |
| Control of VISA/VRSA/GISA | |
| This topic was not included in the updated guidelines | |
Methods for systematic review were in accordance with National Institute for Health and Care Excellence (NICE) approved methodology and critical appraisal followed Scottish Intercollegiate Guidelines Network (SIGN) and other standard checklists. Articles published between 2004 and February 2021 were included. Questions for review were derived from a stakeholder meeting, which included patient representatives in accordance with the Population Intervention Comparison Outcome (PICO) framework. Recommendations are made in the following areas: screening, management of colonised healthcare staff, environmental screening and cleaning/disinfection, surveillance, IPC precautions (including isolation and movement of patients and equipment), and patient information.
Recommendations
1.1 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).
1.2 Use at least a targeted approach but consider using universal screening as appropriate depending on local facilities.
1.3 If a targeted approach is used, define risk factors for MRSA carriage as appropriate for your area.
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.
2.1 Do not perform repeat MRSA screening for patients who screen positive at admission unless the patient undergoes decolonisation therapy.
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.
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.
3.1 Use either PCR or traditional culture methods for MRSA screening as you consider appropriate depending on the local laboratory facilities.
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.
4.1 Do not routinely screen staff for MRSA.
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.
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.
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.
GPP 4.3 If possible, involve the Occupational Health Team in the process of staff screening and management.
5.1 Consider excluding staff from work, reducing their interaction with patients, or offering decolonisation therapy as deemed appropriate.
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.
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.
GPP 5.2 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).
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).
6.2 Use chlorhexidine, either selectively or universally, for body decolonisation to reduce MRSA carriage.
6.3 Consider alternatives (e.g. octenidine) where mupirocin and chlorhexidine are not feasible.
6.4 Monitor the emergence of resistance, especially to mupirocin and chlorhexidine, if used extensively.
GPP 6.1 Follow manufacturers’ guidance when using decolonisation products.
GPP 6.2 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.
GPP 6.3 For skin decolonisation, pay special attention to known carriage sites such as the axilla, groin, and perineal area.
GPP 6.4 After each bath and wash, provide clean clothing, bedding, and towels.
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).
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.
7.1 Do not screen/sample the environment routinely.
7.2 Consider using environmental screening/sampling as part of targeted investigation of an outbreak.
8.1 Continue using currently utilised products approved for use in healthcare.
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.
9.1 Undertake surveillance routinely as part of the hospital’s infection prevention and control strategy and to comply with mandatory national requirements.
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.
11.1 Use standard infection prevention and control precautions in the care of all patients to minimise the risk of MRSA transmission.
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.
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.
11.4 Where isolation is deemed necessary, isolate patients for the shortest possible time to minimise feelings of stigma, loneliness, and low mood.
11.5 Provide clear information to patients about the need for the use of protective equipment to reduce feelings of stigma.
11.6 Be consistent in the use of protective equipment to ensure that patients have confidence in the decision to place them in isolation.
GPP 11.1 Advise visitors about the need and available facilities for hand hygiene.
GPP 11.2 Where applicable, advise visitors about the use gloves and aprons.
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.
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.
GPP 11.5 Prioritise room cleaning and disinfection for MRSA patients placed in isolation or on contact precautions.
12.1 Do not transfer patients between wards, units, hospitals, or other clinical settings unless it is clinically necessary.
12.2 Inform the receiving ward/unit/care home and the ambulance/transport service that the patient is colonised/infected with MRSA.
GPP 12.1 MRSA colonisation is not a barrier to discharging patients to another health care setting, their home or residential care.
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.
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.
GPP 13.2 Introduce policies for staff, patients, and visitors to clean their hands before and after they use the shared equipment.
14.1 Make patients aware of the reasons for MRSA screening and decolonisation.
14.2 Inform patients of their screening result as soon as it is available.
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.
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.
14.5 Provide information in a format and language that the patient and their family is able to understand.
GPP 14.1 Use patient leaflets provided in the Supplementary Materials of this guideline.
GPP 14.2 Inform patients about the possibility of re-colonisation and the importance of changing linen, towels, and clothes daily.
15.1 Follow national guidance for managing infection risks when handling the deceased.
Lay summary
‘MRSA’ stands for meticillin-resistant Staphylococcus aureus, which is a type of bacteria that can cause infection. Infection with MRSA mainly occurs in people who are already ill and can occur wherever care is given. This can be in hospital or in the community such as in residential or nursing care homes or in your own home. Treating MRSA is difficult because the bugs are resistant to some types of antibiotics (penicillins) that would often be used to fight Staphylococcus aureus. This means these types of antibiotics will not work for MRSA infections.
The good news is that the number of MRSA infections in the UK has fallen since 2008, but it does still remain a problem. This guideline is intended to help doctors and other health and social care staff to try and prevent patients from getting MRSA and becoming ill. It may also be of use to patients who already have MRSA, those who care for them (relatives, care staff, etc.) and the general public, by helping them to understand which things work and which do not work to prevent MRSA in hospitals and other care settings.
The guideline contains an explanation, scientific evidence, and a glossary of terms to make it easy to read and use (Supplementary Materials A).
Introduction
Infections due to meticillin-resistant Staphylococcus aureus (MRSA, also referred to as methicillin-resistant Staphylococcus aureus) have decreased significantly in the UK and elsewhere but they continue to cause significant morbidity and mortality. Hence, infection prevention and control (IPC) measures remain essential.
There has been significant progress in recent years in managing MRSA in healthcare settings. Despite these advances the control of MRSA remains demanding, and should be based on the best available evidence to ensure the appropriate use of healthcare resources. This document is an update of the previously published recommendations for the IPC of MRSA in healthcare facilities.
A Joint Working Party of the Healthcare Infection Society (HIS) and the Infection Prevention Society (IPS) has updated the previous guidelines and has prepared the following recommendations to provide advice on the procedures and precautions needed to prevent the spread of MRSA. This includes recommendations on patient and staff screening, patient management, testing strategies, decolonisation, reduction of environmental contamination, surveillance and feedback to minimise transmission and drive system improvement, and the information needs of patients and healthcare professionals.
The process used for the development of this updated version of the guidance was accredited by the National Institute for Health and Care Excellence (NICE). This is an important step in the evolution of the guidance and helps to ensure that users of the document have confidence in the underlying basis for the recommendations made. Although the guidance is most relevant in the UK context, the recommendations will be relevant to healthcare settings in other countries and are based upon a systematic review of UK-based and international literature.
Guideline development team
Acknowledgements
APRW was supported, in part, by the National Institute for Health Research University College London Hospitals Biomedical Research Centre. AD was supported by Public Health England (soon to become UK Health Security Agency, UKHSA).
Source of funding
There was no external funding for this work.
Disclosure of potential conflicts of interest
HH has been in receipt of research funding from Astella and Pfizer in recent years and has received a consultancy fee from Pfizer in the last three years.
APRW: Consultant on Drug Safety Monitoring Board for Roche, Advisory Board for Pfizer.
JRP received consultancy fee from Imperial College London.
DAE received consultancy fees and speaker fees from commercial organisations.
LB received consultancy fee from a commercial organisation.
All declarations of interest are available in Supplementary Materials B.
Relationship of authors with sponsor
The Healthcare Infection Society (HIS) and the Infection Prevention Society (IPS) commissioned the authors to undertake the Working Party Report. The authors are members of both societies.
Responsibility for guidelines
The views expressed in this publication are those of the authors and have been endorsed by HIS and IPS and following a four-week external consultation.
Working Party Report
What is the Working Party Report?
The report is a set of recommendations covering key aspects of the IPC of MRSA in healthcare settings. The guidelines review the evidence for screening, surveillance and management of the individuals who are found to be colonised or infected with MRSA. The treatment of MRSA infections is outside of the scope of these guidelines.
Why do we need a Working Party Report for this topic?
The previous guidelines relating to this topic were published in 2006. MRSA is still an important healthcare-associated pathogen which can be controlled effectively by evidence-based IPC and quality improvement methods. There have been many publications on the subject since 2006 and new technologies have emerged. The effect of these studies on recommended practice needs to be reviewed.
What is the purpose of the Working Party Report's recommendations?
The main purpose of these guidelines is to inform IPC practitioners about the current UK policy and best available options for preventing and controlling MRSA. This document also highlights current gaps in knowledge, which will help to direct future areas of research.
What is the scope of the guidelines?
The main scope of the guidelines is to provide advice for the optimal provision of an effective and safe healthcare service while reducing the risk of MRSA transmission in healthcare settings. The guidelines are suitable for patients of all age groups. These guidelines were largely developed with hospitals in mind but may be useful in other settings where MRSA is a concern, for example long-stay units. The guidelines' main focus was the prevention of transmission to patients, thus pre- and perioperative care was not included. Antibiotic stewardship and treatment are covered in a separate publication. [
[2]
].What is the evidence for these guidelines?
Topics for these guidelines were derived from stakeholder meetings including patient representatives and were designed in accordance with the Population Intervention Comparison Outcomes (PICO) framework (Appendix 1). To prepare these recommendations, the Working Party collectively reviewed relevant evidence from peer-reviewed journals subject to validated appraisal. Methods, which were in accordance with NICE methodology for developing guidelines, are described fully below.
Who developed these guidelines?
The Working Party included infectious diseases/microbiology clinicians, IPC experts, systematic reviewers, and two lay member representatives.
Who are these guidelines for?
Any healthcare practitioner may use these guidelines and adapt them for their use. It is anticipated that users will include clinical staff and, in particular, IPC teams. These guidelines aim to provide recommendations for all health and care settings and to include available evidence for all settings where MRSA is a concern. However, the available reported studies were predominantly conducted in hospital settings. The Working Party believes that while many sections of these guidelines are particularly relevant to hospitals, some evidence and recommendations can be extrapolated to other health and social care settings (e.g. the sections on environment and equipment decontamination, use of personal protective equipment (PPE), transfer of patients and patient information).
How are the guidelines structured?
Each section comprises an introduction, a summary of the evidence with levels (known as evidence statements), and a recommendation graded according to the available evidence.
How frequently are the guidelines reviewed and updated?
The guidelines will be reviewed at least every four years and updated if change(s) are necessary or if new evidence emerges that requires a change in practice.
Aim
The primary aim of these guidelines is to assess the current evidence for all aspects relating to the IPC of MRSA. A secondary aim is to identify those areas in particular need of further research to inform future MRSA guidelines.
Implementation of these guidelines
How can these guidelines be used to improve clinical effectiveness?
Primarily, these guidelines will inform the development of local protocols for preventing MRSA transmission and managing patients colonised or infected with MRSA. They also provide a framework for clinical audit, which will aid in improving clinical effectiveness. In addition, the future research priorities identified by the Working Party will allow researchers to refine applications to funding bodies.
How much will it cost to implement these guidelines?
Provided that existing practice follows current recommendations, it is not expected that significant additional costs would be generated by the recommendations in this document. However, failure to follow best practice, for example by not screening in a population with high prevalence, the hospital should expect to incur higher costs due to MRSA infections.
Summary of audit measures
Regular audit remains an important part of any guideline implementation. Audit is effective only when the results are fed back to staff and when there is a clear plan for the implementation of improvements. Many NHS Trusts also require that the results of audits and interventions are reported through clinical governance structures and to Hospital IPC Committees to help reduce the MRSA burden. The MRSA Working Party suggests the following aspects of patient care to be audited:
- •Compliance with screening protocol.
- •Compliance with decolonisation regimens.
- •Compliance with prescribed isolation precautions.
- •Cleaning/disinfection standards.
- •Antimicrobial Stewardship (please refer to recent MRSA treatment guidelines [[2]]).
- •Emergence of resistance, especially to mupirocin and chlorhexidine (CHG), if used extensively.
- •IPC practices, e.g. hand hygiene, aseptic technique.
- •Compliance with informing the receiving ward/unit/care home and the ambulance/transport service that patient is colonised/infected with MRSA.
Supplementary tools
Lay materials and continuing professional development questions (CPD) are available in the Supplementary Materials (files C and D).
Methodology
Evidence appraisal
Topics for these guidelines were derived from stakeholder meetings including patient representatives. To prepare these recommendations, the Working Party collectively reviewed relevant evidence from published, peer-reviewed journals. Methods were in accordance with NICE-approved methodology for developing guidelines (Supplementary Materials B).
Data sources and search strategy
Three electronic databases (Medline, CINAHL/EMCare and EMBASE) were searched for articles published between July 2004 and February 2021. The searches were restricted to English language studies, non-animal studies and non-in vitro studies. Search terms were constructed using relevant MeSH and free text terms (provided in appendices for each question cluster). The reference lists of identified systematic reviews, guidelines and included papers were scanned for additional studies. Search strategies and the results are available in Appendix 1.
Study eligibility and selection criteria
Search results were downloaded to Endnote database and screened for relevance. Two reviewers (MS, AM, AB, GM, JW or HL) independently reviewed the title and abstracts. Disagreements were addressed by a third reviewer. Two reviewers (MS, AM, AB, GM, JW or HL) independently reviewed full texts. If there were disagreements, these were first discussed between the two reviewers and if a consensus was not reached, a third reviewer was consulted. The guidelines included any controlled trials, cohort studies, interrupted time series (ITS) studies, case-control studies, diagnostic accuracy studies (DAS) and controlled before/after (CBA) studies. Due to the limited number of studies available, uncontrolled before/after (UBA) studies were included and described narratively. These were not used to make recommendations but were included to inform the Working Party of the additional evidence that existed. Similarly, data from mathematical model studies and excluded studies which provided additional evidence were included for each section but were not used when making recommendations. Results of study selection are available in Appendix 2.
Data extraction and quality assessment
Data collection and synthesis for these guidelines started before the NICE update for guideline methodology was published in 2018. Prior to this update, some studies were assessed using the quality assessment tools previously recommended. To ensure consistency, it was decided that the same checklists would be used for the remaining studies. For the type of studies where previous methodology did not recommend the specific checklists, they were assessed using the checklists recommended in the updated methodology. The quality checklists included:
- •Controlled trials (Randomised Controlled Trials (RCT) and non-Randomised Controlled Trials (n-RCT)): SIGN Methodology Checklist 2: Controlled Trials.
- •Cohort studies: SIGN Methodology Checklist 3: Cohort Studies.
- •Interrupted time series (ITS): Cochrane Effective Practice and Organisation of Care (EPOC) Risk of bias for interrupted time series studies.
- •Case-controlled studies: SIGN Methodology Checklist 4: Case-control studies.
- •Controlled before/after (CBA) studies: EPOC Risk of Bias (RoB) Tool (for studies with a control group).
- •Uncontrolled before/after (UBA) studies: Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Quasi-Experimental Studies (non-randomized experimental studies).
- •Diagnostic accuracy studies (DAS): SIGN Methodology Checklist 5: Studies of Diagnostic Accuracy
Studies were appraised independently by two reviewers (MS, AM, AB, GM, JW or HL) and any disagreements were resolved through discussion. Results of quality appraisal are available in Appendix 3.
Data were extracted by one reviewer and checked/corrected by another. For each question cluster the data from the included studies were extracted to create the tables of study description, data extraction and summary of findings tables (Appendix 4). The list of the studies rejected at full text stage with a reason for this decision, is included in the excluded study tables. Due to limited evidence, most of the data were described narratively. Where meta-analysis was possible, this was conducted in Review Manager 5.3 software for systematic reviews. This software only allows the entry for dichotomous data; it was not suitable for meta-analysis for decolonisation where a range of different decolonisation therapies were used. For this, the analyses were calculated manually, with sample proportion and confidence intervals [CI95%] obtained using the Wilson score interval (epitools.ausvet.com.au). For the therapies which showed a significant benefit, the risk ratios were calculated using MedCalc software (medcalc.net).
Rating of evidence and recommendations
For each outcome of the review question the certainty/confidence in the findings was established using considered judgment forms. The evidence was considered and judged using the following ratings: high, moderate, low, and very low, based on the characteristics of the studies included in evidence tables.
When writing recommendations, the Working Party considered the following:
- •Who should act on these recommendations?
- •What are the potential harms and benefits of the intervention and any unintended consequences?
- •What is the efficacy and the effectiveness of each intervention?
- •Is it possible to stop another intervention because it has been superseded by the new recommendation?
- •What is the potential effect on health inequalities?
- •What is the cost-effectiveness of the intervention, including staff resources other economic concerns?
- •Can the recommended interventions be feasibly put into practice?
The wording of the evidence statements and the recommendations reflected the strength of the evidence and its classification. The following criteria were used:
- •‘offer’, ‘measure’, ‘advise’, ‘refer’, ‘use’ or similar wording was used if the Working Party believed that most practitioners/commissioners/service users would choose an intervention if they were presented with the same evidence: this usually means that the benefits outweigh harms, and that the intervention is cost-effective. This reflects a strong recommendation for the intervention. If there is a legal duty, or if not following a recommendation may have serious consequences, the word ‘must’ was used.
- •‘do not offer’ or similar wording was used if the Working Party believed that harms outweigh the benefits or if an intervention is not likely to be cost-effective. This reflects a strong recommendation against the intervention. If there is a legal duty, or if not following a recommendation may have serious consequences, the words ‘must not’ were used.
- •‘consider’ was used if the Working Party believed that the evidence did not support a strong recommendation, but that the intervention may be beneficial in some circumstances. This reflected a conditional recommendation for the intervention.
- •The ‘do not offer, unless … ’ recommendation was made if the Working Party believed that the evidence did not support the strong recommendation, and that the intervention was likely not to be beneficial, but could be used in some circumstances, for instance if no other options were available. This reflected a conditional recommendation against the intervention.
Consultation process
Feedback on draft guidelines was received from the HIS Guideline Committee, and final changes made. These guidelines were then opened to consultation with relevant stakeholders (Supplementary Materials E). The draft report was available on the HIS website for four weeks. Views were invited on format, content, local applicability, patient acceptability, and recommendations. The Working Party reviewed stakeholder comments, and collectively agreed revisions.
Rationale for recommendations
What is the clinical and cost-effectiveness of universal versus targeted screening in minimising the transmission of MRSA?
While in certain instances screening is implemented for every patient entering the healthcare unit, it is not in the current UK NICE guidelines for healthcare facilities to implement universal screening. Screening is completed largely for some pre-operative patients or other high-risk patients, such as those entering the intensive care unit (ICU). Despite this, there is disagreement in the literature about the clinical effectiveness of targeted screening in preventing the transmission of MRSA. Moreover, there is a debate about the cost-effectiveness of universal screening. The effectiveness of universal versus targeted screening was not assessed in previous MRSA guidelines, [
[1]
] although the recommendation endorsed the use of a targeted approach.There was weak evidence of no benefit from one ITS [
[3]
] which investigated the incidence of MRSA acquisition in all patients, excluding new-borns, admitted to hospital with the use of universal screening (n=61,782) as compared to targeted screening (n=76,273). The study found no significant difference in the incidence of MRSA acquisition in patients screened universally (47.5/100,000) as compared to those when a targeted approach was in use (41.8/100,000; P=0.923).There was weak evidence of no benefit from one ITS study [
[3]
] and one CBA study [[4]
] which investigated the incidence of MRSA infection in patients admitted to hospital with the use of universal screening as compared to targeted screening. One study [[3]
] of all patients, excluding new-borns, admitted to hospital found no significant difference in the incidence of MRSA bloodstream infection (BSI) in patients screened universally (1.8/1000pd (patient days) n=61,782), as compared to those when a targeted approach was in use (2.1/1000pd n=76,273; P value not reported). Another study [[4]
] of adult patients admitted to hospital for at least 24 hours with universal screening (n=61,782) compared to targeted screening (n=76,273) found that the rate of healthcare-associated MRSA infection (HCAI-MRSA) did not fall significantly (0.27% before versus 0.15% after the switch to universal screening), while the rate in the control hospital remained the same throughout the study period (0.10%, P=0.34).There was weak evidence of no benefit from one CBA study [
[4]
] which investigated the cost saving from a reduced incidence of healthcare-associated MRSA acquisition per each additional dollar spent on screening in adult patients admitted to hospital for at least 24 hours with the use of universal screening (n=3255) as compared to targeted screening (n=2037). The study found lower cost savings when screening patients universally (USD 0.50 saved) as compared to those when targeted approach was in use (USD 1.00 saved).The Working Party considered the evidence and concluded that the universal screening strategy had no benefit over targeted screening. The clinical experience of the Working Party suggests that universal screening may be easier and more time-effective for staff as it removes the need to perform additional assessments to determine whether patients require such screening. When a targeted approach is used, careful consideration is needed to establish which patients should be considered at risk and that local risk factors are taken into account. The Working Party concluded that for screening to be effective, it needs to be linked to a specific action that either attempts to eradicate or suppress the MRSA in the patients (decolonisation) or minimises contact with MRSA colonised patients (isolation).
Recommendations
1.1 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).
1.2 Use at least a targeted approach but consider using universal screening as appropriate depending on local facilities.
1.3 If a targeted approach is used, define risk factors for MRSA carriage as appropriate for your area.
Good Practice points
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.
What is the clinical and cost-effectiveness of repeat screening people who screen negative/positive on pre-admission/admission to prevent the transmission of MRSA?
If patients screen negative at admission, repeat screening can identify whether they acquired MRSA during their stay, so that appropriate actions can be taken. On the other hand, for those who screen positive, repeat screening can show whether an MRSA patient was successfully decolonised. It is currently unclear whether repeat MRSA screening is clinically and cost-effective and how the repeat screening should be performed. Effectiveness of repeat screening was not assessed in previous MRSA guidelines [
[1]
] and no recommendation was endorsed for its use.No evidence was found from the studies published since 2004, which met the inclusion criteria for the study design, and which assessed the benefit of repeat screening for people who screened negative or positive on pre-admission/admission screening to prevent the transmission of MRSA.
The Working Party additionally considered the evidence from the excluded studies, which reported some benefit of repeat screening and, together with the clinical experience of the group members, suggested that repeat screening could be beneficial in some circumstances.
Recommendations
2.1 Do not perform repeat MRSA screening for patients who screen positive at admission unless the patient undergoes decolonisation therapy.
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.
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.
What is the clinical and cost-effectiveness of rapid molecular diagnostics versus culture in screening to prevent the transmission of MRSA in hospital and non-acute care settings?
During the screening process for MRSA at a hospital or healthcare setting, a swab is taken from the patient and is usually analysed in conventional culture-based assays. This may include enrichment in broth, the use of selective media or chromogenic agar. While this process is straightforward and is considered the gold-standard diagnostic method, the turnaround time (TAT) for results can be more than 48 hours. This delay may result in the patient or healthcare staff transmitting MRSA to others or acquiring MRSA. Moreover, while waiting for results and trying to prevent patients from potentially transmitting MRSA, healthcare workers may need to implement preventative measures such as isolating patients, which are costly. To receive rapid results, rapid diagnostic techniques such as the polymerase chain reaction (PCR) method have been used for screening samples to establish the presence of MRSA in the swab. These molecular techniques may require the use of commercial tests and as a result, they tend to be costlier than culture, although laboratories may develop their own in-house methods. It is currently unknown whether molecular diagnostic techniques are beneficial in clinical practice in comparison to conventional culture methods, in terms of diagnostic accuracy, TAT, transmission rates and costs. Effectiveness of these methods of screening was not assessed in previous MRSA guidelines [
[1]
] and no recommendation was endorsed for their use.There was strong evidence of similar diagnostic accuracy from the meta-analysis of 61 studies [
5
, 6
, - Arcenas S.
- Spadoni S.
- Mohammad A.
- Kiechle F.
- Walker K.
- Fader R.C.
- et al.
Multicenter evaluation of the LightCycler MRSA advanced test, the Xpert MRSA assay, and MRSASelect directly plated culture with simulated workflow comparison for the detection of Meticillin-resistant Staphylococcus Aureus in nasal swabs.
J Mol Diagnostics. 2012; 14: 367-375
7
, 8
, 9
, - Bishop E.J.
- Grabsch E.A.
- Ballard S.A.
- Mayall B.
- Xie S.
- Martin R.
- et al.
Concurrent analysis of nose and groin swab specimens by the IDI-MRSA PCR assay is comparable to analysis by individual-specimen PCR and routine culture assays for detection of colonization by Meticillin-resistant Staphylococcus Aureus.
J Clin Microbiol. 2006; 44: 2904-2908
10
, 11
, 12
, 13
, 14
, 15
, 16
, 17
, 18
, 19
, 20
, 21
, 22
, 23
, 24
, 25
, 26
, 27
, - Hombach M.
- Pfyffer G.E.
- Roos M.
- Lucke K.
Detection of Meticillin-resistant Staphylococcus Aureus (MRSA) in specimens from various body sites: performance characteristics of the BD GeneOhm MRSA assay, the Xpert MRSA assay, and broth-enriched culture in an area with a low prevalence of MRSA infections.
J Clin Microbiol. 2010; 48: 3882-3887
28
, 29
, 30
, 31
, 32
, 33
, 34
, 35
, 36
, 37
, 38
, - Laurent C.
- Bogaerts P.
- Schoevaerdts D.
- Denis O.
- Deplano A.
- Swine C.
- et al.
Evaluation of the Xpert MRSA assay for rapid detection of Meticillin-resistant Staphylococcus Aureus from nares swabs of geriatric hospitalized patients and failure to detect a specific sccmec type IV variant.
Eur J Clin Microbiol Infect Dis. 2010; 29: 995-1002
39
, 40
, 41
, - Mehta M.S.
- Paule S.M.
- Hacek D.M.
- Thomson R.B.
- Kaul K.L.
- Peterson L.R.
Optimization of a Laboratory-Developed Test Utilizing Roche Analyte-Specific Reagents for Detection of Staphylococcus aureus, Meticillin-resistant S. aureus, and Vancomycin-Resistant Enterococcus Species.
J Clin Microbiol. 2008; 46: 2377-2380
42
, 43
, 44
, 45
, 46
, 47
, 48
, 49
, 50
, 51
, 52
, 53
, 54
, 55
, 56
, 57
, 58
, 59
, 60
, 61
, 62
, 63
, 64
, 65
which investigated the diagnostic accuracy of PCR versus culture screening (n=72,952 samples). The results of meta-analysis demonstrated that the overall sensitivity was 91.54% [CI95% 90.75–92.28], specificity was 97.00% [CI95% 96.86–97.12], positive predictive value was 70.03% [CI95% 69.11–70.94] and negative predictive value was 99.33% [CI95% 99.27–99.39]. The overall accuracy of PCR compared to culture results was 96.61% [CI95% 96.47–96.74]. There were an additional nine studies, which were not included in meta-analysis, either because they did not report data on the number of positive and negative values but reported sensitivity and specificity [66
, 67
, 68
, 69
, - Wolk D.M.
- Marx J.L.
- Dominguez L.
- Driscoll D.
- Schifman R.B.
Comparison of MRSASelect agar, CHROMagar Meticillin-resistant Staphylococcus aureus (MRSA) Medium, and Xpert MRSA PCR for detection of MRSA in Nares: diagnostic accuracy for surveillance samples with various bacterial densities.
J Clin Microbiol. 2009; 47: 3933-3936
70
, 71
] or were identified later in the review process. [72
, 73
, 74
] All these studies reported results similar to those obtained from meta-analysis.There was strong evidence of no benefit from the meta-analysis of three RCTs and one n-RCT [
[33]
,[71]
,[75]
,[76]
] which investigated the incidence of MRSA colonisation when using PCR screening (n=16,773) versus culture (n=17,754). The results of meta-analysis showed that the incidence of colonisation did not decrease significantly in the PCR group (n=268, 1.51%) when compared to culture (n=324, 1.94%, OR=0.86 [CI95% 0.73–1.01]). These results are consistent with the results of studies which reported colonisation per 1000pd or 1000pd at risk, with one RCT [[75]
] reporting significantly lower incidence in the PCR group (2.86 versus 4.10/1000pd, P=0.002) while four other studies reported non-significant differences (0.39 versus 0.35/1000pd, P=0.39, [[77]
] 4.4. versus 4.9/1000pd at risk, P=0.27, [[33]
] 2.57 versus 2.83/1000pd at risk, P=0.66, [[76]
] 4.60 versus 5.39/1000pd at risk P value not reported [[71]
]).There was moderate evidence of no benefit from two RCTs [
[33]
,[76]
] which investigated the incidence of MRSA infection when using PCR screening versus culture. One study [[33]
] found no difference in MRSA BSI in the group of patients where PCR was used (1/3553, 0.03%) compared to patients where culture was used (2/3335, 0.06%, P value not reported) and no difference in MRSA wound (included but not limited to surgical wound) infection (21/3335, 0.6% in PCR versus 22/3553, 0.7% in culture, P=0.77). Another study [[76]
] found no significant difference in a rate of infection/1000pd in patients with PCR (5/1063, 4.06/1000pd) versus culture (2/1121, 1.57/1000pd, P=0.281).There was strong evidence of benefit from 14 studies, [
[10]
,[15]
,[27]
,- Hombach M.
- Pfyffer G.E.
- Roos M.
- Lucke K.
Detection of Meticillin-resistant Staphylococcus Aureus (MRSA) in specimens from various body sites: performance characteristics of the BD GeneOhm MRSA assay, the Xpert MRSA assay, and broth-enriched culture in an area with a low prevalence of MRSA infections.
J Clin Microbiol. 2010; 48: 3882-3887
[33]
,[38]
,- Laurent C.
- Bogaerts P.
- Schoevaerdts D.
- Denis O.
- Deplano A.
- Swine C.
- et al.
Evaluation of the Xpert MRSA assay for rapid detection of Meticillin-resistant Staphylococcus Aureus from nares swabs of geriatric hospitalized patients and failure to detect a specific sccmec type IV variant.
Eur J Clin Microbiol Infect Dis. 2010; 29: 995-1002
[42]
,[45]
,[53]
,[59]
,[62]
,[71]
,75
, 76
, 77
] which investigated the TAT of PCR and culture. There was a high degree of heterogeneity as to how TAT was reported across these studies, but they consistently showed significantly decreased TAT for PCR samples. The studies showed that the time from patient admission to results being available for PCR was under 24 hours [[33]
,[71]
,[76]
] and just over 24 hours for admission until isolation, [[62]
,[76]
] while results for culture using the same TAT were 40.4 hours or longer. [[33]
,[62]
,[71]
,[76]
] When TAT was defined as the time from the collection of the screening sample until results were available, it showed that these results could be available in less than two hours [[38]
] and are typically available in under 24 hours for PCR. [- Laurent C.
- Bogaerts P.
- Schoevaerdts D.
- Denis O.
- Deplano A.
- Swine C.
- et al.
Evaluation of the Xpert MRSA assay for rapid detection of Meticillin-resistant Staphylococcus Aureus from nares swabs of geriatric hospitalized patients and failure to detect a specific sccmec type IV variant.
Eur J Clin Microbiol Infect Dis. 2010; 29: 995-1002
[27]
,- Hombach M.
- Pfyffer G.E.
- Roos M.
- Lucke K.
Detection of Meticillin-resistant Staphylococcus Aureus (MRSA) in specimens from various body sites: performance characteristics of the BD GeneOhm MRSA assay, the Xpert MRSA assay, and broth-enriched culture in an area with a low prevalence of MRSA infections.
J Clin Microbiol. 2010; 48: 3882-3887
[59]
,[75]
] The results of culture were available after 28 hours at the earliest [[59]
] and sometimes took more than two days. [[27]
,- Hombach M.
- Pfyffer G.E.
- Roos M.
- Lucke K.
Detection of Meticillin-resistant Staphylococcus Aureus (MRSA) in specimens from various body sites: performance characteristics of the BD GeneOhm MRSA assay, the Xpert MRSA assay, and broth-enriched culture in an area with a low prevalence of MRSA infections.
J Clin Microbiol. 2010; 48: 3882-3887
[38]
,- Laurent C.
- Bogaerts P.
- Schoevaerdts D.
- Denis O.
- Deplano A.
- Swine C.
- et al.
Evaluation of the Xpert MRSA assay for rapid detection of Meticillin-resistant Staphylococcus Aureus from nares swabs of geriatric hospitalized patients and failure to detect a specific sccmec type IV variant.
Eur J Clin Microbiol Infect Dis. 2010; 29: 995-1002
[75]
] The studies which assessed TAT as the arrival of samples at the laboratory to results being available [[15]
,[27]
,- Hombach M.
- Pfyffer G.E.
- Roos M.
- Lucke K.
Detection of Meticillin-resistant Staphylococcus Aureus (MRSA) in specimens from various body sites: performance characteristics of the BD GeneOhm MRSA assay, the Xpert MRSA assay, and broth-enriched culture in an area with a low prevalence of MRSA infections.
J Clin Microbiol. 2010; 48: 3882-3887
[42]
,[45]
,[53]
,[62]
] reported the shortest time for PCR at 1.8 hours and the average time as eight hours, while the shortest time for culture was 24 hours and the average time longer than 40 hours.There was strong evidence of no benefit from eight studies [
[10]
,[15]
,[33]
,[56]
,[62]
,76
, 77
, 78
] investigating the cost of PCR versus culture. One UK study [[15]
] reported that the cost of one screen is approximately 2.5 times more when using PCR than culture (£4.29 versus £1.71, total cost £14,328.60 versus £5711.40 for a total sample of 3340). Another study [[10]
] estimated this cost to be higher: USD 6.71 and USD 7.52 (approx. £5.17 and £5.79) for culture (negative and positive result, respectively) and USD 25.50 (approx. £19.60) for PCR. This study, besides the cost of materials necessary for screening, considered the cost of staff required to process the samples (1.5–2min for culture and 5–9min for PCR per sample). Other studies reported 4–5 times higher screening costs compared to culture, although it is not possible to determine what was included in the estimation of the costs. [[56]
,[78]
] Two studies did not report data on the cost of culture but reported that screening with PCR required an additional €4.961 (approx. £4.27) [[76]
] and €56.22/€69.62 (approx. £48.45/£59.99) [[62]
] depending on the assay. Three studies reported [[33]
,[62]
,[78]
] a potential cost saving when screening with PCR. One of these studies [[78]
] of 232 participants reported that while the PCR screening cost itself was higher (additional CHF104,328.00, approx. £80,332.56 for universal screening and CHF11,988.00 approx. £9,230.76 for targeted screening), there is potential for reducing the costs of pre-emptive isolation by CHF38,528.00, approx. £29,666.56. Hence, while the net cost of universal isolation was still higher (CHF91,509.00, approx. £70,461.93), the targeted screening reduced the net costs by CHF14,186.00 (approx. £10,923.22). Another study, [[62]
] using targeted screening reported a reduction in the daily cost of isolation as €95.77 (approx. £73.74) and €125.43 (approx. £96.58) when using two PCR screening methods compared to culture. One study, [[33]
] which used a universal screening approach reported that PCR screening reduced the number of inappropriately used isolation days from 399 to 277. While the authors did not report the cost analysis, they suggested that there was a potential to counterbalance the cost of PCR screening with the benefit from reducing the number of isolation days. Last study [[77]
] reported that the total cost of screening with PCR was more expensive (CAN 3,656.92, approx. £2,281.92) than culture methods (CAN 2,937.06, approx. £1,832.73), although they did not report any information on how this cost was estimated.Further evidence came from UBA studies, three of which reported a decrease in the incidence of MRSA acquisition when PCR screening was introduced, [
79
, 80
, 81
] and four of which reported a decrease in reducing TAT. [- Hallak G.
- Neuner B.
- Schefold J.C.
- Gorzelniak K.
- Rapsch B.
- al Pfülleret R.
Preemptive isolation precautions of patients at high risk for Meticillin-resistant Staphylococcus Aureus in combination with ultrarapid Polymerase Chain Reaction Screening as an effective tool for infection control.
Infect Control Hosp Epidemiol. 2016; 37: 1489-1491
[11]
,[79]
,81
, - Hallak G.
- Neuner B.
- Schefold J.C.
- Gorzelniak K.
- Rapsch B.
- al Pfülleret R.
Preemptive isolation precautions of patients at high risk for Meticillin-resistant Staphylococcus Aureus in combination with ultrarapid Polymerase Chain Reaction Screening as an effective tool for infection control.
Infect Control Hosp Epidemiol. 2016; 37: 1489-1491
82
, 83
].There was strong evidence from a total of 45 studies, [
[5]
,7
, 8
, 9
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- Grabsch E.A.
- Ballard S.A.
- Mayall B.
- Xie S.
- Martin R.
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Concurrent analysis of nose and groin swab specimens by the IDI-MRSA PCR assay is comparable to analysis by individual-specimen PCR and routine culture assays for detection of colonization by Meticillin-resistant Staphylococcus Aureus.
J Clin Microbiol. 2006; 44: 2904-2908
10
, 11
,[13]
,[14]
,[16]
,[17]
,[19]
,22
, 23
, 24
,[27]
,- Hombach M.
- Pfyffer G.E.
- Roos M.
- Lucke K.
Detection of Meticillin-resistant Staphylococcus Aureus (MRSA) in specimens from various body sites: performance characteristics of the BD GeneOhm MRSA assay, the Xpert MRSA assay, and broth-enriched culture in an area with a low prevalence of MRSA infections.
J Clin Microbiol. 2010; 48: 3882-3887
29
, 30
, 31
, 32
,[35]
,37
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, - Laurent C.
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- Denis O.
- Deplano A.
- Swine C.
- et al.
Evaluation of the Xpert MRSA assay for rapid detection of Meticillin-resistant Staphylococcus Aureus from nares swabs of geriatric hospitalized patients and failure to detect a specific sccmec type IV variant.
Eur J Clin Microbiol Infect Dis. 2010; 29: 995-1002
39
, 40
, 41
,- Mehta M.S.
- Paule S.M.
- Hacek D.M.
- Thomson R.B.
- Kaul K.L.
- Peterson L.R.
Optimization of a Laboratory-Developed Test Utilizing Roche Analyte-Specific Reagents for Detection of Staphylococcus aureus, Meticillin-resistant S. aureus, and Vancomycin-Resistant Enterococcus Species.
J Clin Microbiol. 2008; 46: 2377-2380
[43]
,[45]
,47
, 48
, 49
, 50
, 51
,[53]
[5,7–11,13,14,16,17,19,22–24,27,29–32,35,37–41,43,45,47–51,53,57
, 58
, 59
, 60
, 61
, 62
,[64]
,[65]
,[67]
,[69]
,- Wolk D.M.
- Marx J.L.
- Dominguez L.
- Driscoll D.
- Schifman R.B.
Comparison of MRSASelect agar, CHROMagar Meticillin-resistant Staphylococcus aureus (MRSA) Medium, and Xpert MRSA PCR for detection of MRSA in Nares: diagnostic accuracy for surveillance samples with various bacterial densities.
J Clin Microbiol. 2009; 47: 3933-3936
[72]
,[73]
,[78]
,[84]
which reported the occurrence of PCR inhibition rates. This is important because sometimes these can be mistaken for negative results. Overall, the inhibition rate was 2.98% [CI95% 2.80–3.17], although one study [[73]
] which used a Point-of-Care Testing device, reported the inhibition rates as high as 8.1%.The Working Party considered the evidence and concluded that diagnostic accuracy of PCR is similar to culture and there is a benefit in obtaining results in a shorter time. However, these benefits do not translate into clinical benefit of reducing the incidence of MRSA acquisition or infection and PCR screening may incur higher cost.
Recommendation
3.1 Use either PCR or traditional culture methods for MRSA screening as you consider appropriate depending on the local laboratory facilities.
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.
What is the clinical and cost-effectiveness of screening staff to prevent the transmission of MRSA?
Members of staff in healthcare settings are not routinely screened for MRSA. Usually, they will undergo screening if an MRSA outbreak persists, staff are suspected to be carriers or when the source of the outbreak is unclear. MRSA can be traced back to staff if the strain of MRSA is the same as in patients. Screening under these three circumstances is the most common approach to staff screening, but there are some who argue that screening should be expanded, although the clinical and cost-effectiveness of this approach is not established. Our previous MRSA guidelines [
[1]
] did not recommend routine screening of staff, but the Working Party considered that it could be valuable under certain circumstances (e.g. when transmission of MRSA continues despite implementing preventative measures and epidemiological data suggest staff carriage).No evidence was found in studies published since 2004 which met the inclusion criteria for the study design, and which assessed the benefit of performing staff screening on any patient-related outcomes.
There was weak evidence from one UBA study [
[85]
] which assessed the benefit of performing staff screening on the prevalence of staff MRSA carriage. The authors reported that a total of 27/566 (4.77%) of the staff were colonised with MRSA at their first screening, while 14/445 (3.15%) of staff were colonised at least once at subsequent screenings. While it is not possible to directly compare the before/after prevalence (some staff were screened more than once at subsequent screenings), the authors reported that 9/201 (4.48%) staff were colonised in 2005 and the prevalence from 2006-2008 was 12/207 (5.80%), 11/237 (4.64%) and 7/186 (3.76%) respectively. This suggests that overall, the prevalence did not change. The authors reported that for the staff who were screened more than once (n=221) and were given the decolonisation treatment following the positive screen, the colonisation rate dropped for this group from 5.88% to 2.71% (P=0.55) and the odds ratio of being colonised at second screen was 0.45 (CI95% not reported) compared to the first screen. It is not possible to determine whether the staff were subsequently recolonised at the follow-up screenings.The Working Party considered the evidence from the excluded studies, which did not meet the inclusion criteria for study design and reported no benefit in routine staff screening, and together with the clinical experience of the Working Party members, concluded that staff screening is not beneficial except in certain circumstances described above.
Recommendations
4.1 Do not routinely screen staff for MRSA.
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.
Good practice points
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.
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.
GPP 4.3 If possible, involve the Occupational Health Team in the process of staff screening and management.
What approaches to the management of healthcare staff who are colonised with MRSA are most practical and effective at minimising the risk to patients?
If a member of staff tests positive for MRSA, the hospital is required to comply with appropriate governance to ensure that the risk of acquisition, and potentially infection, is minimised among the patients. This includes sending staff home, reducing their interaction with patients or treatment with topical antimicrobials. The cost-effectiveness and clinical benefit of these management strategies have not been established. Effectiveness of managing staff who screen positive for MRSA was not assessed in previous MRSA guidelines, [
[1]
] although the Working Party recommended developing local protocols which assess the individual staff member's risk of transmission to patients when agreeing their continuation or return to work. It was recommended that only staff members with colonised or infected hand lesions should be off work while receiving courses of decolonisation therapy, but this decision should be based on local risk assessments. To aid staffing resources, it was recommended to temporarily re-allocate staff carriers to low-risk tasks or to non-patient contact activities. The management of staff with nasal carriage was not included in previous guidelines.No evidence was found in the studies published since 2004 which met the inclusion criteria for the study design and, which assessed the management of staff who tested positive for MRSA carriage.
The Working Party considered previous recommendations from MRSA guidelines and, together with the clinical experience of the members, suggested that staff who are identified as MRSA positive may need a course of decolonisation therapy and sometimes may need to be excluded from clinical areas.
Recommendations
5.1 Consider excluding staff from work, reducing their interaction with patients, or offering decolonisation therapy as deemed appropriate.
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.
Good practice points
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.
GPP 5.2 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).
What is the evidence that topical decolonisation therapy is clinically and cost-effective in minimising the transmission or eradication of MRSA? What is the evidence that the selected strategy for topical decolonisation results in resistance?
The most common topical decolonisation therapy offered to patients and staff is CHG and mupirocin, either as combination or alone. There is some disagreement in the literature over the clinical effectiveness of topical decolonisation in preventing MRSA colonisation or its eradication. It is generally acknowledged that complete eradication is not always possible, but a temporary suppression may be sufficient in some circumstances (e.g. prior to surgery). Moreover, there are risks that overuse of topical decolonisation therapies leads to resistance. This has led some healthcare facilities to implement other interventions such as putting patients in single rooms to prevent transmission to others. There is a need to understand clearly the clinical and cost-effectiveness as well as antimicrobial resistance risks of different decolonisation (defined here as a therapy which aims to eradicate or temporarily suppress the MRSA growth) therapies compared to the best standard of care, including those from no decolonisation therapy. Previous MRSA guidelines [
[1]
] recommended prophylactic use of mupirocin in conjunction with CHG for patients undergoing some operative procedures. This was also recommended in outbreak situations. Throat decolonisation with systemic therapy was recommended only on the advice of the consultant microbiologist and was recommended in conjunction with nasal and skin decolonisation therapy with mupirocin and CHG. Skin decolonisation was recommended for pre-operative patients who were found positive for the carriage of MRSA. Skin decolonisation with 4% CHG wash, 7.5% povidone-iodine (PVP) or 2% triclosan was recommended.Chlorhexidine (CHG)
There was strong evidence of benefit from twelve RCTs, [
86
, 87
, - Boonyasiri A.
- Thaisiam P.
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- Judaeng T.
- Suiwongsa B.
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Effectiveness of chlorhexidine cloths for the prevention of multidrug resistant bacterial colonization and hospital-acquired infections in intensive care unit patients: a randomized trial in Thailand.
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88
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, - Camus C.
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- Renault A.
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Mupirocin/chlorhexidine to prevent meticillin-resistant Staphylococcus aureus infections: post hoc analysis of a placebo-controlled, randomized trial using mupirocin/chlorhexidine and polymyxin/tobramycin for the prevention of acquired infections in intubated patients.
Infection. 2014; 42: 493-502
90
, 91
, 92
, - Kline S.E.
- Neaton J.D.
- Lynfield R.
- Ferrieri P.
- Kulasingam S.
- Dittes K.
- et al.
Randomized controlled trial of a self-administered five-day antiseptic bundle versus usual disinfectant soap showers for preoperative eradication of Staphylococcus aureus colonization.
Infect Control Hosp Epidemiol. 2018; 39: 1049-1057
93
, - O'Grady S.
- Hirji Z.
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- Fung S.
- Dedier H.
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A double-blind, randomized, controlled trial of topical polysporin triple compound versus topical mupirocin for the eradication of colonization with meticillin-resistant Staphylococcus aureus in a complex continuing care population.
Can J Infect Dis Med Microbiol. 2009; 20: e49-e55
94
, 95
, 96
, 97
, - Wendt C.
- Schinke S.
- Württemberger M.
- Oberdorfer K.
- Bock-Hensley O.
- von Baum H.
Value of whole-body washing with chlorhexidine for the eradication of meticillin-resistant Staphylococcus aureus: a randomized, placebo-controlled, double-blind clinical trial.
Infect Control Hosp Epidemiol. 2007; 28: 1036-1043
98
] four controlled trials, [99
, 100
, 101
, 102
] eleven ITS studies, [103
, 104
, 105
, 106
, 107
, 108
, 109
, 110
, 111
, 112
, 113
] two retrospective cohort studies [[114]
,[115]
] and one CBA study [[116]
] which investigated the effectiveness of CHG washing on the prevalence of MRSA colonisation, incidence of MRSA acquisition, incidence of MRSA infection and the eradication of MRSA. The results of the meta-analyses showed that decolonisation therapy with CHG, either alone or in combination with another agent (PVP, polysporin or mupirocin), was consistently better than the comparison group (either no decolonisation or placebo) for all outcomes, except for incidence of MRSA acquisition when CHG was used alone. When CHG was used alone, the prevalence of MRSA was 2.1% in CHG group versus 25.5% in control group (P<0.001), the incidence of MRSA acquisition was 3.55% versus 3.04% (P<0.0001), the incidence of MRSA acquisition/1000pd was 2.35 versus 3.10, P=0051, incidence of infection was 1.11% versus 1.49%, P=0.0361 and the incidence of infection per 1000pd was 0.22 versus 0.46, P<0.0001. When CHG was used alone or in combination with another therapy (PVP or mupirocin), the prevalence of MRSA was 5.3% versus 25.5%, P<0.0001, the incidence of MRSA acquisition was 1.57% versus 3.04%, P<0.0001, the incidence of acquisition per 1000pd was 0.89 versus 3.10, the incidence of infection was 1.11% versus 1.49%, P=0.0361, the incidence of infection per 1000pd was 0.08 versus 0.46, P<0.0001 and the rate of MRSA eradication was 60.5% versus 34.5%, P<0.0001, thus showing that CHG performs better when used in combination with nasal decolonisation therapy. The results remained significant when stratified by different types of setting (e.g. surgical, ICU, general ward) or when using a selective (only for MRSA positive patients) or universal (blanket) approaches, although there was large heterogeneity in the reported results between the individual studies. Additional evidence from the studies which provided data not compatible for entry into metanalysis, did not show a significant benefit of using CHG. One small ITS, [[112]
] which used nasal mupirocin and 4% CHG wipes for patients colonised with MRSA in neonatal ICU did not report a significant decrease in the incidence of MRSA acquisition in the intervention period in comparison to pre-intervention (2.00 versus 2.38 events/1000pd, IRR=1.85 (incidence rate ratio) [CI95% 0.80–1.73], P=NR). An RCT [[98]
] conducted in adult ICU patients with a treatment group receiving a daily 4% CHG wash and a control group receiving a daily soap and water wash reported no significant decrease in the incidence of HCAI-MRSA (2/226, 0.9% or 1.08/1000pd versus 6/223, 2.7% or 3.80/1000pd, RR=0.33, [CI95% 0.07–1.61], P=0.1704). Considering the small sample sizes, these two studies were likely underpowered, resulting in type I error. Further evidence came from eighteen UBA studies [117
, 118
, 119
, 120
, 121
, - Climo M.W.
- Sepkowitz K.A.
- Zuccotti G.
- Fraser V.J.
- Warren D.K.
- Perl T.M.
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The effect of daily bathing with chlorhexidine on the acquisition of meticillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and healthcare-associated BSI: results of a quasi-experimental multicenter trial.
Crit Care Med. 2009; 37: 1858-1865
122
, - Fraser T.G.
- Fatica C.
- Scarpelli M.
- Arroliga A.C.
- Guzman J.
- Shrestha N.K.
- et al.
Decrease in Staphylococcus aureus colonization and hospital-acquired infection in a medical intensive care unit after institution of an active surveillance and decolonization program.
Infect Control Hosp Epidemiol. 2010; 31: 779-783
123
, 124
, 125
, 126
, 127
, 128
, 129
, 130
,