Special Edition on Infection Prevention & Control | Page 32

personnel. Of note, there is variation among facilities regarding
use of contact precautions for patients colonized with MRSA,
particularly for asymptomatic carriers. Some before/after
studies have called into question the effectiveness of contact
precautions as a means to control spread of MRSA and have
observed that discontinuation of contact precautions in the
setting of endemic MRSA is not associated with an increase in
the rate of MRSA infections. It has therefore been suggested
that hospitals choosing to forgo contact precautions should
emphasize compliance with various horizontal infection control
strategies (for example, hand hygiene or device bundles) to
help control endemic MRSA.
Tier 1, Intervention 6: Ensure Thorough Environmental
Cleaning of Hospital Environment and Patient Care
Equipment: Because MRSA can survive on hospital surfaces
and contaminate the hospital environment as well as patient
care equipment, dedicated medical equipment for a single
patient known to carry or be infected with MRSA, or cleaning
and disinfection of equipment before use with another patient,
was recommended as a tier 1 strategy. Environmental cleaning
and disinfection reduces opportunities for contamination
of healthcare workers’ hands; consequently, risk for MRSA
acquisition by subsequent room occupants has been reduced
through improvements in cleaning. Thorough cleaning and
disinfection ensures that high-touch environmental surfaces
are cleaned and disinfected with an EPA-registered disinfectant
regularly (for example, daily), when spills occur, when there is
visible contamination, and at the time of discharge. Engaging
environmental service personnel should therefore be an
important component of a hospital’s infection prevention and
control efforts. Indirect methods that assess the thoroughness
of cleaning and disinfection are available and have been used
for regular audit and feedback.
MRSA Tier 2 Interventions
Tier 2, Intervention 1: Use a Guide to Patient Safety
to Perform an MRSA Needs Assessment: When hospitals
struggle with infection prevention, understanding where they
are going wrong in terms of practice and policy is a critical
first step. This “pause” in the problem-solving process could
benefit from a structured approach. A guide to help hospitals
ask and answer critical questions related to infection prevention
has been shown to be useful and helpful when tracking HAIs,
such as catheter-associated urinary tract infection. Therefore,
for MRSA, a guide to patient safety (GPS) comprising 7 key
questions that hospitals should ask when examining sustained
MRSA rates was created for this project. Questions included
assessing whether dedicated personnel existed for focusing
on MRSA prevention, support from leadership, collection
of MRSA-related data, and feedback to frontline staff. A
hospital-onset MRSA bacteremia GPS was considered the first
step that hospitals would take among the tier 2 interventions.
Tier 2, Intervention 2: Daily Chlorhexidine Gluconate
Bathing for Patient Populations at Risk for MRSA
Bloodstream Infections: Daily bathing of ICU patients with
chlorhexidine gluconate (CHG) serves as a means of “source
control” and has been shown to significantly reduce potential
pathogens, including MRSA , on patients’ skin. Downstream
benefits of decreasing the burden of patient skin contamination
include 1) preventing infections due to potential pathogens on
patient skin, 2) reducing the opportunity for health care workers
to contaminate their hands during patient care activities, 3)
reducing environmental contamination, and 4) decreasing
spread of potential pathogens to other patients. Daily patient
bathing with CHG has been examined in a variety of units, with
data showing reduction in risk for acquisition of multidrug-resistant
organisms and hospital-acquired bloodstream infections.
Linking back to tier 1, hospitals can use results of the MRSA risk
assessment and hospital-onset MRSA bacteremia case reviews
to identify which patient population may benefit from targeted
daily CHG bathing. Although several studies support routine
use of daily CHG bathing in ICUs, other high-risk populations,
such as those with indwelling central venous catheters (even
in non-ICU settings), may also be candidates for this infection
prevention intervention. Key aspects to implementation of this
intervention are 1) ensuring adequate education of healthcare
personnel who will be performing the daily CHG baths; 2)
ensuring product compatibility of other skin care products
on that medical unit; 3) developing standardized protocols or
order sets to maximize adherence of CHG bathing; 4) ensuring
adequate supplies for CHG bathing and, if dilutions of CHG
soap are being used rather than impregnated cloths, ensuring
appropriate dilutions of products and application techniques;
and 5) performing routine audits of adherence with real-time
feedback to frontline personnel.
Tier 2, Intervention 3: Decolonization for Patients With
MRSA Colonization at High Risk for Infection: Should rates
of hospital-onset MRSA bacteremia remain elevated despite
implementation of tier 1 and early tier 2 strategies, a hospital
can consider decolonization for patients identified as having
MRSA colonization, particularly those at high risk for infection
(for example, patients undergoing surgery or admitted to
an ICU) (3). Decolonization regimens vary and include such
agents as intranasal mupirocin or povidone iodine, with or
without CHG bathing or systemic oral antimicrobial therapy.
In a multicenter study of adult ICUs, universal decolonization
with intranasal mupirocin in conjunction with daily CHG
bathing was the most effective strategy for reducing rates of
MRSA clinical isolates. When implementing decolonization,
consideration should be given to the possible emergence of
resistance, particularly with mupirocin. Furthermore, in studies
examining the durability of decolonization regimens, a large
proportion of individuals have been found to be colonized
again several months after the intervention, suggesting the
limited durability of decolonization regimens. Nevertheless, in
situations with ongoing MRSA infections despite adherence to
tier 1 interventions, decolonization of at-risk patients should
be a consideration.
Tier 2, Intervention 4: Active Surveillance Among
High-Risk Patient Populations: Active surveillance is a strategy
used to detect previously unrecognized asymptomatic MRSA
carriers so that additional infection control measures (such
as placement of these patients into contact isolation) can be
implemented. Active surveillance programs can be instituted for
high-risk populations (such as those in ICUs) as a strategy to help
reduce cross transmission of MRSA in the unit and, ultimately,
to attempt to reduce nosocomial MRSA infections. Often, active
surveillance programs for MRSA involve screening the anterior
nares for MRSA carriage. However, not all studies of active
32 IP&C Special Edition June 2020 • www.healthcarehygienemagazine.com