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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

www.nursingmanagement.com Nursing Management • June 2013 27

Methicillin-resistant Staphylococcus aureus

(MRSA) is an important pathogen both inside

the hospital and within the community. Many

studies have shown that it increases morbid-

ity and mortality when compared with its

less drug-resistant relative—methicillin-sensitive S. aureus. The literature and guidelines are divided into two very

different approaches for the best use of healthcare resources

to minimize transmission of the organism. After years of

debate, a national consensus on best practices is building;

unfortunately, it appears to be at odds with many state

legislature mandates. The good news is that these univer-

sal infection prevention strategies, when followed, may

not only reduce MRSA transmission rates, but also the

spread of other healthcare-associated pathogens.

A history of resistance

Since the 1970s, cyclical increases in S. aureus infection

have been noted in communities and hospitals. During the

outbreak of S. aureus in North America in the 1950s and

1960s, it was firmly established as a healthcare-associated

pathogen. MRSA was first identified in 1961, 2 years after

Focus on universal infection prevention strategies, instead of targeted approaches, to reduce MRSA and other healthcare-associated infections.

By Frank Edward Myers III, MA, CIC

Is it the right infection prevention goal?

Targeting MRSA:

1.9CONTACT HOURS


Targeting MRSA: Is it the right infection prevention goal?


methicillin was approved for treat-

ment of S. aureus infection. MRSA

infection rates continued to increase

slowly but steadily in North America

through the 1970s and 1980s. Regional

variation in North America existed;

certain areas had much higher rates

of infection than others. By the late

1990s, MRSA infection reached epi-

demic proportions.

The MRSA epidemic of the late

1990s and early 2000s wasn’t

driven by an increase in healthcare

transmission or sicker inpatients

getting infected, but by a strain of

MRSA that developed resistance

to treatment—originally called

community-associated MRSA. This

name was discontinued after it was

shown that, in some cases, the com-

munity strain and the healthcare-

associated strain (albeit rarely) were

both being transmitted in the com-

munity.1 The new strain became

known as USA300. Despite head-

lines in the popular press, this

strain didn’t “escape” from hospi-

tals; it developed independently in

the community.2

The contact precautions conundrum

As press coverage of the outbreak

gained in prominence, the search for

answers became more pressing. There

was a broad consensus that contact

precautions for MRSA infections

were necessary. This approach is still

supported by the Healthcare Infec-

tion Control Practices Advisory

Committee (hicpac) guidelines,

commonly known as the CDC guide-

lines.3 Contact precautions allow for

a wide range of practice by facilities.

However, questions surrounding

the implementation of contact pre-

cautions still exist. This is, in part,

because contact precautions have

been associated with several negative

outcomes. (See Table 1.)

Some studies have demonstrated

that healthcare workers, including

attending physicians, are half as

likely to enter the rooms of (or

examine) patients on contact pre-

cautions.4-6 Studies have also

reported that patients in private

rooms and on barrier precautions

for a multidrug-resistant organism

(MDRO), including MRSA, have

increased anxiety and depression

scores.7 A number of patients in

other studies have reported signifi-

cantly more preventable adverse

Table 1: Contact precautions review

Issue Action

Patient room

In acute care hospitals, place patients who require contact precautions in a single-patient room when available.

In long-term-care and other residential settings, make decisions regarding patient placement on a case-by-case basis, balancing infection risks to other patients in the room, the presence of risk factors that increase the likelihood of trans-mission, and the potential adverse psychological impact on the infected or colonized patient.

In ambulatory settings, place patients who require contact precautions in an examination room or cubicle as soon as possible.

Gloves Wear gloves whenever touching the patient’s intact skin or sur-faces and articles in close proximity to the patient, such as medical equipment or bed rails. Put on gloves upon entry into the room or cubicle.

Gowns Wear a gown whenever clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Put on a gown upon entry into the room or cubicle. Remove gown and practice hand hygiene before leaving the patient care environment.

Transport In acute care hospitals and long-term-care and other residential settings, limit transport and movement of patients outside of the room to medically necessary purposes.

When transport or movement in any healthcare setting is necessary, ensure that infected or colonized areas of the patient’s body are contained and covered. Remove and dis-pose of contaminated PPE and perform hand hygiene before transporting patients on contact precautions.

Equipment In acute care hospitals and long-term-care and other residential settings, use disposable noncritical patient care equipment, such as BP cuffs, or implement patient-dedicated use of such equipment. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient.

In home settings, limit the amount of nondisposable patient care equipment brought into the home of patients on contact precautions. Whenever possible, leave patient care equipment in the home until discharge from home care services.

In ambulatory settings, place contaminated reusable noncriti-cal patient care equipment in a plastic bag for transport to a soiled utility area for reprocessing.

Cleaning of the environment

Ensure that the rooms of patients on contact precautions are prioritized for frequent cleaning and disinfection (at least daily), with a focus on frequently touched surfaces (bed rails, overbed table, bedside commode, lavatory surfaces in patient bathrooms, doorknobs, and so on) and equipment in the immediate vicinity of the patient.



events, greater dissatisfaction with

their treatment, and less docu-

mented care than control patients

who aren’t in isolation.8,9 Other neg-

ative outcomes of contact precau-

tions include the cost of personal

protective equipment (PPE) and lon-

ger ED wait times.10 It’s also been

noted in the literature that patients

on contact precautions have higher

acquisition rates of other MDROs.11

According to the hicpac guide-

lines, institutions are encouraged

to develop their own strategies for

MRSA colonized and/or infected

patients. Some institutions require

gowning and gloving for all staff

entering the room of a patient on

contact precautions for easier eval-

uation of staff adherence. Other

institutions require gowning only

when contact with the patient is

expected or only in certain areas of

the patient’s room. This approach

minimizes the costs of PPE. Ironi-

cally, in most cases, hand hygiene

doesn’t appear to increase in contact

precaution rooms compared with

noncontact precautions rooms.12

Active surveillance testing

After this point of theoretical, if

not functional, agreement on the

use of contact precautions for

patients with MRSA, vigorous aca-

demic debate focused on other best

practices, such as active surveillance

testing (AST)—the screening of

patients for MRSA on admittance,

usually via nasal cultures. Some

facilities targeted patients perceived

to be at highest risk for MRSA,

whereas others performed AST on

all patients entering the facility.

Through this method, additional

patients with MRSA colonization

can be identified and placed on con-

tact precautions, which theoretically

reduces MRSA transmission.

The Netherlands and other Scan-

dinavian countries adopted this

“search and destroy” approach to

MRSA and had very low MRSA

infection rates compared with

nations that weren’t using AST.13

A study of AST use in a large

number of U.S. facilities was con-

ducted and the results also indi-

cated MRSA reduction.14 In 2003,

the Society for Healthcare Epide-

miology of America (SHEA) issued

guidelines recommending AST for

detecting MRSA.13

Some facilities embraced AST as a

best practice; others pointed to defi-

ciencies published in the literature,

noting that MRSA occurred more

often in settings where AST was

practiced. Still others discussed the

increased costs associated with the

additional testing. In 1 weeks’ time,

two contradictory articles on AST

were published in high-impact

medical journals.15,16 But the prepon-

derance of data was slowly building

on one side of the argument.

In 2008, an article appeared in the

SHEA journal condemning AST as a

flawed infection control response.17

The authors noted that focusing on a

single organism (MRSA) prevented

far fewer healthcare-associated

infections (HAIs) than did broader

infection prevention approaches.

The article discussed targeted

approaches (AST for MRSA) versus

universal approaches (such as cen-

tral line insertion practice check-

lists) that impacted all infections

related to a device or procedure.

For example, reducing central line-

associated bloodstream infections

(clabsis) by 12.5% is the equivalent

of reducing MRSA infections by

50%. A 25% reduction in clabsis

would be equivalent to eliminating all

MRSA infections. This population-

based argument suggested that a

new, broader approach was needed

to handle MRSA as one of a number

of pathogens rather than as an inde-

pendent problem causing HAIs.

One of many

At the same time, MRSA’s role as

the major healthcare-associated

pathogen was being reexamined. In

2009, an article was published in

JAMA showing that, contrary to

public perception, MRSA had been

in decline as a cause of clabsis

since 2001.18 This was 2 years before

any professional society suggested

AST and around the same time that

the CDC published its hand

hygiene guidelines that supported

the use of alcohol-based hand sani-

tizers in healthcare, a much broader

approach to controlling HAIs.

Recent data suggest that MRSA

infections are becoming even rarer;

a CDC analysis reported that inva-

sive MRSA infections in the United

States have dropped from an esti-

mated 111,000 cases in 2005 to

82,000 in 2010.19

Recently, a three-armed study

demonstrated the superiority of a

universal approach to infection pre-

vention by reducing all infections,

including MRSA. The REDUCE

MRSA Trial was conducted on 74

adult ICUs in 43 hospitals. In this

study, participants were assigned

to one of three arms.20 Arm one

included AST followed by contact

precautions if the patient’s screening

was positive for MRSA. Arm two

was AST followed by contact pre-

cautions if the patient’s screening

was positive for MRSA, decoloniza-

tion with mupirocin in the nose,

and chlorhexidine gluconate (CHG)

baths using a CHG cloth for 5 days.

Arm three had no AST but every

patient was given the decoloniza-

tion regimen of mupirocin in the

nose and daily CHG baths for the

duration of their stay. Arm three

showed a greater reduction in ICU-

attributed MRSA clinical cultures

and an overall reduction in ICU-

attributed clabsis than the other

two arms.




This information, combined with

the increasing prevalence of Clos-tridium difficile and multidrug-

resistant Gram-negative rods,

reveals that best practice should

include a push toward a universal

infection control approach for

dealing with all HAIs.

Universal infection prevention

Universal approaches that are best

supported by the current literature

can be broken into five groupings:

• bundles

• environmental cleaning

• patient hygiene

• healthcare worker hand hygiene

• antimicrobial stewardship.

BundlesBundles have gained visibility in

the last few years. A bundle is

an approach of implementing a

number of interventions aimed at

reducing a problem, such as reduc-

ing clabsis. These bundles can be

introduced in a fashion that will

allow a practitioner to create a

checklist so that he or she may

check off his or her compliance

with these interventions and per-

mit others to validate compliance

with the intervention, allowing

for both process (compliance with

bundle) and outcome measures

(infections).

Now that the Centers for Medi-

care and Medicaid Services links

reimbursement to bundles, such as

the Surgical Care Improvement

Project and central line insertion

bundle, most institutions are very

familiar with these approaches.

Some institutions, however, are less

familiar with the bundle designed

to reduce catheter-associated uri-

nary tract infections. This bundle

focuses on removing unnecessary

catheters, performing routine peri-

operative care, securing the cathe-

ter, maintaining a closed system,

and keeping the bag off the floor

and below the patient’s bladder.21

Other bundles have been developed

to reduce late onset clabsis (cathe-

ter maintenance bundles) by focus-

ing on removing the line as soon as

possible (usually by verifying daily

line necessity), scrubbing the hub

before accessing a line, covering

the site with a dressing, and chang-

ing the dressing every 7 days or as

needed.

Complying with the ventilator-

associated pneumonia (VAP) bun-

dle is another way to reduce MRSA

and other HAIs. The VAP bundle

focuses on removing the patient

from the ventilator as soon as possi-

ble (usually by encouraging daily

assessment for readiness to extu-

bate), reducing sedation for a period

during the day, elevating the head

of the bed between 30 degrees and

45 degrees, and performing daily

CHG oral care. It should be noted

that one area of the original Institute

for Healthcare Improvement VAP

bundle, which uses H2 blockers

and proton pump inhibitors to pre-

vent peptic ulcer disease, is contro-

versial because it may increase the

likelihood of the patient developing

C. difficile.22

Environmental cleaningOccupying a room that previously

housed a patient with MRSA or

another MDRO is a known risk

factor for acquiring that bacteria.23

Recently, studies have shown that

rooms are cleaned much less than

previously thought; one study

noted that at over 40 hospitals, less

than half of the high-touch surfaces

in a patient’s room were cleaned.24

The authors also discovered that,

until recently, we had no way of

knowing whether something was

actually clean.

The use of novel technology, such

as luminescent gel or powder, has

given us the ability to see if items

have been wiped with sufficient

friction to remove bioburden.

When this technology is used,

environmental cleaning markedly

improves.25 It has also been shown

to be an effective teaching method

for environmental service staff

learning how and what to clean. It’s

widely thought that this technology

should also be used for training and

evaluating nursing staff members

because they’re frequently assigned

cleaning responsibilities for patient-

care equipment. In addition, clear

roles about who cleans what on a

patient-care unit need to be defined

and reviewed with all staff on a

regular basis.

Although novel technologies,

such as UV light and hydrogen

peroxide plasma, have shown some

promise in preventing MRSA and

other HAIs, they still require a staff

member to preclean a room. Addi-

tionally, the data aren’t definitive

regarding effectiveness, revealing

that some technologies pose safety

challenges and delays in room turn-

around, which prolongs patients’

stay in EDs where inappropriate

cleaning and hand hygiene chal-

lenges are significant.

Patient hygienePatient hygiene is becoming an

increasing focus for preventing the

transmission of MRSA and other

HAIs. The data to date have focused

primarily, but not exclusively, on

patients in the ICU and the use of

CHG. As shown in the REDUCE

MRSA Trial, MRSA and other HAI

rates can decrease significantly

when the patient is bathed daily.

However, it should be noted that

there are disparities in the litera-

ture; some studies have shown that

CHG with bath basins fails to

reduce MRSA, whereas others have

shown success with CHG.26,27



Nevertheless, given the repeated

studies in different acute care set-

tings demonstrating reduction in at

least some HAIs (MRSA, C. difficile,

clabsis, surgical site infections, and

vancomycin-resistant enterococci)

with CHG use and the marginal

adverse reactions of such an approach,

there’s little rationale for not imple-

menting it.

Healthcare worker hand hygieneHand hygiene has been recognized

as an important step toward inter-

rupting disease transmission. Stud-

ies have also been conducted that

show increasing hand hygiene has

reduced MRSA transmission on a

unit.28,29 Unfortunately, very little

data have been produced that

demonstrate the ability to gain

and maintain 100% hand hygiene

adherence.

However, in the past few years,

new technologies have been devel-

oped that allow for reminders and

evaluation of healthcare worker

hand hygiene at specific times,

such as upon entering and exiting

a patient’s room. These products,

although not infallible, allow unbi-

ased and constant evaluation of

units or, in some cases, specific

healthcare worker hand hygiene

adherence. This technology is

promising but hasn’t yet gained

wide usage in acute care settings.

Antimicrobial stewardshipAntimicrobial stewardship has

been noted to be an effective way

to control MRSA and other

MDROs.30 Antimicrobial steward-

ship is “a set of coordinated

strategies to improve the use of

antimicrobial medications with the

goal of enhancing patient health

outcomes, reducing resistance to

antibiotics, and decreasing unnec-

essary costs.”31 In fact, the early

literature supporting AST for

reducing MRSA at one institution

was mirrored by claims that antibi-

otic controls had also reduced

MRSA at the same institution. Cur-

rently, The Joint Commission and

several states are requiring that

antibiotic stewardship be conducted

by all healthcare institutions.

However, this approach is ill

defined at this time and institutions

with few resources, such as infec-

tious disease pharmacists and/or

infectious disease physicians, are

less likely to implement this inter-

vention than institutions that are

considered resource rich. Nurses

prompting physicians to be aware

of negative culture results or

responding to sensitivities can

reduce inappropriate antibiotic

or broad-spectrum antibiotic use,

thus helping to reduce MRSA and

other HAIs.

This way to best practices

MRSA is still a very important and

dangerous hospital pathogen. The

best practice for reducing MRSA is

to take approaches that will reduce

other healthcare-associated patho-

gens, not solely focusing on MRSA-

specific interventions. NM

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Engl J Med. 2001;344(19):1427-1433.15. Harbarth S, Fankhauser C, Schrenzel J,

et al. Universal screening for methicillin-resistant Staphylococcus aureus at hospi-tal admission and nosocomial infection in surgical patients. JAMA. 2008;299(10):1149-1157.

16. Robicsek A, Beaumont JL, Paule SM, et al. Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. Ann Intern Med. 2008;148(6):409-418.




17. Wenzel RP, Bearman G, Edmond MB. Screening for MRSA: a flawed hospital infection control intervention. Infect Control

Hosp Epidemiol. 2008;29(11):1012-1018.18. Burton DC, Edwards JR, Horan TC, Jernigan

JA, Fridkin SK. Methicillin-resistant Staphy-lococcus aureus central line-associated bloodstream infections in US intensive care units, 1997-2007. JAMA. 2009;301(7):727-736.

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27. Climo MW, Sepkowitz KA, Zuccotti G, et al. The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Entero-coccus, and healthcare-associated bloodstream infections: results of a quasi-experimental multicenter trial. Crit

Care Med. 2009;37(6):1858-1865.

28. Carboneau C, Benge E, Jaco MT, Robinson M. A lean Six Sigma team increases hand hygiene compliance and reduces hospital-acquired MRSA infections by 51%. J Healthc Qual. 2010;32(4):61-70.

29. Davis CR. Infection-free surgery: how to improve hand-hygiene compliance and eradicate methicillin-resistant Staphylococ-cus aureus from surgical wards. Ann R Coll

Surg Engl. 2010;92(4):316-319.30. Madaras-Kelly KJ, Remington RE, Lewis PG,

Stevens DL. Evaluation of an intervention designed to decrease the rate of nosoco-mial methicillin-resistant Staphylococcus aureus infection by encouraging decreased fluoroquinolone use. Infect Control Hosp

Epidemiol. 2006;27(2):155-169.31. SHEA. Antimicrobial stewardship.

http://www.shea-online.org/HAITopics/AntimicrobialStewardship.aspx.

Frank Edward Myers III is an infection preven-tionist III at U.C. San Diego (Calif.) Health System and an editorial board member of Nursing2013.

The author and planners have disclosed that they have no financial relationships related to this article.

DOI-10.1097/01.NUMA.0000430402.57959.15

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