MRSA ScreeningMRSA Screening

Bruce Gamage, RN BSN CICBruce Gamage, RN BSN CIC

Provincial Infection Control Provincial Infection Control NetworkNetwork

OutlineOutline Acute CareAcute Care

RationaleRationale Cost/BenefitCost/Benefit Screening ProgramsScreening Programs Notification/Flagging/TransfersNotification/Flagging/Transfers Screening Health Care WorkersScreening Health Care Workers

Long Term CareLong Term Care Screening and NotificationScreening and Notification Admission Assessment/Room PlacementAdmission Assessment/Room Placement

HemodialysisHemodialysis Admission ScreeningAdmission Screening Prevalence ScreeningPrevalence Screening

SummarySummary

Acute CareAcute Care

Screening - RationaleScreening - Rationale

Undiagnosed MRSA colonization or infections in Undiagnosed MRSA colonization or infections in patients can contribute to the spread of AROs patients can contribute to the spread of AROs within a health care facility. within a health care facility.

MRSA has become more common in healthy MRSA has become more common in healthy individuals living in the community, or in individuals living in the community, or in individuals with no prior admission to a hospital. individuals with no prior admission to a hospital.

Without admission screening 84% of MRSA Without admission screening 84% of MRSA carriers would have been missed at admission carriers would have been missed at admission and 76% during their hospital stayand 76% during their hospital stay

Lucet, JC et al. ICHE; 2005; 26:121-26Lucet, JC et al. ICHE; 2005; 26:121-26

Cost/Benefit of Screening Cost/Benefit of Screening ProgramsPrograms

The institution of routine nares swabs in all The institution of routine nares swabs in all ICU patients (positive cultures resulted in ICU patients (positive cultures resulted in contact precautions) over a 16 month contact precautions) over a 16 month period resulted in a 75% reduction in period resulted in a 75% reduction in MRSA bacteremias in ICU patients MRSA bacteremias in ICU patients (p=.007) and 40% in non-ICU patients (p=.007) and 40% in non-ICU patients (p=.008).(p=.008).

Huang SS et al. J Infect Dis. 2007 Feb 1;195(3):330-8. Huang SS et al. J Infect Dis. 2007 Feb 1;195(3):330-8.

Cost/Benefit of Screening Cost/Benefit of Screening ProgramsPrograms

At a cost of $3,475/month for the At a cost of $3,475/month for the screening program averted 2.5 MRSA screening program averted 2.5 MRSA bacteremias/month for the ICU saving bacteremias/month for the ICU saving $19,714/month in excess costs$19,714/month in excess costs

Clancy et al. ICHE; 2006: 27(10); 1009-1017Clancy et al. ICHE; 2006: 27(10); 1009-1017

Screening ProgramsScreening Programs

All acute care hospitals should have a All acute care hospitals should have a program of active surveillance for AROs program of active surveillance for AROs for all admitted patients which includes: for all admitted patients which includes: screening/identificationscreening/identification followed by cultures if screening indicates. followed by cultures if screening indicates.

Who should have screening cultures done?Who should have screening cultures done? Any patient with a previous admission to an acute care Any patient with a previous admission to an acute care

facility for a stay of from 12 to 48 hours during the last 3 facility for a stay of from 12 to 48 hours during the last 3 to 12 months as determined by your facility and your to 12 months as determined by your facility and your health authority.health authority.

Patients who have been recently incarcerated, live in Patients who have been recently incarcerated, live in shelters, dormitories or other group settings.shelters, dormitories or other group settings.

Patients who have participated in contact sports or any Patients who have participated in contact sports or any sport activities using shared equipment.sport activities using shared equipment.

Patients from long term care settings with known risk Patients from long term care settings with known risk factors (examples: hemodialysis, chronic ventilation or factors (examples: hemodialysis, chronic ventilation or skin breakdown).skin breakdown).

Patients admitted from areas with higher endemic rates Patients admitted from areas with higher endemic rates (examples: ICUs, Burn units, and Oncology units). (examples: ICUs, Burn units, and Oncology units).

Should Previously Positive Should Previously Positive PatientsPatients be Screened?be Screened?

Screening of previously positive patientsScreening of previously positive patients should should be made on a regional or local basis in be made on a regional or local basis in consultation with laboratory. consultation with laboratory.

Patients who are known to have tested positive Patients who are known to have tested positive for MRSA previously may be considered for for MRSA previously may be considered for repeat screening on a selective basis. repeat screening on a selective basis.

If not rescreened the patient should be If not rescreened the patient should be considered MRSA positive. considered MRSA positive.

Recommended Sites for Recommended Sites for Screening CulturesScreening Cultures

MRSAMRSAVREVRE

Anterior nares swabAnterior nares swab Rectal swabRectal swab

Swab of ostomy sitesSwab of ostomy sites Swab of ostomy sitesSwab of ostomy sites

All open woundsAll open wounds All open woundsAll open wounds

Areas of skin breakdown /skin lesionsAreas of skin breakdown /skin lesions Areas of skin breakdown/skin lesionsAreas of skin breakdown/skin lesions

At least one culture of: At least one culture of: Axilla, peri-rectal Axilla, peri-rectal area, rectum, groinarea, rectum, groin or umbilicus.or umbilicus.

It is essential to culture all indicated sitesIt is essential to culture all indicated sites 16% of cases MRSA were culture positive 16% of cases MRSA were culture positive

only in the perianal area.only in the perianal area.

Williams V, Barry C, Verncombe M, Simor A: CJIC Spring 2005Williams V, Barry C, Verncombe M, Simor A: CJIC Spring 2005

Notification/Flagging Notification/Flagging

It is recommended that the patient’s It is recommended that the patient’s medical record and/or computer file be medical record and/or computer file be flagged in some manner for future flagged in some manner for future identification of MRSA status in order to identification of MRSA status in order to facilitate prompt identification on facilitate prompt identification on readmission. readmission.

TransfersTransfers

The transferring facilities should inform The transferring facilities should inform receiving facilities of a patient’s receiving facilities of a patient’s colonization or infection history and MRSAcolonization or infection history and MRSA

If a patient is deemed to have a new If a patient is deemed to have a new MRSA infection or colonization after being MRSA infection or colonization after being admitted from another institution, the admitted from another institution, the receiving institution should inform the receiving institution should inform the original institution of the patient’s status. original institution of the patient’s status.

Discontinuing Precautions Discontinuing Precautions

The absence of MRSA/VRE on the surveillance The absence of MRSA/VRE on the surveillance swabs does not unequivocally mean that swabs does not unequivocally mean that organism has been eradicated from the patient. organism has been eradicated from the patient.

Discontinuing precautions on ‘swab negative’ Discontinuing precautions on ‘swab negative’ patients must be made individually based on patients must be made individually based on patient characteristics and institutional policies.patient characteristics and institutional policies.

Many of these patients become colonized again Many of these patients become colonized again when exposed to antibiotics, or if their condition when exposed to antibiotics, or if their condition worsens. worsens.

Screening Health Care WorkersScreening Health Care Workers

Screening of HCW includingScreening of HCW including

Students physicians, and Students physicians, and

volunteers should bevolunteers should be

considered considered onlyonly if specific if specific

health care workers have beenhealth care workers have been

epidemiologically implicated in epidemiologically implicated in

the transmission of MRSA. the transmission of MRSA.

Screening Health Care WorkersScreening Health Care Workers

Identifying colonizedIdentifying colonized HCW through screening as HCW through screening as part of an outbreak investigation should only be part of an outbreak investigation should only be done at the direction of IPC and OHS, and in done at the direction of IPC and OHS, and in conjunction with the investigation of other conjunction with the investigation of other possible sources of transmission. possible sources of transmission.

Prior to proceeding with any HCW screening a Prior to proceeding with any HCW screening a discussion between OHS, IPC, diagnostic discussion between OHS, IPC, diagnostic laboratories, and the MHO is recommended.laboratories, and the MHO is recommended.

Routine pre-employment Routine pre-employment screeningscreening

Routine screening for MRSA of HCW Routine screening for MRSA of HCW carrying on activities in the hospital is not carrying on activities in the hospital is not required required

OHS Considerations Regarding MRSAOHS Considerations Regarding MRSA

MRSA is not more likely to cause disease in MRSA is not more likely to cause disease in healthy individuals than antibiotic susceptible healthy individuals than antibiotic susceptible organisms. organisms.

HCW are generally identified as asymptomatic HCW are generally identified as asymptomatic carriers of MRSAcarriers of MRSA

If acute illness develops, e.g. draining boils, the If acute illness develops, e.g. draining boils, the person should be managed according to current person should be managed according to current medical management recommendations and medical management recommendations and hospital policy specific to the illness.hospital policy specific to the illness.

Long Term CareLong Term Care

Residential Care Facilities: Rehabilitation Residential Care Facilities: Rehabilitation Facilities, Palliative Care, Complex Care, Facilities, Palliative Care, Complex Care,

Psychiatric Care and Discharge Psychiatric Care and Discharge Planning/Transition Units.Planning/Transition Units.

AdmissionAdmission

Admission should not be denied or delayed by a LTCF on the basis of colonization or infection with an ARO.

All LTCFs should be prepared to implement the appropriate infection control measures and stringently follow Routine Practices for persons who are colonized or infected with an ARO

Screening and NotificationScreening and Notification

Routine screening for MRSA is not Routine screening for MRSA is not currently recommended for residents/ currently recommended for residents/ clients of LTCFs in BC. clients of LTCFs in BC.

Each facility should base decisions Each facility should base decisions regarding admission screening for AROs regarding admission screening for AROs by assessing each resident for the by assessing each resident for the presence or absence of risk factors. presence or absence of risk factors.

Admission AssessmentAdmission Assessment

An assessment of factors related to risk of An assessment of factors related to risk of colonization or infection with MRSA or other colonization or infection with MRSA or other AROs is considered part of the long term care AROs is considered part of the long term care resident’s general admission assessment.resident’s general admission assessment.

Each facility should base decisions regarding Each facility should base decisions regarding MRSA screening cultures, room placement and MRSA screening cultures, room placement and use of additional precautions on the results of use of additional precautions on the results of this risk assessment.this risk assessment.

Risk Assessment ToolRisk Assessment Tool Factors that Increase the Risk that a Long Term Care Resident may be Colonized or Infected with an AROFactors that Increase the Risk that a Long Term Care Resident may be Colonized or Infected with an ARO

Recent Recent transfer form transfer form a tertiary a tertiary care facilitycare facility

Known to Known to be be colonized colonized or infected or infected with an with an AROARO

Contact Contact with or with or proximity proximity to a to a patient patient colonized colonized or infected or infected with an with an AROARO

The The presence of presence of a surgical a surgical wound, wound, decubitus decubitus ulcer, or ulcer, or other chronic other chronic woundwound

Diagnosed Diagnosed with with conjunctivitis conjunctivitis or bacteruriaor bacteruria

The presence of The presence of invasive invasive indwelling indwelling devices devices (intravascular (intravascular lines, urinary lines, urinary catheter, catheter, endotracheal or endotracheal or tracheostomy tracheostomy tube, tube, gastrostomy gastrostomy feeding tube)feeding tube)

Recent Recent anti-anti-microbial microbial therapytherapy

Malnutrition, Malnutrition, immunosuppressimmunosuppression (age, ion (age, medication or medication or condition related) condition related)

Factors that Increase the Risk of Acquiring an ARO in a Long Term Care SettingFactors that Increase the Risk of Acquiring an ARO in a Long Term Care Setting

Decubiti Decubiti or other or other large large open open woundswounds

Received Received broad broad spectrum spectrum antibiotics that antibiotics that select for the select for the emergence of emergence of resistant resistant strainsstrains

The presence of invasive The presence of invasive indwelling devices indwelling devices (intravascular lines, urinary (intravascular lines, urinary catheter, endotracheal or catheter, endotracheal or tracheostomy tube, tracheostomy tube, gastrostomy feeding tube)gastrostomy feeding tube)

Debilitated Debilitated and/or bed and/or bed bound and bound and requires requires extensive hands extensive hands on careon care

Malnutrition, Malnutrition, immunosuppressimmunosuppression (age, ion (age, medication or medication or condition related) condition related)

Recent Cycle of Recent Cycle of Institutionalization or Institutionalization or hospitalizationhospitalization

Room Placement based on Risk AssessmentRoom Placement based on Risk Assessment

If possible, patient or resident placement decisions If possible, patient or resident placement decisions should be made before the patient or resident arrives. should be made before the patient or resident arrives.

Room placement for residents/clients with AROs should Room placement for residents/clients with AROs should take into consideration:take into consideration:

cognition, compliance, continence, and degree and site of cognition, compliance, continence, and degree and site of colonization for all individuals in the room. colonization for all individuals in the room.

Placement options include either a single room or:Placement options include either a single room or: sharing a multi-bed room with other patients or residents/clients sharing a multi-bed room with other patients or residents/clients

also with the same or other AROs (cohorting), also with the same or other AROs (cohorting), sharing a multi-bed room with other persons not colonized.sharing a multi-bed room with other persons not colonized.

Infection Control should be consulted regarding specific Infection Control should be consulted regarding specific placement questions as required. placement questions as required.

Hemodialysis UnitsHemodialysis Units

Admission ScreeningAdmission Screening

Admission to any hemodialysis unit should Admission to any hemodialysis unit should notnot be denied to any BC resident on the be denied to any BC resident on the basis of ARO status.basis of ARO status.

Screening Indications: Screening Indications: AdmissionAdmission

Screening for MRSA/VRE will be completed when the Screening for MRSA/VRE will be completed when the patient is first received on the hemodialysis unit:patient is first received on the hemodialysis unit:

On initial admission to a Community Hemodialysis Unit On initial admission to a Community Hemodialysis Unit (CDU), In-center Hemodialysis Unit (HD) or Peritoneal (CDU), In-center Hemodialysis Unit (HD) or Peritoneal Dialysis Unit (PDU)Dialysis Unit (PDU)

Upon return from admission to an acute care hospital or Upon return from admission to an acute care hospital or a care facilitya care facility

Upon returning from travel Upon returning from travel All Peritoneal dialysis patients after temporary All Peritoneal dialysis patients after temporary

hemodialysis unless swabbed within the previous two hemodialysis unless swabbed within the previous two weeksweeks

Screening Indications: LTCScreening Indications: LTC

Long-term Care Patients Receiving Long-term Care Patients Receiving Hemodialysis:Hemodialysis:

On admission to an acute care facility from On admission to an acute care facility from residential careresidential care

During hemodialysis prevalence screeningDuring hemodialysis prevalence screening As clinically indicatedAs clinically indicated

Screening Indications: Visitors Screening Indications: Visitors and Travelersand Travelers

Incoming Visiting Patients or (Travelers) Incoming Visiting Patients or (Travelers) The decision to accept visitors for dialysis will be based on receiving The decision to accept visitors for dialysis will be based on receiving

a current ARO status report before the patient arrives.a current ARO status report before the patient arrives. Screen all visiting HD patients upon arrival.Screen all visiting HD patients upon arrival. Patients returning from travel inside Canada are screened but not Patients returning from travel inside Canada are screened but not

isolated isolated Patients returning from travel outside Canada are screened, isolated Patients returning from travel outside Canada are screened, isolated

in a private room/separate area on Contact isolationin a private room/separate area on Contact isolationOutgoing Traveling PatientsOutgoing Traveling Patients Patients who will be traveling out of BC may be requested to Patients who will be traveling out of BC may be requested to

demonstrate current ARO status.demonstrate current ARO status. Results of ARO screen are included with the patient’s clinical Results of ARO screen are included with the patient’s clinical

information and forwarded to the receiving dialysis unit.information and forwarded to the receiving dialysis unit.

Prevalence ScreeningPrevalence Screening

The decision, frequency, sites screened The decision, frequency, sites screened and AROs screened for are based on the and AROs screened for are based on the specific facility and program’s unique specific facility and program’s unique indicators, epidemiology, resources and indicators, epidemiology, resources and capacity for prevalence screens. capacity for prevalence screens.

Screening Indications: MRSA or VRE PositiveScreening Indications: MRSA or VRE Positive

Patients with a laboratory-confirmed ARO Patients with a laboratory-confirmed ARO are not routinely screened for the are not routinely screened for the known/alerted ARO. known/alerted ARO.

Patients who are MRSA positive will be Patients who are MRSA positive will be screened for VRE.screened for VRE.

Patients who are VRE positive will be Patients who are VRE positive will be screened for MRSA.screened for MRSA.

SummarySummary

Acute CareAcute Care Rationale/Cost-Benefit of Screening ProgramsRationale/Cost-Benefit of Screening Programs Screening Health Care WorkersScreening Health Care Workers

Long Term CareLong Term Care Screening and NotificationScreening and Notification Admission Assessment/Room PlacementAdmission Assessment/Room Placement

HemodialysisHemodialysis Admission ScreeningAdmission Screening Prevalence ScreeningPrevalence Screening

Questions?Questions?

bgamage@phsa.cabgamage@phsa.ca 604-660-6076604-660-6076