Multi-Drug Resistant Organisms-Infection Control

2 Contact Hours

Author: Kristi Hudson RN, MSN, CCRN

Written: January 26, 2007

Updated: October 14, 2009

Course Description

This course is designed to give an overview of the most commonly hospital acquired infections (MRSA/VRE). Focus will be placed diagnosing and treating MRSA and VRE as well as recognizing the signs and symptoms that present with these infections. Nursing prevention and controlling the spread of these multi-drug resistant organisms including standard and contact precautions will also be presented.  The importance of proper hand hygiene by healthcare workers caring for these patients and the Center for Disease Control’s seven challenges for good hand hygiene will be the final focus of this course.

Course Objectives

Upon completion of this course the student will be able to:

• State the possible signs and symptoms of MRSA and VRE.
• Describe the process for diagnosing MRSA and VRE.
• Discuss treatment options for MRSA and VRE.
• Explain the appropriate measures to prevent and control the spread of MRSA and VRE.
• List the steps to assure that proper hand hygiene is being done.
• List 3 of the 7 CDC challenges for good hand hygiene.

Methicillin Resistant Staphylococcus Aureus (MRSA):

MRSA (which is a bacterium that has developed a resistance to most antibiotics commonly used for staphylococcus infections), has become a prevalent nosocomial pathogen in the U.S. The most common host for the spread of this disease is infected or colonized patients. Poor hand hygiene accounts for the majority of infectious transmission. Although hospital employees can harbor this organism (for sometimes months), they are more commonly identified as the link for transmitting this organism (via the hands or use of contaminated medical equipment between patients).

Diagnosing MRSA:

Diagnosis of MRSA consists of a attaining a sample from the suspected source (blood, sputum, wound drainage and/or stool most commonly) and sending it to the lab for evaluation. The lab places the specimen on a “culture plate” that contains specific nutrients. This plate is then incubated in a warmer so that bacteria can grow and be identified. Once bacteria have grown, the lab exposes the bacteria to several different types of antibiotics in order to see whether or not the bacteria can withstand (resist) the antibiotic or if it is sensitive (meaning the antibiotic kills the bacteria). Diagnosis of the type of bacteria present is then determined.

Treatment for MRSA:

The following antibiotics are known to be “ineffective” in treating MRSA:

• Methicillin
• Nafcillin
• Cephalsporin
• Penicillin
• Vancoymcin (frequently used for older strains but is thought to be ineffective for some of the newer strains)

Newer antibiotics that are giving hope to effectively treating MRSA include:

• Linezolid (an oxaxolidinone) – may be associated with increased survival and cure rates for patients with MRSA infecting the lungs (pneumonia).
• Daptomycin (a cyclic lipopeptide) – recommended for skin infections and possibly bacteremia, but not recommended for deep seated tissue infections or MRSA associated pneumonia.
• Quinupristin-dalfopristin (a semisynthetic perenteral streptogramin) – although used, this drug has not been proven to be more effective then Vancomycin in treating MRSA associated pneumonia.
• Tigecycline (antimicrobial) – active against both gram negative bacteria and MRSA. Has proven equal to Vancomycin for skin infections and is particularly useful in treating surgical wound infections.

Signs and Symptoms Associated with MRSA:

For the most part, symptoms associated with MRSA are similar to those symptoms found with any staphylococci infection. Because staphylococci bacteria produce a toxin an early clinical manifestation of infection is often diarrhea. The most common infections are found on the skin and symptoms include:

• Impetigo
• Abscess
• Lesions (there may be multiple)
• Infected cuts

Infections that invade the blood stream can lead to:

• Pneumonia
• Sepsis
• Arthritis
• Endocarditis
• Meningitis
• Urinary tract infections
• Eye infections

Preventing and Controlling the Spread of MRSA:

Basic infection control practices are the best way to prevent and control the spread of MRSA. It is well documented that proper hand hygiene is the number one preventative measure for spreading hospital acquired infections.

Indications for hand washing and hand antisepsis:

• Hands should be decontaminated when they are visibly dirty (washing for 15 seconds) or contaminated with blood, body fluids, secretions, excretions and/or other contaminated items (whether or not gloves are worn) they should be washed with either a non-antimicrobial soap and water or an antimicrobial soap and water.
• Hands should be decontaminated with an alcohol based hand rub when they are not visibly soiled.
• Hands should be decontaminated before having direct contact with patients.
• Hands should be decontaminated before inserting indwelling urinary catheters, peripheral vascular catheters or any other invasive device.
• Hands should be decontaminated after contact with a patient’s skin (intact or not).
• Hands should be decontaminated after contact when moving from a contaminated body site to a clean body site (from emptying the patient’s urinary catheter to then taking the patients blood pressure for example).
• Hands should be decontaminated after contact with inanimate objects such as medical equipment that is in the immediate vicinity of a patient.
• Hands should be decontaminated after removing gloves.
• Before and after using the restroom and before eating.

Hand Hygiene Techniques:

• When decontaminating hands with an alcohol based hand rub, apply the product to the palm of the hand and rub hands together (covering all surfaces of hands and fingers) until the hands are dry.
• When washing with soap and water, it is recommended to wet hands first, apply the soap product and vigorously rub hands together (covering all surfaces of hands) for 15 seconds (Note: Singing “Happy Birthday” usually covers the time). After washing, rinsing of the hands and thoroughly drying the hands with a disposable towel completes the process.
• If sink does not have a foot control, it is recommended that the faucet be turned off with the disposable towel.
• Warm water is recommended for cleaning as repeated washing with “hot” water can cause dermatitis.
• Liquid, bar, powdered or leaflet forms soap are all considered to be acceptable. If using bar soap, there should be soap rack so drainage of excessive water can occur.

Surgical Hand Hygiene:

• Remove rings, watches, bracelets before beginning the surgical scrub process.
• Clean any debris that is under fingernails (using a nail cleaner under running water).
• Using proper cleansing techniques, cleanse hands prior to donning sterile gloves.

Considerations for Choosing a Hand Hygiene Agent:

• Products with low irritancy potential.
• Solicit input from healthcare workers regarding hand hygiene agents (to maximize compliance).
• The cost of a hand hygiene product should not be the primary influencing factor for selection.
• Check with manufacturer for any known interactions between product and glove use.
• It is important to also evaluate dispenser options and functions (including volumes) that the dispenser can dispense.
• Avoid buying dispensers that can be “topped off” with liquid soap as this can lead to bacterial contamination of the soap itself.

Recommendations for Effective Skin Care:

• Provide and encourage healthcare workers to use hand lotions/creams to minimize skin irritation from frequent cleansing.

Additional Aspects of Hand Hygiene:

• Do not wear artificial fingernails or extenders when having direct contact with patients.
• Keep natural fingernail tips less then ¼ inch long.
• Encourage the use of gloving with any potential contact with blood or body fluids.
• Immediately remove gloves after patient contact.
• Change gloves if moving from contaminated to non-contaminated body sites.
• The issue of wearing rings is still and unresolved issue in the healthcare setting.
• Healthcare workers require initial and ongoing education regarding the advantages of proper hand hygiene.
• Monitoring of hand hygiene compliance.
• Encourage patients and family members to remind healthcare workers to decontaminate their hands.
• Encourage family members and visitors to decontaminate their hands before and after visiting patients. 
• Make proper hand hygiene and institutional priority with appropriate administrative and financial support.
• Implement multi-disciplinary programs designed to improve hand hygiene.

The Proper Use of Standard/Contact Precautions:

All of the following should be employed to assure that the healthcare workers are participating in proper standard precautions when caring for patients:

• Hand washing (again the number one preventative measure).
• Gloving (when touching blood and body fluids/change between patient related tasks).
• Masking (masks and eye protection should be worn when there is a risk of splashing or spraying blood or body fluids).
• Gowning (gowns should be worn to protect skin and soiling of clothes when there is a risk of splashing or spraying blood or body fluids).
• Appropriate Device Handling (high volume touching areas should be frequently cleaned and equipment that is considered to be multi-patient use equipment should be cleaned between patients.
• Appropriate Handling of Laundry (handle and transport soiled linen that prevents contact with the skin and mucous membranes to prevent the transfer of microorganisms).  
• Contact (patients should be placed in a private room, if this is not possible the patient can be placed in a room with another MRSA patient).
• Limiting movement and transport of patient when possible, during transfers ensure that precautions are maintained and the risk of transmitting microorganisms is minimized.
• Ensure that frequently touched patient surfaces and bedside equipment are cleaned on a daily basis.
•  When possible, designate patient care equipment (stethoscope, thermometer etc.) to single patient use.

Vancomycin Resistance Enterococci (VRE):

Enterococci are gram positive bacteria that are normally found in the intestines and female genital tract (as well as in the general environment).  The most common types include Enterococcus faecium, Enterococcus faecalis and Enterococcus species. The spread of most Enterococcal infections occurs when Enterococci is introduced into what would be considered a normally sterile body site (blood or urine). Although Enterococci have a low-level resistance to some antibiotics; some strains of Enterococci have acquired high-level resistance to multiple antibiotics such Vancomycin and Ampicillin.

Diagnosing VRE:

The specimen most commonly used to diagnose VRE (depending on the site of infection or colonization) is blood, purulent drainage, urine or stool. It is thought that a stool or rectal swab is often the most useful site for detection. Specimens are gathered and sent to lab to be cultured as soon as possible (ideally within 1-2 hours). Colonial morphology, gram stain and/or pyrrolidonyl arylamidase (PYR) are the tests used for diagnosis. Although there are more then 19 strains of enterococci, there are specific fermentation patterns of different sugar (in the culture plate) that help determine one strain from another. All strains should be antibiotic tested for resistance or susceptibility.

Treatment for VRE:

Treatment of VRE should be determined by antibiotic susceptibility reports. The same antibiotic choices that are used for MRSA are often also used for the treatment of VRE.

Signs and Symptoms Associated with VRE:

Symptoms associated with VRE often go unnoticed. If a person has a weakened immune system, the following signs and symptoms may be observed (depending on location or site of infection):

• Bacterial blood infection
• Urinary tract infection
• Abscess
• Endocarditis
• Bacteremia
• Pneumonia

Preventing and Controlling the Spread of VRE:

The most common transmission of VRE is from the hands, environmental surfaces and patient care equipment. VRE is known to live on surfaces for long periods of time. For example; VRE has been known to live on countertops for 5-7 days, on bedrails for 24 hours and for up to 60 minutes on telephone hand pieces. Prevention of the spread of VRE in the health care setting is the same as with MRSA of or any other multi-drug resistant organism. The primary goal is to “break the chain of infection”. The following guidelines should be employed to prevent further spread VRE and other multi-drug resistant organism:

• Good hand washing technique.
• Recognizing, diagnosing, and treating persons with diseases.
• Early identification of the infectious agent.
• Prompt and appropriate isolation of the patient.
• Disinfecting inanimate reservoirs of pathogenic organisms.

The CDC Seven Challenges to Good Hand Hygiene:

Number 1: Reduce catheter related adverse events by 50% among patients in the healthcare setting.

Number 2: Reduce targeted surgical adverse events by 50%.

Number 3: Reduce hospitalizations and mortality related to respiratory infections among long term care patients by 50%.

Number 4: Reduce targeted antimicrobial resistant bacterial infections by 50% with the following:

• Preventing infection
• Diagnosing and treating infections promptly and appropriately
• Optimizing antimicrobial use
• Preventing transmission in the healthcare setting

Number 5: Eliminate laboratory errors leading to adverse patient outcomes.

Number 6: Eliminate occupational needle stick injuries among healthcare personnel.

Number 7:  Achieve 100% adherence to the Advisory Committee on Immunization practices (ACIP) guidelines for immunization of healthcare personnel.

References

Boyce, J., M., M.D. & Pittet, D., M.D. (2002). Guidelines for hand hygiene in the healthcare setting. Retrieved on January 20, 2007 at:

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm 

Centers for Disease Control (2001). Seven healthcare safety challenges. Retrieved on January 20, 2007 at:

http://www.cdc.gov/ncidod/dhqp/about_challenges.html

Centers for Disease Control (2007). MRSA. Retrieved on January 20, 2007 at:

http://www.cdc.gov/ncidod/dhqp/ar_mrsa_data.html

Centers for Disease Control (2007). VRSE. Retrieved on January 20, 2007 at:

http://www.cdc.gov/ncidod/dhqp/ar_visavrsa_prevention.html

Centers for Disease Control (2007). VRE. Retrieved on January 20, 2007 at:

http://www.cdc.gov/ncidod/dhqp/ar_vre.html

Department of Health Information/New York. Methicillin Resistant Staphylococcus Aureus. Retrieved on January 21, 2007 at:

health.state.ny.us/diseases/communicable/staphylococcus_aureus/methicillin_resistant/fact_sheet.htm

Kollef, M., H. M.D. (2006). Serious hospital infections: Key principles in antibiotic treatment. Retrieved on February 2, 2007 at:

http://www.medscape.com/editorial/cmetogo/5654

Maryland Department of Human Services (2007). Guidelines for prevention and control of VRE in long term facilities. Retrieved on January 21, 2007 at:

http://edcp.org/guidelines/vre96.html

West Virginia Department of Health and Human Services (1997). Guidelines for the management of VRE in health care facilities. Retrieved on February 2, 2007 at:

http://www.wvdhhr.org/idep/PDFs/IDEP/vre_1997.pdf