South Staffordshire and Shropshire Healthcare NHS Foundation Trust

South Staffordshire and Shropshire Healthcare NHS Foundation Trust Document Version Control Document Type and Title: Authorised Document Folder: New or Replacing: Document Reference: Version No. v1.0 Policy for the Management of MRSA YELLOW Clinical Replacing: Policy for Managing Methicillin Resistant Staphylococcus Aureus (MRSA) C/YEL/ic/06 (June 2010) & Policy for Screening for MRSA C/YEL/ic/25 (December 2009) C/YEL/ic/06 Implementation Date: Equality Impact Assessment Completed Author: Approving body: Yes Judy Carr Quality, Effectiveness and Risk Committee Approval Date: 11 th October 2012 Ratifying body: Board of Directors Ratified Date: 25 th October 2012 Committee, Group or Individual Monitoring the Document: Clinical Policy Group Review Date: October 2015

Index Policy for the Management of MRSA/C/YEL/ic/06/v1.0 1. Policy Statement: 3 2. Scope of the Policy 3 3. Staff Education 3 4. Introduction 3 5. Related Policies 3 6. Colonisation and Infection (Definitions) 4 7. Risk Factors 4 8. Transmission 4 9. Screening of Patients for MRSA Colonisation or Infection 4 9.1 How to screen for MRSA 5 9.2 Procedure for taking swabs and Specimens 5 9.3 Nose swabs 6 9.4 Wound Swabs 6 9.5 Catheter specimens of urine 6 9.6 Indwelling devices 6 10. Patient Management, including standard infection control precautions 7 10.1. Isolation 7 10.2. Precautions 7 10.3. Cleanliness and the clinical environment 8 11. Treatment of MRSA Colonisation or Infection 8 12. Procedure for Decolonisation of MRSA 9 12.1 Instructions for antiseptic wash 9 12.2. Procedure for rescreening 9 13. Discharge/Transfer to another Organisation or Department 9 14. Outbreaks of MRSA 10 15. Visitors 10 16. Staff Issues 10 17. MRSA Bacteraemia (Blood stream infections) 10 18. References 10 Appendix 1 Record of MRSA Screening Results 12 Appendix 2 Treatment of Patients who Require Decolonisation or have MRSA Infection 13 Appendix 3 MRSA Care Pathway 14 Appendix 4 Information about MRSA for patients, relatives and carers 17 Appendix 5 Screening for MRSA 21 2

Meticillin Resistant Staphylococcus Aureus (MRSA) Policy 1. Policy Statement: Policy for the Management of MRSA/C/YEL/ic/06/v1.0 Patients have a right to be protected from preventable infections and healthcare staff have a duty to safeguard the well being of their patients. The health act 2008 requires all NHS bodies to have in place appropriate core policies of which MRSA is one. The purpose of this policy is to provide recommendations on the management of MRSA screening and subsequent decolonisation and guidance about the management and control of MRSA within the healthcare setting. 2. Scope of the Policy This document applies to all South Staffordshire and Shropshire employees and all those visiting the Trusts premises such as contractors, agency/bank/locum staff, students and volunteers. 3. Staff education As training is an essential component in improving practice and increasing awareness of risks, staff will receive training with regards to MRSA and MRSA screening on induction and at regular mandatory infection prevention and control updates. The onus is on each individual qualified health professional to identify knowledge deficits and training needs. 4. Introduction Staphylococcus aureus is a bacterium that is found on the skin and in the nose of 1 in 3 members of the population. Staphylococcus aureus commonly causes boils, abscess or impetigo. MRSA is a strain of staphylococcus aureus which is resistant to some antibiotics normally used to treat staphylococcus aureus infection. Therefore to effectively treat someone with MRSA infection the appropriate antibiotics must be prescribed. MRSA was first identified in 1961 and has become a common healthcare associated infection. However MRSA colonisation is preventable and can be achieved through good infection control practice and by maintaining high standards of environmental cleanliness. There is no evidence of any significant risk from MRSA within mental health trusts. However some service users may have other clinical conditions that may put them at risk of MRSA infection. Identification of colonisation status enables infection prevention and control precautions to be taken to limit the spread to other service users and enables the appropriate decolonisation. 5. Related Policies Hand Decontamination Policy Standard Precautions and personal Protective Equipment Policy Decontamination of Reusable Medical Devices Policy Isolation Policy Guidelines for Glove usage in Clinical Practice Policy Mental Capacity Act Movement of Patients Policy 3

6. Colonisation and Infection Definitions Carrier: a person who harbours MRSA with no signs of disease, but can be a potential source of infection. Carriage can be intermittent or long term. Colonisation: the presence of microbes on or in the body which continue to multiply but do not cause illness or symptoms requiring treatment. Infection: the presence of microbes on or in the body which are causing clinical features of infection e.g. pain, pyrexia, dysuria, presence of pus, purulent sputum and require treatment. Bacteraemia: blood stream infection with MRSA. 7. Risk Factors Risk factors for MRSA colonisation include the following: Elderly Repeated hospital admissions, especially to areas where invasive procedures are likely e.g. operating theatres, ITU, HDU Surgery, especially cardiothoracic, joint, vascular or insertion of stents Inappropriate use of antibiotics leading to increased resistance e.g. under dosing, multiple courses, excessive duration of antibiotic therapy, overuse of broad spectrum antibiotics particularly third generation cephalosporins and floroquinolones Poor cleaning or infection control practise, especially hand decontamination Risk Areas Risk of cross infection can be categorised according to the risk or vulnerability of other patients on the ward or unit. Patients cared for Mental Health or Elderly Long Stay settings are said to be at low risk of MRSA infection as fewer invasive procedures are carried out. 8. Transmission MRSA can be acquired via contact with MRSA positive sites on the body or body fluids. MRSA can also survive in dry and dusty environments or on contaminated patient equipment. Therefore the main route of transmission within healthcare settings is on the hands of healthcare workers. This is why the emphasis for preventing the spread of MRSA is effective hand washing and maintaining a clean and tidy environment. 9. Screening of Patients for MRSA Colonisation or Infection People admitted to mental Heath Trusts and learning disability facilities should not be routinely screened. However some service users may have other clinical conditions that may put them at risk of MRSA infection. Identification of colonisation status enables infection prevention and control precautions to be 4

taken to limit the spread to other service users and enables the appropriate decolonisation. The Screening Flowchart (see Appendix 5) should be used to ensure an informed decision is made regarding the need to screen patients and their appropriate management Screen the patient on admission for MRSA if the service user Is admitted following surgical procedures (including Caesarean sections) Is admitted following admission from an acute Trust following an inpatient stay (excluding admissions from maternity) Is admitted from a nursing home/care homes Is an Intravenous drug users Has self harmed in the last six months Has chronic wounds e.g. leg ulcers, Has an indwelling devices such as catheters or enteral feeding tube Has a history of MRSA 9.1 How to screen for MRSA Screening swabs should be sent from The nose Any wounds/ lesions CSU if the service user has a catheter Any indwelling device (feeding tubes, and peripherally inserted central catheters) Use a black or pink swab (depending on Laboratory preference) 9.2 Procedure for taking swabs and Specimens 1. Inform the service user the reason for taking the swabs and obtain consent. Service users should be given an information leaflet.(appendix 1) 2. If required, moisten the swab with a drop of sterile saline, NOT liquid from the swab tube 3. On completion of procedure, place specimens and swabs in appropriate correctly labelled container, complete microbiology form in full 4. Dispatch specimens promptly to the laboratory with the completed request form requesting MRSA screen 5

9.3 Nose Swabs 1. Decontaminate hands with soap and water, or alcohol gel (if hands are physically clean). Ensure hands are dried thoroughly. 2. Moisten the swab beforehand with normal saline or sterile water 3. Rotated the swab gently just inside the nostrils. It is not necessary to insert the swab too far into the nasal passage 4. One swab can be used for both nostrils 5. Decontaminate hands thoroughly with soap and water 9.4 Wound Swabs (post-op sites, chronic wounds, and other lesions) See Aseptic & Clean Dressing Technique Policy 1. Collect equipment together 2. Put on disposable plastic apron 3. Decontaminate hands with soap and water, or alcohol gel (if hands are physically clean). Ensure hands are dried thoroughly. 4. Screen the patient s bed or area, using curtains or a mobile screen. 5. Loosen the patient s dressing (if applicable) using non sterile gloves. 6. Decontaminate hands again with alcohol rub. 7. Put on gloves 8. Take any swabs required before cleaning procedure begins 9. Rotate the swab gently 10. Finish dressing if appropriate following aseptic & clean dressing technique policy 11. Decontaminated hands thoroughly with soap and water 9.5 Catheter specimen of urine 1. Collect equipment together 2. Put on disposable plastic apron 3. Decontaminate hands with soap and water, or alcohol gel (if hands are physically clean). Ensure hands are dried thoroughly 4. Put on gloves 5. Clean access point with swab an alcohol impregnated swab 6. If no urine is visible in the tubing, apply a non-traumatic clamp/gate clip a few centimetres distal to the sampling port (Fig 1) (Gilbert, 2006). 7. Once sufficient urine has collected in the tube, wipe the sampling port with an alcohol-impregnated swab (Fig 2). Allow to dry. 8. Stabilising the tube below the sampling port, insert the needle into the port at an angle of 45 (Fig 3). 9. In a needle-free system, insert the syringe into the sampling port according to the manufacturer's recommendations. 10. Aspirate the required amount of urine (refer to microbiology department to ascertain volume required) (Fig 4). 11. Remove syringe/needle. 12. Dispose of sharps as appropriate. 13. 'Inject' urine into sterile specimen pot 14. Wipe the sampling port with an alcohol-impregnated swab, allow to dry. 15. Unclamp the catheter tubing as required. 16. Decontaminated hands thoroughly with soap and water 9.6 Indwelling devices (feeding tubes, and peripherally inserted central catheters) 1. Collect equipment together 2. Put on disposable plastic apron 6

3. Decontaminate hands with soap and water, or alcohol gel (if hands are physically clean). Ensure hands are dried thoroughly 4. Screen the patient s bed or area, using curtains or a mobile screen 5. Loosen the patient s dressing (if applicable) using non sterile gloves 6. Decontaminate hands again with alcohol rub 7. Put on gloves 8. Take any swabs required before cleaning procedure begins 9. Rotate the swab gently 10. Finish dressing if appropriate following aseptic & clean dressing technique policy 11. Decontaminated hands thoroughly with soap and water 10. Patient Management, including standard infection control precautions Inform the Infection Prevention and Control Team if any patient has a positive result for MRSA The MRSA Care Pathway is to be used in the inpatient setting (see Appendix 4) 10.1 Isolation The decision on where to nurse the patient will depend on assessment considering the clients safety, privacy and dignity and the identified or potential risks to other patients in that area. Complete isolation is not necessary The following patients should have their own room if this will not adversely affect their rehabilitation; Those with clinical signs of infection Those who have high levels of skin shedding Those with leaking wounds Those who are MRSA positive in their sputum and have a productive cough Those who are MRSA positive in their urine and are incontinent (urine is not contained in a pad) If this is not practical for the patient to have their own room they may be cared for in a shared room where the other residents don t have open lesions/ wounds. Patients with MRSA may join other clients for social activities (e.g., mealtimes, outings etc), provided that any wounds are covered with a dressing, preferably Impermeable. 10.2 Precautions In all settings the following precautions should be adhered to: hands should be washed before and after patient contact, the wearing of gloves and after contact with body fluids, (see hand washing policy) personal protective equipment (PPE) must be worn where there is patient contact or during bed making whenever there is contact and for potential contact with blood, body fluids, secretions and excretions and must be disposed of immediately after use linen/patient clothes should be placed in an infected linen bag or washed on a hot cycle in a domestic washing machine, tumble dried or ironed waste should be disposed of as clinical waste 7

strict aseptic technique should be maintained when inserting invasive devices e.g. urinary catheter or when changing patient dressings clients with MRSA should be helped with handwashing if their mental and physical condition makes it difficult to wash their hands themselves wound dressings or other nursing care for clients who have MRSA should be carried out in their own room. 10.3 Cleanliness and the clinical environment Ensure hotel services are informed who will ensure that barrier cleans are conducted and a terminal clean will be performed on discharge or when barrier precautions are discontinued It is vital that areas are kept tidy and clutter free to enable effective cleaning as MRSA bacteria can survive as spores in dry, dusty environments Where possible equipment in direct contact with the patients skin such as hoist slings, glide sheets and cushions should be patient specific Equipment, such as a commode, should be cleaned with detergent and hot water after use by a resident with MRSA. Cutlery, crockery should be washed in the usual way no special precaution needed. In the patient s own home normal domestic cleaning routines are sufficient to reduce the number of MRSA bacteria found in the environment. Daily cleaning of toilet and bathroom areas with detergent and water will suffice. 11. Treatment of MRSA Colonisation or Infection See antibiotic prescribing formulary The relevant treatment guidance should then be followed (See Appendix 3) Evidence supports the use of targeted, short term decolonisation regimes not long term decolonisation regimes due to the high incidence of re-colonisation and also the increased risk of resistance. Decolonisation should not be attempted on more than two occasions during the same admission. If the patient has medical devices in situ only one attempt to decolonise should be made, whilst the device remains in situ and if unsuccessful a second attempt should be made once all devices have been removed. Re-colonisation of patients is common; therefore, it is important to target those patients who would most benefit from decolonisation or treatment. Where decolonisation is not advocated standard precautions are sufficient to reduce the risk of cross infection within healthcare settings. If the patient has a systemic MRSA infection i.e. bacteraemia, the patient should be transferred to the acute setting as soon as possible. The Infection Prevention and Control team should also be notified. 8

Deep infection such as wounds, pneumonia etc may be difficult to treat and may require systemic antibiotic treatment, for further information contact the consult microbiologist At Queens Hospital Burton via switch board on -01283 56633 12. Procedure for Decolonisation of MRSA Mupirocin sensitive MRSA Bactroban Nasal (mupirocin) ointment, apply 3 times daily to the inner surface of each nostril for 5 days. Concurrently apply Bactroban cream on small skin lesions if present. Mupirocin resistant MRSA Naseptin (chlorhexidine 0.1%) cream, apply to nostrils 4 times daily for 10 days. Wash with antiseptic (e.g. Skinsan) for five days in combination with nasal treatment. 12.1 Instructions for antiseptic wash 1. Wet skin: apply approximately 30mls of solution directly on to the skin using a disposable cloth. Do not dilute in bath or bowl of water. 2. Use the antiseptic wash as a liquid soap and shampoo. Wash from head to toe. Pay special attention under the arms and between the legs. Hair should be washed at least twice within the 5 day treatment 3. Thoroughly rinse the antiseptic off the skin 4. Dry the skin and use a clean towel each time the treatment is carried out 5. If the patient develops irritation from the treatment, discontinue the treatment and contact the consultant Microbiologist /infection control doctor or infection control nurse for advise 6. Change the clothing and the bedding daily after the body washes After 5 days topical treatment and after the completion of any systemic antibiotic treatment wait 2 further days and then send screening swabs If these are negative no further decolonisation treatment is required. 12.2 Procedure for rescreening After 5 days topical treatment and after the completion of any systemic antibiotic treatment wait 2 further days and then send screening swabs If these are negative no further decolonisation treatment is required DO NOT ATTEMPT MORE THAN TWO DECOLONISATION DURING ANY ONE ADMISSION. 13. Discharge/Transfer to another Organisation or Department If a patient is colonised with MRSA then their discharge home or transfer to another organisation should not be delayed. 9

If a patient has MRSA infection this should be resolved before discharge to their home setting. If the patient is to be transferred to another organisation or department, they should be informed of the patient s MRSA status and current management and the transfer form completed (see Movement of patients, policy) The patient s GP and the residential home, where relevant, should be informed of the patient s MRSA status and management during their hospital stay On discharge home, management of the MRSA colonisation should be discussed with the patient and their carers 14. Outbreaks of MRSA Outbreaks of MRSA are usually due to cross infection and should not occur if the above precautions are followed. Infection Prevention and Control team will review the situation, in liaison with relevant organisations, and advise the ward accordingly. The Infection Prevention and Control team will continue to monitor the situation until it is satisfactorily resolved. 15. Visitors For a patient with MRSA there should be no restriction upon visits, i.e. friends and relatives. Protective clothing is not necessary but visitors should be encouraged to wash their hands on leaving the care setting 16. Staff Issues Routine screening of staff is not recommended Any issues relating to staff and MRSA colonisation or infection should be referred to the Occupational Health team All staff should practice good hygiene at all times, this is important to prevent the spread of all infections not just MRSA. Staff should cover cuts and grazes with a waterproof dressing before commencing work and should follow the infection control guidelines outlined above. 17. MRSA Bacteraemia (Blood stream infections) Department of health mandatory surveillance requires that all MRSA blood stream infections are reported as serious untoward incidents (SUI). An investigation must be undertaken including a root cause analysis of the circumstances associated with the bacteraemia. 18. References Coia. JE et al (2006) Guidelines for the Control and Prevention of Meticillin Resistant Staphylococcus Aureus (MRSA) in Healthcare Facilities by the Joint BSAC/HIS/ICNA Working Party on MRSA. Journal of Hospital Infection. 63S; S1-S44. Criddle. P, Potter. J (2006) Exploring Patient s Views on Colonisation with MRSA. British Journal of Infection Control. April. Vol7; No2; p24-28. Department of Health (2006) A Simple Guide to MRSA. DH Publications. 10

Fawley. UN et al (2006) Surveillance for Mupirocin Resistance Following Introduction of Routine Peri-operative Prophylaxis with Nasal Mupirocin. Journal of Hospital Infection. 62; 327-332. Gemmel. CG et al (2006) Guidelines for the Prophylaxis and Treatment of Meticillin Resistant Staphylococcus Aureus (MRSA) Infections in the UK. Journal of Antimicrobial Chemotherapy. February. Lincolnshire Care Pathway Partnership. March 2006. Mallett. J, Bailey. C, ed (2004) Manual of Clinical Nursing Procedures. 6 th edition. Royal Marsden NHS Trust. Screening for MRSA colonisation- a strategy for NHS Trust: a summary of best practice available on the Department of Health website MRSA screening-operational Guidance, 31 July 2008, Department of Health Gateway reference number 10324. MRSA Screening- operational Guidance 2 31st December 2008, department of Health, Gateway reference number 11123 With thanks to Derby County PCT infection Control Team 11

Record of MRSA Screening Results Appendix 1 Patient Name: Hospital Number/Date of Birth: Swabs/Samples to be carried out Date/Result Date of screen Nose Result Date of screen Result Date of screen Result Date of screen Result Date of screen Result Date of screen Result Date of screen Result Date of screen Result Date of screen Result 12

Appendix 2 Policy for the Management of MRSA/C/YEL/ic/06/v1.0 Treatment of Patients who Require Decolonisation or have MRSA Infection This guidance only applies to those individuals who have MRSA isolated and fulfil the criteria for treatment outlined in the screening flowchart Nose Skin Carriage e.g. Perineum, PEG site Open Wounds, Leg Ulcers, Pressure Sores etc Urine or Sputum Eye Systemic Infections Day 1-5 apply 2% Mupirocin ointment as far up nostrils as possible. Three times a day Day 6-7 no treatment Day 8 rescreen all sites Do not recommence Mupirocin until results from screen available. If positive a further course of treatment can be prescribed. NB. No more than 2 five day treatments should be prescribed to prevent resistance. If patient not decolonised management should be discussed with microbiologist or infection prevention and control team. For Mupirocin resistant MRSA or if Mupirocin unavailable Naseptin can be used. This is a 10 day course. The patient should be encouraged to wash their hands after handling their nose and dispose of tissues correctly. Day 1-5 daily wash, shower or bath with Triclosan (Aquasept) or Skinsan Day 6-7 no treatment Day 8 rescreen all sites If positive result, recommence washes and repeat Day 1 8 If after second screen the patient is still positive, consult the infection control team to discuss future management. Staff or patients should wash their hands following the administration of the treatment. NB if PEG site is clinically infected it should be treated as for open wounds etc. Treat as for skin carriage. In addition: The appropriate dressing should be used that will encourage wound healing. If the wound is clinically infected the relevant antibiotic therapy should be commenced, based on sensitivities or microbiologist advice. The wound should be kept covered until healed to reduce the risk of cross infection. Gloves and aprons should be worn, aseptic technique maintained when dressing the wound. Hands to be washed before and after dressing wound. If the patient has clinical signs of infection or requires decolonisation, the relevant antibiotic therapy should be commenced, based on sensitivities or microbiologist advice. If the patient has a urinary catheter, this should be reviewed. Where possible the catheter should be removed or changed to reduce the amount of MRSA colonisation and increase effectiveness of antibiotics where used Gloves and aprons should be worn when handling urine or sputum Patient and staff should be encouraged to wash their hands following contact with urine or sputum. If exudate present bathe the eye with normal saline as required. The relevant eye drops/ointment should be prescribed according to sensitivities or microbiological advice. When administering eye drops/ointment ensure good hand hygiene and practice to reduce the risk of cross infection. Encourage the patient to wash their hands whenever they have had contact with their eyes. If the patient has signs of MRSA bacteraemia (blood stream infection) an urgent medical review should be sought. The patient should be admitted to an acute hospital as soon as possible. The relevant intravenous antibiotic therapy should be commenced as soon as possible, based on sensitivities or microbiologist advice. The patient should be closely monitored for changes in condition i.e. blood pressure, pulse, temperature. The infection prevention and control team to be informed of bacteraemia and patient management decisions 13

MRSA Care Pathway (2 pages) This Pathway is for patients with MRSA colonisation or infection. Yes No Screening of Patients Date Has patient been assessed for screening according to screening flowchart Is screening required? Has initial screening been completed and screening record commenced? Time Appendix 3 If variance has relevant form been completed Isolation of Patients Complete isolation is not necessary Does the patient fulfil any of the above criteria? If yes, is the patient in their own room? If a side room is unavailable or isolation would compromise patient safety, has the management of the patient been discussed with the primary care infection control team? The following patients should have their own room if this will not adversely affect their rehabilitation. Those with clinical signs of infection Those who have high levels of skin shedding Those with leaking wounds Those who are MRSA positive in their sputum and have a productive cough Those who are MRSA positive in their urine and are incontinent (urine is not contained in a pad) Yes No Date Time If variance has relevant form been completed Infection Control Precautions Is relevant equipment available i.e. gloves aprons? Yes No Date Time If variance has relevant form been completed Is the appropriate infection control precautions sign displayed near the patient s bed space? Communications Infection control team informed Clinician responsible for patient management informed of positive MRSA status Yes No Date Time If variance has relevant form been completed 14

Have the patient/relatives been informed of the infection control measures and the reasons why? e.g. hand hygiene before and after visiting Has the patient/relatives been given an information leaflet to support this explanation? Do the patient/relatives have any questions/concerns? Have these been addressed? When care pathway discontinued this is discussed with the patient On discharge or transfer to another organisation GP or organisation informed of MRSA status and current management Cleaning Has Hotel Services been informed of the isolation and the need to undertake daily barrier precaution clean? Once isolation discontinued has Hotel Services been informed of need for terminal clean of area Yes No Date Time If variance has relevant form been completed Treatment, where relevant Medications have been prescribed via: Patient Group Directive Clinician Has a stop date been provided for prescribed antibiotic therapy? If not, has the relevant prescriber addressed this? If Mupirocin nasal ointment has been prescribed is this for 5 days only? If not, has the relevant prescriber addressed this? Has the patient had more than two courses of Mupirocin? If yes, Mupirocin should be stopped immediately and management should be discussed with the clinician responsible for the patient s care Yes No Date Time If variance has relevant form been completed This pathway is discontinued when: the patient is discharged from community hospital setting the patient has had three consecutive negative screens and clinical signs of infection are no longer present (where applicable) and the wound has healed completely (where applicable) Pathway discontinued 15

MRSA Care Pathway Variance Sheet Date Description of Variance Reason for Variance Alternative Action Taken Signature 16

Appendix 4 Policy for the Management of MRSA/C/YEL/ic/06/v1.0 Infection Prevention and Control Team South Staffordshire and Shropshire Healthcare NHS Foundation Trust Trust Headquarters Corporation Street Stafford ST16 3AG Telephone: 01785 221483 Website: www.southstaffshealthcare.nhs.uk Infection Prevention and Control Team MRSA Ref: MRSA02 Ver: 1 February 10 17 Information for patients and visitors

This information leaflet is designed to tell you a little bit more about MRSA and try to answer some of your questions. MRSA stands for meticillin (M) resistant (R) Staphylococcus (S) aureus (A). This is a type of a bacterium (germ) called Staphylococcus aureus that does not respond to commonly used antibiotics. If you have been told that you have MRSA it doesn't automatically mean you are infected so there's no need to be alarmed. Some people carry MRSA as one of their 'normal' body germs. This is not at all harmful and is known as being colonised with MRSA. MRSA can sometimes cause infections if it gets inside the body, for example through a wound or a medical device such as a drip or a catheter. Symptoms MRSA can live in warm, moist areas on the body such as the nostrils or in the groin area and under normal circumstances does not cause illness. People colonised with MRSA do not look or feel different from other people so they may have no symptoms at all. Policy for the Management of MRSA/C/YEL/ic/06/v1.0 Using Bactroban Nasal Ointment (Mupirocin 2%) Bactroban nasal ointment should be applied four times daily up each nostril for between five and seven days. Use a clean finger or a cotton bud to apply the ointment. Squeeze the required amount on to the cotton bud or finger - this may be a thin line of ointment about 1cm long or a small blob about the size of a match head. Apply the ointment to the inside of one nostril and repeat for the other nostril. Close nostrils by pressing the sides of the nose together for a moment. This ensures that the ointment is spread inside each nostril. You will taste the ointment at the back of your throat after a while. This should reassure you that you have applied the ointment correctly Please wash your hands after applying the ointment. Infections with MRSA can look the same as other infections and the symptoms will depend on the site of the infection. General signs of infection include: High temperature Pain, redness and swelling in a wound Pain, and difficulty passing urine if an infection is in the bladder 18

Using Antiseptic Skin Cleanser whilst in hospital Policy for the Management of MRSA/C/YEL/ic/06/v1.0 Individuals should bath, shower or wash daily with the special skin antiseptic. Particular attention must be paid to the armpits, groin and any other skin folds on the body. Hair should be washed at least twice a week (daily if possible). The skin antiseptic must be applied directly to wet hair and skin, as you would shampoo or liquid soap. Use your hands, a disposable cloth or your own clean wash cloth to apply the antiseptic, leave for a couple of minutes if possible, then rinse and dry your skin / hair with a clean towel. Bed linen and clothing or nightwear should be changed every day directly after bathing if possible. Do not pour the antiseptic into the bath / wash water as the correct dilution will not be achieved. If you want to have a bath rather than a shower, wet all your skin in the bath water, stand or kneel up, apply the lotion with your hands or a clean face cloth (flannel). Massage your body with the antiseptic for 3 minutes and then immerse yourself in the bath water and rinse it off. If you can't bathe or shower, have a strip wash every day and apply the lotion, massaging it for 3 minutes all over your body with a clean face cloth (flannel) or your hands, rinse and dry. Always use disposable wipes or clean towels and washcloths every day. It may be best to use hospital towels for the duration of the therapy Diagnosis Infections can be caused by many different bacteria and the only way to know for certain is for the laboratory to identify the MRSA in samples sent for investigation. There is a separate leaflet about MRSA Screening that gives more information about the tests. The normal process for investigating infections is for doctors or nurses to collect swabs or samples from any body site thought to be infected. If MRSA is causing the infection, this will be picked up by laboratory staff and the results will be given to ward staff. Treatment If a person is colonised with MRSA, this does not always need to be treated. In some cases, MRSA disappears naturally over a short period of time; however, in others, colonisation may be prolonged. If a person is in hospital or due to come into hospital, he / she may be asked to use a special antiseptic soap for the hair and body and an antibiotic cream for the nose. This is called MRSA clearance therapy or MRSA decolonisation therapy. More instructions about this are included at the end of this leaflet. Some people may have a wound infection that requires a special type of dressing but MRSA can also cause serious infections and some people will require antibiotics as well. If you come into hospital or if you have an infection at any time, it is really important that you tell your doctor that you have had MRSA before or if anyone has ever found MRSA on your body. This is because infections with MRSA 19 can look the same as other infections but MRSA needs a different type of antibiotic to treat it.

Prevention of spread Unfortunately MRSA can survive in the environment especially in dust, on bed sheets, curtains and other surfaces. It is important for patients to have high standards of hand hygiene and to change their clothing and towels daily or sooner if they become soiled. If your wound dressing is wet or the wound is leaking through the dressing, please tell a member of staff so that a fresh dressing can be applied as soon as possible. Always tell the staff if you are experiencing pain, redness or swelling from any wound or other sites. If you have any tubes, drips, drains, catheters or breathing aids (such as a nebuliser) ask your nurse how you can help to keep them clean. There is no need to use plastic cutlery or crockery or special clothing as MRSA can be destroyed easily outside the body at normal washing temperatures and the germs removed with soap and water. Hand hygiene Hospital staff should take care to wash their hands before and after touching a patient or use the special hand hygiene rub at the bedside. Other sources of information A variety of Infection Prevention and Control information leaflets are available on the trust website: www.southstaffshealthcare.nhs.uk Official Websites The Health Protection Agency in the UK display information on their website at www.hpa.org.uk Instructions for MRSA Decolonisation (Clearance Therapy) There are slight differences in MRSA decolonisation in hospital and we ask people who have MRSA and those who have had MRSA in the past to use a special antiseptic wash for the duration of their stay in hospital. Thorough hand washing using soap and water is always important especially after using the toilet; after helping someone else to use the toilet; before serving food or eating and after cleaning the environment. 20

Appendix 5 Algorithm for Screening for MRSA on admission People admitted to mental Heath Trust should not be routinely screened Screen the patient on admission for MRSA if the service user Policy for the Management of MRSA/C/YEL/ic/06/v1.0 Is admitted following surgical procedures (including Caesarean sections) Is admitted following admission from an acute Trust following an inpatient stay (excluding admissions from maternity) Is admitted from a nursing home/care home Is an Intravenous drug users Has Self harmed in the last 6 months Has chronic wounds e.g. leg ulcers, Has an indwelling devices such as catheters or enteral feeding tube Has a history of MRSA Negative Positive (Inform Infection Prevention and Control Team) MRSA Policy applies No further action necessary Eradication successful No more than 2 attempts at decolonisation therapy: Nasal Cream and body washes x 5 days Eradication Unsuccessful Inform Infection Prevention and Control Team 21