What Is MRSA?
Methicillin-resistant Staphylococcus aureus (MRSA) is a multidrug-resistant strain of Staphylococcus aureus. The characteristic feature of this strain is being resistant to the antibiotics Methicillin or Oxacillin1. When patients with MRSA have been compared to patients with less resistant bacteria, MRSA-colonized patients develop more frequent symptomatic infections. Furthermore, higher fatality rates have been observed for certain MRSA infections such as bacteremia and surgical site infections2. Common sites of MRSA colonization include the nares, skin, rectum, and perineum3.
Elderly and disabled residents are at risk for colonization with resistant organisms such as MRSA4. Within a long-term care facility (LTCF), the length of stay and accommodation of rooms with multiple beds have also been identified as risk factors for the transmission of MRSA. When MRSA becomes endemic within a facility, elimination is highly unlikely4. A colonized or infected MRSA resident especially one who has impaired cognition or certain other conditions, has a much greater chance of contaminating the facility’s environment when compared to a resident who has good personal hygiene3.
Approaches to the isolation of LTCF patients vary substantially across facilities. The implementation of isolation precautions is usually identical to those found in hospitals. However, this may result in undesirable social and psychological consequences and functional decline for residents4. Since 1996, the Centers for Disease Control and Prevention (CDC) has recommended the use of Standard and Contact precautions for multidrug-resistant organisms (MDRO) such as MRSA2.
How MRSA is Spread and How To Prevent It
The most common mechanisms of transmission attributed to MRSA are through contact. Two types of contact can occur: direct and indirect. Direct transmission occurs after contact with contaminated skin or body fluids of a patient who is colonized or infected with MRSA. Indirect transmission occurs after contact with contaminated objects or the environment that contain MRSA. Therefore, contact precautions are implemented when transmission of MRSA may be reasonably anticipated to occur. Contact precautions require the use of wearing gloves; gowns; and possibly masks, eye shields, and/or goggles especially if procedures are being performed that involves the potential of splashing or spraying of bodily fluids. Examples of situations that will require implementation of contact precautions include but are not limited to: patients with active MRSA infection, MRSA-colonized residents who have risk factors for transmission such as poor hygiene or open and draining wounds, residents implicated in known MRSA transmission to other residents, and MRSA-colonized residents in specialized units such as those with ventilators4.
Hand hygiene is an essential component of Standard and Contact Precautions. Furthermore, there is convincing evidence that improved hand hygiene can reduce infection rates. In fact, there are more than 20 hospital-based-studies on the impact of hand hygiene on the risk of healthcare-associated infections that have been published between 1977 and 20085. Hand hygiene may be performed by either use of an alcohol-based hand rub, or by washing with soap and water. Alcohol-based hand rub may be used for routine use while washing hands with soap and water should always be performed when hands are visibly soiled or caring for a patient with a diarrheal illness. Sinks with soap and alcohol-based hand rub dispensers should be conveniently located for healthcare workers and visitors to use. Gloves are never a substitute for adequate hand hygiene. Although hand hygiene guidelines have been in place for decades, compliance among healthcare workers still remains poor6.
Single resident rooms are always preferred for residents who are infected or colonized with MRSA. However, most LTCF are not equipped with enough single rooms to accommodate their MRSA population so it is necessary to assess each patient for the appropriate placement of the MRSA- positive resident with a roommate. When single rooms are not available, facilities may cohort patients with MRSA in the same room or patient-care area. When facilities are unable to cohort patients with MRSA, it is advised to place patients with MRSA with patients who are at low risk for developing associated adverse outcomes or acquiring MRSA1. It is also not recommended for LTCF to refuse MRSA cases but develop an institutional strategy for control of the resistant organisms based on local considerations4.
Interestingly, one survey found that 90.5% of facilities accepting patients with MRSA stated that they followed contact precautions despite only 39.7% placing them in private rooms. However, additional evidence-based studies defining the specific isolation needs within LTCF are needed4.
In summary, infection control measures and strict compliance by healthcare personnel can help minimize the spread of MDROs such as MRSA, especially in long-term care facilities.