Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities

https://doi.org/10.1016/j.jhin.2006.01.001Get rights and content

Summary

Meticillin-resistant Staphylococcus aureus (MRSA) remains endemic in many UK hospitals. Specific guidelines for control and prevention are justified because MRSA causes serious illness and results in significant additional healthcare costs. Guidelines were drafted by a multi-disciplinary group and these have been finalised following extensive consultation. The recommendations have been graded according to the strength of evidence. Surveillance of MRSA should be undertaken in a systematic way and should be fed back routinely to healthcare staff. The inappropriate or unnecessary use of antibiotics should be avoided, and this will also reduce the likelihood of the emergence and spread of strains with reduced susceptibility to glycopeptides, i.e. vancomycin-intermediate S. aureus/glycopeptide-intermediate S. aureus (VISA/GISA) and vancomycin-resistant S. aureus (VRSA). Screening for MRSA carriage in selected patients and clinical areas should be performed according to locally agreed criteria based upon assessment of the risks and consequences of transmission and infection. Nasal and skin decolonization should be considered in certain categories of patients. The general principles of infection control should be adopted for patients with MRSA, including patient isolation and the appropriate cleaning and decontamination of clinical areas. Inadequate staffing, especially amongst nurses, contributes to the increased prevalence of MRSA. Laboratories should notify the relevant national authorities if VISA/GISA or VRSA isolates are identified.

Section snippets

1. Preamble

Guidelines for the control of meticillin-resistant Staphylococcus aureus (MRSA) infections in hospitals in the UK have been published previously by a Joint Working Party of the British Society for Antimicrobial Chemotherapy and the Hospital Infection Society in 19861 and 1990,2 and together with the Infection Control Nurses Association in 1998.3 With the increased media and public interest, the advent of glycopeptide-resistant S. aureus and new drugs, including linezolid and teicoplanin, the

2. Grades of evidence and recommendations

Each recommendation, as graded by the US Centers for Disease Control and Prevention (CDC), is categorized on the basis of existing scientific data, theoretical rationale, applicability and economic impact. These grades were chosen in preference to those published by the Scottish Intercollegiate Guidelines Network or the National Institute for Clinical Excellence as they include scientific evidence and are not exclusively clinical. The CDC/Hospital Infection Control Practices Advisory Committee

3. Background

MRSA was first reported in 1961;4 it has since been regarded both as a rare condition and of doubtful clinical significance,5 and as a major pathogen in many countries.6 Control is necessary because of the recent emergence of VISA and VRSA.7, 8 In some countries, such as The Netherlands, the proportion of S. aureus bloodstream infections that are meticillin resistant is small9 (under 1%) compared with Germany (19%), Belgium (28%), France (33%), the USA (50%) and the UK (40%).9, 10 The low rates

4. Surveillance

‘Epidemiologic surveillance is the ongoing systematic collection, analysis, and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know. The final link in the surveillance chain is the application of these data to prevention and control.’

Thacker SB, Berkelman RL. Public health surveillance in the United States. Epidemiol Rev 1998;10:164–190.

5.1. Antibiotic stewardship

Inappropriate antibiotic use promotes the emergence and spread of antibiotic resistance. The emergence of meticillin resistance in previously sensitive strains of S. aureus appears to be relatively rare. Excessive use of antibiotics, however, promotes the spread of existing strains of MRSA through reduction in colonization resistance in patients and by giving resistant strains a survival advantage in the hospital environment.68

Antibiotic use and compliance with local guidelines needs to be

6. S. aureus with reduced susceptibility to vancomycin

Susceptibility to vancomycin in S. aureus is defined as a minimum inhibitory concentration (MIC) ≤4 mg/L.154, 155 Until relatively recently, strains with an MIC nearing that breakpoint were unheard of. However, since the first description of VRE in the mid 1980s156 and the subsequent demonstration in vitro that such resistance mediated by vanA genes was transmissible to S. aureus,157 there was considerable anxiety and speculation amongst clinical microbiologists about the potential for the

7. Recommendations for future research

  • The Working Party recommend a study of the clinical and cost-effectiveness of rapid screening methods (such as polymerase chain reaction) for MRSA, linked to their ability to direct efficient use of physical isolation facilities and procedures, decolonization procedures and glycopeptide surgical prophylaxis;

  • The Working Party recommend that studies should be carried out to determine the sensitivity and clinical effectiveness of different screening strategies for considering patients free from

Acknowledgements

This exercise was initiated by the Specialist Advisory Committee on Antimicrobial Resistance, an independent advisory committee set up to provide expert scientific advice on resistance issues arising from medical, veterinary and agricultural use of antimicrobials. Established in 2001 following recommendations in the House of Lords Select Committee on Science and Technology's original report ‘Resistance to Antibiotics and other Antimicrobial Agents', the Committee advises the UK Government on

Glossary of terms

Bacteraemia
presence of bacteria in the blood.
Bloodstream infection
the presence of microbes in the blood with significant clinical consequences, e.g. shock.
Carrier of MRSA
a person who harbours MRSA with no overt expression of clinical disease, but who is a potential source of infection. Recognized carrier sites for MRSA include the nose, throat and certain skin sites including the perineum, groin, axilla and buttock. The carriage of MRSA can be transient, intermittent or chronic.
Clinical trial
A

References (196)

  • M. Cosseron-Zerbib et al.

    A control programme for MRSA (methicillin-resistant Staphylococcus aureus) containment in a paediatric intensive care unit: evaluation and impact on infections caused by other micro-organisms

    J Hosp Infect

    (1998)
  • J.A. Cepeda et al.

    Isolation of patients in single rooms or cohorts to reduce spread of MRSA in intensive-care units: prospective two-centre study

    Lancet

    (2005)
  • W.C. Huskins et al.

    Controlling methicillin-resistant Staphylococcus aureus, aka ‘Superbug’

    Lancet

    (2005)
  • T. Kunori et al.

    Cost-effectiveness of different MRSA screening methods

    J Hosp Infect

    (2002)
  • A. Rampling et al.

    Evidence that hospital hygiene is important in the control of methicillin-resistant Staphylococcus aureus

    J Hosp Infect

    (2001)
  • M. Washio et al.

    Risk factors for methicillin-resistant Staphylococcus aureus (MRSA) infection in a Japanese geriatric hospital

    Public Health

    (1997)
  • G. Dziekan et al.

    Methicillin-resistant Staphylococcus aureus in a teaching hospital: investigation of nosocomial transmission using a matched case–control study

    J Hosp Infect

    (2000)
  • S. Hori et al.

    The Nottingham Staphylococcus aureus population study: prevalence of MRSA among the elderly in a university hospital

    J Hosp Infect

    (2002)
  • Report of a Combined Working Party of the Hospital Infection Society and British Society for Antimicrobial Chemotherapy. Guidelines for the control of meticillin-resistant Staphylococcus aureus

    J Hosp Infect

    (1986)
  • Working Party Report. Guidelines for the control of epidemic methicillin-resistant Staphylococcus aureus

    J Hosp Infect

    (1990)
  • G. Duckworth et al.

    Revised methicillin-resistant Staphylococcus aureus infection control guidelines for hospitals. Report of a Working Party of the British Society for Antimicrobial Chemotherapy, the Hospital Infection Society and the Infection Control Nurses Association

    J Hosp Infect

    (1998)
  • D.F.J. Brown et al.

    Guidelines for the laboratory diagnosis and susceptibility testing of methicillin-resistant Staphylococcus aureus (MRSA)

    J Antimicrob Chemother

    (2005)
  • M.P. Jevons

    Celbenin-resistant staphylococci

    BMJ

    (1961)
  • M. Barber

    Methicillin-resistant staphylococcus

    J Clin Pathol

    (1961)
  • S. Harbarth et al.

    Methicillin-resistant Staphylococcus aureus

    Lancet Infect Dis

    (2005)
  • K. Hiramatsu

    Reduced susceptibility of Staphylococcus aureus to vancomycin – Japan, 1996

    MMWR Morb Mortal Wkly Rep

    (1997)
  • Centers for Disease Control and Prevention

    Staphylococcus aureus resistant to vancomycin – United States

    JAMA

    (2002)
  • European Antimicrobial Resistance Surveillance System (EARSS)

    Annual report EARSS – 2003

    (2004)
  • C.D. Salgado et al.

    Community-acquired methicillin-resistant Staphylococcus aureus: a meta-analysis of prevalence and risk factors

    Clin Infect Dis

    (2003)
  • Communicable Disease Surveillance Centre, Public Health Laboratory Service

    Antimicrobial resistance in 2000. England and Wales

    (2002)
  • A.P. Johnson et al.

    Surveillance and epidemiology of MRSA bacteraemia in the UK

    J Antimicrob Chemother

    (2005)
  • E.W. Tiemersma et al.

    Methicillin-resistant Staphylococcus aureus in Europe, 1999–2002

    Emerg Infect Dis

    (2004)
  • E.L. Teare et al.

    Stop the ritual of tracing colonised people

    BMJ

    (1997)
  • M. Farrington et al.

    Winning the battle but losing the war: methicillin-resistant Staphylococcus aureus (MRSA) infection at a teaching hospital

    Q J Med

    (1998)
  • T. Shannon et al.

    Much ado about nothing: methicillin-resistant Staphylococcus aureus

    J Burn Care Rehabil

    (1997)
  • P. Kotilainen et al.

    Elimination of epidemic methicillin-resistant Staphylococcus aureus from a university hospital and district institutions, Finland

    Emerg Infect Dis

    (2003)
  • J.M. Boyce et al.

    Do infection control measures work for methicillin-resistant Staphylococcus aureus?

    Infect Control Hosp Epidemiol

    (2004)
  • H. Grundmann et al.

    Risk factors for the transmission of methicillin-resistant Staphylococcus aureus in an adult intensive care unit: fitting a model to the data

    J Infect Dis

    (2002)
  • C.A. Muto et al.

    SHEA guidelines for preventing nosocomial transmission of multi-drug-resistant strains of Staphylococcus aureus and Enterococcus

    Infect Control Hosp Epidemiol

    (2003)
  • A. Srinivasan et al.

    Vancomycin resistance in staphylococci

    Clin Microbiol Rev

    (2002)
  • Staphylococcus aureus resistant to vancomycin – United States, 2002

    MMWR Morb Mortal Wkly Rep

    (2002)
  • Anon

    Report: Deaths involving MRSA: England and Wales, 1999–2003.

    Health Stat Q

    (2005)
  • L.A. Selvey et al.

    Nosocomial methicillin-resistant Staphylococcus aureus bacteremia: is it any worse than nosocomial methicillin-sensitive Staphylococcus aureus bacteremia?

    Infect Control Hosp Epidemiol

    (2000)
  • J. Romero-Vivas et al.

    Mortality associated with nosocomial bacteraemia due to methicillin-resistant Staphylococcus aureus

    Clin Infect Dis

    (1995)
  • M. Whitby et al.

    Risk of death from methicillin-resistant Staphylococcus aureus bacteraemia: a meta-analysis

    Med J Aust

    (2001)
  • S.E. Cosgrove et al.

    Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a meta-analysis

    Clin Infect Dis

    (2003)
  • J. Rello et al.

    Ventilator-associated pneumonia by Staphylococcus aureus: comparison of methicillin-resistant and methicillin-sensitive episodes

    Am J Respir Crit Care Med

    (1994)
  • J.J. Engeman et al.

    Adverse clinical and economic outcomes attributable to methicillin resistance amongst patients with Staphylococcus aureus surgical site infection

    Clin Infect Dis

    (2003)
  • M. Abramson et al.

    Nosocomial methicillin-resistant and methicillin-susceptible Staphylococcus aureus primary bacteraemia: at what costs?

    Infect Control Hosp Epidemiol

    (1999)
  • T. Kim et al.

    The economic impact of methicillin-resistant Staphylococcus aureus in Canadian hospitals

    Infect Control Hosp Epidemiol

    (2001)
  • Cited by (449)

    • Benign breast disorders

      2022, Surgery (United Kingdom)
    View all citing articles on Scopus

    In this document, ‘meticillin’ has been used in place of the established ‘methicillin’ in accordance with the new International Pharmacopoeia guidelines.

    View full text