Recommendations for Prevention and Control of Methicillin-Resistant Staphylococcus aureus (MRSA) in Acute Care Settings

Updated 3/2013

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Recommendations for Prevention and Control of Methicillin-Resistant Staphylococcus aureus (MRSA) in Acute Care Settings (PDF)

Executive Summary

An estimated 1.7 million health care-associated infections occur each year in the United States resulting in over 98,000 deaths.1 A recent study conducted by the Centers for Disease Control and Prevention estimated that there were 94,000 invasive MRSA infections in the United States in 2005, 86% of which were health care-associated.2 Furthermore, the proportion of all S. aureus isolates that are resistant to methicillin has been increasing each year and MRSA now accounts for over 60% of all S. aureus isolated from intensive care unit patients.3

This report serves as the Minnesota Department of Health (MDH) Recommendations for Methicillin-Resistant Staphylococcus aureus (MRSA) Control in Acute Care Facilities (hereafter referred to as The Recommendations) as required under Minnesota Statutes, section 144.585. The purpose of this document is to provide a standard set of recommendations for the prevention and control of MRSA in acute care facilities in Minnesota. It is expected that facilities will implement The Recommendations by January 1, 2009.

This document was created to enhance rather than duplicate existing published recommendations and guidelines for MRSA control in acute care settings. Extensive literature reviews, expertise from the MDH MRSA Recommendations Task Force (MDH-MRTF) and discussions with national content experts served as the basis for the Recommendations. MDH will review The Recommendations annually and modify them as needed to reflect new scientific developments concerning effective MRSA prevention and control.

Public comments were solicited on a draft version of The Recommendations. The MDH MRSA Recommendations Task Force (MDH-MRTF) reviewed and evaluated the public comments and made revisions to the draft version in creating the final Recommendations.

Minnesota Statutes, section 144.585 states: “In developing the MRSA recommendations, the Department of Health shall consider the following infection prevention and control practices: 1) identification of MRSA-colonized patients in all intensive care units (ICU) or other at-risk patients identified by the hospital; 2) isolation of identified MRSA-colonized or MRSA-infected patients in an appropriate manner; 3) adherence to hand hygiene requirements; and 4) monitor trends in the incidence of MRSA in the hospital over time and modify interventions if MRSA infection rates do not decrease.”

Infection prevention and control practices two through four in the statute are included in The Recommendations as standard MRSA infection prevention and control practices for acute care facilities. The statute also calls on MDH to consider active surveillance testing in a subset of patients (practice 1 in the statute). The MDH-MRTF carefully considered this practice and concluded that requiring identification of MRSA-colonized patients through active surveillance testing in a pre-defined subset of patients for all admissions, at all times, in all acute care facilities in Minnesota is not the ideal approach to decrease health care-associated MRSA and other health care-associated infections. The main factor behind this decision is that acute care facilities, the populations they serve (including populations with varying degrees of risk for MRSA) and the services they provide, vary across the state. Rather than requiring active surveillance testing in a pre-defined subset of patients, The Recommendations require acute care facilities to conduct an annual MRSA risk assessment using active surveillance testing to identify patients at high risk for MRSA colonization or units with high rates of MRSA transmission. This process will allow acute care facilities to identify, target and monitor interventions to their individually identified high-risk populations and/or units creating the potential for greater reduction in transmission of MRSA. Under The Recommendations, acute care facilities must also consider the standard use of active surveillance testing in targeted populations or units as a part of an enhanced infection prevention and control program when routine infection prevention and control practices do not result in decreased MRSA infection rates.

The Recommendations are comprised of four sections: Infrastructure and culture to support MRSA infection prevention and control, Baseline infection prevention and control recommendations, Tier One Recommendations, and Tier Two Recommendations. The baseline infection prevention and control recommendations will prevent the transmission of MRSA and be useful in decreasing transmission of other health care-associated infections including Clostridium difficile, extended-spectrum beta-lactamase producing Gram-negative bacteria, and vancomycin-resistant enterococci. Transmission of MRSA within acute health care facilities is of great concern, although it is estimated that MRSA is responsible for less than 15% of all health care-associated infections.4,5

General infection prevention and control measures include administrative support, process measures, and infection prevention and control measures. Administrative support for infection prevention and control activities (e.g. adequate funding and staffing) is critical to the success of programs aimed at reducing health care-associated infections. Process measures involve implementing a group of interventions that, when used together, have been shown to achieve better health care-associated infection prevention outcomes than if implemented alone such as interventions for preventing ventilator-associated pneumonia, central-line associated bloodstream infections, and surgical site infections.6,7 Infection prevention and control measures include hand hygiene, Standard Precautions and Transmission-Based Precautions.

In addition to general infection prevention and control measures, The Recommendations adopt a two-tiered approach for preventing and controlling MRSA transmission in acute care facilities. Tier One Recommendations for MRSA control in acute care settings include core MRSA infection prevention tools such as strict adherence to Contact Precautions, adherence to recommended hand hygiene practices, and thorough environmental cleaning. In facilities not performing facility-wide active surveillance testing, Tier One Recommendations require acute care facilities to conduct an annual MRSA risk assessment using active surveillance testing to determine populations or units at risk for MRSA colonization and/or to determine MRSA transmission rates. This annual assessment will assist facilities in determining when Tier Two Recommendations are indicated.

Tier Two Recommendations are indicated when hospital-acquired MRSA infection rates are not decreasing despite implementation of and adherence to the general infection prevention and control measures and Tier One Recommendations. Tier Two Recommendations call for monitoring health care worker compliance with infection prevention and control measures in identified high-risk units or populations, intensified environmental measures, and active surveillance testing for all admissions to identified high-risk units or of high-risk populations.

Prevention and control of MRSA necessitates that health care facilities implement an antimicrobial stewardship program to augment their infection prevention and control program. Antibiotic misuse, including overuse of broad-spectrum antibiotics, is the biggest driver of antimicrobial resistance and contributes appreciably to the development of resistant organisms including MRSA. Effective antimicrobial stewardship programs are necessary to optimize therapeutic outcomes while minimizing unintended consequences of antimicrobial use.8

Facility-wide commitment to antimicrobial stewardship and infection prevention and control practice measures are essential to prevent health care-associated infections. An institutional philosophy that supports these elements is critical to achieving success in decreasing transmission of MRSA and other health care-associated infections.