by Diane Gilmour RGN, PGCEA,
BN, DANS, Dip in Infection Control Nursing, ENB 176,
Methicillin Resistant Staphylococcus Aureus (MRSA)
is now an everyday problem within healthcare
organisations including those in the community. For
Infection Control teams it can be their biggest
challenge, particularly those in hospital, as it
remains a significant cause of hospital - acquired
infection. This article will describe MRSA, its
microbiology and epidemiology, and how within the
perioperative environment, practitioners can adopt
evidence based practices to minimise and prevent the
spread of MRSA to patients and colleagues. The article
will also examine the wide variations in incidence
within areas of Europe.
What is MRSA?
S. Aureus is a common pathogenic commensal bacterium
found in warm, moist areas of the body, particularly
the nose, axilla and perineum. Approximately 30% of
the population are colonised with the bacterium Ė that
is they carry S. Aureus but it does not cause them
harm and they do not require treatment. However,
within the hospital environment this means that
potentially both patients and staff can act as a
reservoir and source for the spread of infection to
susceptible individuals (1,2).
S. Aureus causes a range of infections from
superficial abscesses and boils to the more serious
infections of osteomyelitis, septicaemia and
pneumonia. MRSA causes the same types of infection and
again people can be colonised with the bacterium, in
some cases even the more sensitive strains of S.
Aureus have been replaced by MRSA. S. Aureus is a
gram-positive bacterium with a thick cell wall able to
adapt to the presence of antibiotics and develop
resistance by infiltrating the antibiotic molecule and
disrupting its structure. Certain strains of S. Aureus
became resistant to penicillin and an alternative
antibiotic was found - methicillin.
However shortly after its introduction in 1960
resistant strains were reported and incidences
increased with many serious outbreaks in hospitals (2).
Methicillin is now used as a screening process in the
laboratory for sensitivity testing and hence the title
MRSA. As new antibiotics appeared then incidences from
the 1970ís until the 1980ís decreased. Gradually MRSA
became more resistant and reports of outbreaks
increased, with epidemic strains (EMRSA) being
reported in London in the mid 1980ís. (EMRSA 3 is
often isolated from pressure sores; EMRSA 15 is often
associated with pulmonary infections) (3,2).
MRSA is now endemic in many hospitals - that is MRSA
regularly occurs (is compulsorily reported to the
Public Health Laboratory Service (PHLS)) and shows
little variation in its incidence.
Why is it dangerous?
MRSA can only be treated with the glycopeptide group
of antibiotics such as vancomycin, which are
expensive, can only be given intravenously and are
associated with renal impairment (4).
In 2002 the latest figures from the PHLS revealed that
MRSA infection rates have reached a plateau but that
new strains of vancomycin resistant S. Aureus (VRSA)
are emerging. The first known case of VRSA was
reported in Japan in 1997 and although still rare in
incidence it must not be ignored (3).
The PHLS reported the first case of intermediate
resistance to vancomycin in England and Wales in 2002.
This development is potentially hazardous with
disastrous consequences as it reduces the treatment
options for those patients with MRSA (5).
It has been identified that the implications for a
patient who contracts MRSA in hospital include :
extended length of stay, loss of earnings, scarring,
pain, anxiety and depression (1,6).
For the hospital staff the effects include increased
workload, disruption to ward routine and may even
result in temporary ward closures. The financial cost
to both the patient and organisation cannot be
measured. However managing and controlling MRSA
outbreaks can have less of a financial impact than if
the outbreak is uncontrolled.
Costs in excess of £40,000 at Kettering during an
outbreak for the provision of an isolation ward have
been cited (7), in London £13,000 for
screening, antibiotics and clothing but did not
include hotel costs and during an large outbreak in
Madrid costs exceeded £700,000 due to the cost of
antibiotics, extended length of stay for the patients
and the treatment for wound infections.
How does it get there?
The primary mode of transmission of MRSA is by direct
contact, usually with another personís hands. MRSA has
also been isolated from peopleís hands after touching
contaminated material or equipment (8).
MRSA may also be released in to the atmosphere on skin
squames and fibres from clothing and carried as dust
particles. About 300 million dead skin squames are
shed daily, with as many as 10,000 per minute shed
during excessive movement, of which 10% may carry
micro-organisms (2). Therefore it is
essential that all equipment and inanimate objects are
kept clean and free from dust.
MRSA is a common isolated organism in postoperative
wound infections, but can also be isolated from
intravenous catheter tips, chest drains and burn
wounds. MRSA was identified as the cause of surgical
site infection in almost 25% of all wounds examined,
and the commonest staphylococci in large bowel
surgery, vascular and limb surgery, open reduction of
long bone fracture and hepato-biliary surgery (6).
The majority of wound infections arise from the
patientsí own skin flora (endogenous) although some
come from the Operating Theatre and its staff (9).
How do we control it?
It has been advocated that an active programme of
controlling MRSA and its spread is essential to
reducing the impact on the organisation as well as the
financial burden (7). In their view
not doing anything is not an option. In the
Netherlands and Western Australia active and
aggressive screening and infection control policy
(search and destroy) has led to improvements and
It has been shown that although the number of cases of
serious S. Aureus infections reported in the
Netherlands, also Sweden, Denmark and Iceland has
increased this is still low in comparison to the rest
of Europe- 3% as opposed to 46% in the United Kingdom,
(the highest in a recent European survey) closely
followed by Israel and Greece (10,15).
The policy in Northern Europe includes the selective
and prudent use of antibiotics in the management of
many other diseases. It has been suggested that
doctors should question the need for antibiotics and
monitor the length of time the patient is on them and
their effectiveness (3). It has also
been identified that in Southern Europe the prevalence
of MRSA within healthcare organisations is very high
and that the attitude is one of inevitability and that
prevention is inappropriate (10).
Each healthcare organisation must have a policy for
the management of patient(s) infected with MRSA. The
primary aim of any infection control policy is to
prevent the acquisition and spread of MRSA by patients
and staff (7). Guidelines were
produced to address the problems encountered with the
wide and varied management of these patients in
different organisations. They recommended four
categories of risk.
Risk Assessment classifies MRSA cases into low, medium
or high in an attempt to guide nurses on how to manage
these patients (1). High risk areas -
those with the potential to develop serious infection
as a result of acquiring MRSA include intensive care,
transplant units, orthopaedic and trauma wards, burns
units and neonatal units. The guidelines suggest
actions to be taken in organisations where MRSA is
endemic and how to effectively utilise resources and
Screening of all patients for MRSA as part of the
pre-operative assessment process may be impractical
and costly, but for selected groups may be beneficial.
For the patient undergoing major joint surgery,
screening for MRSA prior to surgery will allow all
precautions to be taken to prevent prolonged hospital
stay, breakdown of the wound, the potential for
infection of the joint and breakdown of the prosthesis
Controversy continues about how to deal with MRSA and
despite advocating a flexible approach in their
guidelines many nurses still insist that patients
infected with MRSA should be isolated (1).
It has been argued that with a limited number of side
rooms available and that precautions taken should
reflect what we are going to do to the patient and not
by what we know of their infection status (4).
The RCN (11) support this idea and
state that we should assess the patientís individual
risk to others and the risk to themselves by the
presence of invasive devices for example.
Within the perioperative environment the guidelines,
limited as they are, recommend that if at all possible
MRSA should be eliminated prior to surgery. However,
this is not always achievable and so it was suggested
that vancomycin or teicoplanin are given
prophylactically, patients are recovered in the
operating theatre or isolated area to avoid possible
contamination of the usual area, and that all theatre
surfaces in contact with or near the patient should be
disinfected before the next patient (7).
Implementing contact precautions by isolating patients
within the Operating Theatre Department will involve
moving them directly in to the theatre itself,
bypassing any holding area, and post-operatively
nursing them in a designated isolation area or nursing
them in theatre itself. The practices in local
hospitals were reviewed for the management of MRSA
infected patients through the perioperative
environment and it was concluded that there is a need
for clearer guidance and evidence based
recommendations to ensure high standards of care are
Following the review by Brown & Cumberland (9),
the practices outlined below have now been suggested:
1. MRSA positive patients are operated on at
the end of the list. Such patients are likely to
disperse micro-organisms into the atmosphere and
potentially are a risk to other patients (12).
However operating lists can be delayed and the MRSA
positive patient may not receive their surgery on that
2. All non-essential equipment should be
removed to prevent contamination for subsequent
3. Minimal staff should be present in the
theatre to prevent cross-contamination between staff
4. The Operating Theatre and associated
equipment should be cleaned with a hypochlorite
solution once the wound is closed and the theatre
rested between patients. The transmission of infection
between successive patients is probably airborne on
items of equipment or surfaces that have been in
contact with the infected patient (12).
MRSA can survive in dry conditions and for some
considerable time so it is essential that the
appropriate cleaning solution be used (13).
5. If no further surgery is to follow then
theatre personnel need only change their scrub suits
and theatre greens.
6. Patients will be recovered within the
The single most effective method of preventing and
controlling the spread of MRSA is by the effective
decontamination of hands after every patient episode
of contact. It was identified that hand hygiene is not
performed adequately nor often enough (frequency and
quality are poor) but recognised that facilities may
be insufficient, with ineffective hand solutions, no
mixer taps and paper towels which are harsh and
The National Audit Office (6) agree
with these findings but showed through studies that
decontamination of hands between every patient can
reduce hospital infection rates. Practitioners should
implement strict hand washing practices as recommended
by the National Evidence-based Guidelines for
Preventing Healthcare associated Infections (14).
Hand washing should be carried out all times following
any patient contact and with all patients. Hands
should also be washed following the removal of
protective clothing, before handling invasive devices
and after handling body fluids and items contaminated
with body fluids (11).
As practitioners we should question our own knowledge
and practices for the management of the patient with
MRSA. Does the Department have an Infection Control
Policy and were theatre staff involved in writing it?
One could question theatre practitionerís ability to
wash their hands as we are excellent at knowing how to
"scrub up" but between patients, after any patient
contact do we always wash our hands? And what do we
wash them with? Excessive use of chlorhexidine or
iodine solutions could be detrimental to the condition
of the hands but do the scrub sinks or sluices have
MRSA clearly warrants the name "super bug" and we
should not be complacent. As theatre practitioners we
have an important role to play in preventing the
spread of MRSA not only to patients but also to
colleagues. Being accountable means that through our
actions or omissions we do the patient no harm.
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