Methicillin Resistant Staphylococcus aureus (MRSA) and Vancomycin Resistant enterococcus (VRE) continue to be found in skilled nursing facilities. There does not seem to be wide-spread outbreaks of these organisms. While infection MRSA and VRE may be difficult to treat, they do not cause more serious infections then their antibiotic sensitive cousins.
There are been many different State guidelines on the care and treatment of residents with MRSA or VRE. In California, the Department of Health Services published a guideline in 1996. A copy of the complete text is available on the Internet at www.cacc.net .
-
Infection or colonization with MRSA or VRE should not be a reason to deny admission, unless the facility does not have a appropriate room or roommate.
- MRSA and VRE are not airborne. Routine use of masks is unnecessary.
- Colonization is the presence of the bacteria (detectable when cultured) and the absence of signs/symptoms of infection.
- Decolonization has not been found to be an effective measure in the management of MRSA colonization.
- If the facility chooses to use Contact Precautions with residents identified with MRSA or VRE, it must also decide on criteria to discontinue these special precautions. While the CDC has recommended precautions until the patient is culture negative, this is not practical and probably not necessary in long term care facilities.
- The California State Guidelines do not require nor recommend clearance cultures.
- Contact Precautions for residents infected or colonized with MRSA should be based on the following criteria:
The resident is no longer symptomatic AND
The residentıs body fluids can be contained AND
The resident does not have behavior or hygiene that would leave his body fluids on himself or environmental surfaces
- Standard housekeeping practices, include low level disinfectants are adequate to kill MRSA and VRE.
- Standard laundry practices are adequate to kill MRSA and VRE. No special linen handling practices are necessary.
- Plain handwashing soap is adequate for routine handwashing. Antibacterial soaps have not lead to increased resistance.
- Standard dietary practices are adequate. Disposable dishes are not necessary. Insure that the dishwashing process is up to current standards.
- Standard waste disposal is adequte. Isolation or red bag trash is neither required nor recommended for MRSA/VRE
If you are using the 1996 CDC Isolation Guidelines for Hospitals, they need to be modified for your practice setting.
Antibiotic Review:
Baby Steps
Goal:
To promote the rational use of antimicrobial agents and to limit the extent of antibiotic resistance
Objectives:
- To reduce the number of unnecessary antibiotics given
- To reduce cost of medications given
- To prevent the development of antibiotic resistant bacteria
- To prepare a report for presentation at Quarterly Committee Meeting
Supplies needed:
Graph paper, Pencil, Antibiotic orders (50-100 needed) include antibiotic name, course of treatment, reason for treatment, Facility antibiogram from the laboratory (at least one year of data)
Exercise:
Create Tables:
- Antibiotic by classification
- Antibiotic by High Cost Antibiotic
- Diagnosis by High Cost Antibiotic
- Antibiotic by Volume
- Diagnosis by Volume
- Select most commonly isolated bacteria
- Select site of most common bacteria
- Is the most frequently prescribed antibiotic at least 85% sensitive to that bacteria?
These tables should be presented as part of the Infection Control Committee's antibiotic review process.
References
Nicolle LE, Bentley D, Garabaldi R, Neuhaus E, Smith P, SHEA Long Term Care Committee. Antimicrobial Use in Long-Term-Care Facilities. Infection Control and Hospital Epidemiology, Vol. 17, No. 2. February 1996. pp. 119-128.
Warren W, Palumbo FB, Fitterman L, Speedie SM. Incidence and Characteristics of Antibiotic Use in Aged Nursing Home Patients. Journal of the American Geriatrics Society. Vol. 39, No. 16, October 1991. pp. 963-972.
Strausbaugh LJ, Crossley KB, Nurse BA, Thrupp LD, SHEA Long Term Care Committee. Antimicrobial Resistance in Long-Term-Care Facilities. Infection Control and Hospital Epidemiology Vol. 17, No. 2. February 1996. pp. 129-140.
Gilbert DN, Moellering RC, Sande MA. The Sanford Guide to Antimicrobial Therapy- 1998. Hyde Park, VT. Telephone 802-888-2855.
James Marx © 1999
