Effectiveness of Interventions to Prevent MRSA Infection in Hospitals

This systematic review explores the effectiveness of interventions targeted at preventing MRSA infections among patients in hospital settings. It examines various preventive programs and interventions, such as personal hand hygiene, contact precautions, and environmental disinfection procedures. The review highlights the importance of healthcare organizations implementing a range of interventions to prevent MRSA occurrence and associated complications.

A SYSTEMATIC REVIEW PROTOCOL OF EFFECTIVENESS
OF INTERVENTIONS TO PREVENT MRSA INFECTION
AMONG PATIENTS ADMITTED IN HOSPITAL SETTINGS
ABSTRACT
AIM: The aim of this study to describe the effectiveness of intervention programs targeted at prevention of MRSA
infections occurring among patients in hospital settings.
BACKGROUND:MRSA or Methicillin-resistant Staphylococcus aureus, is a type of Staphylococcus bacteria
possessing resistance to wide range of antibiotics and is major cause of infectious acquired in clinical environments
such as hospitals, dialysis centers and nursing homes. Lack of adequate treatment and management of MRSA
negatively impacts the skin resulting in symptoms like boils, blisters, skin peeling and infections at the root of the
hair follicles. Symptoms of MRSA infection occur from the emergence of reddish bumps in the skin, with swelling
and pain, further aggravating to an infected area which is warm upon touch, is filled with pus or other fluids coupled
with fever in the patent. Further lack of treatment can result in chronic impact associated with infections transmitting
to the bones, blood and surrounding organs and tissues resulting in multiple organ failure, sepsis and death. Hence, to
prevent the same, healthcare organizations like hospitals must engage in administration of preventive measures
against MRSA incidences.
DESIGN:A qualitative research design will be adopted using systematic review and thematic analysis.
METHODS:A systematic review will be undertaken to evaluate and critically appraise existing literature on
preventive programs available in hospitals to eradicate MRSA infection occurrence. A systematic review will be used
for the collection and synthesis of essential data components after an extensive exploration of a broad range of
published research. An electronic search strategy will be conducted using appropriate keywords and along with

1. INTRODUCTION
Methicillin resistant Staphylococcus aureus (MRSA) is a pathogenic strain of bacteria found to
be resistant to a wide group of antibiotics such as amoxicillin, methicillin, oxacillin and
penicillin, hence resulting in symptoms associated with infections on the skin. Due to its
hastened transmission as a result of direct, skin to skin contact, individuals with injuries, bruises
and cuts pose high susceptibility in acquiring the infection, which is why MRSA imposes high
along with Boolean operators, via databases such as CINAHL, MEDLINE, Education Resources Information Center
(ERIC) and Academic Search Complete. Articles with relevance to the keywords and studies published in English
language between the years 2009 – 2019 will be included.While, those irrelevant to the keywords, timeframe and
dealing with non-hospital preventive programs or patient populations other than adults, such as community and
residential settings based preventive measures or evaluation of paediatric and neonatal populations, will be
excluded.After selecting the required 15 articles, a quality assessment was conducted using JBI critical appraisal tool
specific for summary tables in systematic reviews – which evaluated the methodological credibility of the studies
using GRADE recommendations and 10 questions for critiquing.
RESULTS: The systematic review, revealed the emergence of a number of preventive interventions for MRSA,
grouped into 4 themes. These themes comprised primarily of organizational interventions, contact precautions,
isolation and screening and environmental disinfection procedures. A majority of studies advocated for multiple
interventions for MRSA prevention.
DISCUSSION:Anumberof interventions have been implicated to be beneficial in MRSA prevention include
personal hand hygiene, using disinfectants and antibiotics for patient management, administration of contact
precautions like glove usage and screening and isolation of patients. Hence, healthcare organizations must seek to
administer a range of interventions to prevent MRSA occurrence and associated complications with immediate
effect.
KEYWORDS

rates of prevalence across hospital and healthcare based environments (Costill, 2016). A number
of invasive situations are highly susceptible to MRSA infections. MRSA can occur due to
MRSA pathogenic strains infectingwounds acquired due to surgery or during invasive
procedures due to catheter insertion resulting in infectionacross heart valves, bones, soft tissues
and organ abscesses further resulting in sepsis if left untreated (Haysomet al.2018). As
highlighted, MRSA infections undergo rapid transmission through direct skin contact, inhalation
of droplets due to coughing, or through directly contacting items which have been infected with
the strain. Often, MRSA strains can form potential colonies in individuals, making them carriers
of the infection even without administering symptoms (Braun et al. 2016). It is due to such high
rates of transmission which have prompted healthcare organizations to work promptly and
collaboratively for the prevention of this infection – hence resulting in the formulation of
preventive organizational policies, some of which will be systematically reviewed in this thesis.
Rates of MRSA prevalence have been implicated to reduce after undertaking preventive
measures by healthcare organizations, such as adherence to protective attire like gowns, gloves
and masks, isolation of patients and prevalence of precautionary signs and symptoms at doors for
patients inflicted with the infection (Hassounet al. 2017). This systematic review will aim to
focus upon such healthcare based interventions, conducted across healthcare environments such
as hospitals, as an attempt to the establish a useful guidance for existing healthcare organizations
as well as pave the way for future research on developing improved preventive interventions for
enhanced MRSA prevention.

2.BACKGROUND
MRSA or Methicillin-resistant Staphylococcus aureus, is a type of Staphylococcus bacteria
possessing resistance to wide range of antibiotics and is major cause of infections acquired in
clinical environments such as hospitals, dialysis centers and nursing homes (Vaidyaet al. 2015).
The infection caused by this bacterial strain occurs primarily due to the performance of invasive
procedures such as surgical interventions, joint replacement and placements of tubing
intravenously. Such MRSA infections are primarily known as health-care associated MRSA
(HA-MRSA)(Baucomet al. 2016). Infections caused due to the MRSA strain undergo rapid rates
of transmission especially by means of direct contact across hospital settings especially when a
patient comes in contact with items and equipment infected by the bacteria. Additionally, MRSA
infection can also occur due to upon wounds due to unhygienic therapeutic handling resulting in
symptoms of septicaemia, septic shock and untimely death (Coll et al. 2017). Despite, the
widespread and extensive rates of prevalence of this infection considering its resistance to
antibiotics, healthcare organizations at present seek to work collaboratively on undertaking
infection prevention strategies as well as establishment of organizational policy guidelines which
may dictate standards of quality clinical workforce functioning towards collective eradication of
the same (Chow et al. 2017). Hence, this systematic review will aim to focus upon such
healthcare based interventions, conducted across healthcare environments such as hospitals.
Upon infection, treatment targeted towards MRSA are generally determined by infection type,
rate of progression of symptoms, site of infections and antibiotics towards which the strain is
resistant. Infections of MRSA occurring at the soft tissues and the skin can be treated further by
medications like rifampicin, clindamycin, linezolid, minocycline, doxycycline, sulfamethoxazole
and trimethoprim (Van Gaalenet al. 2017). Additional therapeutic interventions which may

prove to be beneficial in the management of spread of infection include hygienic wound
management, drainage of pus from the lesion, testing of MRSA cultures from the material which
has been drained and administration of antimicrobial therapy (TosasAuguetet al. 2017).
According to the World Health Organization (2019), almost 90% of MRSA incidences occur at
the site of surgery. If left untreated sepsis associated with MRSA contributes to almost 30 to
50% of mortality incidences in hospitals. According to the Center for Disease Dynamics,
Economics & Policy (2019), the prevalence rate of MRSA in Ireland has been estimated to be
40%.In general, patients admitted across healthcare organizations are at risk of acquiring MRSA
infections, since MRSA undergoes rapid transmission via direct contact such as skin-to-skin
contact, during wound management, usage of invasive procedures like catheters, direct contact
with equipment already contaminated with the strain and improper hand hygiene. The Centers
for Disease Control and Prevention also notes that across healthcare settings, an estimated 33%
of patients are carriers of MRSA in their nose, and 2 patients out of 100 are estimated to be
infected with the strain (Centers for Disease Control and Prevention 2019). The global
prevalence and risk factors of MRSA infections have been explored extensively by Sabbagh et
al. (2018), who noted that patients suffering from HIV pose high rates of susceptibility to the
infection. The research postulated that the highest prevalence of MRSA was uncovered in South
East Asia (16%) and the American continent (10%), with the least rates of prevalence discovered
in the continent of Europe (1%). The risk factors which determined the acquisition of MRSA
infections across patients suffering from HIV, include previous history of the infection, history
of being hospitalized since the last 1 year and the excessive use of antibiotics. The worldwide
transmission of MRSA has displayed incidence rates prevalent to that of the Staphylococcus
aureus strains which are resistant towards penicillin. It is now not uncommon to uncover MRSA

incidences in hospital and healthcare settings. Despite discrepancies in global statistics of the
disease prevalence due to variations across study design and patient populations, it has been
reported that areas of South America, Malta, North America and Asia present the highest rates of
the infection, greater than 50%. Followed by countries of Australia, China and Africa at rates of
25 to 50%. Additional countries with alarming rates of the disease include Romania (34%),
Portugal (49%), Italy (37%) and Greece (40%). European nations such as the Scandinavian
countries and the Netherlands have significantly low rates of prevalence (Reyes et al. 2016).
Lack of adequate treatment and management of MRSA negatively impacts the skin resulting in
symptoms like boils, blisters, skin peeling and infections at the root of the hair follicles.
Symptoms of MRSA infection occur from the emergence of reddish bumps in the skin, with
swelling and pain, further aggravating to an infected area which is warm upon touch, is filled
with pus or other fluids coupled with fever in the patent (Salgeet al. 2017). Further lack of
treatment can result in chronic impact associated with infections transmitting to the bones, blood
and surrounding organs and tissues resulting in multiple organ failure, sepsis and death. A
number of interventions have been implicated to be effective in the prevention and management
of MRSA (Hardgribet al. 2016). Hence, the importance of conducting this systematic review,
lies in its ability to educate healthcare organizations on a range of preventive interventions which
may be used to prevent occurrences of MRSA incidences as well as progression of its chronic
harmful consequences and as a result, eradicate high patient mortality rates.
At present, in order to prevent the increasing transmission of MRSA infections, clinical settings
such as hospitals are increasingly adopting preventive strategies and intervention programmes
(Ray 2017). Examples of interventions which have been implicated to be beneficial in MRSA
prevention include personal hand hygiene, using disinfectants and antibiotics for patient

management, administration of contact precautions like glove usage and screening and isolation
of patients (McDonald 2017). Strategies of personal hand hygiene comprise of health
professionals engaging in frequent washing of hands using disinfectants and hand sanitising
agents, along with educating the patient on appropriate measures regarding the same. Adherence
to contact precautions are beneficial in the prevention of MRSA infections considering that
pathogenic MRSA transmit and colonize via direct contact across individuals (Balbale et al.
2015). An additional key way in which contact precautions can be administered is via the usage
personal protective equipment such as gloves and gowns in order to prevent infection
transmission from person to person. Usage of antibiotic based bathing solutions like
chlorhexidine can also be a beneficial MRSA preventive intervention since it daily washing
eradicates the possibilities of re-colonization and re-transmission of MRSA pathogenic strains
(Evans et al. 2017). Alternatively, disinfecting the surroundings such as cleaning of hospital
environments with disinfectants and detergents prove to be an indirect method of MRSA
prevention by avoiding colonization of pathogenic strains on the surface area of the
surroundings. For long term prevention and maintenance of low or negligible incidences of
transmission, it has been postulated that implementation of organizational policies which may
train and educate the hospital staff on MRSA prevention strategies contribute positively,
especially in terms of improved hospital workforce awareness and knowledge (Ziakas et al.
2015). Additionally, hospitals now seek to conduct comprehensive assessment and screening on
the detection of MRSA symptoms across patients in order to conduct early preventive
therapeutic interventions for effective eradication and reduction of the disease severity. Further
preventive strategies to be followed upon administration of screening procedures include,
isolating susceptible patients in separate wards to prevent contact based transmission of disease

(Zingg et al. 2015). The systematic review, will thus, aim to expound upon each of these
preventive intervention strategies and in the process pave the way for presenting a comparative
finding based upon effectiveness of each of these strategies aimed at MRSA infection
prevention.
3.THE REVIEW
3.1AIM
The aim of this review isto describe the effectiveness of interventions targeted at the prevention
of MRSA infections among patients in hospital settings.
3.2 OBJECTIVES
The final PICOS question originated after extensive evaluation of existing research and prevalent
gaps in literature. The initial PICOS question will only focus on exploration of existing
interventions for MRSA prevention, and hence, will read as: What are the various intervention
programs targeted at prevention of MRSA infections?
However, upon conducting research on the above, extensive studies were obtained, with
however, negligible researches focusing on an evaluation of how effective such interventions
may be (Leung 2015). Hence, considering that research should consider identification of research
gaps and answering unanswered research questions, the PICOS question will hence be revised
as:What is the effectiveness of intervention programs targeted at prevention of MRSA
infections?
However, considering that MRSA infections occur prevalently at the hospital as compared to the
community level, in order to narrow down the search and remove confounding factors, the final

PICOS question upon revision, read as: What is the effectiveness of intervention programs
targeted at prevention of MRSA infections occurring among patients in hospital settings.
Hence, based on the above, the objectives of the review are:
1. To identify the various interventions associated with MRSA infection prevention in
hospital settings.
2. To compare the effectiveness between various interventions associated with MRSA
infection prevention in hospital settings.
3. To evaluate future recommendations for best practice of MRSA infection prevention in
hospital settings.
4. To assess factors effective in MRSA infection prevention?
3.2.1 PRIMARY REVIEW QUESTIONS
1. What are the interventions used to prevent MRSA infection?
2. How effective are these interventions in preventing MRSA infection?
3. What are the factors effective in preventing MRSA infection?
3.2.2 SECONDARY REVIEW QUESTIONS
1. Which MRSA intervention reports highest rates of prevention, upon comparison of
multiple strategies?
3.2.3 DESIGN
A systematic review is a form of literature review characterized by usage of systematic methods
for secondary data collection, followed by critical appraisal of selected studies and synthesis of

findings into relevant categories and themes (Shamseeret al. 2015). For the purpose of data
collection and data analysis in this thesis, a systematic review will be conducted. Qualitative as
well as quantitative papers whichwill be focusing upon usage of various interventions for the
prevention of MRSA infections among adult patients in hospital settings, will guide the review
and analysis of findings in this thesis (Moher et al. 2015).
3.2.4 TYPES OF STUDY TO BE INCLUDED
Peer reviewed, scholarly studies, both qualitative and quantitative in nature, evaluating the
effectiveness of preventive MRSA interventions on reduction of MRSA incidences, particularly
in the hospital will be included.Any study which engages in evaluating the effectiveness of
interventions aimed at prevention of MRSA will be included, which can comprise of randomized
controlled trials, prospective studies, retrospective studies, survey based studies, before and after
studies and cohort studies.
Population
The population of the studies will comprise of adult patients admitted in hospital settings.
Intervention
Preventive measures aimed at reducing incidence rates of hospital acquired MRSA will comprise
of the intervention of the chosen studies.
Comparators
For the selected articles discussing MRSApreventive interventionswill be compared before and
after implementing interventional programme with same group.
Settings

Hospital settings will be considered for selection and screening of articles.
Main Outcome
Decrease the incidence rates of MRSA infections in the hospital will be the primary outcome
of this study.
Additional Outcome
Awareness on MRSA prevention among hospital staff as well as prevalence of MRSA
intervention training programs and policies will be additional outcomes measured in this thesis.
3.2.5 INCLUSION AND EXCLUSION CRITERIA
Articles with relevance to the keywords and published in English languagebetween the years
2009 – 2019 will be included while those irrelevant to the keywords, timeframe, language and
dealing with non-hospital preventive programs or patient populations other than adults, such as
community and residential settings based preventive measures or evaluation of paediatric and
neonatal populations, will be excluded. Further, publications which will evaluate the comparative
differences between incidences of MRSA prior to and after administration of MRSA preventive
interventions will be included whereas publications which are primarily opinion articles not
engaging in pre and post intervention comparative analysis will be excluded (Machiet al. 2016).
The articles for the systematic review will be selected on the following components of the
PICOS question:
The inclusion criteria will be:
• P: Population: Studies that focus onAdults Patients admitted in Hospitals
• I: Interventions: All MRSA infection prevention intervention programs

• C: Comparison: Pre and post intervention with same group
• O: Outcome: Reduction of MRSA infections in Hospitals
• S: Setting: Hospital settings
The exclusion criteria will be:
 Studies that focus on paediatrics and neonates
 Studies without an MRSA infection prevention intervention element
 Community and residential based settings
3.2.6 SEARCH STRATEGY
An electronic search strategy will be conducted using keywords such as: prevent * OR avoid*
OR control OR reduc*OR decreas*AND interven* OR program* OR therap*OR treat* AND
MRSA OR “methicillin resistant staphylococcus aureus”AND Hospital* OR “Acute care
setting*” OR “Acute care*” OR “Acute setting*” OR “Clinical setting*” OR “In patient” OR
Inpatient OR Ward* OR Unit* -along with Boolean operators, via databases such as CINAHL,
MEDLINE, ERIC and Academic Search Complete (McGowan et al.2016).
The above databases will be considered due to their usage of peer reviewed, scholarly research
based on subjects like healthcare, nursing and biomedicine, which are relevant to the research
question. In addition to the above, for the selection of articles for the systematic review, the
journals of choice which will be considered, include the Journal of Hospital Infection (Impact
Factor: 3.354, American Journal of Infection Control (Impact Factor: 1.929) and Journal of
Advanced Nursing (Impact Factor: 2.267). Such journals have been chosen due to their emphasis
on articles on infection prevention and control and health and biomedical sciences.Additionally,
to enhance and expand screening of articles, search terms truncation symbols, MESH terms and

quotations will be included since these allow articles with similar terms to be included in the
search results (example: such as different articles using similar terms like ‘preventive’,
‘prevention’ etc.). Synonyms will be included to include articles using different terms with same
meaning (example: prevention, avoidance, eradication) (McGowan et al., 2016).
Instead of incorporating grey literature, databases have been used for extensive searching and
collection of articles. This is due to the fact that databases, like the health and life based ones
mentioned above, are known to contain and provide studies which are scholarly and peer
reviewed as compared to grey literature based searches (McKeever et al. 2015). Peer reviewed
and scholarly sources are essential and have been chosen for this thesis since they have been
implicated to yield findings which are valid and credible. The selection of peer reviewed articles
encompasses inclusion of those studies whose results have been evaluated and reviewed by more
than one credible author. Screening of findings by more than one or two individuals reduces the
possibility of bias and increases validity, credibility and significance of study findings - which is
why such papers have been included in the search strategy and findings for this thesis (Nicholas
et al. 2015).
3.2.7 SEARCHES
The searches will be conducted based on screening and monitoring for peer reviewed, scholarly
publications dealing with administration of interventions targeting prevention of MRSA. The
searches will be conducted based on the previously identified key words and Boolean operators.
3.2.8 DATA EXTRACTION
The process of data extraction encompasses retrieval of data acquired from various sources to aid
in summarization and emphasis on key findings for improved research analysis. The process of

data extraction in research is utilized by researchers for obtaining essential characteristics of the
chosen articles in a summarized and concise form which further aid in the establishment of
essential research conclusions by associating the obtained research results with the chosen
research aims, objectives and questions (Jonnalagaddaet al.2015).
All records identified through electronic database such as CINAHL, Academic Search Complete,
MEDLINE and ERIC will be exported to a reference manager (EndNote) where duplicates will
be deleted. The records will be then transferred to Covidence, an online screening platform used
by Cochrane reviewers. Studies will be peer reviewed based on the review inclusion and
exclusion criteria on the basis of title and abstract. Full texts of potentially eligible papers will be
obtained and screened further. Disagreements regarding title, abstract, and full-text screenings
will be resolved by consensus or a third reviewer. The study identification, screening, and
selection processes with reasons for exclusion will be presented using the PRISMA flow diagram
(Moher et al. 2009).
Data extraction tables will be incorporated for highlighting the results of the chosen studies since
it will allow the easy identification of findings associated with MRSA infection prevention along
with obtaining information on the quality, validity and presence of bias Moeyaertet al.2016). The
data extraction table will be presented as two tables. The characteristics of included papers will
be presented as first table with name of author, year, country and aim of the study, study design,
setting and sample size, data collection and instrument, intervention, outcomes measured and
quality assessment .The second table will be presented the key findings according to the review
questions. Data will be extracted by the first person and crosschecked by the facilitator and
members of the review team.

3.2.9 DATA ANALYSIS AND SYNTHESIS
For the analysis of the acquired data, narrative synthesis will be used which will comprise of
grouping of acquired data based on themes. The themes will comprise of various MRSA
preventive interventions grouped in terms of specific outcomes obtained or type of interventions
use, such as hand hygiene, screening, isolation, environmental disinfection and organizational
training to name a few. Narrative synthesis has been chosen as the preferred mode of data
analysis since it allows in easy identification and summarization of key findings in a situation of
broad research questions and outcomes which in this case, proves to be beneficial in the
identification of important themes and findings from a wide range of MRSA infection prevention
strategies (Cruzes et al. 2015).Data analytical methods of meta-analysis has been avoided instead
with this respect due to disadvantages like increased possibilities of ignoring differences across
studies, which may result in incorrect results and misinterpretation of research hypothesis.
Further, meta analysis often leads to summarization of a huge quantity of data into a single
number which is often regarded as controversial resulting in invalid results. This can result in
issues of research validity since data obtained from a large number of studies which have
explored multiple, heterogeneous interventions and diverse outcome measures, are reduced to
merely to a single value or number – characteristic in meta analysis.Such concise reporting of
large amounts of heterogeneous data in meta analysis can lead to erroneous outcomes and
incorrect postulation of hypothesis.This results in the skewing of data and increase in the
likelihood of acquiring type II statistical errors which is associated with the inability underlying
rejection of a false null hypothesis (Cooper 2015).

3.2.10 QUALITY ASSESSMENT
For assessing the quality of the studies selected for the systematic review, the critical appraisal
tool developed by the Joanna Brigg’s Institute (JBI) will be used. JBI Critical Appraisal Tools
are widely renowned and commonly used for their comprehensive evaluation of the validity,
effectiveness and trustworthiness of results of the studies, with the aid of a wide range of
questionnaires, or ‘checklists’. JBI Checklists assesses the validity of a variety of research
designs, of which, checklists for randomized controlled trials, cohort studies, case control
studies, cross sectional studies and quasi-experimental studies will be considered since such
designs are most relevant for assessment of effectiveness of MRSA preventive interventions
evaluated in researches. The checklists developed by JBI, are generally comprised of 9 to 13
questions and assess studies on a variety of parameters such as, presence of concealment,
blinding, confounding variables, validity and reliability of outcomes and exposure interventions,
adherence to randomization and cause-effect relationships. Studies scoring high number of
positive responses will act as a prompt for researchers to consider them to be of moderate to high
quality and include them in this thesis. Overall, JBI will be chosen for this research, due to its
worldwide credibility in the development of comprehensive critical appraisal tools. The ability to
assess a wide variety of research designs is also another reason for choosing JBI. Further, JBI
will be chosen since its checklists are relatively easy to understand and every checklist comes
with its own set of guidelines and recommendations for enhanced comprehension of the
researcher during critically appraising studies (Joanna Brigg's Institute 2019).
3.2.11 CONCLUSION
Hence to conclude, the review protocol successfully identified the prerequisites for this research.
Indeed, MRSA is a growing problem which must be tackled in hospitals with immediate effect.

Hence, considering the same, this thesis will focus upon systematically reviewing the various
preventive measures aimed at reduction of MRSA infections across hospitals. Through the
inclusion of relevant, peer reviewed scholarly literature, the research will focus upon drawing
relevant themes from the obtained findings and categorizing using data extraction processes.