Comprehensive Analysis: MRSA Control Policy of Ireland Report

This report offers a critical analysis of the MRSA Control Policy of Ireland, focusing on the prevention and control of Methicillin-resistant Staphylococcus aureus (MRSA) infections. It begins with an executive summary highlighting the significance of the policy in addressing MRSA-related patient mortality and morbidity. The report then delves into the introduction, prevalence, and incidence rates of MRSA, emphasizing its impact in healthcare settings. Key components of the policy, including prevention measures like screening, infection control in acute and non-acute settings, and antibiotic stewardship, are thoroughly examined. The analysis covers treatment and surveillance aspects, identifies barriers and facilitators, and concludes with recommendations. The report underscores the policy's contribution to educating healthcare workers about necessary precautions to prevent MRSA transmission and improve patient care.

Running head: MRSA CONTROL POLICY OF IRELAND
MRSA CONTROL POLICY OF IRELAND
Name of the Student
Name of the University
Author Note

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Executive Summary
Methicillin resistant Staphylococcus aureus (MRSA) infections are a huge concern with respect
to increased patient mortality and morbidity. The healthcare professionals struggle to keep at bay
the spread of such infections. This report critically analyzes a policy designed by the Royal
College of Physicians Ireland regarding the control and prevention of MRSA. The policy
describes various precautionary measures to decrease patient morbidity and mortality and
providing quality care to patients. The policy also provides information about treatment,
surveillance and evaluation of MRSA. Thus, it can be concluded that the policy significantly
contributes in educating the healthcare workers about necessary precautionary measures to
prevent MRSA transmission.

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Table of Contents
Introduction......................................................................................................................................3
Prevalence and incidence rates of MRSA.......................................................................................4
Key components of the policy.........................................................................................................5
Critical analysis...............................................................................................................................5
Prevention measures....................................................................................................................6
Screening.................................................................................................................................6
Prevention in acute settings.....................................................................................................7
Prevention in non-acute settings..............................................................................................7
Prevention of neonate MRSA..................................................................................................8
Prevention of community associated MRSA...........................................................................8
Decolonization.........................................................................................................................9
Antibiotic Stewardship............................................................................................................9
Prevention of occupational health MRSA.............................................................................10
Treatment and Surveillance...................................................................................................10
Barriers and Facilitators.................................................................................................................11
Recommendations..........................................................................................................................11
Conclusion.....................................................................................................................................12
Reference List................................................................................................................................13

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Introduction
Staphylococcus aureus lives harmlessly on the skin or in the nose of a normal healthy
person. S. aureus causes infections in hospitals as well as in community patients that range from
boils or infected eczema to severe infections like surgical site infections, bacteraemia, among
others (Now 2012). Methicillin Resistant Staphylococcus aureus (MRSA) is a Gram-positive
bacterium. MRSA is resistant to a wide variety of antibiotics. It is genetically different from
various other strains of Staphylococcus aureus. MRSA can cause several complicated diseases
that can range from skin infections to sepsis, pneumonia and other bloodstream infections.
MRSA is highly prevalent in hospitals, nursing homes, where individuals with open wounds or
provide with invasive devises like catheters or immunocompromised individuals are at a high
risk of acquiring the nosocomial infection (Verkade, Ferket and Kluytmans 2014).
The treatment of MRSA is difficult because it is resistant to most of the antibiotics.
MRSA was first discovered in 1961 and it is found to be resistant to methicillin, penicillin,
amoxicillin, oxacillin, among others (Jacobs 2014). In hospitals, MRSA can be prevented by
isolating the infected individuals and keeping them in isolation. Healthcare workers and visitors
are required to wear gloves, masks and other personal protective equipments. Moreover, it is also
necessary to properly disinfect contaminated surfaces and infected patient laundry items (Seibert
et al. 2014).
This report describes the policy titled “Prevention and Control Methicillin-Resistant
Staphylococcus aureus (MRSA) (National Clinical Effectiveness Committee 2013). The clinical
advisory group of the Royal College of Physicians Ireland (RCPI) developed this National
clinical guideline. The report carries out a clinical analysis of the policy and provides necessary
recommendations for improvement.

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Prevalence and incidence rates of MRSA
MRSA is not only limited to acute care hospitals but a high prevalence is also found
amongst the staff and residents of a long-term care facility, thereby making such facilities a
natural reservoir for these deadly organisms. The prevalence of MRSA among the residents of
the long -term care facilities ranged from 1.1% in Germany to about 20% in the United Kingdom
and 30% in the United States. An 8.6% prevalence rate was reported from Irish nursing homes in
the year 2000. There were vast differences in the rates of colonization ranging from 0-73% in the
long-term care facilities. The rates of colonization was dependant on various factors like the
prevalence of MRSA in the healthcare facilities, the colonized resident population like the
patients as well as the staff and the prevention or treatment practices carried out in the healthcare
facilities. Antibiotic use has been found to be associated with MRSA colonization. Percentage of
MRSA carriage was reported to be ranging between 47% and 65%, of which 19-25% showed
transient carriage and 9-23% showed intermittent carriage. Colonization of the patients in
nursing homes was associated with higher mortality rates in Belgium. A longitudinal study
carried out in UK revealed that incidence of MRSA was associated with previous or subsequent
infections of MRSA, but was not associated with hospital admissions or mortality (National
Clinical Effectiveness Committee 2013). A prevalence study in 2006 revealed that out of the
7541 patients of the Republic of Ireland surveyed, 369 had healthcare associated infections, of
which 37 had MRSA. MRSA surveillance in the hospital ICUs of Ireland revealed that 2.9-
21.2% of the patients were colonized with MRSA. There were 1240 number of reported blood
stream infections in Ireland of which 33.9% had MRSA. The incidence of MRSA in Ireland,
although was found to be low it was still found to be significantly higher than other European
countries (Www.pfizer.ie, 2017).

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Key components of the policy
The policy titled “Prevention and Control of Methicillin Resistant Staphylococcus aureus
(MRSA)” National Clinical Guideline was formulated by the clinical advisory group of the
Royal College of Physicians Ireland (RCPI). The key components of the policy included the
precautions associated with the importance of hand hygiene, use of personal protective
equipment, respiratory hygiene or coughing manners, maintenance of safety and disposal of
sharps, management of blood and other body fluid spills, proper disinfection of patient clothing
and other infected laundry, maintenance of environmental hygiene, disinfection of other medical
devices, isolation of infected patients, movement and transfer, carrying out practices related to
safe injection and practices related to infection control in association with lumbar punctures. The
policy also provided information about treatment and importance of surveillance measures.
Critical analysis
The policy at first provides definitions for MRSA. The policy was generated keeping in
mind the healthcare officials involved responsible for the care of patients or other residents or
clients at risk of contracting MRSA or already having MRSA. The policy targeted the healthcare
workers of the acute care hospitals, nursing homes, long-term care facilities, among others. The
healthcare workers include medical practitioners, nurses or midwives, biomedical scientists,
pharmacists, among others. The policy defines the emergence of community acquired MRSA.
The aim of the policy was to provide effective prevention or control measures against MRSA in
order to improve care of patients, minimize the patient mortality and morbidity rates and also to
minimize the healthcare costs in association with MRSA. The objectives of the policy was to
enhance and further bring about improvements in the control and prevention of MRSA, to
improve patient care by reducing MRSA infections related to surgical site infections, respiratory

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tract, joint and bone infections, to improve antibiotic usage in association with MRSA infections
and to raise awareness about healthcare associated infections among the healthcare professional
and the public regarding appropriate measures of control and prevention, standard precautions
and the importance of such implementations.
Prevention measures
Screening
The policy describes the roles of the infection prevention and control team and other
officials in the control and prevention of MRSA in Ireland. These measures include effective
screening strategies. It describes the importance of early detection to control the MRSA
infections. Screening was linked to isolation of patients and carrying out contact precaution
measures (Huang et al. 2013). These help to prevent the transmission of MRSA, which spread by
direct or indirect contact with a patient or the infected environment of the patient (Otter et al.
2013). The policy also describes that successful detection of MRSA carriages was based on the
type of laboratory methods used, the nature of the samples, time when the samples are obtained
and on the frequency of patient screening. The policy also provides the details of the patients
likely to get screened. These include patients who had previous MRSA infections or are getting
readmitted in acute care, patients admitted from one hospital to another, patients who spent the
last six months in acute or long term care settings, patients who had been transferred from a
hospital situated in some other country, patients with ulcers, wounds, endoscopic gastronomy
tubes, central nervous system and urinary catheters, patients undergoing medium or high risk
surgeries, patients in intensive care units and special baby care units, patients provided with renal
dialysis and healthcare officials who are in direct contact with patients (Zimlichman et al. 2013).

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Prevention in acute settings
Other measures include infection control and prevention measures in acute and non acute
hospital environments, in neonates and obstetrics, in community, eradication of MRSA carriages,
antimicrobial stewardship and occupational health aspects in association with MRSA. Control
and prevention measures in acute care settings were defined and these were contact isolation,
cohorting of patients, hand hygiene, cleaning of the environment, active surveillance and
antimicrobial stewardship (Calfee et al. 2014). It also describes the role of the healthcare
professional in preventing overcrowding of patients and maintenance of adequate staffing. It also
defines the importance of staff education and training programs. The policy also described the
importance of the moments of hand hygiene. The hand hygiene guidelines included washing
hands before and after patient contact, before carrying out an aseptic procedure, after contact
with surroundings of patients, which may include body fluid spillages (Chou, Achan and
Ramachandran 2012). The policy also describes that the patients and visitors to carry out
effective hand hygiene. Risk management was described by the use of personal protective
equipments. The use of personal protective equipment is determined by the nature of the
intervention, risk of exposure to body fluids including blood and the risk of contaminating skin
and clothes. Proper disinfection of patient rooms, medical devices in contact with the patients
and patient clothing or infectious waste substances needs to be carried out.
Prevention in non-acute settings
Non-acute health care centers include adult care centers, homeless centers or special
schools, nursing homes, residential homes and mental care facilities. Prevention and control
measures in non-acute settings involved the use of personal protective equipments and hand
hygiene (Mody et al. 2015). Moreover, educating the staff about the standard screening and

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precautionary measures are also important. The policy describes the importance of educating the
staff about invasive devices like tracheostomies, urinary catheters, among others. At homes, the
precautionary guidelines mentioned were proper hand washing before and after touching of
wounds, care-givers should wash their hands after contact with the infected person, use of
disposable gloves, covering of cuts in the skin, disinfection of linen and cleaning of patient
environment (Traverse and Aceto 2015).
Prevention of neonate MRSA
Neonates are at a high risk of contracting MRSA and need to be screened. The
recommended site for cleaning of the neonates includes the umbilical site. On the context of
detection of MRSA carriage among antenatal pregnant women, decolonization is recommended,
which involves the topical use of nasal mupirocin. A lactating mother with MRSA mastitis, is
recommended to carry out breast feeding and subsequently receive antibiotic therapy. Antibiotic
therapy is recommended for neonates having MRSA colonization (Shrem et al. 2016).
Prevention of community associated MRSA
The characteristics of community associated MRSA include that the isolate should be
confirmed as MRSA, patients with community associated MRSA usually reside within the
community and have no associated risk factors, they are usually resistant to beta lactam
antibiotics, while remaining susceptible to other antibiotics. Such patients usually have skin and
other infections of the soft tissues. They can also contract pneumonia. Community associated
MRSA is usually caused by Staphylococcal Chromosomal Cassette (SCC) mec types IV and V
(Stefani et al. 2012). The normal sites recommended for the screening of community associated
MRSA include the nostrils, skin lesions, throat, among others. The prevention strategies
recommended involves carrying out hand hygiene, avoiding the use of contaminated razors,

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brushes, clothing and water bottles, covering of skin lesions, among others (Skov et al. 2012).
The treatment recommended involves incision and drainage of surgical site infections, antibiotic
therapy like the use of doxycycline, cotrimoxazole. Antibiotic therapy for surgical site infections
involve the use of linezolid, clindamycin, daptomycin, among others. In severe cases, adjunctive
therapy like administration of intravenous immunoglobulin can be carried out (Mantero et al.
2017).
Decolonization
MRSA decolonization refers to the use of systemic or topical agents for eradicating a
carriage. This is carried out to prevent the spread of infection among patients. One study reported
significant reduction of nosocomial MRSA infections in intensive care units was found to be
caused by the use of Mupirocin along with Chlorhexidine. Another study reported that the use of
Mupirocin delayed the infection but did not reduce the risk. MRSA decolonization among
neonates also involves the use of Mupirocin (Fritz et al. 2013).
Antibiotic Stewardship
The policy claims that the prolonged use of broad spectrum antibiotics should be avoided.
The policy recommends the healthcare institutions in Ireland to implement the strategies
recommended in the “Strategy for the Control of Antimicrobial Resistance in Ireland (SARI
2009)” (Www.hpsc.ie, 2017). The policy recommends the implementation of antibiotic
stewardship programs in long term care giving facilities. It also advices the consultation with a
microbiologist or a infectious disease specialist before providing antimicrobial therapy for
MRSA treatment, avoiding the use of antibiotics like cephalosporins, fluroquinolones and
macrolides, which are known to be associated with MRSA selection and or resistance and

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avoiding the use of topical therapies for treatment of superficial skin infections (Kim et al.
2013).
Prevention of occupational health MRSA
Occupational health staff provides protection, promotion and maintenance of employee
health in a healthcare organization. Their role is to reduce the infection transmission to and from
healthcare workers by carrying out best practices in a legal manner. The four components that
define an effective occupational health program include risk assessment and control, evaluation
and education. The healthcare workers are advised to seek help from occupational health
workers. The occupational health staff are required to identify healthcare workers showing
MRSA risk factors and are required to provide education regarding risks in the workplace. The
occupational health staff assess the healthcare workers based on their illness, MRSA risk factors,
colonization sites, previous infection history, among others (Aw, Gardiner and Harrington 2013).
Treatment and Surveillance
The policy also provides management recommendations for MRSA, which include
treatment and prophylaxis. Treatments include the use of linezolid, vancomycin and daptomycin.
Administration of an intravenous glycopeptides is recommended for treatment of patients with
life threatening MRSA infections (Sader, Flamm and Jones 2013). Surveillance involves the
reporting of blood stream infections to the health protection surveillance center (HPSC),
maintenance of records of MRSA cases, which includes patient identification, specimen and
MRSA isolation site, date of positive results, hospital ward name and date of admission.
Although the policy provides information about necessary precaution strategies as well
as treatment and surveillance, it does not address the issues regarding to antibiotic resistance in

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other sectors apart from healthcare like the agricultural sectors (Vandendriessche et al. 2013).
The policy also does not address the challenges associated with the development of new drugs
and the potential consequences associated with laboratory modernization.
Barriers and Facilitators
There are some barriers that will impact the full implementation of the policy. Most of
the measures provided are cost neutral since it is a modification of the previous policy with the
addition of some measures. Most of the recommended measures like hand hygiene are common
but there are other measures, which are specific and can give rise to resource implications.
Significant numbers of acute care settings lack isolation rooms, microbiology laboratories and
antimicrobial experts. The healthcare professionals do not understand their responsibilities in the
prevention of infection control. The facilitators involve enabling the healthcare professionals to
understand and appreciate the policy guidelines for the sake of patient care and safety. Increased
awareness of the patients and the demands raised by them for obtaining high quality care can act
as facilitators of the implementation of the policy. Describing the barriers associated with the
implementation can also act as a facilitator (National Clinical Effectiveness Committee 2013).
Recommendations
The recommendations to the policy involves the addition of information regarding the
antimicrobial resistance mechanisms. Providing information about the mechanisms will help to
educate the healthcare professionals and the general public about the necessary causes. It will
also help them to device precaution strategies based on the mechanism. The policy only
describes MRSA infection prevention in various types of healthcare settings, but MRSA can also
arise in agricultural or farming sectors and can result in the transfer of infections between