MRSA Question. 2. Name of Sender: Tammy MacDonald

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1 DATE: February 26, 2014 QUESTION: MRSA colonized patients and when is it considered safe to remove the flag which then indicates the patient is no longer MRSA positive/colonized and that isolation precautions are no longer required. Please answer the following questions: 1. What are the required steps to deem a person MRSA negative? FOR NEW POSITIVES 3 SETS OF NEGATIVE SPECIMENS FOLLOWING DISCONTINUING OF APPROPRIATE ABX FOR 48 HRS. FOR PAST POSITIVE PATIENTS ON RE-ADMISSION, 1 SET OF SPECIMENS FOR ALL PREVIOUSLY POSITIVE SITES. 2. What time line and how many negative swabs required? FOR ANY PAST POSITIVE PATIENT THEY ARE ISOLATED ON RE-ADMISSION UNTIL SPECIMENS OF PREVIOUS POSITIVE SITES ARE RESULTED AND NEGATIVE 3. How long the patient should be off their antibiotic therapy before swabs can be collected? 48 HOURS (ONLY THOSE ABX TO WHICH THE ARO IS SENSITIVE) RESPONSES: 1. Name of Sender: Laurel Biluk address of Sender: LBiluk@ierha.ca We follow a process where three negative swabs are required at least one week apart while a patient is off antibiotics for at least 48 hours. Routine decolonization is discouraged. The patient will remain on alert in Health Records as MRSA Previous and will required screening swabs on admission into hospital. 2. Name of Sender: Tammy MacDonald 1 address of Sender: Tammy.MacDonald@cdha.nshealth.ca At [facility name], we use the following process to deflag for MRSA: A period of eighteen months begins after the first negative swab. There will be at least three consecutive negative swabs. If there is a positive result, the eighteen month waiting period starts again. The swabs should occur at least quarterly during the eighteen month period. Carriers are to be re-cultured during any subsequent admissions. Swabs should not be collected within one week of finishing a course of antibiotics. We also take into consideration if the patient has any of the following : Chronic dermatological condition such as eczema or psoriasis Unhealed or draining wounds/ulcers High risk immune compromised status or chronic medical conditions in consult with IC Medical Director Frequent antibiotic therapy (more than once a year) Frequent admissions to hospital (more than once a year) Requiring health care on a continuous basis in the community Chronic indwelling device

2 3. Name of Sender: Jim Gauthier address of Sender: 1. We require 3 negative swabs one week apart from positive sites (unless it was bloodstream). If we get a positive we wait a month before testing again. 2. We then swab once per month for 3 months, then we go every 6 months 3. We wait 48 hours after they are off antibiotic therapy, before starting the 3 weekly swabs. 4. Name of Sender: Diane Quinn address of Sender: Diane.Quinn@HorizonNB.ca 1. What are the required steps to deem a person MRSA negative? Person cannot be taking antibiotics or be free of antibiotics x 48hrs before any swabs collected (antibiotic creams, ointments included). The person should not have active MRSA infection-being treated for same. Must have appropriate sets of swabs collected as outlined in next question. 2. What timeline and how many negative swabs required? The patient must have three sets of clearance swabs (nares, rectum, and any other positive sites) collected. Each set must be collected 1 week apart x 3. If all three sets of swabs are negative, they are considered cleared of MRSA. 3. How long the patient should be off their antibiotic therapy before swabs can be collected? X 48hrs 5. Name of Sender: Jackie Potter address of Sender: potterj3@kgh.kari.net What are the required steps to deem a person MRSA negative? See below re. question 2 and 3. In addition, as far as sites that are swabbed, we collect from all previous + sites (including wounds if still open) and nares for the 3 sets. If we have a patient who was MRSA+ in a clinical specimen/blood isolate, but not MRSA+ in Nares, then we ensure we collect a perianal swab on the third set of clearing swabs. Here, we do not routinely do perianal swabs. 2. What timeline and how many negative swabs required? 3 sets of negative swabs, collected at least 1 week apart 3. How long the patient should be off their antibiotic therapy before swabs can be collected? 48 hours unless renal patient-our dialysis unit then waits 1 week 2

3 6. Name of Sender: Krystal Fergus address of Sender: [Facility name] has not moved to delisting MRSA patients but in previous hospitals if someone was MRSA positive we did the following: 1) If someone had an alert on but did not appear to be infected before discharge they would get a total shower or bed bath with Hibiclens this was the start of the process. Then on re admission they would be swabbed. 2) The person had to have 3 negative MRSA swabs on 3 separate admissions before they would be delisted. 3) They also had to be off abx for at least 2 weeks or more. 7. Name of Sender: Louise Holmes address of Sender: LHolmes-02@cw.bc.ca Here is our delisting procedure BCCH_W-MRSA delisting.pdf 8. Name of Sender: Gail Barwise address of Sender: gjbarwise@ihis.org 1. What are the required steps to deem a person MRSA negative? 2 year period of negative plus a medical assessment to make decision to remove alert from electronic record. Based on history no additional precaution but culturing upon admission. 2. What timeline and how many negative swabs required? usually a minimum of 3 or more over a 2 year period. children based on pediatrician assessment 6 months and 3 negatives 3. How long the patient should be off their antibiotic therapy before swabs can be collected? depends on the antibiotic... 5 day for withdrawal 9. Name of Sender: Kasey Gambeta address of Sender: GambetaK@smh.ca At [facility name]: We require the patient to have 3 negative MRSA specimens at least one week apart. If the patient is in hospital and there is time, we do a decolonization protocol that lasts one week followed by a set of three swabs at least one week apart. The first swab is collected 48 hours after completion of the decolonization protocol. If these are negative we can dc. If they do not meet criteria for decolonization, we put them on a bioburden reduction protocol until they meet criteria for decolonization or they are discharged from hospital. 3

4 If the patient is discharged. We will re-screen upon admission. If positive on admission, we put them either on bioburden reduction and decolonization and follow the protocol above. If they are readmitted and are negative on admission, we will continue screening until we get the three negatives one week apart or become positive again (this is regardless of whether or not the patient had a decolonization protocol previously). 10. Name of Sender: Kellie McLean address of Sender: Kellie.McLean@vitalitenb.ca We require a doctor s order for: Three sets of cultures at one week intervals of the nose and rectum (standard) + any previous positive sites. The patient must be free of antibiotics for 48 hours prior to obtaining the cultures. If all three set are negative the flag is changed not removed. We change the flag to a past positive (PP) which means that when admitted the patient is isolated until one set of cultures come back negative. If attending an ambulatory clinic or presenting to ER, the past positive patients are not isolated. 11. Name of Sender: Debora Giese address of Sender: debora.giese@northernhealth.ca At [facility name] in British Columbia, once a patient is diagnosed with an MRSA positive culture, whether screening/colonization or infection, they are flagged as MRSA, entered into NH MRSA database and are considered 'MRSA positive' for life. We do not re-swab or retest MRSA status for this patient. 12. Name of Sender: Glenda McFadden address of Sender: gmcfadden@ckha.on.ca We used to remove MRSA flags after great consideration when the patient had at least 3 negatives and ensuring they had no false negatives due to antibiotic use or Chlorhexidine baths. We have recently stopped doing this (in the last 6 months) and here is why. We had 2 different patients that had been MRSA pos in the distant past, probably 2 years ago, one sight, one time and both had several negatives (at least 5 or 6 each). We researched both histories to make sure they were not false negatives and after careful consideration removed flags on both patients. During the hospital stay for both patients (when we had just removed the flags), they were transferred to different units and required retesting and both of them tested positive again. I also have a patient right now that tested positive only in the nares 11/02/2010 and had no other admissions with us until 01/30/2014 and tested negative on admission and tested negative again 4 days later when transferred to another unit. Nursing staff questioned this because the positive was in the distant past. We declined to remove the flag and sure enough the patient was transferred to another unit approximately 2 weeks later and tested positive again in the nares. So to answer your question, we no longer remove the MRSA positive flags regardless of the length of time it has been or the number of negatives the patient has had. 4

5 13. Name of Sender: Fitzsimmons, Roxanne address of Sender I think that PICNet would offer the best explanation. I don t recall ever removing an MRSA status on patients. Very interesting question around decolonization though. 14. Name of Sender: Josie Taylor address of Sender: josie.taylor@horizonnb.ca 1. What are the required steps to deem a person MRSA negative? Must have three sets of all applicable sites done 7 days apart without the influence of antibiotics 48 hours prior to collections. Sites include nares, perianal, device sites, urine if catheter in place, wounds and any other open area at the time of screenings. 2. What timeline and how many negative swabs required? Three sets and 7 days apart each set 3. How long the patient should be off their antibiotic therapy before swabs can be collected? 48 hours 15. Name of Sender: Kim Burrows address of Sender: Kim.Burrows@pnrha.ca This is what we use as our guidelines for MRSA in acute care: If we get three negative screens for a patient colonized/infected with MRSA, at least one week apart we will remove flag. Duration of Precautions: Patients colonized with MRSA The majority of patients colonized with MRSA will remain colonized for weeks to months therefore colonized patients will remain on additional precautions for the duration of their stay. Follow up cultures are not required Previously positive MRSA Patients: these patients may be identified through screening process or by facility flagging system These patients will be placed on contact precautions and a MRSA screen will be performed. Continue Contact Precautions until screening(s) returns negative. For patients who have completed treatment for an MRSA infection, Contact Precautions can be discontinued once the following requirements are met: 1. Three consecutive sets of negative follow up cultures (includes-nares, groin as well as previously positive sites) at least one week apart 2. The first follow up cultures must be taken when the patient is not receiving antibiotics to which the bacteria is sensitive as results may be a false negative. Take the cultures 72 hours after completion of antibiotics. Note MRSA FOLLOW UP on requisition. 3. If any culture remains positive for MRSA, discontinue subsequent cultures, and maintain contact precautions for the duration of their stay. 5

6 NOTE: If patient remains in hospital for an extended period of time after being cleared of MRSA (e.g. has had 3 consecutive sets of negative cultures), consider monthly screening cultures from nares and groin and open wounds, to monitor if MRSA returns. If MRSA returns, institute contact precautions and inform the physician 16. Name of Sender: Allan Ronald address of Sender: aronald@cc.umanitoba.ca The rules for declaring someone MRSA free are variable and controversial and require some interpretation depending on 1. hospital 2. other health care institution 3. at home 4. has there been evidence of spread to others? 5. employed in health care? The rules/generalities where I ve worked are as follows 1. MRSA cultures to determine eradication begin one week after antimicrobial treatment including efforts to decolonize 2. cultures are obtained weekly x3 from anterior nares, MRSA infection sites and if deemed necessary from vagina/anus 3. only after three negative sets of cultures is an individuals declared MRSA free -and even then 5-10% recur within weeks/months-presumably due to relapse from a site not monitored or reinfection from a source 17. Name of Sender: Frances Little address of Sender: FLittle@pmh-mb.ca We would not routinely decolonize someone with MRSA.this is done on a case-by-case basis in consultation with an ID physician. If they are treated.we would have to have 3 sets of negative swabs done at least 1 week apart (off all antibiotics). They must be finished the treatment for at least 48 hour prior to sending the swabs. If all three sets are negative, then the patient would then be considered MRSA suspect which means they do not require additional Contact Precautions but would be swabbed each time admitted to an Acute Care facility..once positive we never wipe them out of the data base as pt with a history of being MRSA positive are at risk for recolonization in the future. 6

7 18. Name of Sender: Patricia Byers address of Sender: 1. What are the required steps to deem a person MRSA negative? Three sets of least one week apart, all are to be negative, which would include nares, rectum, Plus if they have any wounds they should be swabbed as well as IV sites and PICC lines. Just a quick note if the patient in question was positive from a wound and now that wound is healed we still require 3 sets of negative swabs from the nares and rectum. 2. What timeline and how many negative swabs required? Answered this in the above sentence 3. How long the patient should be off their antibiotic therapy before swabs can be collected? 3 days with no treatment then we swab. 19. Name of Sender: Claude Bussière address of Sender: claudebussiere@montfort.on.ca To deem a patient ex-carrier of MRSA we follow PIDAC s recommendation. 1. We must have a negative culture from last admission our present admission, without antibiotics to start this process 2. We make sure that the patient is no longer on antibiotics and that for at least 48 hrs before testing 3. We take cultured specimens from nares, rectum and any wounds that the patient has and we do this in 7 day intervals until we get 3 negatives from all sites. 4. Once declared ex-carrier, we screen our patients weekly while they are admitted and that for 4 weeks and then q30 days 5. If we get one positive during this testing we stop the testing. If a patient is here for 30/60/90.. days, we retest the patient for MRSA and VRE Here is a link to our advisory committee. IPC_Annex_A_Screening_Testing_Surveillance_AROs_2013.pdf page: Name of Sender: Lori Kraft address of Sender: KraftL@sah.on.ca Our policy is to swab colonized patients on a monthly basis. When they have a negative result, we ask for two more swabs a week apart (total of 3 negative swabs). Then we will take them off precautions. In acute care, once precautions are discontinued they are to be swabbed weekly while hospitalized. In our long term care population they are swabbed monthly x 6 months after 7

8 precautions are discontinued. We keep the alert in their electronic record and indicate if they require precautions or not and ask that they be swabbed each admission. The alert changes as their status changes. If the patient is on antibiotics, they must be off them for 48 hours before swabbing. Basically, we try to follow the Provincial Infectious Diseases Advisory Council (PIDAC) recommendations. 21. Name of Sender: Paul Chisholm address of Sender: The last time I read national (UK) guidelines and from UK practice: The research is not clear. The process of 'deeming a person MRSA negative' was not considered appropriate for a number of reasons: recommendations time consuming - up to seven consequetive negative screens, over several weeks; management of patients previously identified with MRSA mitigates risk; logistically difficult - who screens in the community? and costly for dubious gain. Antibiotics given for systemic infections. They have no affect on MRSA colonization. Focus on this aspect of MRSA 'control' misses the point. Primary aim of MRSA managment is to prevent MRSA septicaemia. 22. Name of Sender: Brenda Earles address of Sender: Brenda.Earles@easternhealth.ca I am the ICP for [facility name] here in Newfoundland which is part of Eastern Health. We do not deflag people. Once positive for MRSA the chart remains flagged forever. We do not do decolonization. 23. Name of Sender: Bridget Maxwell address of Sender: Bridget.Maxwell@iwk.nshealth.ca Please see the excerpt from our MRSA policy at [facility name] in Halifax, NS. DISCONTINUATION OF PRECAUTIONS Patients with known MRSA colonization or infection: The duration of colonization with MRSA is not well defined. Colonization can persist for many months or years. If there is question regarding a patient s MRSA colonization status, a process for determining colonization can be initiated through guidance from IPCS. Discontinuation of precautions will be considered on a case by case process. Precautions are NOT to be discontinued until reviewed by Infection Prevention & Control. 1. Re-swabbing should not be done for at least one year following the date of the most recent positive MRSA result. 2. Removal of precautions and flagging can be considered with a minimum of three sets of negative specimens taken no closer than monthly. Each set of specimens are to include 8

9 swabs taken from the nose, the groin and whenever possible, a specimen from the site originally found to be colonized or infected with MRSA. 3. Swabs should not be collected within one week of finishing a course of antibiotics. 4. Once these swabs have been obtained and all results are negative, discontinuation of precautions will be considered following consultation by IPCS. 24. Name of Sender: Christine Cohoon address of Sender: Christine.Cohoon@horizonnb.ca 1. What are the required steps to deem a person MRSA negative?. If an known MRSA pt. is admitted, we swab on admission. If those swabs are negative we remove them from isolation but do not remove the alert from the chart. If a pt. is being decolonized we would swab 48 hours after the protocol is completed. If those are negative, we repeat swabs in a week and if those are negative we would remove from isolation. We would then swab weekly for the duration of that hospital stay. 2. What timeline and how many negative swabs required? To take an alert off of a chart we require 3 sets of negative swabs over a two year period 3. How long the patient should be off their antibiotic therapy before swabs can be collected? 48 hours 25. Name of Sender: May Griffiths-Turner address of Sender: griffitm@stjosham.on.ca 1. What are the required steps to deem a person MRSA negative? If colonized: 3 sets of negative swabs, collected I week apart, a minimum of 48 hours post completion of antibiotics, from nose, rectal, open wounds. If infected: Resolution of clinical infection plus 3 sets of negative swabs, collected I week apart, a minimum of 48 hours post completion of antibiotics, from nose, rectal, open wounds. 2. What timeline and how many negative swabs required? 1 week intervals, 3 sets of negatives 3. How long the patient should be off their antibiotic therapy before swabs can be collected? A minimum, of 48 hours post completion of antibiotic therapy. 26. Name of Sender: James Wong address of Sender: JWong2@mtsinai.on.ca We have three levels of precautions. MRSA Positive = private room, gowns, gloves, surgical mask Previous MRSA = private room only Old MRSA = no precautions 9

10 After three negative swabs (one week apart), we downgrade a patient from Positive to Previous. After three months (and they continue to test negative), we downgrade them to Old MRSA. If they are on ABx that has action against MRSA, I usually wait 48 hours after stopping to swab. 27. Name of Sender: Tracey Spencer address of Sender: spetr@bgh-on.ca 1. What are the required steps to deem a person MRSA negative? -We require 3 negative swabs from all positive sites taken at least a week apart. 2. What timeline and how many negative swabs required? -if a person is admitted and found to be positive we don t do any further swabs on that admission, the next set of swabs would be taken if the patient is readmitted at a later time. If those admission swabs are negative we would continue to do further swabs a week apart until we have 3 consecutive negatives, if any of those swabs are positive we would not continue to try and clear the patient 3. How long the patient should be off their antibiotic therapy before swabs can be collected? We wait until 48 hrs after effective antibiotic therapy has been discontinued 28. Name of Sender: Hilary McIver address of Sender: mciverh@tbh.net Our MRSA patients if colonized stay for 1 year and after one year we obtain both Nasal and rectal X 3 a week a part. The patient should be off antibiotic therapy at least hours or week (these are the standards we use) depending on the nature of the wound 29. Name of Sender: Brenda Wehbe address of Sender: bwehbe@hsnsudbury.ca 1. What are the required steps to deem a person MRSA negative? FOR NEW POSITIVES 3 SETS OF NEGATIVE SPECIMENS FOLLOWING DISCONTINUING OF APPROPRIATE ABX FOR 48 HRS. FOR PAST POSITIVE PATIENTS ON RE-ADMISSION, 1 SET OF SPECIMENS FOR ALL PREVIOUSLY POSITIVE SITES. 2. What timeline and how many negative swabs required? FOR ANY PAST POSITIVE PATIENT THEY ARE ISOLATED ON RE-ADMISSION UNTIL SPECIMENS OF PREVIOUS POSITIVE SITES ARE RESULTED AND NEGATIVE 3. How long the patient should be off their antibiotic therapy before swabs can be collected? 48 HOURS (ONLY THOSE ABX TO WHICH THE ARO IS SENSITIVE) 10

11 30. Name of Sender: Jim Gauthier address of Sender: We use the criteria of 3 negative cultures from previously positive sites, one week apart, to remove someone from isolation, we do not remove the flag on our electronic patient chart until 3 more negatives one month apart. We wait 48 hours after cessation of antibiotics before swabbing. 11