Does MRSA ever go away
Frequently asked questions (FAQ) about MRSA
The FAQ (Frequently Asked Questions) listed in the following subdirectory and their answers provide information from the MRE-Netz Rhein-Main. They were made available by EUREGIO MRSA-net Twente / Münsterland.
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Last update: May 11, 2009
- Microbiological screening costs money, are these costs effective? [Answer]
- Are there any risk factors for becoming a carrier of MRSA? [Answer]
- I have MRSA and I will be discharged soon. What do I have to do to protect my family from MRSA? [Answer]
- Is it Dangerous to be in the same room with a MRSA patient? [Answer]
- Can you treat MRSA? [Answer]
- Can my child get MRSA if they are around an MRSA carrier? [Answer]
- Can MRSA Spread? [Answer]
- Can MRSA carriers in the hospital be accommodated together in one room if one of them is already being rehabilitated? [Answer]
- Can MRSA carriers be accommodated together in one room in the hospital? Does this also apply to patients with different MRSA genotypes? [Answer]
- Do special protective measures have to be observed when a MRSA patient is discharged? [Answer]
- Are the new molecular rapid tests better than the classic cultural evidence? [Answer]
- When do staff have to be screened for MRSA? [Answer]
- Why is there repopulation in rehabilitated patients? [Answer]
- If risk factors are present, why does an examination for the presence of MRSA carrier have to be carried out before or upon admission to the clinic (screening examination)? [Answer]
- Why do you have to be patient when it comes to the rehabilitation of MRSA patients? [Answer]
- Why do MRSA patients only have to in the hospital Are isolated in a single room, but not at home, in the nursing home or in the doctor's office after they have been released? [Answer]
- Why are MRSA so much rarer in the Netherlands than in Germany? [Answer]
- Why are more than half of MRSA detected in German hospitals when patients are admitted? [Answer]
- What does "MRSA contact patient" mean? [Answer]
- What does MRSA mean? [Answer]
- What does redevelopment mean? [Answer]
- What does "community acquired" CA-MRSA mean? [Answer]
- What is the difference between infection and colonization? [Answer]
- What is meant by the MRSA cycle? [Answer]
- What does an examination for MRSA cost? [Answer]
- What is the difference between the Dutch “search and destroy” strategy and the German MRSA guidelines? [Answer]
- What significance does the initial screening of MRSA-risk patients have for the staff in the hospital? [Answer]
- What measures must be taken in the hospital for a patient with (suspected) MRSA? [Answer]
- What are the main strategies against the spread of MRSA? [Answer]
- How do you get MRSA and how common is MRSA in Germany? [Answer]
- How long can MRSA persist on the (mucous) skin of humans? [Answer]
- How long does an MRSA carrier have to be cared for in a single room with additional hygiene measures in the hospital? [Answer]
- How can MRSA be detected? [Answer]
- What does the rehabilitation of an MRSA carrier look like? [Answer]
- How is MRSA transmitted and how can it be avoided? [Answer]
- How is an examination done for MRSA? [Answer]
- Why is a one-time control smear after a renovation of a nursing home resident not enough to say that someone is finally MRSA-free? [Answer]
1. What does MRSA mean?
Staphylococcus aureus are bacteria that naturally appear on the mucous membrane of the nasal vestibule and, less frequently, on the skin of every third person, e.g. T. every second person live. Usually these bacteria do not cause infections. If the skin is injured or as a result of medical measures such as an operation, S. aureus can cause wound infections. Such infections can run dry (abscess, pus formation, etc.), but with a weakened immune system it can also lead to serious infections such as blood poisoning and pneumonia. In the event of infection, antibiotics help eliminate bacteria. Some Staphylococcus aureus have become insensitive (resistant) to the antibiotic "methicillin" and most other antibiotics. Such methicillin-resistant Staphylococcus aureus is called for short MRSA.
2. What is the difference between infection and colonization?
Colonization means that MRSA bacteria settle and multiply on the (mucous) skin of humans without causing an illness. Such patients are also called MRSA carriers. Infection means that the MRSA penetrates the body through the (mucous) skin and also makes the affected person sick. In both cases, the same hygiene measures must be carried out. The difference is that patients with colonization can be treated preventively, i.e. washing and nasal ointment are used to try to get the MRSA off the skin before it can trigger an infection. Patients with an infection also receive antibiotic therapy in tablet form or as an infusion. Patients who are only colonized are usually not given any antibiotics (tablets or infusions).
3. How do you get MRSA and how common is MRSA in Germany?
MRSA is a skin germ and you can get it from other people to your skin every day. However, MRSA cannot easily implant and spread on the (mucous) skin and in the body of a healthy person, since the healthy skin and mucous membrane (flora) of the person provides protection against MRSA (resistant to colonization). However, if you have certain risk factors, such as wounds, punctures, surgery, etc., frequent contact with MRSA patients or take antibiotics frequently and for a long time, MRSA can permanently adhere to the skin / mucous membrane and also cause infections. The risk factors mentioned are regularly found in patients in hospitals. If an infection does occur, it most often happens with the bacteria that already settle on the human skin. The more often MRSA occurs on the skin, the more often MRSA will be the cause of an infection. On average, MRSA is responsible for every fourth Staphylococcus aureus infection in German hospitals.
4. Are there any risk factors for becoming a carrier of MRSA?
Yes. MRSA can then nestle particularly easily on the skin and mucous membrane of a person if there are special factors, so-called risk factors for MRSA colonization.
These factors are mainly:
- A positive MRSA history, i.e. having once been a MRSA carrier, even if a successful rehabilitation has been carried out.
- Contact with an MRSA carrier
- Hospital stay (> 24 h) within the last 6 months or (<3 days) within the last 12 months in a German hospital (exception: the hospital is known to be MRSA-free)
- Stay in an old people's / senior's / nursing home (> 24 h) within the last 6 months (exception: facilities are known to be MRSA-free)
- Antibiotic therapy within the last 6 months
- Chronic dependency
- Catheter (DK, SPDK, PEG etc.)
- Dialysis requirement
- Open chronic wounds, deep soft tissue infections or ulcers ("open leg")
- Professional direct contact with animals in agricultural animal fattening (pigs)
5. If there are risk factors, why does an examination for the presence of MRSA carrier have to be carried out before or upon admission to the clinic (screening examination)?
Not all people carry MRSA on their skin / mucous membrane, and not everyone who has MRSA on their skin / mucous membrane can transmit MRSA to others. The knowledge about the MRSA carrier is first of all important for the individual patient who is facing medical treatment. Infections following medical measures, such as ventilation, surgery or immunosuppression, are often unavoidable and are most often caused by the bacteria that already live on the person. If MRSA is already alive on a person at the time of hospital admission, a later infection with MRSA can occur. Early and effective antibiotic treatment is decisive for the success of the therapy. The healing success depends on the correct choice of an effective antibiotic. The attending physician must use antibiotics based on empirical values when an infection occurs (so-called calculated antibiotic therapy). None of the antibiotics commonly used in such situations are sufficiently effective against MRSA. Valuable time is lost.
A smear upon admission therefore has a threefold meaning
- Protection of the affected MRSA carrier: If the carrier is known, rehabilitation can be attempted before the operation. Sanitation can significantly prevent infections (Perl TM et al 2002. N Engl J Med).
- A smear is a look into the future: If the doctor knows that his patient is MRSA carrier, he will include this pathogen in his calculated antibiotic therapy if an infection occurs.
- Protection of other patients: MRSA carriers receive special treatment in hospitals (!). You are in a single room and gloves and protective gowns prevent the transmission of MRSA through staff to other patients. The staff wears a face mask in order not to colonize themselves with MRSA in the long term - if unknown risk factors are present - and then to spread MRSA to other patients.
6. How is an examination for MRSA carried out?
To detect MRSA, a microbiological test must be done in a laboratory. For this purpose, a swab from the skin / mucous membrane (mostly nasal vestibule, throat, possibly wounds, less often armpits, groin) is carried out with a cotton swab or polyurethane swab. A laboratory determines the presence of MRSA through a culture record. If no MRSA is detected, the person examined is considered MRSA negative. If the result has to be available quickly (upcoming surgery, etc.), a rapid test (molecular method) can be carried out.
7. Are the new molecular rapid tests better than the classic culture evidence?
The gold standard for the detection of MRSA is the microbiological cultural detection of MRSA. Modern molecular methods are very promising and, above all, due to their very high speed and sensitivity, they are suitable for excluding MRSA carriers. Positive rapid test results must be confirmed culturally. The importance of positive rapid test evidence without evidence of culture, especially in examinations after remediation or under antibiotic therapy, has not yet been clarified and the aim of several examinations.
8. What does an examination for MRSA cost?
The “perceived” costs of a microbiological examination for the detection of MRSA are higher than the real costs. One can assume costs of 3 to 15 €. If MRSA is detected, the costs are around € 35 to € 75. As a result, there are additional costs due to necessary control cuts etc.
Each new transmission of MRSA to another patient causes additional costs of around € 3,000 to € 6,000. Screening high-risk patients is therefore always worthwhile.
Note: Quick test procedures are sometimes 3 to 10 times more expensive than cultural procedures. The added value of the significantly shorter detection time must decide whether to use it.
9. Microbiological screening costs money, are these costs effective?
Many studies show that in-hospital screening programs for MRSA are cost-effective (Karchmer 2002 J Hosp Inf, Jernigan JA 1995. Inf Control Hosp Epidem, Wernitz et al. 2006. J Clin Microbiol., Chaix C, et al. JAMA 1999, Diller et al al. 2007).
Each MRSA infection causes additional costs of up to € 17,000. Since MRSA spreads clonally and 25% of colonizations lead to an infection, each new colonization means up to € 4,000 additional costs. The average cost of a screening program is between € 3 and € 15 per patient. 260 to 1,300 swab examinations are already cost-effective if a single MRSA transmission is avoided.
10. What measures must be taken in the hospital for a patient with (suspected) MRSA?
- As an MRSA patient, you will be cared for in a single room or together with other MRSA carriers in isolation to prevent the germ from spreading to other people.
- The staff will come to you in the room with protective gowns, mouth and nose protection and gloves, if necessary a hood. Hand disinfection is carried out before staff or you leave the room. Protective clothing is removed beforehand.
- Your visitors must also wear protective clothing and disinfect their hands when leaving the room.
- If necessary, rehabilitation therapy (see below) will be carried out on you after consultation with your treating doctor.
- Smears will be taken from you from the nasal vestibule and, if necessary, from the throat, the region around the anus and from wounds, etc. These are sent to the laboratory for examination. If no MRSA is found 3 times in a row in these smears, they are provisionally "MRSA-negative"; and the special hygiene measures can be lifted.
- Please remember that you should have another two or three checks within 12 months to see whether the result is still negative.
- Whenever you visit a doctor or stay in hospital, mention that you have been MRSA positive so that it can be checked that the MRSA is still no longer on your skin. This procedure is for your own protection.
11. How can MRSA be detected?
MRSA can be detected on the skin, mucous membrane of the nasal vestibules, in the throat, under the armpits, the hairline, in the groin, and in the stool / rectum, in infections in the wound, in the blood and in the urine. The nasal atrium, throat, and wound are examined most often. Such an examination is carried out using a swab. The average cost of such a swab is around € 3 to € 15 (see questions 6 and 8).
12. Can MRSA spread?
Yes. MRSA can spread to other patients. The MRSA often disappears from the skin. An infection can only occur if someone has injured skin (wounds, etc.) or is very ill and also has a weak immune system. The simple transmission is usually not enough for MRSA to remain permanently on the skin of the "recipient", which in turn would be a prerequisite for further transmissions and cannot be controlled by regular hand disinfection. This happens when certain risk factors are present. It is not the simple carrier but the "carrier" or "spreader" that is of epidemiological interest. Since patients in hospitals often have multiple risk factors, MRSA is the easiest to transmit between patients in acute hospitals.
Once again with great clarity !: Caution!, don't be fooled into thinking that MRSA can be transmitted through any contact you can think of. All considerations on this are mostly of a theoretical nature and overlook the fact that the transmission of an MRSA pathogen does not follow mathematical, but biological principles and the following basic requirements are necessary:
- Sufficient number of MRSA bacteria on the skin of the MRSA carrier,
- Direct and repeated contact (exposure) with colonized body surfaces of the MRSA carrier,
- Transmission of a sufficient number of MRSA bacteria from one patient to another,
- Reaching the skin / mucous membrane of the contact person,
- Multiplication and penetration of the MRSA bacteria on the skin of the contact person,
- The contact person has risk factors (antibiotics, wounds, catheters, etc.).
MRSA can survive in the environment and from there get onto a person's skin. For this, however, frequent contact several times a day is necessary again. This situation is only found in communal facilities. For this reason, special surface disinfection measures are necessary there.
13. What does "MRSA contact patient" mean?
If you are an MRSA contact patient, it means that you share or have shared the room with an MRSA carrier. This means that there is a possibility that you are also colonized with this pathogen. In order to rule out or to confirm this, you must also take swabs once for an examination for MRSA.If you are going to be re-admitted to a hospital in the future, please indicate that you have already had contact with an MRSA patient so that your settlement status can be checked for your own protection and that of your fellow patients.
14. How is MRSA transmitted and how can it be avoided?
As explained above, MRSA is mainly transmitted in acute hospitals. Transmission almost always takes place through contact and extremely rarely through droplets and not through the air. The most important measure to avoid transmission is to know if someone is MRSA carrier. However, smear tests must be carried out for this. In addition, then only in the hospital Special precautionary measures (protective gown, face mask, gloves, if necessary hair protection, single room) are used to prevent spreading to other patients. None of these measures are necessary in the nursing home, in the doctor's office, in the ambulance and certainly not at home. Depending on the activity, the application of well-considered standard hygiene (avoidance of contact with wounds, sequence of treatments or activities, hand hygiene, etc.) and hygiene measures adapted to the situation are completely sufficient.
15. Can you treat MRSA?
Yes. Although MRSA is resistant to most antibiotics, there are so-called reserve antibiotics that can be used to treat MRSA. These antibiotics are usually only given in the hospital. In any case, MRSA must also be removed from the skin and mucous membrane of the patient (so-called remedial therapy) so that the basis for future infections with this pathogen is eliminated.
16. What does redevelopment mean?
The so-called remediation or remediation therapy is used to remove the MRSA bacteria from the skin and the mucous membranes of the wearer. In healthy people without risk factors, MRSA can be easily removed from its main reservoir, the nasal vestibule. For this purpose antibiotic or antiseptic effective nasal ointments are used. The MRSA is removed within a few days and the success of the renovation must be confirmed with a swab. The success rate of this simple renovation is very high and permanent. If there are factors that inhibit rehabilitation (wound, catheter, etc.), it is often necessary to wait for the factor to heal or end before proceeding with the final MRSA rehabilitation. Nevertheless, in this phase, rehabilitation therapy to reduce germs can be useful in order to avoid an MRSA infection (e.g. a wound that has not yet germinated) by reducing MRSA colonization (e.g. in the nose).
17. How long can MRSA stay on the (mucous) skin of humans?
The duration of the colonization depends on whether there are any factors that inhibit rehabilitation, such as an ulcer, catheter or antibiotics. Rehabilitation is then less successful and the patient can carry MRSA for up to 40 months or more. In most cases, if there are no factors that inhibit renovation, renovation can be completed within 2 weeks. Without renovation-inhibiting factors and without renovation, the duration of the project can last up to 1 year and longer.
18. How long must an MRSA carrier be cared for in a hospital in a single room with additional hygiene measures?
All efforts are directed towards the therapy of the underlying disease (e.g. wound, decubitus) and the subsequent sanitation of the MRSA carrier in order to get the MRSA away from the patient's skin and mucous membrane. The attending doctor, together with the doctor for microbiology and the doctor for hygiene, decides how long a rehabilitation must be carried out. The special hygiene measures only have to be carried out in the hospital until the MRSA is no longer detected on the skin / mucous membrane. Depending on the underlying disease (e.g. wound), the rehabilitation therapy can take days, weeks or even longer. In any case, it must be continued and monitored even after discharge from the hospital, even if the primary focus is on curing the underlying disease.
19. Do special protective measures have to be observed when a MRSA patient is discharged?
- Retirement / nursing homes
- doctor's office
- at home
- With outpatient care or home care
During the ambulance, a transfer to the staff is only possible if it is closed intense Contact or more direct Personnel exposure during dressing changes or intubation occurs. For this reason, a face mask is only to be worn by the staff in these last-mentioned situations. (Exception: stay in the MRSA patient room). Otherwise it is only necessary to wear gloves and a protective gown if there is direct contact. Immediate hand disinfection is required after taking off the protective clothing. The wearing of white, liquid-tight protective overalls with a hood and a half mask / face mask should not be worn when transporting MRSA patients. The excessive protection leads to insecurity for relatives or roommates and to unnecessary costs. These should be used specifically for consistent compliance with standard hygiene, hand disinfection and training.
The KRINKO Commission at the RKI has clear recommendations for dealing with MRSA carriers in nursing homes. MRSA carriers do not have to be cared for in isolation, situation-adapted hygiene measures are sufficient and extended measures are only necessary in rare cases in the event of direct contact. The consistent continuation of a rehabilitation therapy is in the foreground. This can initially consist in the healing of the underlying disease (wound, decubitus) until the actual MRSA treatment (see above) takes place.
In no case are measures required in the doctor's office as in the hospital. Good practice logistics (do not let MRSA patients wade in the overcrowded waiting room) and consistent standard hygiene (including hand disinfection) are required here. Here, too, the focus is on the consistent continuation of remedial therapy. This can initially consist in the healing of the underlying disease (wound, decubitus) until the actual MRSA treatment (see above) takes place. In any case, the success of the final MRSA remediation must be checked.
Carriers of classic MRSA that are acquired in hospitals do not pose a threat to their relatives. Contact persons who have open wounds or are severely immunocompromised should adhere to personal hygiene - not just because of the MRSA. Pregnant women are not particularly at risk and, in addition to good personal hygiene, should wash their hands after contact with an MRSA patient.
In general, the measures are to be applied analogously to the Home Directive. When dealing directly with infected wounds, secretions, stool, etc., protective measures such as gloves should be used and hand disinfection should be carried out afterwards. Please ask the attending physician, a hygienist / microbiologist, on a case-by-case basis.
20. Is it dangerous to be in the same room with a MRSA patient?
In all clarity: For healthy people, the risk of an MRSA infection (triggered by classic hospital-acquired MRSA - haMRSA) is negligible. Of course, as with all infections, there is a residual medical risk. As long as relatives and visitors are healthy, it does no harm to be in a room with an MRSA patient. Normal contact, such as shaking hands or hugging, is possible. After contact, the hands should be washed preventively and, if necessary, disinfected.
21. Why do MRSA patients only have to in the hospital Are isolated in a single room, but not at home, in the nursing home or in the doctor's office after they have been released?
MRSA can be particularly problematic in the hospital for three reasons:
- Cohort situation
- Frequent contact
- Selection by antibiotics
Continuous presence of many patients, some of whom are severely immunocompromised or operated on and ventilated, etc.; MRSA can spread in hospitals for weeks to months without any measures.
Countermeasures: special hygiene measures (gloves, face mask, protective gown, etc.), isolation in the single room
Care, often intensive care with hundreds of hand contacts from patient to patient.
Countermeasures: Hand hygiene, gloves
Up to 50% of patients receive antibiotics. This antibiotic selection pressure means that MRSA carriers can spread the pathogen, MRSA can easily establish itself on the skin / mucous membrane of contact persons and can be transmitted again from there. For this reason, personnel are relatively protected. Frequent and continuous contact with MRSA patients can nevertheless lead to staff becoming long-term carriers.
Countermeasures: Controlled administration of antibiotics
If one of the three factors mentioned is already missing, MRSA can only be transmitted in rare cases. Simple hygiene is sufficient to prevent MRSA from being transmitted efficiently from person to person.
22. Can my child get MRSA if they are near an MRSA carrier?
Healthy people, including children, have a negligible risk of developing MRSA infections. Only in so-called community acquired MRSA [CA-MRSA] are children and adolescents particularly at risk. However, these MRSA are not to be confused with conventional hospital-acquired MRSA. They are not found in the elderly and the sick, but in young people who have not previously been to the hospital.
23. I have MRSA and I will be discharged soon. What do I have to do to protect my family from MRSA?
Any rehabilitation therapy that has been started should be continued after discharge. If no remedial therapy has been started, one should be carried out through the family doctor. If you are colonized or infected with MRSA, you should - in addition to any therapy - observe the following measures to prevent the spread of MRSA in your family.
- Follow good personal hygiene.
- Mention to any caregiver / nurse or doctor or before and during your next hospital stay that you have had MRSA. In this way, measures can be taken and remedial therapy can be started.
24. Why are more than half of MRSA detected in German hospitals when patients are admitted?
Publications show that in Germany more than 50% of the MRSA detected are already positive at the time of admission. Investigations of the genetic fingerprint of MRSA on discharge, in old people's homes, in the doctor's office and on readmission show that it is often the same MRSA strains that circulate in this cycle of inpatient and outpatient care. The mean duration of wear is - depending on the existing risk factors - between 6 months and 4 years. This also explains why entry screening is so important in preventing the spread of MRSA. If a MRSA carrier is not identified early on on re-admission and no special hygiene measures are taken, MRSA can be transmitted to other people with each hospital stay. The MRSA circuit continues to spin and becomes an ascending spiral.
25. What are the main strategies against the spread of MRSA?
Basically, the following measures are necessary to slow down the MRSA IUD:
1. Controlled and rational antibiotic therapy in inpatient and outpatient medical care
i.e. as many antibiotics as necessary and as little as possible
- Implementation of the hygiene measures in accordance with the valid recommendations (especially hand hygiene)
- Isolated care of all MRSA carriers and MRSA infected people in the hospital
i.e. MRSA cannot be controlled in the hospital with normal hygiene measures such as solely relying on regular hand disinfection.
- 3. Surveillance
- The early laboratory diagnostic identification of carriers (screening) in order to avoid nosocomial transmission as early as possible.
- Typing of MRSA in order to recognize transmission chains and to gain an overview of the dynamics of the spread and the persistence in the patient
i.e. MRSA is not the same as MRSA. The more than 1000 different MRSA can be differentiated by typing.
- 4. Therapy and remediation
of infected or colonized persons during and especially after their inpatient stay
i.e. have a long breath and continue to care for MRSA patients. This can also mean treating the underlying disease first and then targeting the treatment of MRSA.
- 5. Education of the population
i.e. everyone needs to know what MRSA means and what it is Not it is an infectious disease such as avian flu or SARS; In addition, it must be clear to everyone that MRSA can only be solved across institutions and that everyone has to help.
- 6. Networking
i.e. the separation of inpatient and outpatient medical care has many advantages for people. However, dangers and problems such as MRSA must be addressed through a networked approach. In the case of MRSA, this cooperation must take place along the MRSA cycle and include all actors who deal with MRSA on a daily basis (hospitals, medical practices, laboratories, old people's / nursing homes, health authorities, health insurance companies, etc.).
26. What is meant by the MRSA cycle?
MRSA clean-up takes longer than the average inpatient stay. Patients therefore leave the hospital with MRSA on their skin. This is not a problem for fellow human beings as long as they do not have open wounds or a severely weakened immune system. Special hygiene measures are therefore not required outside of hospitals for this type of MRSA. However, there is a problem: Since there is a risk of transmission to other patients again during the next hospital stay, everything must be done so that the affected patients are no longer colonized with MRSA (rehabilitation, professional wound management). The MRSA patient must continue to be cared for from the acute hospital, through the rehabilitation clinic, the resident doctor, in the old people's and nursing home up to the next hospital stay with the involvement of the local MRSA experts (doctors for microbiology, doctors for hygiene) and the health authorities become. All actors in the health care system must now help together along the MRSA cycle (joint task).
27. Why do you have to be patient when rehabilitating MRSA patients?
All actors along the MRSA cycle must help treat MRSA in those affected (so-called rehabilitation therapy, professional wound management). This must also be done if the patient has no infection and the MRSA only "lives" on the patient's skin (colonization), whereby it does not cause any disease. While special hygiene measures (such as single rooms and face masks) are in the foreground in the hospital, the consistent further treatment of MRSA is particularly important outside the hospital.
Starting in the acute hospital, through the rehabilitation clinic, the doctor's office, the old people's / nursing home up to the next hospital stay, an MRSA patient must be continuously looked after, if necessary with the involvement of MRSA specialists (doctors for microbiology, hygienists) and the health authorities until the MRSA can no longer be detected on the skin. Only through this preventive treatment can future infection and transmission to others be prevented. In any case, smears must be taken to monitor success. MRSA treatment usually lasts about 2 weeks. If there are risk factors with proven MRSA contamination (e.g. chronic wounds, foreign bodies such as catheters, antibiotics), the risk factor often has to be cured first, so that in rare cases MRSA treatment can only be successful after months to years. Here the practitioner and the patient have to have a lot of staying power. However, if there are risk factors without proven contamination (e.g. open wound without MRSA evidence) and evidence of MRSA colonization elsewhere (e.g. nose), remedial measures should be sought right from the start in order to prevent infection (e.g. the open wound) by MRSA.
28. What does “community acquired” CA-MRSA mean?
The dimension of the MRSA problem has been exacerbated in recent years by the occurrence of MRSA infections that are acquired outside of the hospital by healthy people [CA-MRSA]. The latter represent a completely new category of MRSA and should not be confused with the MRSA problem in hospitals. CA-MRSA are able to cause serious infections, even in healthy people outside of hospitals, which in some cases can be fatal (e.g. fatal abscessing bronchopneumonia). Sooner or later, people colonized or infected with CA-MRSA will be admitted to hospitals, where they will exacerbate the already existing MRSA situation. Entry screenings and microbiological diagnostics are the most effective protection against this risk.
29. Can MRSA carriers be accommodated together in the same room in the hospital? Does this also apply to patients with different MRSA genotypes?
Yes. MRSA carriers can be accommodated together in a double patient room.This also applies in the event that different MRSA genotypes are present in the patients. Colonization with two different MRSA clones is considered a very rare occurrence and can be neglected. An exception is when one of the MRSA is highly virulent community acquired [CA-MRSA]. These often have the PVL toxin, fusidic acid resistance or belong to certain spa types (e.g. t044, t008, t002, etc.).
30. Can MRSA carriers be accommodated together in the same room in the hospital if one of them is already being rehabilitated?
Basically yes. Of course, there is a risk that patients who are already in an advanced phase of the rehabilitation will be repopulated by the patient who is only just beginning the rehabilitation. Phases B, C, D (see question 31) are to be adapted so that patient rehabilitation is syntonized. The success rate of the renovation is, however, lower than for renovation in a single room.
31. What does the rehabilitation of an MRSA carrier look like?
The final removal of MRSA from a person's skin and mucous membrane is called sanitation. If there are factors that facilitate the presence of MRSA (factors that inhibit rehabilitation: antibiotic therapy, wound, MRSA infection, catheter, etc.), rehabilitation can only be successful in rare cases. Here the healing or termination of these factors is in the foreground. Nasal ointments or skin washes used during this time can, however, reduce the number of MRSA in individual cases in order to prevent infection. But be careful! This can stress the patient's skin / mucous membrane. Precise consideration is therefore necessary. If there is no risk factor (e.g. in the case of staff, children) or if the risk factor has been eliminated (wound "granulated"), the final rehabilitation can be started.
A distinction must be made here between six phases of renovation:
- Phase A (smear): A patient is at risk of MRSA and needs to be wiped out. If there is no settlement status of the predilection sites for MRSA, a colonization status (nasal vestibule, throat, armpits, groin or rectum, possibly wound) must be ascertained before treatment.
- Phase B (treatment): If the patient does not have any inhibiting factors, the patient receives MRSA treatment (rehabilitation). This is individually adapted and, depending on the underlying disease, consists of the use of an antibiotic nasal ointment, possibly throat rinse or tablets and a disinfecting shampoo / hair conditioner. The duration of the treatment phase is usually between 5 and 7 days.
- Phase C (break): This phase is necessary so that residues of antimicrobial substances do not produce false negative smear results. The duration of this phase can last 2 to 4 days (RKI: 3 days).
- Phase D (success control) Control smears: If the cultural evidence is used, 3 smears must be taken in the hospital on three consecutive days at all previously MRSA-positive locations. In individual cases, it is possible to talk to the laboratory about the possibility of partial "pooling" of the swabs in the laboratory (!). When checking, it is initially only of interest whether the patient is MRSA-free. In the doctor's office, a smear control is sufficient.
- Phase E (repetitive smears): Since it is known that up to 50% of the rehabilitated people will repopulate within a year, control smears are necessary. The frequency of smears differs depending on whether the patient is being treated as an inpatient or an outpatient. In the hospital, smear controls are carried out after 1 month, between the 3rd and 6th or after 12 months. In the doctor's office, control smears are taken between the 3rd and 6th month and the 6th and 12th month after the sanitation (note the smear results from hospital stays!)
- Phase F (free): After 12 months and negative MRSA smears, the rehabilitated person is considered MRSA-free. However, he has a positive MRSA history and must be screened upon admission to hospital and prophylactically isolated until exclusion.
32. What significance does the initial screening of MRSA-risk patients have for the staff in the hospital?
Personnel are only colonized with MRSA because they have contact with MRSA patients without protecting themselves. In the rarest of cases, this is due to the fact that nurses and doctors do not adhere to the hygiene measures. No, this is mainly because hospitals do not check MRSA-risk patients for MRSA upon admission and thus do not make MRSA visible to their staff.
Again! In the hospital, you can only protect yourself from MRSA colonization if you take special measures. These can only be carried out for the entire duration of the stay and for all invasive measures if it is known that a patient has MRSA. This is all the more important when highly virulent community-acquired MRSA is circulating in the region in which the hospital is located. In any case, the information in TRBA 250 applies to the protection of personnel against MRSA.
33. When do staff have to be examined for MRSA?
Healthy personnel only need to be screened for MRSA if they are MRSA carriers. This may be necessary in the hospital, less often in the old people's / nursing home. In the doctor's office, in the ambulance service and at home, preventive screening of personnel is neither sensible nor hygienically necessary. Again, with great clarity! Not the short-term MRSA carrier, but the real MRSA carrier is important and should be remedied by MRSA. Routine screening of staff or screening directly after MRSA contact therefore makes no sense. There is a risk that random short-term carriers will be identified that are no longer carriers after a few days and therefore cannot spread MRSA. For this reason, primary MRSA isolates from patients in the hospital spa should be typed. If two or more MRSA with an identical spa type occur on a ward without another plausible reason for the transmission (e.g. same room / bathroom), then it is obvious that an MRSA carrier is working on the ward . In this case it makes sense to screen the personnel who are considered to be carriers. This approach can save a lot of money and keep staff out of trouble.
34. Why is there repopulation in rehabilitated patients?
Repopulation with MRSA can have different causes (e.g. frustrating remediation, inadequate remediation concept in the presence of factors that inhibit remediation, repopulation through household contacts colonized with MRSA, repopulation through new MRSA, additional MRSA reservoir). In order to understand the cause, a spa typing of the two isolates (before and after remediation) can be useful. After researching the possible causes of the repopulation, a second remediation cycle can be carried out after consulting an MRSA expert. In a second rehabilitation cycle, systemic antibiosis that is effective against MRSA may also be necessary in individual cases, which must be coordinated with a specialist in microbiology in each case.
35. Why are MRSA so much rarer in the Netherlands than in Germany?
In the Netherlands, the fight against MRSA began in the early 1980s. Since then, guidelines have been implemented that include a search for MRSA-colonized patients, consistent contact isolation of MRSA patients in hospitals and sustainable decontamination (destroy) of the germ in MRSA-positive patients. This strategy is therefore also called “search and destroy policy”. In Germany, the spread of MRSA and its importance as a cause of hospital-associated infections were only recognized later, so that MRSA was able to spread widely before the introduction of MRSA control measures. In addition, Dutch research groups state that the consumption of antibiotics in the Netherlands is very low, which has a positive effect on the pressure of multi-resistant pathogens to develop. The lowering of the MRSA rate in the Netherlands is therefore favored by the greater general acceptance of the preventive measures considered necessary, the consistent auditing of facilities such as hospitals, the very cautious use of antibiotics, a close network of outpatient and inpatient care facilities and the consistent treatment of MRSA carriers in the outpatient sector.
Finally, the different structure of the two health systems must be taken into account. On the one hand, the number of patient beds per 1000 inhabitants in the NL is around 40-50% lower than in Germany, on the other hand, specialists are only available in hospitals and polyclinics and not in their own practice as in Germany.
36. What is the difference between the Dutch “search and destroy” strategy and the German MRSA guidelines?
The general handling of MRSA patients and the special hygiene measures applied (isolation, coat care, face mask, gloves, hand disinfection) do not differ significantly. The difference lies in the targeted search for MRSA carriers among the patients. The Dutch MRSA guidelines define weighted (high, medium, low) risk groups that have an increased probability of MRSA colonization. In the NL, these are mainly patients who were treated as inpatients within a certain period of time in hospitals abroad (in countries with a high MRSA incidence, such as Germany, Belgium, Japan, UK). These patients are prophylactically isolated in a single room until MRSA colonization has been ruled out. Overall, it is estimated that around 10-40% of MRSA in Dutch hospitals is imported from foreign hospitals. The German MRSA guideline also defines risk factors that make MRSA more likely and smear screening of patients with these risk factors is required. Since MRSA is now endemic in Germany, patients who were cared for in a German hospital would also have to be screened.
37. Why is a one-time control smear after a renovation of residents of old people's homes not enough to say that someone is finally MRSA-free?
In fact, it is known that up to 40% of patients become positive again within the following months after rehabilitation. The reasons have not yet been adequately clarified. The remaining risk factor, a new acquisition of MRSA or failure of the renovation are discussed. Since an average duration of wearer of 1 year and longer is described, it was determined for the EUREGIO that a patient in the outpatient area counts as provisionally negative after a single negative smear (nasal atrium, throat, possibly wound or previously positive area). However, it only becomes definitively negative after a 2nd (3-6 months) and a 3rd (6-12 months) smear. During this time, it must only be noted that if the patient is admitted to an acute hospital, prophylactic isolation must be carried out until exclusion, as there is a positive MRSA history. In the doctor's practice, in the nursing home and at home, no measures beyond standard hygiene are required in this phase.
The 3 negative smears on three consecutive days are only used for stripping in the hospital.
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