Clinicians advise strict policy for first VRSA case

Limit HCW contact with patient

The following infection control measures are recommended by medical epidemiologists in the event of the appearance of vancomycin-resistant Staphylococcus aureus in a clinical setting.1 Summarized below, the recommendations are based on limited data and individual institutions may adopt some or all of the proposals depending on local circumstances and resources, the authors note.

Isolation of infected/colonized patients: A patient who is infected or colonized with VRSA should be placed in a private room, and all persons entering the room should wear clean, nonsterile gloves and a disposable gown. Gloves and gowns should be removed before leaving the room. After the gloves are removed, hand washing with 4% chlorhexidine or 60% isopropyl alcohol is required. A monitor could be placed at the door to prevent unauthorized access and to enforce hand washing and barrier precautions. The names of all persons entering the room should be recorded for future use should obtaining nasal surveillance cultures become necessary.

A standard surgical mask and safety glasses must be worn by persons doing procedures that might generate an aerosol (i.e., suction, bronchoscopy). Patients with VRSA pneumonia requiring mechanical ventilation should have a filter or condensate trap placed on the expiratory phase tubing of the mechanical ventilator circuit. If oxygen therapy by nasal cannula is required, a standard surgical mask should be worn by all persons entering the room. Although few data support the idea that airborne transmission of staphylococci is possible, we prefer a conservative approach until the epidemiology of VRSA is delineated. Sharing of noncritical equipment such as electronic thermometers, blood pressure cuffs, stethoscopes, intravenous poles, bedside commodes, and wheelchairs is not permitted. Isolation must continue for the duration of the hospital stay.

Decolonization/antibiotic use: If the patient is colonized in the nares, decolonization with mupirocin should be attempted. However, because clinical isolates have not been available for the performance of susceptibility testing, the activity of mupirocin against VRSA is unknown. We do not recommend adding other drugs, such as rifampin or trimethoprim-sulfamethoxazole, because these drugs have not been necessary with mupirocin and — unlike mupirocin — may cause serious adverse effects. Infectious disease consultants should review the patient’s antimicrobial therapy, making every effort to reduce the selection of VRSA by eliminating or substituting antibiotics. Prudent use of antimicrobial agents should be stressed in both inpatient and outpatient settings, even before the emergence of VRSA. Vancomycin use should be reduced throughout the hospital.

Health care workers: The number of health care workers who have contact with the infected or colonized patient should be limited. Care of the patient should be done by no more than one nurse and one physician per shift when possible. Phlebotomy and other ancillary services should be done by the primary nurse or primary physician. Until more is learned about the epidemiology of VRSA, all health care workers caring for the patient should have nasal surveillance cultures done every two weeks. Health care workers known to be at higher risk for staphylococcal colonization (those with exfoliative dermatitides or diabetes mellitus requiring treatment with insulin) should not care for patients with VRSA.

Environmental cleaning: Housekeeping personnel should be instructed to clean all horizontal surfaces in the patient’s immediate vicinity daily with a quaternary ammonium compound. Cleaning cloths used in the room should not be used to clean other patients’ rooms and equipment, but should be carefully discarded. After the infected or colonized patient is discharged and housekeeping personnel have completed terminal disinfection of the room, environmental cultures should be obtained. The room should remain closed to new admissions until negative cultures have been reported. All equipment used in the room must be disinfected.

Discharge/readmissions/unit transfers: An epidemiology alert sticker should be affixed to the cover of the patient’s chart, and a notation should be made in the hospital’s information system. Any patient with previous VRSA infection or colonization who is readmitted should be placed in isolation immediately. Isolation should continue until surveillance cultures of the nares and of any previously infected, open sites have been obtained and are negative. If nosocomial transmission is documented on a hospital unit, the unit should be closed to new admissions. Any previously uninfected patient from this unit who requires transfer to another hospital unit should be placed in isolation in the receiving unit until two nasal cultures — 48 hours apart — are negative.

Reference

1. Edmond MB, Wenzel RP, Pasculle AW. Vancomycin-resistant Staphylococcus aureus: Perspectives on measures needed for control. Ann Intern Med 1996; 124:329-334.