SPONSORS

INFECTION CONTROL
MRSA Prevention:
A Guide for Environmental Services

First discovered in the United Kingdom in 1961, Methicillin-resistant Staphylococcus aureus (MRSA) is now found worldwide. Though the majority of MRSA infections occur among patients in hospitals or other health care settings, it is becoming more common in the community setting as seen by the numerous outbreaks in schools across the nation in 2007. In fact, a 2003 Journal of American Medicine study suggests that 12% of clinical MRSA infections are community- associated, though this varies by geographic region and population.

MRSA prevention requires constant vigilance, training and
education; however, by working together we can make our
facilities cleaner, safer and healthier places to be.

MRSA and People
Outbreaks of MRSA are now being reported in schools, daycare centers and other community settings. Community associated MRSA infections, some of which are severe enough to be fatal, are genetically different from hospital or health care associated MRSA. This shows that the community strains did not “escape” from the hospital but rather that they became resistant on their own. Because MRSA spreads on contaminated objects as well as through direct contact, it is difficult to eradicate in environments that have a fluid population such as schools, hospitals and other settings like daycare centers and sports facilities.

MRSA can affect people in two ways: colonization or infection. When a person carries the flora on his skin or in his nose without showing any signs or symptoms of infection, the person is said to be “colonized.” If a person has signs of infection that are caused by MRSA, such as abscesses, wound infections, blood, stool or urinary tract infections, the person is said to be “infected.” Approximately 25% to 30% of the population is colonized in the nose with staph bacteria. Staph bacteria, including MRSA, can cause skin infections that look like a pimple or boil. These can be red, swollen, painful or tender, warm to the touch and may also have pus or other drainage. If left untreated, these can develop into more serious infections, causing pneumonia, bloodstream infections or surgical wound infections.

How MRSA is Transmitted
MRSA and other types of staph bacteria are spread either by direct physical contact or indirect touching of contaminated objects. In hospitals, this can happen through patient-to-patient contact, contaminated surfaces or equipment, or contaminated hands of health care workers. In schools it can be transmitted by close contact sports (e.g. football, wrestling, lacrosse, etc.), or shared sports equipment such as mats, jerseys or weights or personal items such as towels and razors. In some cases, coaches, staff or students who come into contact with colonized individuals can contract the bacteria.

A study conducted over 15 years ago found that methicillinresistant Staphylococcus aureus (MRSA) and other infection causing germs like Acinetobacter left thousands of viable cells on the surface after 25 days under dry conditions.i If MRSA and other pathogenic organisms are present and able to survive on surfaces for long periods of time, then there would seem to be an obvious relationship between the level of contamination and infection rate, but studies looking at these relationships have had mixed results.

The reason gaps still exist when attempting to conclusively connect poor surface disinfection and transmission of MRSA is that it is difficult to test for all the variables that could cause an outbreak even in clinical conditions. Disinfection alone might improve infection rates, but needs to be part of an overall system to help prevent MRSA transmission that includes personal hygiene, hand washing and other behaviors that reduce germs.

Beyond hard surface disinfection, “soft” surfaces should also be taken into consideration. One study that looked at 22 strains of both antibiotic sensitive and resistant Staphylococci and Enterococci on hospital linens such as scrubs, lab coats, privacy drapes, and aprons, found all strains survived for at least one day. Some survived for more than 90 days. Though antibiotic resistance or sensitivity had no impact on how long these organisms survived on fabric, this study underscores the need to clean all types of surfaces that could potentially spread MRSA.ii

In another study conducted at Tripler Army Medical Center in Honolulu, swab samples of computer keyboards and faucet handles within a hospital found the colonization rate for keyboards and faucets in occupied and unoccupied rooms was about the same (26% and 24% for keyboards; 15% and 11% for faucets, respectively). MRSA was present on 49% of the samples collected. What was telling about the study was that it found the same strain of MRSA from two patients was linked to the faucet handles and keyboards in their respective rooms and other keyboards throughout the ICU, including the doctor’s station. To resolve the problem the facility began using protective keyboard covers and hands-free faucets and cleaning the areas daily. Still it shows the need for a comprehensive, multi-layered approach to MRSA prevention.iii Though this study was in a hospital setting, best practices from that environment can be applied within school facilities as well.

Cleaning and MRSA
Careful cleaning and disinfection substantially helps the overall control of MRSA transmission but needs to be done on a regular basis to be effective. Housekeeping surfaces can be divided into two groups–those with minimal hand contact (e.g., floors and ceilings) and those with frequent hand contact (high touch surfaces). High touch surfaces in health care and school environments include: toilet handles, toilet lids, sinks, door knobs, hand rails (in stairwells and handicapped restroom stalls), telephones, elevator buttons, tables and chair armrests.

The methods, thoroughness, frequency of cleaning and the products used are typically determined by the individual facility’s preference. Generally speaking though, high-touch housekeeping surfaces in high traffic areas should be cleaned and disinfected more frequently than surfaces with minimal hand contact. In health care facilities, infection control practitioners typically use a risk-assessment approach to identify high-touch surfaces and then coordinate an appropriate cleaning and disinfecting strategy and schedule with the housekeeping staff.iv Within schools, administrators and facilities managers can take a similar approach to prioritize what areas like restrooms, locker rooms and the nurses office have a higher risk for transmission and require more frequent cleaning and disinfection.

There are many EPA-registered hard surface disinfectant products available for schools and hospitals that can be used to clean hard surfaces and kill MRSA bacteria. Within hospitals, it is recommended that EPA-registered hospital disinfectants, which bear a claim of effectiveness against MRSA, be used according to the manufacturer’s instructions. This is very important because manufacturers know the features and limitations of the chemical composition and at what dilution it is effective at killing germs.v Some factors that impact the efficacy of a disinfectant include:

• Its active ingredients;
• Its concentration;
• How long it is used to treat a surface or its exposure time;
• The temperature and pH of the product; and
• The hardness of the water used to dilute the product.

The most important information for the end-user is the dilution specified on the label. It is imperative that disinfectants be diluted properly or they will not clean and disinfect properly.

Disinfectants that are diluted to be a higher concentration than the label recommends can be toxic to individuals or the environment, causing skin and lung irritation or tissue damage and is a violation of federal law.vi Another thing to keep in mind is the local regulations about the disposal of certain chemical germicides in the sewer system.vii In some cases, high levels of disinfectants have been known to kill the organisms used in waste water treatment.

In contrast, using too low of a concentration does not kill germs properly. When in doubt about what pathogens a disinfectant is effective against or proper usage, read the label carefully or contact the manufacturer for guidance.

With high employee turnover and frequent language barriers, consistent training in proper procedures is also key to helping ensure a clean and disinfected environment. It is important to not only teach the procedures, but also indicate WHY they need to be performed. Within any facility, whether it is a school or hospital, helping staff, students and visitors understand how cleaning and hand hygiene practices impact the health and safety of everyone can help with adoption of the effort.

Cleaning validation tools have also been shown to improve the cleaning of high touch points in hospitals. Some hospitals use fluorescent materials to mark areas that are important to clean and monitor cleaning. Using a black light to show areas they have missed is a great teaching tool for the housekeeping staff.viii ix The SHEA Guideline for Preventing Multi-drug Resistant Organisms in Health Care Facilities specifically recommends that cleaning performance be monitored upon patient discharge to ensure consistent cleaning and disinfection of surfaces.x

Hand contamination is closely tied to cleaning and disinfecting hard and soft surfaces, so both need to be encouraged. But it is important to remember that proper hand washing and teaching hand hygiene is still the most important way to help prevent the spread of MRSA.

Schools and hospitals are dynamic environments with a constant flow of people coming and going. Preventing the spread of MRSA is a constant challenge and affects every individual regardless of environment. Prevention requires constant vigilance, training and education; however, by working together we can make our facilities cleaner, safer and healthier places to be.

Kirsten Thompson, Technical Services Expert, Ecolab Healthcare

i Hirai Y. Survival of bacteria under dry conditions; from a viewpoint of nosocomial infection. Journal of Hospital Infection. 1991; 19:191-200.

ii Neely AN, Maley MP. Survival of Enterococci and Staphylococci on Hospital Fabrics and Plastic. Journal of Clinical Microbiology. Feb. 2000, P. 724-726.

iii Bures S, Fishbain JT, Uyehara CFT, Parker JM, Berg BW. Computer keyboards and faucet handles as reservoirs of nosocomial pathogens in the intensive care unit. American Journal of Infection Control 2000; 28:465-70.

iv Centers for Disease Control and Prevention. Guidelines for environmental infection control in health care facilities: recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR 2003; 52 (No. RR-10): 1-48.

v Al-Masaudi, S.B., Day, M.F., Russell, A.D. Sensitivity of methicillin-Resistant Staphylococcus aureus Strains to Some Antibiotics, Antiseptics, and Disinfectants. Journal of Applied Bacteriology. 1988; 65: 329-337.

vi Association of Operating Room Nurses Recommended Practices for Chemical Disinfection. 147-150.

vii Rutala, William H. APIC Guideline for Selection and Use of Disinfectants. American Journal of Infection Control. August 1996. 24; 4: 313-342.

viii Carlin PC, Briggs JL, Perkins J, Highlander D. Improved Cleaning of Patient Rooms Using a New Targeting Method. Clin Infect Dis 2006; 42:385-8.

ix Carling PC, Parry MF, Von Beheren SM. Identifying Opportunities to Enhance Environmental Cleaning in 23 Acute Care Hospitals. Infect Control Hosp Epidemiol 2008; 29:1-7.

x SHEA Guideline for preventing Nosocomial Transmission of Multidrug resistant Strains of Staphylococcus aureus and Enterococcus. Infect Control Hosp Epidemiol 2003; 24:362-386.

Back to top ▲