Letter to the editor – Letter to the Editor
The feature article “When Drugs Don’t Kill ‘Bugs'” in the May 2003 issue of Nursing Homes/Long Term Care Management [pp. 70-73] was very interesting, but I have some concerns. Dr. Sharbaugh mentions that many residents and healthcare personnel have been shown to be colonized [with MRSA (methicillin-resistant Staphylococcus aureus)] and that environmental contamination is not viewed as a major mode of the spread of staphylococci.
He further states, “Thus, the use of masks and gowns is neither necessary nor recommended when one is involved in the delivery of routine nursing care unless soiling is felt to be likely.” Routine care in a long-term care facility frequently involves soiling; the mode of transmission of MRSA is contact. When a resident has MRSA in his or her sputum or urine, whether by colonization or infection, contact is still how it is transmitted. The Standard Precautions include Contact Precautions, which are most appropriate for the resident with MRSA, unless one wants to have it transmitted throughout the facility. This article has set long-term care facilities back, for administration will question using gowns and the cost of doing so.
When a resident with MRSA is transferred to an acute care facility, it is most important that the EMTs be informed that he or she has MRSA, because once that resident is admitted to the acute care facility, he or she will be placed on Contact Precautions. Is there a different standard for healthcare facilities? I think not. Long-term care facilities and acute care facilities give care to the same person who was transferred.
Dr. Sharbaugh’s final paragraph reads: “A facility policy addressing AROs [antibiotic-resistant organisms] should include ongoing education, proper resident placement, surveillance, the proper use of barrier precautions, and good hand washing. These are the basic necessities in preventing the transmission of all microorganisms, including MRSA.” This statement contradicts his statement: “Thus, the use of masks and gowns is neither necessary nor recommended when one is involved in the delivery of routine nursing care unless soiling is felt to be likely.” Barrier precautions include the use of gowns and masks.
My next concern is regarding the following statements in Dr. Sharbaugh’s article: “Upon the transfer of a patient colonized and/or infected with MRSA from a hospital, private facility, or another facility to a nursing home or other long-term care facility, nursing and ancillary personnel need to understand that AROs are primarily opportunistic pathogens, in that they tend to cause infections in individuals who are debilitated and prone to the development of infectious complications, such as LTC residents. AROs, including MRSA and VRE [vancomycin-resistant enterococci], do not pose any significant threat to healthcare providers who enjoy a good state of health.”
This is very true and is why the resident needs to be on Contact Precautions. The resident is the most important person in the long-term care facility and must be protected from AROs. Healthcare personnel should realize that the client over the age of 65 years does have a greater chance to acquire infections, and this should be part of their ongoing education.
My final concern goes back to the statement, “Although many LTC residents and healthcare personnel have been shown to be colonized, but not infected, with MRSA in the nasopharynx, there is little supporting evidence that nasal carriage is a major threat.” This is true except when the colonized person has a cold or poor hygiene. My healthcare personnel would be most upset to read this sentence. Nurses and CNAs have at times been adamant about having a nares culture done, due to their fear of being colonized or being a carrier of MRSA and bringing it home to the family. To relieve their anxiety a nares culture has been done, and the results have always been negative. Acute care facilities in larger cities may have many healthcare employees colonized, but I have not found this to be true. Some hospitals are treating those employees who are colonized/carriers to help eliminate future problems.
Diane F. Kitson-Clark, BSN, RNC
Infection Control Nurse
I am happy to respond to the concerns raised by the reader.
The assumption that Contact Precautions are part of Standard Precautions is simply incorrect and begs for clarification. If one refers to “Guideline for Isolation Precautions in Hospitals” by Garner (the second article listed under “Suggested Reading” at the end of my article), it becomes abundantly clear that precautionary measures are divided into two distinct categories: Standard Precautions and Transmission-Based Precautions. Transmission-Based precautions are further subdivided into three types: Airborne, Droplet, and Contact Precautions.
Standard Precautions are intended to be used for all patients/residents regardless of their diagnosis or perceived infectious status. The primary components of Standard Precautions are clearly defined in the article and include the use of appropriate barrier precautions such as gowns when soiling is likely. On the other hand, Transmission-Based Precautions are designed for residents who are documented or suspected to be infected with highly transmissible or epidemiologically important pathogens for which additional precautions beyond Standard Precautions are needed.
As a subtype of Transmission-Based Precautions, Contact Precautions are designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. Such organisms would include MRSA, VRE, and other AROs.
Concerning the need, or lack thereof, for isolation, further examination of the “Guideline for Isolation in Hospitals” reveals the following recommendation for Contact Precautions: “Patient Placement–Private room or, if a private room is not available, patient cohorting or, if neither is available, prudent patient placement.”
I would hasten to point out that these same recommendations are made in the article being discussed. It need also be said that this guideline was intended primarily for acute care hospitals and not for other healthcare delivery settings, such as long-term care facilities and home healthcare. There are, however, well-recognized, highly credible recommendations for the control of AROs in long-term care facilities. Boyce et al (the first reference listed under “Suggested Reading” in my article) make the following comments with specific reference to MRSA:
1. Wearing gowns when caring for MRSA patients is based on the assumption that MRSA is transmitted by clothing of personnel. However, there is little evidence to support this assumption. Therefore, the wearing of gowns during routine patient care activities should be based on the likelihood of soiling clothing, not on knowledge of the MRSA status of patients.
2. A single nasal culture positive for MRSA is not sufficient evidence to implicate a healthcare worker as the source of MRSA transmission: most colonized personnel are recipients rather than sources of MRSA. Obtaining personnel cultures is most appropriate during outbreaks or in facilities where MRSA is endemic and serious infections are common. Such cultures are seldom warranted in nursing facilities.
Two additional points relative to MRSA and the use of isolation precautions need to be made:
1. MRSA is endemic in the communities of the United States. It is a virtual certainty that many residents of long-term care facilities are colonized with MRSA and/or other ARCs but go undetected and are, therefore, not placed under Contact Precautions. To require that all such residents be placed in a private room (thus employing Contact Precautions) would, in most instances, demand the availability of many more private rooms than are usually enjoyed by most LTC facilities. In addition, the routine use of Contact Precautions for ail such residents would not, in this author’s opinion, be cost-effective.
2. Long-term care facilities are unique in that residents are encouraged to join in group activities, participate in physical and occupational therapy, and eat in a common dining room. To automatically isolate ambulatory residents colonized with MRSA or other AROs would be contrary to the philosophy and policy of most facilities. Thus, unless, an outbreak has occurred, the routine use of Contact Precautions in such instances would be neither encouraged nor recommended.
Robert J. Sharbaugh, PhD, CIC
Charleston, South Carolina
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