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Infection risks in patients are constantly changing based on their treatment and procedures. The process of care is based on patient assessment, planning and implementing care and evaluating its outcome. The quality of assessment is dependant upon the individual practitioner’s level of knowledge and understanding of what is a risk. Not only should there be an initial assessment of a patient’s risk to acquiring an infection but this should be reviewed on a daily basis.

Patient risk factors to infection include:

Specific precautions are taken to prevent the transmission of microbes from:

• patient to patient
• patients to staff
• staff to patients.

See standard (universal) and transmission-based precautions.

In The when and how of isolation, Coleman describes the practice as a ‘bitter, toxic and costly pill’ because:

• it is an unpleasant experience for patients to ‘swallow’
• it is ‘toxic’, as the side-effects include depression and alienation from other patients, staff and visitors due to reduced contact and exacerbated by the use of personal protective equipment
• it is costly in terms of time and resources.

Many healthcare professionals are unclear as to how different infections are spread and what precautions need to be undertaken to reduce the risks of cross infection. When a patient requires isolation the following points should be considered.

Since the 1990s there has been an increase in the prevalence of MRSA in healthcare settings. An expert working party was established to develop guidelines and make recommendations on the approach to managing the risk of infection with MRSA.

The risk factors identified included intravenous devices, surgical wounds, pressure sores and care in intensive care units. Four categories of risk were linked to the potential for developing a serious infection as a result of acquiring MRSA. The categories are:

• high risk areas
• moderate risk areas
• low risk areas
• minimal risk areas.

To make the recommendations appropriate to local situations, infection control teams adapt the guidelines to suit local circumstances.

Standard infection control precautions should be taken with all patients [link to standard precautions in this site] and in addition to these, the following precautions may also need to be taken dependent upon specific circumstances and local policy:

• systemic antibiotics or topical treatment for colonised or infected patients
• use of isolation unit, ward or side room
• keeping the door closed especially during patient care activities
• screening of other patients in wards, contact tracing, admissions, discharges and transfers
• screening of healthcare staff – nose, groin, axillae, any open sores or lesions
• careful placement of agency or bank nurses.

Precautions to be taken in these areas include:

• isolation of MRSA positive patients
• isolation of higher risk patients (those who were previously positive, admitted from a hospital or residential/nursing home with a known MRSA problem, transferred from a hospital abroad) until screening results are known
• screen index case to assess carriage sites and to assess clearance of MRSA (three separate sets of negative screening swabs taken at 24 hour intervals)
• screen patient contacts of cases
• screen other patients on admission and on discharge
• consider screening of healthcare staff, especially those with skin lesions
• eradicate carriage in patients and healthcare staff
• emphasise good infection control practices of hand and general hygiene.

Precautions to be taken in these areas include:

• isolation of MRSA positive patients
• isolation of higher risk patients (those who were previously positive, admitted from a hospital or residential/nursing home with a known MRSA problem, transferred from a hospital abroad) until screening results are known
• screen index case to assess carriage sites and to assess clearance of MRSA (three separate sets of negative screening swabs taken at least 24 hour intervals apart)
• screen patient contacts of cases
• screen other higher risk patients on admission and on discharge
• consider screening of healthcare staff, especially those with skin lesions
• eradicate carriage in patients and healthcare staff
• emphasise good infection control practices of hand and general hygiene.

Precautions to be taken in these areas include:

• consider screening of healthcare staff, especially those with skin lesions
• eradicate carriage in patients and healthcare staff on clinical grounds
• emphasise good infection control practices of hand and general hygiene.

The difference between the precautions recommended in different risk areas reflects the patients within those areas and those who are most at risk of acquiring MRSA infection. Patients should only be placed in isolation rooms once a risk assessment has been undertaken under the guidance of the infection control team as some patients may suffer psychologically from the lack of contact with others. This is one of the reasons why patients cared for in minimal risk areas are not isolated in single rooms with the door shut.

Treatment of MRSA
Those patients with a clinical infection will usually need a course of antibiotics dependent upon where the infection is and the particular strain of MRSA.

Application of skin antiseptics containing triclosan or chlorhexidine may get rid of the skin colonisation. Nasal colonisation is treated with mupirocin ointment three times a day for 5 to 7 days, but should be restricted to two courses of treatment so that resistance to this ointment doesn’t occur.

Staff health
Local policies should apply to agency and bank staff as well permanent healthcare workers.

Studies have shown that healthcare staff caring for patients in healthcare settings where MRSA is present do, during the course of their shift, pick up MRSA. However, such carriage of the organism is usually transient, lasting only a few hours. It is because of this that healthcare staff are not routinely screened for MRSA carriage and pre-employment screening is not recommended.

Should a member of staff become infected with MRSA, the condition is usually seen as occupationally acquired and should be treated through the Occupational Health Department. Because of this it then becomes reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). However, treatment is very effective in those who are otherwise healthy people.