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Dear colleagues
We currently perform MRSA screening (culture) for all of our patients
undergoing elective orthopaedic hips and knees prosthetic procedures.
The swabs are taken in pre admission clinic and if they come back MRSA
positive a decolonisation program is implemented and the antibiotic
prophylaxis adjusted.
We now wish to extend the screening to our non elective and emergency
patients with #NOF’s using the rapid Gene Expert PCR so we can get the
results back quickly before the surgery. We anticipate that we would
need the emergency department staff to perform the screening when the
patient presents.
We would like to ask 3 questions:
1. is anybody out there using the rapid Gene Expert PCR for this type of
screening and if so are there any issues or advice you could offer.
2. what do you use for your pre op decolonisation eg. nasal mupirocin,
tricolan, chlorhex body washes
3. for patients colonised with MRSA do you use IV vancomycin alone or
with cephazolin
Thanks for your help
Warm regards
Sue
Sue Thorpe
Clinical Nurse Consultant
Senior Infection Preventionist
Employee Exposure Management & Immunisation Services (EEMIS)
Infection Prevention and Control Unit
Peninsula Health
PO Box 52
Frankston 3199Peninsula Health – Metropolitan Health Service of the Year 2007 & 2009
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Hi Sue,
Our facility introduced rapid PCR for MRSA swabs for all our patient
groups. However there are high costs associated with this introduction
and we have had to revise the groups that use this method. We are now
using a combination of culture and PCR. PCR is used for any patient
identified in the Emergency dept as being a ‘high risk’ MRO, this
includes our #NOF patients, it is also used in the ICU.I am happy to speak with you off line about our facility experience.
In relation to the decolonisation for pre-op patients this is done on
the advice of the ID physician to the surgeon prior to admission.
Generally colonised patients having surgery have vancomycin alone for
prophylaxis – but this can vary depending on the surgeon.Fiona De Sousa
Infection Prevention & Control Coordinator
Sydney Adventist Hospital
185 Fox Valley Road, Wahroonga, NSW, 2076
________________________________
Behalf Of Thorpe, Sue
for ortho emerg proceduresDear colleagues
We currently perform MRSA screening (culture) for all of our patients
undergoing elective orthopaedic hips and knees prosthetic procedures.
The swabs are taken in pre admission clinic and if they come back MRSA
positive a decolonisation program is implemented and the antibiotic
prophylaxis adjusted.We now wish to extend the screening to our non elective and emergency
patients with #NOF’s using the rapid Gene Expert PCR so we can get the
results back quickly before the surgery. We anticipate that we would
need the emergency department staff to perform the screening when the
patient presents.We would like to ask 3 questions:
1. is anybody out there using the rapid Gene Expert PCR for this type of
screening and if so are there any issues or advice you could offer.2. what do you use for your pre op decolonisation eg. nasal mupirocin,
tricolan, chlorhex body washes3. for patients colonised with MRSA do you use IV vancomycin alone or
with cephazolinThanks for your help
Warm regards
Sue
Sue Thorpe
Clinical Nurse Consultant
Senior Infection Preventionist
Employee Exposure Management & Immunisation Services (EEMIS)
Infection Prevention and Control Unit
Peninsula Health
PO Box 52
Frankston 3199
Peninsula Health – Metropolitan Health Service of the Year 2007 & 2009
Messages posted to this list are solely the opinion of the authors, and
do not represent the opinion of AICA.Archive of all messages are available at http://aicalist.org.au/archives
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Dear Sue
We’ve used a PCR method for preop, icu and hosp admission screening. This commercial assay allows us to pool swabs to reduce cost. As well it detects MSSA which is advisable for preop screens as such patients also benefit from preop load reduction measures (see NEJM 2010 paper ). We did look at genexpert and were not impressed with its cost! Our existing assay costs a fraction of that and has worked very well on extensive evaluations. And so I do think that you should ask your lab to look at the relative costs of different approaches!
Other studies show that it is only the high grade carriers that have increased risk of post op staph infection. Hence in the landmark study above they used a PCR assay that was not optimally sensitive in order not to detect low level carriers. They used load reduction with nasal mup and topical chlorhexidine body wash that commenced the day before surgery. Best to call it load reduction as one cannot document decolonisation as such in these patients. One assumes they remain colonised.
Chlorhexidine 4% aqueous for body wash best – probably less resistance than with triclosan. However isolates from Aust have not been tested against either to my knowledge. There are some chlorhex R isolates of MRSA detected in UK. The utility of preop body wash alone has never been studied. However most now accept it as part of the package
If MRSA carriage detected, would definitely recommend a glycopeptide alone for px. Note that TG: Antibiotic Edition 14 has higher doses for px – 1.5 g . Logistics considerable- the infusion needs to complete before the patient goes under. Many use teicoplanin instead as it is more able to be given at the right time etc.
Needless to say, HICSIG site has protocols for preoperative staph management – see for instance-
http://www.asid.net.au/hicsigwiki/index.php?titlePatient_Staphylococcus_aureus_preoperative_decolonisation_instructionsWe currently try to complete the 5 day protocol within the 2 wk period prior to surgery. However the Dutch study above shows that immediate preop load reduction is effective and so we are reconsidering our approach. The ability of day before treatment to work makes load reduction also feasible for emergency cases etc.
One does need to ensure that the lab tests isolates of staph for mupirocin resistance.
Best wishes
John
Dr John Ferguson
Microbiologist and Inf Diseases Physician
Hunter New England Health
Newcastle________________________________
Hi Sue,
Our facility introduced rapid PCR for MRSA swabs for all our patient groups. However there are high costs associated with this introduction and we have had to revise the groups that use this method. We are now using a combination of culture and PCR. PCR is used for any patient identified in the Emergency dept as being a high risk MRO, this includes our #NOF patients, it is also used in the ICU.
I am happy to speak with you off line about our facility experience.
In relation to the decolonisation for pre-op patients this is done on the advice of the ID physician to the surgeon prior to admission. Generally colonised patients having surgery have vancomycin alone for prophylaxis but this can vary depending on the surgeon.
Fiona De Sousa
Infection Prevention & Control Coordinator
Sydney Adventist Hospital
Fiona.Desousa@sah.org.au
185 Fox Valley Road, Wahroonga, NSW, 2076________________________________
Dear colleagues
We currently perform MRSA screening (culture) for all of our patients undergoing elective orthopaedic hips and knees prosthetic procedures. The swabs are taken in pre admission clinic and if they come back MRSA positive a decolonisation program is implemented and the antibiotic prophylaxis adjusted.
We now wish to extend the screening to our non elective and emergency patients with #NOF’s using the rapid Gene Expert PCR so we can get the results back quickly before the surgery. We anticipate that we would need the emergency department staff to perform the screening when the patient presents.
We would like to ask 3 questions:
1. is anybody out there using the rapid Gene Expert PCR for this type of screening and if so are there any issues or advice you could offer.
2. what do you use for your pre op decolonisation eg. nasal mupirocin, tricolan, chlorhex body washes
3. for patients colonised with MRSA do you use IV vancomycin alone or with cephazolinThanks for your help
Warm regards
SueSue Thorpe
Clinical Nurse Consultant
Senior Infection Preventionist
Employee Exposure Management & Immunisation Services (EEMIS)
Infection Prevention and Control Unit
Peninsula Health
PO Box 52
Frankston 3199Peninsula Health – Metropolitan Health Service of the Year 2007 & 2009
If you are not the intended recipient you are hereby notified that any dissemination, distribution or reproduction of this message
is prohibited. If you have received this message in error please notify the sender immediately, then destroy the original message.
Any views expressed in this message are solely those of the individual sender, except where the sender is specifically authorised
by Sydney Adventist Hospital to state that they are the views of Sydney Adventist Hospital.
_____________________________________________________________________
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Scanning Services – powered by MessageLabs. For further information
visit http://www.messagelabs.com
Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of AICA.Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.
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Hi Sue and colleagues,
As part of the Victorian Clean Start Program 2007-2011, we were provided with a Cepheid GeneXpert system for fully integrated real-time MRSA PCR testing. We implemented this in December 2008. Bendigo Health will have a poster about this very topic at the AICA conference in Perth, so check it out for more information.
In response to your questions,1. We are specifically using this for patients presenting via ED who are either having surgery or likely to be admitted; the orthopaedic unit has taken this on board for their elective hips/knees as well. Issues we’ve experienced include: staff education (ensuring all staff understand this testing and it’s purpose as well as provision of education to direct users about correct collection method), continuation of staff education to capture new/changing staff, incorrect use for wounds and/or other sites (although some hospitals have had their microbiology departments validate for wounds). My tip is education, education and more education!
2. We use mupirocin ointment for nasal decolonisation and chlorhexidine for body washing.
3. For those patients colonised w/ MRSA, we advise the use antibiotics as per the Therapeutic Guidelines 13th version for Antibiotics, which state: ‘Routine use of vancomycin prophylaxis should be discouraged, to prevent selection pressure for vancomycin-resistant enterococci (VRE) and vancomycin-intermediate MRSA (VISA). However, vancomycin should replace the cephalosporin or penicillin component of the regimen in the following circumstances:
a. Preoperative patients infected or colonised with an MRSA strain (hospital-acquired or community-associated) currently or in the past.
b. Patients having major surgery who are at high risk for MRSA colonisation (eg those who have resided for longer than 5 days in a health care facility where MRSA is endemic)
c. Patients undergoing prosthetic cardiac valve, joint or vascular surgery where the procedure is a re-operation (return to theatre or revision)
d. Patients hypersensitive to penicillins and/or caphalosporins.
We do try to ensure patients get tested so as to get the correct antibiotic prophylaxis.
I hope this helps,
Cheers,
CatinaCatina Eyres
Nurse Consultant
Infectious Diseases & Infection Control
Bendigo Health
PO Box 126 Bendigo 3552
ceyres@bendigohealth.org.au
p 03 5454 8414 (Infection Control)
p 03 5454 8422 (Infectious Diseases)
f 03 5454 8419
m 0409 230 871
pager 023Dear colleagues
We currently perform MRSA screening (culture) for all of our patients undergoing elective orthopaedic hips and knees prosthetic procedures. The swabs are taken in pre admission clinic and if they come back MRSA positive a decolonisation program is implemented and the antibiotic prophylaxis adjusted.
We now wish to extend the screening to our non elective and emergency patients with #NOF’s using the rapid Gene Expert PCR so we can get the results back quickly before the surgery. We anticipate that we would need the emergency department staff to perform the screening when the patient presents.
We would like to ask 3 questions:
1. is anybody out there using the rapid Gene Expert PCR for this type of screening and if so are there any issues or advice you could offer.
2. what do you use for your pre op decolonisation eg. nasal mupirocin, tricolan, chlorhex body washes
3. for patients colonised with MRSA do you use IV vancomycin alone or with cephazolinThanks for your help
Warm regards
SueSue Thorpe
Clinical Nurse Consultant
Senior Infection Preventionist
Employee Exposure Management & Immunisation Services (EEMIS)
Infection Prevention and Control Unit
Peninsula Health
PO Box 52
Frankston 3199Peninsula Health – Metropolitan Health Service of the Year 2007 & 2009
Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of AICA.Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.
Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au
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