Matthew Kerr Policy Paper

Policy on Dual Nare Screening for Methicillin-Resistant Staphylococcus aureus
Antibiotic resistance is an increasing threat to established antibiotic medications and the heath of the general public (4). Methicillin-Resistant Staphylococcus aureus (MRSA) has gained public attention do to rising infections in hospitals and community living centers (2,3). Staphylococcus aureus is a bacterium that has acquired a resistance to methicillin medications, increasing its difficult in treatment. The data is not clear how this strand of Staphocuccus aureus had developed a resistance, but precautions to prevent further spread of the bacterium needs to be evaluated.
MRSA is acquired from close contact with contaminated people, clothing, or equipment (1,3). Controlling the spread is the first step in lowering antibiotic resistance of MRSA bacterium. Hospitals patients with MRSA or high risk patients (nursing homes and other facilities with outbreaks) will be placed in MRSA precautions rooms atomically upon admission to Mercy Medical Center (MMC). Decreasing the spread of MRSA at MMC can be attained by increasing the accuracy of the testing protocol, potentially lowering the amount of hospital acquired MRSA infections. The protocol for MRSA testing at Mercy Medical Center in Sioux City requires the insertion of a sterile swab into the nostril of the patient twisting gently when met with resistance. If the patient currently has a wound/cut/incision this site will also need to be swabbed along the surface. This method provides the samples needed to conduct subsequent tests to check if a patient is colonized with MRSA.
Dual nare screening for MRSA is needed to increase the effectiveness of MMC screening process. According to a resent undergraduate research group there data suggests that it is possible for a person to be colonized with MRSA in a single nostril (5).
I. Two or more sterile swabs will be needed to conduct one MRSA test per patient. The first swab will be placed in the patients nostril until met with resistance and turned clockwise and counterclockwise and replaced back into the sealed plastic swab container. The opposite nostril is repeated with a second swab treated in the same manner. Subsequent swabs will be brushed across site of wounds/cuts/incision to the skin (one swab per site).

II. The use of more then one swab is to increase the accuracy of the test by collecting colonies that may form in both or one nostril and breaks in the skin. The same swab should not be used for two sites of collection to avoid transfer of colonized bacteria to new sites.

The proposed protocol addresses the possibility of MRSA colonizing only one nostril opposed to both nostrils. The application of this policy at MMC may lower the amount of false negatives from patients that only have one nostril colonized and was missed during initial testing. The false negatives increase the amount of hospital acquired MRSA infections, increasing the spread of bacterial infections. The transmission of MRSA infections continues to strengthen the bacterial resistance.
Improving accuracy of MRSA testing will decrease the amount of exposure these patients place on staff and other patients in the hospital. Precaution isolation at MMC requires all staff to where protective gowns, gloves, sterilize all equipment upon leaving the room, and wash hands/hand sanitizer before leaving the room. Isolation precautions are good methods in place to control the spread of MRSA and faster inundation of these protocols helps lower hospital acquired MRSA infections (2).
If this policy was to be placed into affect, the cost of the initial testing would increase by 100%. The test would be using a second nasal swab, and twice the amount of media needed to perform the needed metabolic tests of the bacteria. This will make MRSA tests more expensive for the patient and/or insurance companies, but decreases the patients potential for the hospital to misdiagnosis an MRSA infection. Hospital acquired infections can increase the time a patient would spend in the hospital, costing more then a simple MRSA testing increase.
The need to use one swab per nostril is to avoid the transfer of bacterial colonization from one nostril to the other. MRSA can be present in the nose, but not an active infection in the body. Transferring the bacteria to another nostril increases the chances of the bacteria reaching a break in the epithelial cells and becoming an active infection.
Antibiotic resistance is and increasing problem that directly threatens antibiotics ability to kill bacterial. This policy has the potential to decrease the spread of MRSA and the promotion of antibiotic resistance if enforced at MMC.

1. Safdar, Nasia, et al. “Comparison of Culture Screening Methods for Detection of Nasal Carriage of Methicillin-Resistant staphylococcus aureus: a prospective Study Comparing.” Journal of Clinical Microbiology. July 2003. P.3163-3166.
2. Van Hal S.J., et al. Methicillin-Resistant Staphylococcus aureus (MRSA) Detection: Comparison of Two Molecular Methods (IDI-MRSA PCR Assay and GenoType MRSA Direct PCR Assay) with Three Selective MRSA Agars (MRSA ID, MRSASelect, and CHROMager MRSA) for Use with Infection-Control Swabs.” Journal of Clinical Microbiology. August 2007. p. 2486-2490.
3. Simor, Andrew E., et al. ‘The mangagement of colonization due to methicillin-resistant Staphylococcus aureus: A CIDS/CAMM position paper.” Can J Infect Dis Vol 15 No 1. January/Februaray 2004. p. 39-48.
4. Gilbert, Peter; McBain Andrew J. “Potential Impact of Increased Use of Biocides in Consumer Products on Prevalence of Antibiotic Resistance.” Clinical Microbiology Reviews April 2003. p. 189-208.
5. Kildow, Beau, et al. Astract submitted to the North Central Branch of the American Society for Mircobiology Annual Metting, October 17, 2008, St Cloud MN.

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