Methicillin Resistant Disease Control

Implementation Date: 4/2013

Date of Last Revision: 3/2022

Next Review Due:

 

Reviewed by VTH Administrative Team: 3/2013

Reviewed by VTH Board: N/A

 

Reviewed by Legal Counsel: N/A

Reviewed by Biosecurity Subcommittee: 3/2022

Subject to modification by the Biosecurity Subcommittee of the CVM Occupational Health and Safety Committee without approval.

Policy

Protocol for Methicillin Resistant Organisms (MRO) - includes case identification/confirmation as well, as 
protocol for removal of status, once the case has been resolved to remove warnings and labeling on the 
case and in the medical records.

Guidelines

• Because Methicillin-resistant Staphylococci (MRS), (Staphylococcus aureus (MRSA) and Staphylococcus pseudintermedius (MRSP), and coagulase negative Staphylococcus sp.), are relatively widespread in asymptomatic animal and human populations, it is incumbent on the VTH to provide policies for controlcontainment of these organisms when confirmed in VTH patients and/or the environment.
• In healthy normal individuals, carriage of MRO usually presents little or no risk to health including to pregnant women, or those living or working with such patients. Carriage can be prolonged or intermittent.
• MRO may be passed between humans by direct contact with hands, nasal secretions, or contaminated surfaces. 
• Normal healthy skin and mucous membranes form an efficient barrier against local tissue infection.
• Animals and people with compromised immune systems can be susceptible to MRO which can be considered zoonotic agents. Thus, the young, old, pregnant and immunocompromised may be susceptible.
• Cleaning solutions to be used should be broad spectrum disinfectant with antiviral properties.

Procedure (if applicable)

1. It is essential that patients with known MRO infections be handled to limit the risks of transmission to other patients, CVM/VTH personnel, clients and associated environments.
2. MRO can be effectively controlled through the use of well known – but strictly adhered to – sanitation and hygiene practices.
3. In all patient-management situations, wash hands thoroughly with a disinfectant soap for at least 20 seconds between handling of patients.
4. Disposable gloves shall always be worn when handling an MRO positive, probable or suspected patient. After handling, the gloves should be discarded in a biohazard container and hands washed before handling “clean surfaces,” other patients or touching personnel.

MANAGEMENT OF PATIENTS WITH CONFIRMED, SUSPECTED OR PROBABLE MRO

1. MRO suspected or probable patient

   1. When a patient is admitted into the hospital and is suspected to have a MRO by the appropriate personnel, they should be placed into an examination room and remain in this room until either discharged or a MRO is ruled out.
   2. When faculty, staff, and students are interacting with suspected or probable patients, gloves and a removable outer garment should be worn which can be disposed of or disinfected after contact with the patient.
      
      

2. MRO confirmed patients

          I.  Admission

   1. When the appointment is being scheduled ask the owner to have the pet remain in the vehicle or outdoors until the patient can be taken to an appropriate examination area via the transportation recommendations below.
   2. Appropriate examination area includes an examination room that is able to be disinfected, a current MRO isolation area, or outside in the car or close proximity of the car.
   3. Following examination and removal from the examination area, hospital personnel will disinfect the area which is able to be disinfected (examination room and MRO isolation area) with a broad spectrum disinfectant with antiviral properties 
      

      
      II. Recheck Examination 

   4. These patients should be scheduled when the risk of possible cross-contamination is reduced. Inform clients prior to the visit that they should register without their pet in the admission area so as to reduce risk of exposure to others in the waiting room.
   5. At the time of re-examination, if the infection is not resolved and at the discretion of the clinician in charge, should be reevaluated further including potential reculture. The patient shall be handled using PPE.

III. Transportation Into and Within the Hospital

1. 1. Any open wounds (per supervising clinician instructions) are covered if possible with an appropriate impermeable dressing during transportation
   2. Best transportation practices into and within the hospital areas of infected or suspected patients include transportation via metal gurney or carrier, but for awake large animals this is not advisable. Instead, you may bandage any open wounds with impermeable bandages for transportation. This will include paws as the only lesions present being covered with disposable paw covers. DO NOT TRANSPORT ANIMALS BY CARRYING THEM IN YOUR ARMS.
   3. Any floor or other surface contamination involved must be promptly disinfected with broad spectrum disinfectant with antiviral properties.

                  IV. Hospitalization and Handling of Positive or Suspect MRO Patients

1. 1. Patients with culture positive or suspect MRO with pending cultures shall be quarantined in designated areas. Only faculty, staff, and students wearing PPE, that are required to provide standard of care, shall have contact with the MRO positive or suspected patients. Limiting the number of faculty, staff, and students in contact is highly recommended.
   2. The diagnosis of MRO shall be promptly entered and the appropriate flag applied in both chart and electronic medical record by medical records personnel
   3. A MRO patient alert card shall be attached to the patient’s cage/stall
   4. The owner/client and referring veterinarian are to be notified by the attending clinician as soon as possible and communications documented in the electronic medical record.
   5. Staff and/or students with skin disorders (such as, but not limited to, eczema or psoriasis) including open cuts shall not be involved in directly handling MRO positive patients.
   6. Personnel handling MRO positive patients must wear PPE including a disposable gown, gloves, shoe covers, and long hair must be tied back, wear a surgical cap or disposable hair bonnet at a minimum. If the MRO infection is respiratory or urinary, a face mask should be worn as well. 
   7. Avoid wearing watches and rings (other jewelry) when handling known MRO patients
   8. Hands shall be washed immediately after removal of disposable gloves with soap or detergent equivalent for a minimum of 20-30 seconds
   9. Pencils, pens, thermometers and stethoscopes, etc. shall be dedicated for use with the affected patient only and thoroughly disinfected or disposed of when treatment/hospitalization is completed.
   10. The floor and other areas where MRO patients have been shall be disinfected with broad spectrum disinfectant with antiviral properties
   11. Use disposable bedding for confirmed, probable or suspect MRO patients and dispose of the bedding in a biohazard bag

• • • If small animal patient bedding is to be reused, it is placed in a plastic bag clearly labeled with “MRO CONTAMINATION” prior to transport to the laundry
    • For contaminated MRO laundry, the bedding shall be removed by personnel wearing PPE and immediately placed in a 1:9 sodium hypochlorite (bleach) solution for 10 minutes then washed as usual. 
    • Personnel having contact with potentially contaminated bedding shall wear PPE
    • Large animal patients, when medically advisable, shall be maintained in stalls with either no bedding or bedding that can be composted immediately after removal from the stall

   3. Patients shall be discharged from the VTH as soon as deemed safe (and medically appropriate) by the attending clinician.

1. 1.  Attending clinician will discuss patient care needs and any owner/family precautions that shall be taken. This information will be documented in the electronic medical record.
   2. Immediately following discharge all accommodations used for the respective patient shall be thoroughly disinfected following the cage disinfection protocol by the caretakers.
      
      

IN-HOSPITAL DEATH OF MRO SMALL ANIMAL PATIENT: MANAGEMENT OF REMAINS.

1. Any open wound shall be covered with an impervious covering (plastic) and tape.
2.  Remains placed in a cadaver bag, then in an additional cadaver bag that is identified with an MRO labeling for disposal.
3. If the patient is going to necropsy: Pathology staff shall be notified via VDL submission form and health information system request by the clinician in charge that a necropsy is to be conducted on an MRO patient or suspect-MRO patient.

GENERAL CONTAINMENT

1. Owners visiting their animals that have an MRO should be advised of the risk involved and will use the protection provided.
2. Precautions will be taken to reduce the risk of cross-contamination between large and small animal hospital.
3. Students, faculty a,nd staff in direct contact with an MRO patient shall not wear PPE outside of their respective MRO patient care environment.

CLEARANCE OF INFECTIOUS DISEASE IDENTIFICATION

1. Once the infectious nature of the case has been resolved warnings and labeling requirements for the case should be updated in the medical records. A case is considered resolved at the clinicians discretion which is dependent on the location of the infection. (Examples: A case with a MRO skin infection is considered resolved if a wound has healed completely with negative cytological findings. A case with a MRO urinary tract infection is considered resolved with a negative bacterial culture.)

USEFUL RESOURCES

• Infection Prevention and Control Best Practices For Small Animal Veterinary Clinics. Canadian Committee on Antibiotic Resistance (2008). Available at https://wormsandgermsblog.lexblogplatformtwo.com/files/2008/04/CCAR-GuidelinesFinal2.pdf (Specifics for MRS+ organisms and Client and Hospital Information)
  
  
• Veterinary Infection Control Committee, National Association of State Public Health Veterinarians. Compendium of Veterinary Standard Precautions for Zoonotic Disease Prevention in Veterinary Personnel (2015); JAVMA 247:11, 1252-1277 (general to specific for program development and implementation re zoonotic (contagious) disease control.
  
  
• Hanselman, B.A., et al. Methicillin-resistant Staphylococcus aureus colonization in veterinary personnel. Emerg. Infect Dis [serial on the internet] 2006. Available at www.cdc.gov/nudod/EID/vol12no12/06-0231.htm.
• Peterson, A.D., et al. Frequency of isolation and antimicrobial susceptibility patterns of Staphylococcus intermedius and Pseudomonas aeuginosa isolates from canine skin and ear samples over a 6-year period (1992-1997). 2002 JAAHA 38: 407-413.
  
  
• O’Malony, et. Al. Methicillin-resistant Staphylococcus aureus (MRSA) isolated from animals and veterinary personnel in Ireland. (2005). Vet Microbiology 109 (3-4), 285-296 (see especially the table on distribution of positive specimens.

Definitions (if applicable)

Broad Spectrum Disinfectant with Antiviral Properties - aldehyde based (formaldehyde, glutaraldehyde), sodium hypochlorite based (bleach), oxidizing agents (hydrogen peroxide, Virkon S, Trifectant)

MRO positive – any patient with already confirmed MRO infection no matter the location (i.e. skin, urinary bladder, central nervous system, joints, implants, etc.).

MRO probable – any patient presenting with a chronic non-healing wound or bacterial infection that has samples submitted and results pending or with a previous history of MRO positive within the last 6 months.

MRO suspect – any patient presenting with a chronic non-responsive bacteria infection with lack of response to appropriate first line antibiotics.

Personal Protective Equipment (PPE) - Personal protective equipment may include items such as gloves, safety glasses and shoes, earplugs or muffs, hard hats, respirators, or coveralls, vests and full body suits.

Veterinary Teaching Hospital (VTH) - The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.