C1353331

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Managing MRSA (Methicillin-Resistant Staphylococcus aureus) colonization in neonates in the UK, within the NHS, is a critical aspect of infection control, particularly in neonatal units (NICUs).¹ Neonates, especially premature and those with underlying medical conditions or invasive devices, are highly vulnerable to MRSA infection, which can lead to severe illness.²

While specific guidelines can vary slightly between individual NHS Trusts, the overarching principles are consistent across the UK. These guidelines are dynamic, reflecting the latest evidence and national recommendations (e.g., from Public Health England/UK Health Security Agency, NICE).

Here's a summary of the general approach and key components of MRSA colonization management in neonates within the NHS:

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Management (Mx) of MRSA Colonization in Neonates (UK NHS Guidelines)

The primary goals are to prevent infection in the colonized neonate, prevent spread to other vulnerable neonates, and, where appropriate, decolonize the neonate.

1. Screening for MRSA Colonization:

• Routine Admission Screening: Most neonatal units in the UK screen all babies on admission or transfer from other units for MRSA.
• Weekly Rescreening: Infants who remain in the neonatal unit are often screened weekly to detect new colonization.
• Swab Sites: Common sites for swabbing include the nose, groin/perineum, and umbilicus. Other sites like axillae or any skin lesions/wounds may also be swabbed.
• Maternal Screening: If the mother is known to be MRSA positive, the baby will be screened on admission.
• Purpose of Screening: To identify colonization early, inform care planning (e.g., isolation, antibiotic choices if infection occurs), and implement control measures to prevent spread.
• Colonization vs. Infection: It's crucial to explain to parents that colonization means the bacteria are present on the skin without causing illness. Most colonized babies remain well.

2. Infection Prevention and Control Measures (Crucial for all neonates, especially colonized ones):

• Hand Hygiene: This is the single most important measure. All staff, parents, and visitors must practice meticulous hand hygiene (alcohol hand rub or soap and water) before and after touching the baby or their environment.
• Isolation Precautions:
  • Single Room/Cohort Nursing: If a neonate is identified as MRSA colonized (or infected), they should ideally be nursed in a single room. If a single room is not available, cohort nursing (grouping MRSA-positive babies together) within a bay may be an alternative, in a closed incubator.
  • Contact Precautions: Healthcare staff should wear disposable gloves and aprons for all direct patient contact.
• Dedicated Equipment: Use dedicated or single-patient equipment where possible (e.g., stethoscopes, thermometers). Shared equipment must be thoroughly cleaned and disinfected between uses.
• Environmental Cleaning: Rigorous and regular cleaning of the baby's cot, incubator, and surrounding environment with appropriate disinfectants.
• Parental Education: Educate parents on strict hand hygiene, not touching other babies, and the importance of infection control measures. Parents are generally encouraged to continue skin-to-skin contact with their own baby.
• No Delay in Care: MRSA colonization should not delay essential medical care, investigations, or transfer of the neonate, but the receiving unit must be informed of the MRSA status.

3. Decolonization Strategies (When Indicated):

Decolonization aims to reduce the bacterial load on the skin and nose. It's not routinely done for all colonized healthy neonates, but is often considered for:

• Neonates at higher risk of developing invasive infection (e.g., extreme prematurity, very low birth weight, presence of invasive lines like central venous catheters, planned surgery, underlying immune deficiencies).

• During an outbreak in the unit.

• If the neonate has recurrent MRSA infections.

• Common Decolonization Regimen (typically for 5 days):

  • Topical Nasal Ointment: Mupirocin 2% nasal ointment applied to both nostrils, typically three times daily. Caution regarding prolonged or repeated use due to risk of resistance development.
  • Antiseptic Body Wash:
    • Octenisan® antimicrobial wash is commonly used as a daily body wash for neonates. It's applied undiluted to moistened skin, left for a short contact time (e.g., 1 minute), then rinsed off.³
    • Chlorhexidine gluconate 4% solution (Hibiscrub®) is also used, but specific guidance for neonates (especially very premature or those with fragile skin) may involve dilution or careful application due to potential skin irritation or absorption.
  • Hair Washing: The antiseptic solution is often used as a shampoo at least twice during the 5-day period.
  • Hygiene Measures: Use clean towels, clothes, and bedding daily after washes.
  • Parent/Household Decolonization: If the baby is repeatedly re-colonized or if the parents/household members are identified as the source, decolonization of close contacts may be considered in conjunction with the Infection Prevention & Control team.

4. Monitoring and Follow-up:

• Post-Decolonization Swabs: Repeat screening swabs are typically taken at least 48 hours after completing the decolonization regimen.
• Confirmation of Clearance: A neonate is generally considered decolonized if three consecutive screening swabs (taken at least 48 hours apart) are negative for MRSA.
• Clinical Monitoring: Continued vigilance for any signs of infection (fever, poor feeding, lethargy, worsening skin lesions) even if colonization is present or after decolonization.
• Alert Status: The neonate's medical records will typically have an alert flag for MRSA colonization, ensuring that future admissions are aware of their status for appropriate infection control measures and empirical antibiotic choices if needed.

Important Considerations:

• Individualized Care: Every neonate's case is assessed individually, considering their clinical condition, gestational age, and risk factors.
• Microbiology Consultation: Close collaboration with the microbiology and infection prevention and control teams is essential for guidance on screening, decolonization, and antibiotic management.
• Resistance Patterns: Local MRSA resistance patterns will influence antibiotic choices if an infection develops. Mupirocin resistance is a growing concern.

This comprehensive approach aims to minimize the risk of MRSA-related morbidity and mortality in this vulnerable patient population within the NHS.

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