Clinical Corner: Infection Control

Issues related to the placement of individuals with VRE or MRSA

1. What criteria should be used for placing an individual with VRE or MRSA?

   Criteria should include:

   • Whether there is adequate staffing
   • Whether a cognitively intact patient understands and will maintain adequate personal hygiene and comply with infection control procedures, or whether the family or other representative for a cognitively impaired patient understands possible restrictions on the patient in order to provide adequate infection control measures to protect other patients

   Criteria specifically for VRE are:

   • Whether there is adequate equipment to provide dedicated equipment for the room of the affected patient(s)
   • The availability of a private room, or a room with (an) appropriate VRE infected or colonized roommate(s)

   Criteria specifically for MRSA are: Availability of a private room, or a room with (an) appropriate MRSA infected or colonized roommate(s) for patients colonized or infected with MRSA who have any of the following:

   • respiratory colonization and a productive cough
   • colonization of a draining wound that cannot be contained
   • colonized patients who do not understand basic hygiene and have an active skin condition which may facilitate transmission of MRSA (e.g., eczema)
   • colonized patients who may soil the room with body substances to such an extent that a roommate would be likely to have inadvertent contact.


2. Can two MRSA patients share a room?

   Yes. Two patients who both have MRSA may share a room.

3. What if two patients have MRSA at different sites, for instance, one has MRSA in his sputum, and the other has MRSA in a pressure sore?

   They can still share a room. In most cases, the fact that one patient has MRSA in his sputum is of relatively little concern. Although one study has demonstrated a dramatic increase in airborne dissemination of MRSA from a colonized individual in the face of a viral URI, for the most part, sputum is thick and heavy and most respiratory secretions propelled into the air land very close to the patient. If the patient has MRSA colonization in the sputum, it would be reasonable for healthcare workers to wear a mask to do tracheostomy care or suctioning (this is mandated under OSHA guidelines for prevention of TB transmission anyway), or when providing care directly to a patient who is coughing. At the discretion of the healthcare worker, a gown may also be appropriate if the patient is projecting sputum. If a patient with known MRSA colonization develops a URI, it may be reasonable to restrict the patient from activities until the URI resolves in order to reduce the exposure of other patients (but the value of this remains unproven).

4. What if one patient has MRSA in a pressure sore, and the other has MRSA in a fresh surgical wound?

   They can still share a room. As always, hands must be washed after caring for the pressure sore, before touching another site on the same patient, or before touching the other patient. After washing hands, clean (not necessarily sterile) gloves should be put on before changing the dressing on the surgical site.

5. Can two patients with VRE share a room?

   If they are known to carry the same strain (by antibiogram or DNA strain typing) then it is permissible to cohort. If they have different antibiograms (i.e., different strains), private rooms are preferred, but cohorting is permissible, if necessary. If it is not feasible to try to identify each patient's VRE strain, then they may still share a room.

6. Can one patient with MRSA share a room with another patient who has VRE and MRSA?

   Preferably not. The VRE patient should have his/her own room unless able to be cohorted with another patient who is also colonized/infected with both MRSA and VRE.

7. With whom should a patient be placed if he or she develops VRE while in the facility?

   Follow the same principles as outlined above. If no private room or appropriately colonized/infected roommate is available for cohorting, place the patient with the patient least likely to be affected (e.g., with no feeding tubes, no catheters, no renal failure or diabetes, no pressure sores or open wounds, and if possible, cognitively intact enough to understand the need for basic hygiene).

Excerpt from AMDA's Information kit Critical Issues in Infection Control: Focusing on VRE and MRSA in the Long Term Care Setting.