Eliminating MRSA transmission in a tertiary neonatal unit–A quality improvement initiative


      • Simple infection control measures can help to eliminate MRSA transmission in NICU.
      • Improving hand hygiene and environmental hygiene compliance are pivotal.
      • Active surveillance to detect positive cases and contact precaution are crucial.
      • Cohorting outborn babies prior to surveillance swab result is key to prevention.
      • Sustainability of results need reinforcement of infection control practices.


      Health care facility-onset methicillin-resistant Staphylococcus aureus (HO-MRSA) colonization or infection is a major cause of health care–associated infection (HAI) worldwide. HAIs are preventable and considered a health care quality outcome indicator. A quality improvement project to eliminate HO-MRSA transmission was conducted in a tertiary care neonatal unit over a 9-month period, and sustainability data were monitored. The primary aim of this project was to achieve zero transmission of MRSA among all neonatal unit admissions, and secondary aims were to improve hand hygiene (HH) and environmental hygiene compliance to 100%.


      Existing inpatient admission processes, staff HH, and environmental hygiene practices were critically analyzed. Sequential interventions were implemented, including reinforcing staff awareness on infection control practices through regular education and updates, providing “just in time” feedback, ensuring easy availability of cleaning equipment, individualizing items for all patients, keeping personal belongings away from clinical areas, and revising admission work flow for ex-utero transferred babies from other hospitals.


      The neonatal unit achieved zero MRSA transmission to previously noninfected and noncolonized patients over the 9-month period, and HH and environmental hygiene compliance improved from a preintervention median of 87.1% and 82.2%, respectively, to 100%, which has been sustained to date.


      Intensive reinforcement of infection control practices, strict cohorting of ex-utero transfers, universal surveillance on admission, and improvement in HH and environmental hygiene compliance were key to infection prevention and control measures, resulting in elimination of MRSA transmission in our neonatal unit.

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      1. Centers for Disease Control and Prevention. Methicillin-resistant Staphylococcus aureus (MRSA). Available from: Accessed January 5, 2019.

        • Blatnik J
        • Lesnicar G
        Propagation of methicillin-resistant Staphylococcus aureus due to the overloading of medical nurses in intensive care units.
        J Hosp Infect. 2006; 63: 162-166
        • Ramsing BG
        • Arpi M
        • Andersen EA
        • Knabe N
        • Mogensen D
        • Buhl D
        First outbreak with MRSA in a Danish neonatal intensive care unit: risk factors and control procedures.
        PLoS One. 2013; 8: e66904
        • Pinto AN
        • Seth R
        • Zhou F
        • Tallon J
        • Dempsey K
        • Tracy M
        Emergence and control of an outbreak of infections due to Panton-Valentine leukocidin positive, ST22 methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit.
        Clin Microbiol Infect. 2013; 19: 620-627
        • Harris SR
        • Cartwright EJ
        • Torok ME
        • Holden MT
        • Brown NB
        • Ogilvy-Stuart AL
        Whole-genome sequencing for analysis of an outbreak of methicillin-resistant Staphylococcus aureus: a descriptive study.
        Lancet Infect Dis. 2013; 13: 130
        • Nelson MU
        • Gallagher PG
        Methicillin-resistant Staphylococcus aureus in the neonatal intensive care unit.
        Semin Perinatol. 2012; 36: 424-430
        • Seybold U
        • Halvosa JS
        • White N
        • Voris V
        • Ray SM
        • Blumberg HM
        Emergence of and risk factors for methicillin-resistant Staphylococcus aureus of community origin in intensive care nurseries.
        Pediatrics. 2008; 122: 1039-1046
        • Coughenour C
        • Stevens V
        • Stetzenbach LD
        An evaluation of methicillin-resistant Staphylococcus aureus survival on five environmental surfaces.
        Microb Drug Resist. 2011; 17: 457-461
        • Gerber SI
        • Jones RC
        • Scott MV
        • Price JS
        • Dworkin MS
        • Filippell MB
        • et al.
        Management of outbreaks of methicillin resistant Staphylococcus aureus infection in the neonatal intensive care unit: a consensus statement.
        Infect Control Hosp Epidemiol. 2006; 27: 139-145
        • Gordon RJ
        • Lowy FD
        Pathogenesis of methicillin-resistant Staphylococcus aureus infection.
        Clin Infect Dis. 2008; 46: 350-359
        • Tiemersma EW
        • Bronzwaer SL
        • Lyytikäinen O
        • Degener JE
        • Schrijnemakers P
        • Bruinsma N
        • et al.
        Methicillin-resistant Staphylococcus aureus in Europe, 1999-2002.
        Emerg Infect Dis. 2004; 10: 1627-1634
        • Stefani S
        • Chung DR
        • Lindsay JA
        • Price JS
        • Dworkin MS
        • Filippell MB
        • et al.
        Methicillin-resistant Staphylococcus aureus (MRSA): global epidemiology and harmonisation of typing methods.
        Int J Antimicrob Agents. 2012; 39: 273-283
        • Diekema DJ
        • Pfaller MA
        • Schmitz FJ
        • Smayevsky J
        • Bell J
        • Jones RN
        • et al.
        Survey of infections due to Staphylococcus species: frequency of occurrence and antimicrobial susceptibility of isolates collected in the United States, Canada, Latin America, Europe, and the Western Pacific region for the SENTRY Antimicrobial Surveillance Program, 1997-1999.
        Clin Infect Dis. 2001; 32(: 114-132
        • Chen CJ
        • Huang YC
        New epidemiology of Staphylococcus aureus infection in Asia.
        Clin Microbiol Infect. 2014; 20: 605-623
        • Zervou FN
        • Zacharioudakis IM
        • Ziakas PD
        • Mylonakis E
        MRSA colonization and risk of infection in the neonatal and pediatric ICU: a meta-analysis.
        Pediatrics. 2014; 133: e1015-e1023
        • Washam M
        • Woltmann J
        • Haberman B
        • Haslam D
        • Staat MA
        Risk factors for methicillin-resistant Staphylococcus aureus colonization in the neonatal intensive care unit: a systematic review and meta-analysis.
        Am J Infect Control. 2017; 45: 1388-1393
        • Song X
        • Perencevich E
        • Campos J
        • Short BL
        • Singh N
        Clinical and economic impact of methicillin-resistant Staphylococcus aureus colonization or infection on neonates in intensive care units.
        Infect Control Hosp Epidemiol. 2010; 31: 177-182
        • Gould IM
        • Reilly J
        • Bunyan D,
        • Walker A
        Costs of healthcare-associated methicillin-resistant Staphylococcus aureus and its control.
        Clin Microbiol Infect. 2010; 16: 1721-1728
        • Ling ML
        • Apisarnthanarak A
        • Madriaga G
        The burden of healthcare-associated infections in southeast Asia: a systematic literature review and meta-analysis.
        Clin Infect Dis. 2015; 60: 1690-1699
      2. World Health Organization. Division of emerging and other communicable diseases, surveillance and control. Recommendations for the control of methicillin-resistant Staphylococcus aureus (MRSA). Available from: Accessed January 5, 2019.

      3. World Health Organization. WHO guidelines on hand hygiene in health care: a summary. Available from: Accessed January 5, 2019.

        • Allegranzi B
        • Pittet D
        The role of hand hygiene in healthcare-associated infection prevention.
        J Hosp Infect. 2009; 73: 305-315
        • Brown SM
        • et al.
        Use of an alcohol-based hand rub and quality improvement interventions to improve hand hygiene in a Russian neonatal intensive care unit.
        Infect Control Hosp Epidemiol. 2003; 24: 172-179
        • Girou E
        • Lubimova AV
        • Khrustalyeva NM
        • Shulaeva SV
        • Tekhova I
        • Zueva LP
        • et al.
        Association between hand hygiene compliance and methicillin resistant Staphylococcus aureus prevalence in a French rehabilitation hospital.
        Infect Control Hosp Epidemiol. 2006; 27: 1128-1130
        • Boyce JM
        • Potter-Bynoe G
        • Chenevert C
        • Lemire A
        • Poulain C
        • Allaire A
        • et al.
        Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications.
        Infect Control Hosp Epidemiol. 1997; 18: 622-627
        • Harrington G
        • Watson K
        • Bailey M
        • Land G
        • Borrell S
        • Houston L
        • et al.
        Reduction in hospitalwide incidence of infection or colonization with methicillin-resistant Staphylococcus aureus with use of antimicrobial hand-hygiene gel and statistical process control charts.
        Infect Control Hosp Epidemiol. 2007; 28: 837-844