Infection control and management of MRSA:
assessing the knowledge of staff in an acute
P.M. Eastona,*, A. Sarmab, F.L.R. Williamsc, C.A. Marwickd,
G. Phillipse, D. Nathwanif
aDirectorate of Change and Innovation, Tayside NHS Board, Dundee, UK
bNinewells Hospital and Medical School, Dundee, UK
cSection of Public Health, Division of Community Health Sciences, University of Dundee, Dundee, UK
dInfection Unit; East Block, Ninewells Hospital and Medical School, Dundee, UK
eMedical Microbiology, Ninewells Hospital and Medical School, Dundee, UK
fInfection Unit, East Block, Ninewells Hospital and Medical School, Dundee, UK
Received 17 July 2006; accepted 15 December 2006
Available online 20 February 2007
lococcus aureus (MRSA) has focused on hygiene in hospitals, but it is unclear
how much hospital staff know about the treatment and management of pa-
tients who are colonized or infected with MRSA. The aim of this study was to
assess the knowledge and perceived practice of staff regarding MRSA and its
management in an acute hospital setting. A further aim was to determine
what staff felt was needed in terms of information or education on the risks,
through group administration during a study day and by face-to-face inter-
views. Subjects included in the questionnaire were infection and coloniza-
tion, treatment, and the availability of local support and advice. There
on many aspects of MRSA and its management was deficient, although the
majority of participants who felt that they required additional information
about MRSA acknowledged this. The survey confirmed that assumptions
should not be made about adequate knowledge and expertise of staff in
Much of the recent work in tackling meticillin-resistant Staphy-
* Corresponding author. Address: Directorate of Change and Innovation, Tayside NHS Board, Kings Cross, Clepington Road, Dundee
DD3 8EA, UK. Tel.: þ44 01382 424191; fax: þ44 01382 424.
E-mail address: email@example.com
0195-6701/$ - see front matter ª 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
Journal of Hospital Infection (2007) 66, 29e33
relation to MRSA. Gaps in awareness of aspects of care and management
were highlighted and information and educational needs identified.
ª 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights
Staphylococcus aureus (MRSA) has focused on hy-
giene in the healthcare environment.1,2Awareness
of the risks of colonization and subsequent infec-
tion, effective treatment and the appropriate use
of antibiotic prescribing remain as high priorities.
Even when procedures are routine, knowledge
and expertise of staff should not be assumed. This
measurement, which found that many nurses did
not understandor perform the techniqueproperly.3
Similar findings were reported with radiation expo-
sure and treatment of pressure ulcers.4,5
There is some information about healthcare
workers’ knowledge and attitudes in relation to
these areas.6,7The success of MRSA protocols was
examined in five Dutch hospitals using a question-
naire and a practical test. Results identified ade-
quate knowledge of, and attitude to, protocols but
tical application. This study also highlighted that it
pital staff due to the different decisions staff have
to take according to circumstances.8
In Tayside, specific training and publicity aimed
formulary and sepsis protocol have led to improve-
ment in the management of sepsis among junior
doctors.9It is unknown whether this understanding
of antibiotic prescribing is applicable to MRSA
in relation to physicians’ adherence to clinical
practice guidelines.10In a review of barriers to phy-
sicians’ adherence to clinical guidelines, Cabana
et al. concluded that behaviour change based on
influencing knowledge and attitudes is probably
more sustainable than indirect manipulation of be-
in the process, stating that when physicians comply
with practice guidelines they must first become
aware of the guidelines, then intellectually agree
with them; decide to adopt them in the care they
provide, and then regularly adhere to them at
workto eradicate meticillin-resistant
appropriate times.12If, as previous studies suggest,
it is unlikely that good practice will follow.3e8With
this in mind, the present study was developed.
A questionnaire was developed to establish knowl-
edge of the nature of Staphylococcus aureus; risk
factors for MRSA, common sites of colonization,
infection and clinical complications, screening,
decolonization and treatment, and knowledge of
information and advice resources to support infec-
tion control. Demographic data were also col-
lected including post, specialty, age group and
time since professional qualification. All but one
question, which was open-ended, invited the
selection of answers from a range of options.
The questionnaire had face and content valid-
ity, having been developed in consultation with
a group of experts on questionnaire design and on
infectious diseases. The questionnaire was piloted
face-to-face with 10 doctors and nurses, by one of
the interviewers (A.S.), in order to check compre-
hension and clarity of the questions.
Data were analysed using SPSS v.11.5. Correct
answers were identified from the local guidelines,
from the literature if appropriate; all questions
were verified with our local Infectious Diseases
Consultant (D.N.). Proportions of correct responses
or correct combinations of responses were calcu-
lated with 95% confidence intervals (CIs) and dif-
ferences between staff groups were compared
using a Chi-squared test (P < 0.05).
Settings, participants and data collection
A convenience sample was recruited from two
acute hospitals in Tayside, Scotland. All partici-
pants attending an infection study day completed
questionnaires and returned them during the
session; face-to-face interviews were carried out
by two of the authors (A.S. and C.M.) with staff in
medical and surgical wards over a three-month
period from September to December 2004, using
the same questionnaire.
30P.M. Easton et al.
The two methods of administration of the
questionnaires were adopted to gain an appropri-
ate sample size over the three-month period.
Required sample size was calculated with the
advice of a statistician. A sample of 95 was plan-
ned in order to estimate a proportional response in
the region of 50% with a 95% CI of ?10.
In order to be able to measure differences
between doctors and nurses, it was agreed to
continue for the three-month period and interview
as close as possible to that number for each group.
The resulting sample of 87 doctors and 87 nurses
allowed the estimation of a proportional response
for each group in the region of 50% with a 95% CI
of ?10.5 and an estimation of the difference be-
tween responses in the two groups with a 95% CI
of ?14.9 (for proportions near 50%).
The purpose of having the questionnaires com-
pleted at the time of distribution or interview was
so that answers were spontaneous, without the use
of reference materials such as textbooks or Inter-
net websites. Doctors and nurses were recruited
opportunistically from medical and surgical wards.
Staff are required to attend an infection study day
once a year and this particular day fell within our
study period, providing an opportunity to gain
responses from a number of staff in a range of
posts and specialties. Completion of the question-
naire was presented as a required part of the study
day. This augmented the face-to-face interviews
which covered a considerable number but used
a method which is much more time-consuming.
One hundred and twenty-seven face-to-face inter-
views were carried out and 47 self-completed
questionnaires were returned. Staff who attended
the study day did not have any characteristics that
Most respondents (63%) were aged <35 years;
the previous five years and more than two-thirds
were received from a wide range of specialties
within medical and surgical wards but numbers
representing individual specialties were small.
There was considerable variation in responses
between doctors and nurses answering correctly
(Table I). No significant differences were found
between interview and self-completed responses so
icant differences were found between interviewers,
across age groups or time since qualification.
The majority of respondents (83%) correctly
identified S. aureus as a Gram-positive organism,
although significantly more doctors than nurses
did so (P< 0.001) (Table I). Thirty-six percent of
nurses compared with 30% of doctors identified
the correct anatomical sites for MRSA colonization
but this difference was not significant (Table I).
The majority of respondents (70%) could not
identify local infection control measures for MRSA
colonization, and although nurses were more likely
to answer correctly, the difference was not signif-
icant. The availability of infection control advice
24 h a day was known by 64% of respondents but
25% thought that advice was available during work-
ing hours only (Table I).
Few respondents (12%) identified all four risk
factors for MRSA colonization and infection. Regard-
ing individual risk factors, doctors were more likely
to recognize recent antibiotic usage as a risk factor
(P¼ 0.001). Urinary catheterization risk was identi-
fied by a greater proportion of nurses (P¼ 0.004).
The majority of respondents (74%) failed to
identify the two most common sites for MRSA in-
fection, namely blood and wound/skin. Thirty-four
percent of doctors answered this question correctly
compared with 17% of nurses (P¼ 0.009) (Table I).
Doctors were more likely than nurses to identify
endocarditis and death as two important and com-
mon complications of MRSA bacteraemia, although
the difference was not significant. Forty-four per-
cent of the total sample believed MRSA to be more
likely to cause death than meticillin-susceptible S.
aureus (MSSA) and 34% did not know the answer to
this question. Fifty-six percent of doctors and 32%
of nurses believed MRSA to be a more likely cause
of death than MSSA (P< 0.001) (Table I).
Doctors were significantly more likely to state
that they would treat MRSA bacteraemia with
antibiotics (P< 0.001) (Table I). Doctors were also
significantly more likely to select the combination
of antibiotic treatment and nursing in a single
room as the best option for MRSA infection manage-
ment (P< 0.001) although less than one in six (16%)
of all respondents answered this correctly.
Seventy-nine percent of respondents correctly
selected either intravenous (IV) vancomycin or IV
vancomycin with rifampicin as the appropriate
treatment for MRSA bacteraemia, but only 9% of
respondents identified both teicoplanin and line-
zolid as alternative agents. Forty-six percent
identified 14 days as the appropriate duration of
treatment for uncomplicated bacteraemia. Doc-
tors were significantly more likely to identify the
first-line antibiotic choice (P ¼ 0.003), to identify
alternative agents (P ¼0.009) and to state the
correct duration of therapy (P< 0.001).
Infection control and management of MRSA 31
An open-ended question asked when staff would
consider an alternative to their first-line choice of
antibiotic. Ten percent of doctors and 38% of nurses
were unable to give any answer. The main reasons
given for considering an alternative were lack of
Overall, only four respondents stated that they
would consult the two recommended locally pro-
duced and supported resources for infection man-
agement (Tayside Prescribing Guide and Sepsis
Protocol). A further six respondents stated that
they would consult these two resources along with
one or more other sources of information. Most
staff selected these other resources, such as the
British National Formulary, or asking an Infectious
Diseases Consultant, with a significant difference
in overall choices (P < 0.001) between doctors and
nurses, but no significant difference in those using
the recommended resources.
When asked if they felt that information or
education was required by staff within their
specialty on MRSA colonization, infection, viru-
lence and outcomes, risk factors, or general MRSA
management and drug treatment, 68% responded
that information or education was required for all
of these. Only two people felt that information or
education was not required on any of the topics.
On each individual topic, 80% or more of respon-
dents stated that further education was required
within their specialty. Ninety-two percent opted
for tutorials or lectures as a means of deliver-
ing this. There were no significant differences
between doctors and nurses in the responses.
We acknowledge that not all of the questions set
have clear-cut correct responses based on good
evidence. For example, there is still lack of clarity
and evidence about whether MRSA is more patho-
genic or virulent than MSSA and this may explain the
aetiology of meticillin-resistant Staphylococcus aureus (MRSA)
Summary of correct questionnaire responses from hospital clinical staff about the management and
Total (N¼ 174)
% (95% CI)
(N ¼87) %
(N¼ 87) %
P: doctors vs nurses
Is Staphylococcus aureus a Gram-negative
or Gram-positive organism?
Which sites would you swab to
detect MRSA colonization?
What methods of infection control
should be implemented in the management
of a patient colonized with MRSA?
When is infection control advice available?
Which of these are common risk factors for
MRSA colonization or infection?
Which of these are among the most common
sites of MRSA infection (not colonization)?
What are the two most common
complications of MRSA bacteraemia?
Do you believe that MRSA infection is more
likely to be a cause of death than MSSA?
Would you usually treat MRSA bacteraemia
What methods of infection control should
be implemented in the management of a
patient infected with MRSA?
What would be your first-line choice of
one antibiotic for the treatment of
Duration of therapy for bacteraemia
Are any of these agents alternatives
for treating MRSA bacteraemia?
Reasons given for considering alternative
to first-line choice antibiotic
Would consult recommended resources
only for infection management?
Information/education needed on all
suggested MRSA topics
32.8 (25.8e39.8)3036 NS
25.9 (19.4e32.4)34 17 0.009
41.4 (34.1e48.7) 47 35NS
43.7 (36.3e51.1) 5632
74.7 (68.2e81.2) 87 62
16.1 (10.6e21.6) 257
79.3 (73.3e85.3)89 70 0.003
76.0 (69.6e82.4) 9062
2.3 (0.1e4.5) 3.41.1NS
67.8 (60.9e74.7) 6967NS
MSSA, meticillin-sensitive Staphylococcus aureus; CI, confidence interval; NS, not significant.
32 P.M. Easton et al.
proportion (44%) who believed that MRSA is more Download full-text
has highlighted a range of knowledge deficiencies
in healthcare staff as well as significant inter-pro-
fessional differences in the key areas of infection
control and management, similar to findings else-
where.6e8A considerable proportion of the sample
had trained at a time of increasing awareness and
concern over MRSA but participants were not asked
about their source of knowledge of MRSA. Although
some differences are to be expected (for example,
nurses were more knowledgeable than doctors
demonstrated higher awareness of antibiotic choice
and duration of treatment), the need to improve
overall knowledge is evident. Although nurses’
knowledge of treatment was higher than expected
for a non-prescribing group, improving all clinicians’
awareness and encouraging use of local guidelines
and protocols will aid clarity and consistency in
tion and infection.
At the time of the study, MRSA guidelines were
available through the Tayside Area Prescribing
Guide in the form of a pocket-sized paper booklet,
but these did not include information about risk
advice on seeking specialist help. Senior medical
students and all junior doctors were sent copies,
along with the clinical departments, and their use
was promoted at educational meetings. However,
recommended sources for MRSA management. The
survey has stimulated the development of a co-
ordinated multi-professional educational strategy,
and information needs on MRSA.
MRSA guidelines are now available to all clinical
staff through the intranet and revised MRSA guide-
available at the time of clinical decision-making.
This will support clinicians, including GPs, seeking
advice on treatment as well as act as a standard of
care for a prescribing audit. The protocol will form
part of undergraduate and postgraduate medical
information of value.
While accepting the limitations of our survey,
the results confirm that assumptions should not be
made about staff knowledge or awareness of MRSA
control and management. If good infection prac-
tice is to occur amongst all non-specialist staff,
improving generic knowledge about MRSA and
better use of local guidance ought to be a priority.
The recently published national guidelines for
MRSA prevention, control and treatment will pro-
vide the evidence base for local adaptation,
adoption and training of healthcare staff.13,14
The authors thank Dr Simon Ogston for statistical
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