A survey of methicillin-resistant Staphylococcus aureus control strategies in Italy

Nation-wide survey of screening practices to detect carriers of multi-drug resistant organisms upon admission to Swiss healthcare institutions

As emergence and spread of multi-drug resistant organisms (MDRO) requires a standardized preventive approach, we aimed to evaluate current MDRO admission screening practices in Swiss hospitals and to identify potential barriers impeding their implementation. In early 2018, all Swiss public and private healthcare institutions providing inpatient care were contacted with a 34-item questionnaire to investigate current MDRO admission screening policies. Among 139 respondents representing 180 institutions (response rate, 79%), 83% (149) of institutions implemented MDRO admission screening, while 28% of private and 9% of public institutions did not perform any screening. Targeted high-risk screening included carbapenemase producers, extended-spectrum beta-lactamase producers and methicillin-resistant Staphylococcus aureus at the institutional level for respectively 78% (115), 81% (118) and 98% (145) of screening institutions. Vancomycin-resistant enterococci (44% of institutions), multi-resistant Acinetobacter baumanii (41%) and Pseudomonas aeruginosa (37%) were systematically searched only by a minority of screening institutions. A large diversity of risk factors for targeted screening and some heterogeneity in body sites screened were also observed. Admission-screening practices were mostly impeded by a difficulty to identify high-risk patients (44%) and non-compliance of healthcare workers (35%). Heterogeneous practices and gaps in small and privately-owned institutions, as well as a mismatch between current epidemiologic MDRO trends and screening practices were noticed. These results highlight the need for uniform national MDRO screening standards.

Barriers and enablers to meticillin-resistant Staphylococcus aureus admission screening in hospitals: a mixed-methods study

BACKGROUND

To reduce the risk of transmission of meticillin-resistant Staphylococcus aureus (MRSA), international guidelines recommend admission screening to identify hospital patients at risk of colonization. However, routine monitoring indicates that optimum screening compliance levels are not always achieved. In order to enhance compliance, we must better understand those factors which influence staff screening behaviours.

AIM

To identify factors which influence staff compliance with hospital MRSA screening policies.

METHODS

A sequential two-stage mixed-methods design applied constructs from normalization process theory and the theoretical domains framework to guide data collection and analysis. Initial qualitative findings informed subsequent development of a national cross-sectional survey of nursing staff (N = 450). Multiple regression modelling identified which barriers and enablers best predict staff compliance.

FINDINGS

Three factors were significant in predicting optimum (>90%) compliance with MRSA screening: having MRSA screening routinized within the admission process; category of clinical area; feedback of MRSA screening compliance within the clinical area. Integration of data-sets indicated that organizational systems which 'make doing the right thing easy' influence compliance, as does local ward culture. Embedded values and beliefs regarding the relative (de)prioritization of MRSA screening are important.

CONCLUSION

To our knowledge, this is the first study to provide original evidence of barriers and enablers to MRSA screening, applying both sociological and psychological theory. As antimicrobial resistance is a global health concern, these findings have international relevance for screening programmes. Future policy recommendations or behaviour change interventions, based on the insights presented here, could have significant impact upon improving screening compliance.

Policy implementation for methicillin-resistant Staphylococcus aureus in seven European countries: a comparative analysis from 1999 to 2015

Background: Policies to reduce methicillin-resistant Staphylococcus aureus (MRSA) infections, both healthcare-acquired (HA-MRSA) and livestock-associated (LA-MRSA) are implemented Europe-wide, but evaluations are difficult for countries yet to implement such policies. A descriptive study was conducted, describing multinational MRSA rates and policy implementation, focusing on MRSA mandatory surveillance. We also investigated antibiotic use and MRSA rates and the use of veterinary antibiotics. Methods: This study used Europe-wide surveillance data on infectious diseases (EARS-Net), antibiotic consumption (ESAC-Net), and veterinary medicine (ESVAC). We visualized LA- and HA-MRSA related policies and MRSA rates from 1999 to 2015 in seven European countries. Changes in MRSA rates after implementation of an MRSA mandatory surveillance policy were investigated by setting each country as rate of 1.0 and compared countries with and without such policy. Correlations between antibiotic use and MRSA rates from 1999 to 2012 were investigated using defined daily dose. Sales data were used to investigate veterinary antibiotic use. Results: MRSA rates were 1-45.4% across the seven countries between 1999 and 2015. MRSA rates changed between 0.61 and 0.24 after the implementation of mandatory surveillance policies within a 6-12 year span. The rate of decrease rate in implemented and non-implemented countries ranged from 10% in Spain to 76% in the UK. The correlation between MRSA rate and cephalosporin consumption was r = 0.419, and for fluoroquinolones r = 0.305. Mean annual sales of veterinary cephalosporin and quinolone antibiotics were lowest in the UK (0.8 mg/PCU) and highest in Spain (9.7 mg/PCU) between 2009 and 2014. Conclusions: There were similar but different health policy implications in the seven countries regarding LA- and HA-MRSA. Although causation could not be defined, some policies such as mandatory surveillance may be helpful for countries that have yet to implement an MRSA policy. Further investigations are needed to evaluate each policies.

Costs and Benefits Associated with the MRSA Search and Destroy Policy in a Hospital in the Region Kennemerland, The Netherlands

Objective

The objective of this study was to analyze the costs and benefits of the MRSA Search and Destroy (S&D) policy between 2008 and 2013 in the Kennemer Gasthuis, a 400 bed teaching hospital in the region Kennemerland, the Netherlands.

Methods

A patient registration database was used to retrospectively calculate costs, including screening, isolation, follow-up, contact tracing, cleaning, treatment, deployment of extra healthcare workers, salary for an infection control practitioner (ICP) and service of isolation rooms. The estimated benefits (costs and lives when no MRSA S&D was applied) were based on a varying MRSA prevalence rate (up to 50%).

Results

When no MRSA S&D policy was applied, the additional costs and deaths due to MRSA bacteraemia were estimated to be € 1,388,907 and 33 respectively (at a MRSA prevalence rate of 50%). Currently, the total costs were estimated to be € 290,672 (€ 48,445 annually) and a MRSA prevalence rate of 17.3% was considered as break-even point. Between 2008 and 2013, a total of 576 high risk patients were screened for MRSA carriage, of whom 19 (3.3%) were found to be MRSA positive. Forty-nine patients (72.1%) were found unexpectedly.

Conclusions

Application of the MRSA S&D policy saves lives and money, although the high rate of unexpected MRSA cases is alarming.

New non-alcoholic formulation for hand disinfection

Hand washing is considered as the single most important strategy to prevent infections. World health organization (WHO) defines hand hygiene as a primary issue of personal care with particular reference to hospital personnel and health facility workers. In this work, we investigated a new combination for hand disinfection as an alternative to alcohol-based and chlorhexidine products. The new combination of 5-pyrrolidone-2-carboxylic acid (PCA) and copper sulphate pentahydrate (CS) was tested upon different bacterial species that normally colonize hands, including Staphylococcus aureus, methicillin resistant S. aureus (MR S. aureus), Staphylococcus epidermidis, multidrug resistant S. epidermidis (MDR S. epidermidis), Streptococcus pyogenes, Streptococcus agalactiae, Escherichia coli, Candida albicans and three clinical isolates: MR S. aureus, MDR S. epidermidis, and an E. coli strain. Minimal inhibitory concentrations (MICs), Minimal bactericidal concentrations (MBCs), fractional inhibitory concentration (FIC) indices, and fractional bactericidal concentration (FBC) indices were evaluated. Ethanol 70% V/V, isopropanol 60% V/V, and 4% w/V chlorhexidine solution were used as reference hand disinfectants. Copper sulphate pentahydrate was very effective against all tested microorganisms: The MIC and MBC for CS ranged from 781 mg/l against S. pyogenes to 12500 mg/l against E. coli strains and C. albicans. In addition, PCA exhibited a good antimicrobial activity, in particular, against S. pyogenes and S. agalactiae. The combination of CS and PCA showed a strong synergistic effect and all FIC indices were ≤0·500. The combination of CS and PCA were more effective than ethanol 70% V/V and isopropanol 60% V/V. In addition to antimicrobial activity, the new formulation possesses peculiar features such as residual activity and moisturizing effect. This work identifies a new strategy for hand disinfection.