Control of nosocomial methicillin-resistant Staphylococcus aureus: where shall we send our hospital director next time?

Sustained fall in inpatient MRSA prevalence after a video-reflexive ethnography project; an observational study

BACKGROUND

Maintaining optimal infection prevention and control (IPC) in a busy, clinical environment is challenging. Video-reflexive ethnography (VRE) is a collaborative, interventionist approach to practice improvement. We hypothesised that giving clinicians opportunities to view and reflect on video footage of everyday ward activities would raise awareness of, and suggest strategies to reduce, pathogen transmission risks. We undertook a VRE project, between March and September 2013, in two tertiary hospital surgical wards, with persistently high methicillin resistant Staphylococcus aureus (MRSA) endemicity, despite previous IPC interventions.

METHODS

This study was a retrospective/prospective observational study, using interrupted time-series analyses, to assess the effects of the VRE project on hand hygiene compliance, inpatient MRSA infections (newly infected patients, per 1000 occupied bed days) and inpatient MRSA colonisation prevalence, measured by serial point prevalence surveys. Follow-up continued until June 2016.

RESULTS

The VRE project was associated with changes in IPC behaviour and outcomes. Hand hygiene compliance increased (from 62% to 75%; p < 0.0001) and MRSA colonisation prevalence decreased significantly, in both wards (baseline 42%; average post-VRE 12%; p=<0.0001), MRSA infection rate decreased in one ward. Interpretation of results was complicated by a potential confounding effect of unplanned environmental hydrogen peroxide decontamination (HPD). Improved hand hygiene compliance was a predicted outcome of VRE, but also a potential contributor to reduced MRSA transmission.

CONCLUSION

Separate contributions of VRE (the intervention), HPD and hand hygiene compliance were uncertain, but their combined effect was significantly reduced MRSA endemicity, which previously had been resistant to attempted IPC interventions.

Trends in Methicillin-ResistantStaphylococcus aureus(MRSA) Bloodstream Infections: Effect of the MRSA “Search and Isolate” Strategy in a Hospital in Italy with Hyperendemic MRSA

Objective:

To evaluate the secular trends in MRSA BSIs after the introduction of a nosocomial MRSA control intervention.

Design:

Before-after study.

Setting:

An 850-bed community hospital with an ICU and vascular surgery, neurosurgery, bone marrow transplantation, and AIDS units. MRSA is endemic at this hospital; the prevalence of methicillin resistance among patients withS. aureusinfection is greater than 50%.

Patients:

Among all inpatients, MRSA BSI was identified, its origin defined, and incidence rates calculated by ward and origin.

Intervention:

A MRSA control program was implemented based on active surveillance cultures to identify MRSA-colonized patients, followed by isolation using contact precautions. Incidence rates of MRSA BSI during the intervention (ie, July 1, 1997, to December 31, 2001) and preintervention (ie, January 1, 1996, to June 30, 1997) periods were compared.

Results:

Sixty-nine MRSA BSIs were identified. When compared with the preintervention period, the incidence rate of MRSA BSI was reduced from 0.64 to 0.30 per 1,000 admissions (RR, 0.46; CI95, 0.25–0.87;P= .02) during the intervention period. The impact was greater in the ICU, with an 89% reduction (RR, 0.11; CI95, 0.01–0.98;P= .03), and for CVC-associated MRSA BSIs, with an 82% decrease (RR, 0.17; CI95, 0.05–0.55;P= .002). Methicillin resistance amongS. aureusblood isolates decreased from 46% to 17% (RR, 0.36; CI95, 0.22–0.62;P= .0002).

Conclusion:

A reduction in MRSA bacteremia is achievable through use of the MRSA “search and isolate” intervention even in a hospital with high rates of endemic MRSA.

The role of healthcare personnel in the maintenance and spread of methicillin-resistant Staphylococcus aureus

Healthcare workers may acquire methicillin-resistant Staphylococcus aureus (MRSA) from patients, both hospital and home environments, other healthcare workers, family and public acquaintances, and pets. There is a consensus of case reports and series which now strongly support the role for MRSA-carrying healthcare personnel to serve as a reservoir and as a vehicle of spread within healthcare settings. Carriage may occur at a number of body sites and for short, intermediate, and long terms. A number of approaches have been taken to interrupt the linkage of staff-patient spread, but most emphasis has been placed on handwashing and the treatment of staff MRSA carriers. The importance of healthcare workers in transmission has been viewed with varying degrees of interest, and several logistical problems have arisen when healthcare worker screening is brought to the forefront. There is now considerable support for the screening and treatment of healthcare workers, but it is suggested that the intensity of any such approach must consider available resources, the nature of the outbreak, and the strength of epidemiological associations. The task of assessing healthcare personnel carriage in any context should be shaped with due regard to national and international guidelines, should be honed and practiced according to local needs and experience, and must be patient-oriented.

Control of endemic methicillin-resistant Staphylococcus aureus--recent advances and future challenges

Although the exact burden of disease caused by methicillin-resistant Staphylococcus aureus (MRSA) remains largely unknown, most experts agree that MRSA infections are an important clinical and public health problem. Thousands of reports have been published during the last four decades concerning epidemiological and microbiological aspects of MRSA, but uncertainty remains about the best approach to prevent and control this worldwide plague, especially endemic MRSA. Epidemiological methods, e.g., risk scores for targeted screening upon admission, rapid molecular tests and pre-emptive isolation of high-risk patients, new decontamination regimens and restriction of certain antibiotic classes, are all promising approaches that may decrease MRSA cross-transmission; however, further evidence is needed before these strategies can be implemented on a wide scale. Control of community MRSA is an additional challenge for the future, requiring improved surveillance and contact tracing, as well as education and treatment of both infected cases and colonised contacts. This review summarises recent advances and studies that address these issues. Overall, it seems that there is no level of MRSA prevalence for which active control measures are no longer warranted.

Antimicrobial drug use and infection control practices associated with the prevalence of methicillin-resistant Staphylococcus aureus in European hospitals

Major regional variations in the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) are observed across Europe. This study investigated hospital MRSA prevalence in relation to patterns of antimicrobial use and infection control policies in an observational, cross-sectional study that used retrospective data from 2001 and linear regression to model relationships. MRSA prevalence (median 20.8%, n = 173 hospitals) and antimicrobial consumption (median 55.2 defined daily doses/100 bed-days, n = 140 hospitals) both varied significantly according to geographical region (p <0.001). MRSA prevalence and antimicrobial consumption data were provided by 128 hospitals, and showed a strong statistical relationship between macrolide use and MRSA prevalence. Use of (i) third-generation cephalosporins, (ii) all antimicrobial agents, and (iii) all antimicrobial agents except glycopeptides was also associated with MRSA prevalence. Up to 146 hospitals provided data on MRSA prevalence and key infection control parameters. Adjusted linear regression modelling provided strong evidence that infection control policy recommendations associated with lower MRSA prevalence rates were (i) use of alcohol-based solutions for hand hygiene (mean difference 10.3%, 99% CI 1.2-10.3), and (ii) placement of MRSA patients in single rooms (mean difference 11.2%, 99% CI 1.4-20.9). Hospitals with problems in implementing isolation policies had higher resistance levels (mean difference 12%, 99% CI 3.8-20.1). Additional recommendations showed less evidence of association with a low MRSA prevalence. Overall, this study highlighted significant associations between MRSA prevalence, antimicrobial use and various key infection control parameters, all of which showed significant individual variations according to geographical region.

Tackling contamination of the hospital environment by methicillin-resistant Staphylococcus aureus (MRSA): a comparison between conventional terminal cleaning and hydrogen peroxide vapour decontamination

The hospital environment can sometimes harbour methicillin-resistant Staphylococcus aureus (MRSA) but is not generally regarded as a major source of MRSA infection. We conducted a prospective study in surgical wards of a London teaching hospital affected by MRSA, and compared the effectiveness of standard cleaning with a new method of hydrogen peroxide vapour decontamination. MRSA contamination, measured by surface swabbing was compared before and after terminal cleaning that complied with UK national standards, or hydrogen peroxide vapour decontamination. All isolation rooms, ward bays and bathrooms tested were contaminated with MRSA and several antibiogram types were identified. MRSA was common in sites that might transfer organisms to the hands of staff and was isolated from areas and bed frames used by non-MRSA patients. Seventy-four percent of 359 swabs taken before cleaning yielded MRSA, 70% by direct plating. After cleaning, all areas remained contaminated, with 66% of 124 swabs yielding MRSA, 74% by direct plating. In contrast, after exposing six rooms to hydrogen peroxide vapour, only one of 85 (1.2%) swabs yielded MRSA, by enrichment culture only. The hospital environment can become extensively contaminated with MRSA that is not eliminated by standard cleaning methods. In contrast, hydrogen peroxide vapour decontamination is a highly effective method of eradicating MRSA from rooms, furniture and equipment. Further work is needed to determine the importance of environmental contamination with MRSA and the effect on hospital infection rates of effective decontamination.

Effect of targeted surveillance for control of methicillin-resistant Staphylococcus aureus in a community hospital system

OBJECTIVE

To examine the cost associated with targeted surveillance for methicillin-resistant Staphylococcus aureus (MRSA) and the effect of such surveillance on the rate of nosocomial MRSA infection in a community hospital system.

DESIGN

A before-and-after study comparing the rate of MRSA infection before (BES) and after (AES) the initiation of expanded surveillance. Cost-effectiveness was calculated as the difference between the cost savings associated with preventing nosocomial MRSA bacteremias and surgical site infections AES and the cost of MRSA cultures and contact isolation for patients colonized with MRSA.

SETTING AND PARTICIPANTS

Patients in a 400-bed tertiary-care facility (Roper Hospital) and a 180-bed suburban hospital (St. Francis Hospital), both in Charleston, South Carolina.Interventions. Beginning in September 2001, patients were screened for MRSA colonization upon admission to the intensive care unit and weekly thereafter. In July 2002, surveillance was expanded to include targeted screening of patients admitted to general wards who were at risk of MRSA colonization. Colonized patients were placed in contact isolation.

RESULTS

The mean rate of nosocomial MRSA infection decreased at Roper (0.76 cases per 1,000 patient-days BES and 0.45 per 1000 patient-days AES; P = .05) and at St. Francis (0.73 cases per 1,000 patient-days BES and 0.57 cases per 1000 patient-days AES; P=.35). Surveillance was cost-effective, preventing 13 nosocomial MRSA bacteremias and 9 surgical site infections, for a savings of 1,545,762 US dollars.

CONCLUSIONS

Targeted surveillance for MRSA colonization was cost-effective and provided substantial benefits by reducing the rate of nosocomial MRSA infections in a community hospital system.

Performance of methicillin-resistant Staphylococcus aureus protocols in Dutch hospitals

BACKGROUND

Although numerous studies have stressed the importance of compliance with methicillin-resistant Staphylococcus aureus (MRSA) protocols with regard to cost reduction and a safer environment for health care workers and patients, an evaluation of the usability of the protocols themselves is lacking. In this study, we evaluated the usability and performance of those protocols.

METHODS

The performance of MRSA protocols was examined in 5 Dutch hospitals by means of a questionnaire (n = 63), followed by a practical test (n = 50), in a stratified random sample of 3 types of health care workers (physicians, nursing staff, and cleaning personnel). The questionnaire consisted of constructs related to exposure to risk, risk perception, knowledge of and attitude toward the protocols and safety preventive measures, self-reported behavior, and social and organizational support. The practical test consisted of "what if" scenarios that simulate the actual use of the protocol as a guideline for solving infection problems. The health care workers were asked to verbalize their thoughts and actions while using the protocol.

RESULTS

The questionnaire demonstrated adequate knowledge of and attitude toward the MRSA protocols. However, the practical test revealed that the majority of respondents had problems with the accessibility, comprehensibility, applicability, and acceptability of the protocols. Problems not only occurred because of unclear information about the preventive measures and a poor infrastructure but also because of preventive measures that conflict with principles in providing care.

CONCLUSION

The protocols do not reflect the practical needs of the health care workers. In view of the different decisions that health care workers have to take in various circumstances, it would be impracticable to use the same MRSA protocol for all hospital staff. Finally, the practical test provided more reliable results than the questionnaire.

High prevalence of carriage of methicillin-resistant Staphylococcus aureus at hospital admission in elderly patients: implications for infection control strategies

BACKGROUND

Despite contact isolation precautions for patients with methicillin-resistant Staphylococcus aureus (MRSA), MRSA infections are increasing in many countries.

OBJECTIVE

To evaluate the role of a potential unrecognized reservoir of MRSA carried by patients in acute care wards, we determined the prevalence of MRSA at hospital admission, with special emphasis on screening-specimen yields.

SETTING

A 1100-bed teaching hospital in Paris, France.

METHODS

Nasal screening cultures were performed at admission to a tertiary-care teaching hospital for patients older than 75 years.

RESULTS

MRSA was isolated from 63 (7.9%) of 797 patients. On the multivariate analysis, variables significantly associated with MRSA carriage were presence of chronic skin lesions (adjusted odds ratio [AOR], 5.10; 95% confidence interval [CI95], 2.52-10.33); transfer from a nursing home, rehabilitation unit, or long-term-care unit (AOR, 4.52; CI95, 2.23-9.18); and poor chronic health status (AOR, 1.80; CI95, 1.02-3.18). Without admission screening, 84.1% of MRSA carriers would have been missed at hospital admission and 76.2% during their hospital stay. Furthermore, 81.1% of days at risk for MRSA dissemination would have been spent without contact isolation precautions had admission screening not been performed.

CONCLUSIONS

MRSA carriage at hospital admission is far more prevalent than MRSA-positive clinical specimens. This may contribute to failure of contact isolation programs. Screening cultures at admission help to identify the reservoir of unknown MRSA patients.

Semmelweis' legacy: insights from an international survey among 265,000 students in 32 countries

The Programme for International Student Assessment (PISA) 2000 study assessed a wide range of knowledge and skills attained by 265,000 15-year-olds in 32 industrialized countries. One survey unit of the scientific literacy section addressed infection control issues, based on Semmelweis' landmark research on the causes and prevention of puerperal fever. The present report describes the questions and student performance for this infection control exercise set and evaluates performance variability between countries.