Society for Healthcare Epidemiology of America Guideline Approach Works to Control a Methicillin-ResistantStaphylococcus aureusOutbreak

What To Think If the Results of the National Institutes of Health Randomized Trial of Methicillin-ResistantStaphylococcus aureusand Vancomycin-ResistantEnterococcusControl Measures Are Negative (and Other Advice to Young Epidemiologists): A Review and an Au Revoir

The incidence of methicillin-resistantStaphylococcus aureus(MRSA) and vancomycin-resistantEnterococcus(VRE) infections continues to rise in National Nosocomial Infections Surveillance system hospitals, and these pathogens are reportedly causing more than 100,000 infections and many deaths each year in US healthcare facilities. This has led some to insist that control measures are now urgently needed, but several recent articles have suggested that isolation of patients does not work, is not needed, or is unsafe, or that a single cluster-randomized trial could be used to decide such matters. At least 101 studies have reported controlling MRSA infection and 38 have reported controlling VRE infection by means of active detection by surveillance culture and use of isolation for all colonized patients in healthcare settings where the pathogens are epidemic or endemic, in academic and nonacademic hospitals, and in acute care, intensive care, and long-term care settings. MRSA colonization and infection have been controlled to exceedingly low levels in multiple nations and in the state of Western Australia for decades by use of active detection and isolation. Studies suggesting problems with using such data to control MRSA colonization and infection have their own problems, which are discussed. Randomized trials are epidemiologic tools that can sometimes provide erroneous results, and they have not been considered necessary for studying isolation before it is used to control other important infections, such as tuberculosis, smallpox, and severe acute respiratory syndrome. No single epidemiologic study should be considered definitive. One should always weigh all available evidence. Infection with antibiotic-resistant pathogens such as MRSA and VRE is controllable to a low level by active detection and isolation of colonized and infected patients. Effective measures should be used to minimize the morbidity and mortality attributable to these largely preventable infections.

How Often Do Asymptomatic Healthcare Workers Cause Methicillin-ResistantStaphylococcus aureusOutbreaks? A Systematic Evaluation

A systematic search was performed to identify outbreaks of methicillin-resistantStaphylococcus aureusinfection and colonization caused by healthcare workers (HCWs). Of 191 outbreaks identified, 11 had strong epidemiological evidence that HCWs were the source. In 3 of these outbreaks, asymptomatic carriers were the cause. The frequent practice of screening asymptomatic HCWs should be reconsidered.

Detection of Panton-Valentine Leukocidin-Positive Methicillin-Resistant Staphylococcus aureus Nasal Carriage among Egyptian Health Care Workers

BACKGROUND

Transmission of methicillin-resistant Staphylococcus aureus (MRSA) among patients is linked mainly to health care personnel. The Panton-Valentine leukocidin (PVL) is a cytotoxin that causes leukocyte lysis. Virulence of pvl-positive-MRSA has been attributed to its ability to express PVL toxin.

METHODS

Swabs for detection of nasal carriage of pvl-positive MRSA among health care personnel at Fayoum University Hospital, Fayoum, Egypt, were collected from 223 health care personnel including 70 doctors (31.4%), 95 nurses (42.6%), 21 laboratory technicians (9.4%), and 37 housekeeping staff (16.6%). Detection of MRSA was done using conventional screening methods and confirmed by multiplex polymerase chain reaction (PCR) for mecA, or its homologue mecC, and pvl genes amplification. Re-swabbing after decolonization therapy was done to evaluate the efficacy of decolonization therapy.

RESULTS

Fifty-one of 223 participants (22.9%) were colonized with S. aureus. This included 13.5% (30/223) colonized with MRSA and 2.2% (5/223) colonized with PVL-positive MRSA. Moreover, all MRSA isolates were negative for mecC genes. Decolonization therapy was successful in 80% of MRSA carriers including all pvl-positive MRSA carriers.

CONCLUSIONS

This is the first report on nasal carriage of pvl-positive MRSA among Egyptian health care personnel. High carriage rate of MRSA among health care personnel has been attributed mainly to poor hand hygiene compliance and non-judicious use of antibiotics. Improving compliance, reducing antibiotic overuse, screening for carriers, and decolonization are recommended strategies for reducing the spread of MRSA. Multiplex PCR could be used for confirmation of results obtained by conventional phenotypic methods.

Impact of hand hygiene on the infectious risk in nursing home residents: A systematic review

BACKGROUND

In nursing homes, the infectious risk is high, making infection control using approaches such as hand hygiene (HH) a major issue. However, the effectiveness of HH in these settings is not well documented, and HH compliance is low.

METHODS

We systematically searched PubMed, Scopus, Web of Science, and Cochrane Clinical Trials for studies in nursing homes that either described a HH-related intervention or assessed HH compliance and included a measured infectious outcome. Two reviewers independently performed the study selection.

RESULTS

Fifty-six studies met the inclusion criteria and were reviewed. Most were outbreak reports (39%), followed by observational studies (23%), controlled trials (23%), and before-after intervention studies (14%). Thirty-five studies (63%) reported results in favor of HH on at least one of their outcome measures; in addition, the infection control success rate was higher when at least one HH-related intervention (eg, staff education on HH, increased availability of handrub solution) was included (70% vs 30% for no intervention). However, only 25% of randomized trials concluded that HH-related interventions led to a reduction in the infectious risk.

CONCLUSION

The results of this systematic review suggest that more evidence on HH effectiveness in nursing homes is needed. Future interventional studies should enhance methodologic rigor using clearly defined outcome measures, standardized reporting of findings, and a relevant HH observation tool.

Political Versus Epidemiological Correctness

In the March issue of the journal, the Joint SHEA and APIC Task Force indicates that the Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC) support the use of active detection and isolation (ADI) for controlling nosocomial infections due to methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) “in appropriate circumstances, as recommended in previously published guidelines”1(p250) (those published by SHEA and the Healthcare Infection Control Practices Advisory Committee [HICPAC]), but that SHEA and APIC oppose the use of legislation for mandating any infection control approach, including this one as tried in 2006 in Illinois and Maryland.

Both supporters and opponents of controlling MRSA and VRE with ADI probably will agree that legislation is not the optimal way to control nosocomial infections in general, but this position statement undoubtedly will please the latter more than it does the former because the SHEA/APIC Task Force argues that ADI is not ready for routine use throughout all healthcare facilities, directly opposing the position of the original SHEA guideline. As an author of that SHEA guideline, I would like to comment. First, the new position seems politically correct (since most infection control professionals have not yet bothered using ADI to control MRSA and VRE), but many of the planks of the SHEA/APIC Task Force position statement are misleading.

An integrated approach to methicillin-resistant Staphylococcus aureus control in a rural, regional-referral healthcare setting

OBJECTIVE

To curtail the prevalence and cross-transmission of methicillin-resistant Staphylococcus aureus (MRSA) in a rural healthcare setting.

DESIGN

Before-after, quasi-experimental quality improvement study.

SETTING

A regional-referral hospital, 5 affiliated nursing homes, and an outpatient MRSA clinic.

INTERVENTIONS

Residents of the 5 nursing homes were screened for MRSA at baseline and 1 year later. Active surveillance cultures were performed on subsequently admitted nursing home residents, "high-risk" patients admitted to the hospital, and household contacts of clinic patients. The decolonization regimen consisted of systemic therapy with minocycline and rifampin and topical therapy with nasal mupirocin ointment and 5% tea tree oil body wash. Three separate samples for cultures to document clearance of MRSA colonization were obtained at 1-week intervals 1 month after the completion of decolonization therapy. Samples for follow-up cultures were obtained at month 6 and month 12 after the completion of decolonization therapy.

RESULTS

After intervention and follow-up for 12 months or more, the prevalence of MRSA carriage at the nursing homes decreased by 67% (P < .001), and 120 (82%) of 147 nursing home residents and 111 (89%) of 125 clinic patients remained culture-negative for MRSA. Twenty-three (24%) of 95 new clinic patients had at least 1 MRSA-positive contact. Mupirocin resistance did not develop. In the hospital, the incidence rate of nosocomial MRSA infection decreased from 0.64 infections per 1,000 patient-days before the interventions to 0.40 infections per 1,000 patient-days 1 year after the interventions and to 0.32 infections per 1,000 patient-days 2 years after the intervention (P < .01).

CONCLUSIONS

Use of active surveillance cultures and decolonization therapy was effective in decreasing the prevalence of asymptomatic carriage, the incidence of nosocomial infection, and the overall prevalence of MRSA in our rural healthcare setting.

Implementing the MRSA recommendations made by the Commission for Hospital Hygiene and Infection Prevention (KRINKO) of 1999 - current considerations by the DGKH Management Board

In Germany, recommendations on dealing with patients who are colonised with methicillin-resistant S. aureus (MRSA) for the inpatient sector have been published in 1999 by the Commission for Hospital Hygiene and Infection Prevention (KRINKO). Some challenges arise with regard to the practical implementation of the KRINKO recommendations. These challenges do not principally question the benefit of the recommendations but have come into criticism from users. In this commentary the German Society for Hospital Hygiene (DGKH) discusses some controversial issues and adds suggestions for unresolved problems regarding the infection control management of MRSA in healthcare settings.

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.

Health-care workers: source, vector, or victim of MRSA?

There is ongoing controversy about the role of health-care workers in transmission of meticillin-resistant Staphylococcus aureus (MRSA). We did a search of the literature from January, 1980, to March, 2006, to determine the likelihood of MRSA colonisation and infection in health-care workers and to assess their role in MRSA transmission. In 127 investigations, the average MRSA carriage rate among 33 318 screened health-care workers was 4.6%; 5.1% had clinical infections. Risk factors included chronic skin diseases, poor hygiene practices, and having worked in countries with endemic MRSA. Both transiently and persistently colonised health-care workers were responsible for several MRSA clusters. Transmission from personnel to patients was likely in 63 (93%) of 68 studies that undertook genotyping. MRSA eradication was achieved in 449 (88%) of 510 health-care workers. Subclinical infections and colonisation of extranasal sites were associated with persistent carriage. We discuss advantages and disadvantages of screening and eradication policies for MRSA control and give recommendations for the management of colonised health-care workers in different settings.

Controlling methicillin-resistant Staphylococcus aureus by stepwise implementation of preventive strategies in a university hospital: impact of a link-nurse system on the basis of multidisciplinary approaches

BACKGROUND

Current approaches in the control of methicillin-resistant Staphylococcus aureus (MRSA) in the large tertiary referral hospital have not been universally successful.

METHODS

The trend of MRSA rates and their relationship with stepwise implementation of preventive strategies in Tokai University Hospital during a 76-month period from September 1998 to December 2004, was retrospectively analyzed with a quasi-experimental design.

RESULTS

Implementation of strategies including a feedback process with case and epidemic reporting, an infection control team and office, and a preventive guideline for MRSA did not result in reduction in monthly MRSA rates in the hospital, as analyzed with Shewhart u charts. When infection control link nurses were organized and their activities became full-scale, there appeared significant reduction in arithmetic mean of the monthly rates of MRSA from 6.3% to 5.0% in June 2002. Meanwhile the mean values for monthly counts of new MRSA cases also dropped in 15 of 25 wards/units in June 2002, as analyzed with Exponentially Weighted Moving Average charts. Concurrently, there was a significant increase (17.3%) in the monthly consumption of handwashing liquid plain soap. Thereafter the MRSA rates remained low for 2 years within three standard deviations.

CONCLUSIONS

The sustained reduction of MRSA rates in the hospital can be related to introduction of the infection control link-nurse system on the basis of continuous enforcement of basic and multidisciplinary approaches such as hand-hygiene compliance.