The use of a critical care consult team to identify risk for methicillin-resistant Staphylococcus aureus infection and the potential for early intervention: a pilot study

A systematic literature review and meta-analysis of factors associated with methicillin-resistant Staphylococcus aureus colonization at time of hospital or intensive care unit admission

OBJECTIVE

Screening for methicillin-resistant Staphylococcus aureus (MRSA) in high-risk patients is a legislative mandate in 9 US states and has been adopted by many hospitals. Definitions of high risk differ among hospitals and state laws. A systematic evaluation of factors associated with colonization is lacking. We performed a systematic review of the literature to assess factors associated with MRSA colonization at hospital admission.

DESIGN

We searched MEDLINE from 1966 to 2012 for articles comparing MRSA colonized and noncolonized patients on hospital or intensive care unit (ICU) admission. Data were extracted using a standardized instrument. Meta-analyses were performed to identify factors associated with MRSA colonization.

RESULTS

We reviewed 4,381 abstracts; 29 articles met inclusion criteria (n = 76,913 patients). MRSA colonization at hospital admission was associated with recent prior hospitalization (odds ratio [OR], 2.4 [95% confidence interval (CI), 1.3-4.7]; P < .01), nursing home exposure (OR, 3.8 [95% CI, 2.3-6.3]; P < .01), and history of exposure to healthcare-associated pathogens (MRSA carriage: OR, 8.0 [95% CI, 4.2-15.1]; Clostridium difficile infection: OR, 3.4 [95% CI, 2.2-5.3]; vancomycin-resistant Enterococci carriage: OR, 3.1 [95% CI, 2.5-4.0]; P < .01 for all). Select comorbidities were associated with MRSA colonization (congestive heart failure, diabetes, pulmonary disease, immunosuppression, and renal failure; P < .01 for all), while others were not (human immunodeficiency virus, cirrhosis, and malignancy). ICU admission was not associated with an increased risk of MRSA colonization (OR, 1.1 [95% CI, 0.6-1.8]; P = .87).

CONCLUSIONS

MRSA colonization on hospital admission was associated with healthcare contact, previous healthcare-associated pathogens, and select comorbid conditions. ICU admission was not associated with MRSA colonization, although this is commonly used in state mandates for MRSA screening. Infection prevention programs utilizing targeted MRSA screening may consider our results to define patients likely to have MRSA colonization.

Review of indicators for cross-sectoral optimization of nosocomial infection prophylaxis - a perspective from structurally- and process-oriented hygiene

In the care of patients, the prevention of nosocomial infections is crucial. For it to be successful, cross-sectoral, interface-oriented hygiene quality management is necessary. The goal is to apply the HACCP (Hazard Assessment and Critical Control Points) concept to hospital hygiene, in order to create a multi-dimensional hygiene control system based on hygiene indicators that will overcome the limitations of a procedurally non-integrated and non-cross-sectoral view of hygiene.

Three critical risk dimensions can be identified for the implementation of three-dimensional quality control of hygiene in clinical routine: the constitution of the person concerned, the surrounding physical structures and technical equipment, and the medical procedures. In these dimensions, the establishment of indicators and threshold values enables a comprehensive assessment of hygiene quality. Thus, the cross-sectoral evaluation of the quality of structure, processes and results is decisive for the success of integrated infection prophylaxis.

This study lays the foundation for hygiene indicator requirements and develops initial concepts for evaluating quality management in hygiene.

Methicillin-resistant Staphylococcus aureus infection and hospitalization in high-risk patients in the year following detection

BACKGROUND

Many studies have evaluated methicillin-resistant Staphylococcus aureus (MRSA) infections during single hospitalizations and subsequent readmissions to the same institution. None have assessed the comprehensive burden of MRSA infection in the period after hospital discharge while accounting for healthcare utilization across institutions.

METHODOLOGY/PRINCIPAL FINDINGS

We conducted a retrospective cohort study of adult patients insured by Harvard Pilgrim Health Care who were newly-detected to harbor MRSA between January 1991 and December 2003 at a tertiary care medical center. We evaluated all MRSA-attributable infections associated with hospitalization in the year following new detection, regardless of hospital location. Data were collected on comorbidities, healthcare utilization, mortality and MRSA outcomes. Of 591 newly-detected MRSA carriers, 23% were colonized and 77% were infected upon detection. In the year following detection, 196 (33%) patients developed 317 discrete and unrelated MRSA infections. The most common infections were pneumonia (34%), soft tissue (27%), and primary bloodstream (18%) infections. Infections occurred a median of 56 days post-detection. Of all infections, 26% involved bacteremia, and 17% caused MRSA-attributable death. During the admission where MRSA was newly-detected, 14% (82/576) developed subsequent infection. Of those surviving to discharge, 24% (114/482) developed post-discharge infections in the year following detection. Half (99/185, 54%) of post-discharge infections caused readmission, and most (104/185, 55%) occurred over 90 days post-discharge.

CONCLUSIONS/SIGNIFICANCE

In high-risk tertiary care patients, newly-detected MRSA carriage confers large risks of infection and substantial attributable mortality in the year following acquisition. Most infections occur post-discharge, and 18% of infections associated with readmission occurred in hospitals other than the one where MRSA was newly-detected. Despite gains in reducing MRSA infections during hospitalization, the risk of MRSA infection among critically and chronically ill carriers persists after discharge and warrants targeted prevention strategies.

Methicillin-resistant staphylococcus aureus screening and eradication in the surgical intensive care unit: Is it worth it?

BACKGROUND

The problem of intensive care unit methicillin-resistant Staphylococcus aureus (MRSA) infections has led to routine surveillance and eradication strategies.

METHODS

Our surgical intensive care unit (SICU) admissions receive MRSA nares cultures and if positive are isolated followed by eradication treatment. This strategy was retrospectively reviewed.

RESULTS

Our nares-positive culture rate was 21% (30/145), and the sputum positive (sputum+) rate was 18% (26/145). Positive nares culture (Nares+) was eradicated in 63%. The rate of sputum+ in Nares+ patients was 36% (9/25). The rate of sputum+ in Nares- was 10% (12/115; P = .003). The sputum+ SICU length of stay (LOS) (18 ± 12 days in 23 S+ patients) is longer than in sputum- (10 ± 9 days in 69 S-patients, P = .0002).

CONCLUSIONS

This SICU has high rates of both nares and sputum MRSA cultures. Our data suggest eradicating nares colonization may prevent pneumonia and might decrease SICU LOS.

Methicillin-resistant Staphylococcus aureus nasal colonization is a poor predictor of intensive care unit-acquired methicillin-resistant Staphylococcus aureus infections requiring antibiotic treatment

OBJECTIVE

To test whether intensive care unit (ICU) nasal screening for methicillin-resistant Staphylococcus aureus (MRSA) predicts the presence or absence of MRSA infections requiring antimicrobial treatment.

DESIGN

A prospective cohort study.

SETTING

Medical ICU at Barnes-Jewish Hospital, a 1252-bed urban teaching hospital.

PATIENTS

Seven hundred forty-nine consecutive patients admitted to the medical ICU over a 7-mo period (November 2007 through June 2008).

INTERVENTIONS

Nasal swabs were obtained at ICU admission and weekly thereafter for MRSA detection by using polymerase chain reaction. All subjects were followed for the development of MRSA infection during their ICU stay.

MEASUREMENTS AND MAIN RESULTS

One hundred sixty-four (21.9%) patients had positive nasal colonization with MRSA at the time of ICU admission. The predictive accuracy of MRSA nasal colonization for ICU-acquired MRSA infections, either lower respiratory tract infection or bloodstream infection, was poor (lower respiratory tract infection: sensitivity, 24.2%; specificity, 78.5%; positive predictive value, 17.7%; and negative predictive value, 84.4%; and bloodstream infection: sensitivity, 23.1%; specificity, 78.2%; positive predictive value, 11.0%; and negative predictive value, 89.7%). Addition of nasal-colonization results obtained during the ICU stay did not appreciably change the predictive accuracy of this test for identification of subsequent lower respiratory tract infections and bloodstream infections attributed to MRSA requiring antimicrobial treatment.

CONCLUSIONS

In this analysis, nasal colonization with MRSA was found to be a poor predictor for the subsequent occurrence of MRSA lower respiratory tract infections and MRSA bloodstream infections requiring antimicrobial treatment. Clinicians should be cautious in using the results of nasal-colonization testing to determine the need for MRSA treatment among patients with ICU-acquired infections.