Cost comparison of MRSA screening and management - a decision tree analysis

Effectiveness of methicillin-resistant Staphylococcus aureus surveillance among exposed roommates in community hospitals: Conventional culture versus direct PCR

BACKGROUND

Roommates of unrecognized nosocomial methicillin-resistant Staphylococcus aureus (MRSA) cases are at a higher acquisition risk; however, optimal surveillance strategies are unknown.

METHODS

Using simulation, we analyzed surveillance testing and isolation strategies for MRSA among exposed hospital roommates. We compared isolating exposed roommates until conventional culture testing on day 6 and a nasal polymerase chain reaction test on day 3 (PCR3) with/without day 0 culture testing (Cult0). The model represents MRSA transmission in medium-sized hospitals using data and recommends best practices from the literature and Ontario community hospitals.

RESULTS

Cult0 + PCR3 incurred a slightly lower number of MRSA colonizations and 38.9% lower annual cost in the base case compared to Cult0 + culture testing on day 6 because the reduced isolation cost compensated for the increased testing cost. The reduction in MRSA colonizations was due to a 54.5% drop in MRSA transmissions during isolation as PCR3 reduced the exposure of MRSA-free roommates to new MRSA carriers. Removing the day 0 culture test from Cult0 + PCR3 increased total cost, the number of MRSA colonization, and missed cases by $1,631, 4.3%, and 50.9%, respectively. Improvements were higher under aggressive MRSA transmission scenarios.

DISCUSSION AND CONCLUSIONS

Adopting direct nasal polymerase chain reaction testing for determining post-exposure MRSA status reduces transmission risk and costs. Day 0 culture would still be beneficial.

Current molecular approach for diagnosis of MRSA: a meta-narrative review

Introduction:

Detection and diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) are important in ensuring a correct and effective treatment, further reducing its spread. A wide range of molecular approaches has been used for the diagnosis of antimicrobial resistance (AMR) in MRSA. This review aims to study and appraise widely used molecular diagnostic methods for detecting MRSA.

Methods:

This meta-narrative review was performed by searching PubMed using the following search terms: (molecular diagnosis) AND (antimicrobial resistance) AND (methicillin-resistant Staphylococcus aureus). Studies using molecular diagnostic techniques for the detection of MRSA were included, while non-English language, duplicates and non-article studies were excluded. After reviewing the libraries and a further manual search, 20 studies were included in this article. RAMESES publication standard for narrative reviews was used for this synthesis.

Results:

A total of 20 full papers were reviewed and appraised in this synthesis, consisting of PCR technique (n = 7), deoxyribonucleic acid (DNA) Microarray (n = 1), DNA sequencing (n = 2), Xpert MRSA/SA BC assay (n = 2), matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) (n = 2), MLST (n = 4), SCCmec typing (n = 1) and GENECUBE (n = 1).

Discussion:

Different diagnostic methods used to diagnose MRSA have been studied in this review. This study concludes that PCR has been extensively used due to its higher sensitivity and cost-effectiveness in the past five years

Perception of Professionals from Different Healthcare Units Regarding the Use of Spray Technology for the Instantaneous Decontamination of Personal Protective Equipment during the Coronavirus Disease Pandemic: A Short Analysis

Within the context of the coronavirus disease (COVID-19) pandemic, different disinfection technologies have been developed to efficiently exercise microbial control, especially to minimize the potential risks that are associated with transmission and infection among healthcare professionals. Thus, the aim of this work was to evaluate the perception of professionals regarding the use of a new technology (chamber) for the instantaneous decontamination of personal protective equipment before the doffing stage. This was a cross-sectional descriptive study where the study data were obtained by using a questionnaire with qualitative questions. In total, 245 professionals participated in the study in three hospitals. Healthcare professionals represented 72.24% (n = 177) of the investigated sample. Approximately 69% of the professionals considered the disinfection chamber as a safe technology, and 75.10% considered it as an important and effective protective barrier for healthcare professionals in view of its application before the doffing process. The results found in this study demonstrate that the use of spray technology in the stage prior to the doffing process is acceptable to professionals, and that it can be an important tool for ensuring the additional protection of the professionals who work directly with patients who are diagnosed with COVID-19.

Meticillin-resistant Staphylococcus aureus Contact Screening Strategy in a Low Prevalence Setting; a Nested Case-Control Study

Background

The optimal screening strategy in hospitals to identify secondary cases after contact with a meticillin-resistant Staphylococcus aureus (MRSA) index patient in a low prevalence setting is not well defined. We aimed at identifying factors associated with documented MRSA transmissions.

Method

Single center, retrospective, nested case-control study. We evaluated the screening strategy in our 950 bed tertiary care hospital from 2008 - 2014. Room and ward contacts of MRSA index patients present at time of MRSA identification were screened. We compared characteristics of Staphylococcus aureus Protein A (spa)-type matched contact patients (cases) to negative or spa-type mismatched contact patients (controls).

Results

Among 270,000 inpatients from 2008 - 2014, 215 MRSA screenings yielded 3013 contact patients, and 6 (0.2%) spa-type matched pairs. We included 225 controls for the nested case-control study. The contact type for the cases was more frequently "same room" and less frequently "same ward" compared with the controls (P = 0.001). Also, exposure time was longer for cases (median of 6 days [IQR 3-9]) than for controls (1 day [0-3], P=0.016).

Conclusion

The extensive MRSA screening strategy revealed only few index/contact matches based on spa-typing. Prolonged exposure time and a shared room were significantly associated with MRSA transmission. A targeted screening strategy may be more useful in a low prevalence setting than screening entire wards.

Predictors of Staphylococcus Aureus Nasal Colonization in Joint Arthroplasty Patients

Early identification and treatment of Staphylococcus aureus (S. aureus) nasal colonization can reduce the risk of prosthetic joint infection. The purpose of this study was to evaluate patient-specific predictors for S. aureus nasal colonization in total joint arthroplasty patients to aid in preoperative screening protocols. A total of 2,147 arthroplasty patients who were preoperatively screened for S. aureus nasal colonization were retrospectively reviewed. Factors analyzed consisted of procedure type, primary diagnosis, gender, ethnicity, body mass index, the presence of chronic obstructive pulmonary disease, obstructive sleep apnea, hypertension, diabetes mellitus, use of immunosuppression medication, smoking history, and chronic kidney disease. Univariate and multivariate analyses were performed with significance p < 0.05 and 95% confidence intervals. Overall, 3.7% (79) of our cohort tested positive for methicillin-resistant Staphylococcus aureus (MRSA), and 23.2% (493) tested positive for methicillin-sensitive Staphylococcus aureus (MSSA). Independent predictors for MRSA colonization were of Hispanic ethnicity (p = 0.001, odds ratio [OR] 13.98, confidence interval [CI] 2.97-65.76), immunosuppression medication use (p = 0.006, OR 2.82, CI 1.35-5.87), and revision total hip arthroplasty (THA) procedure (p < 0.001, OR 7.51, CI 2.58-21.89). Independent predictors for MSSA colonization were body mass index (BMI) >35 (p = 0.002, OR 1.57, CI 1.19-2.1). Variables were found to be protective against MSSA colonization including female gender (p = 0.012, OR 0.76, CI 0.61-0.94), age 60 to 69 (p = 0.025, OR 0.75, CI 0.58-0.96), and age 70 to 79 (p = 0.002, OR 0.63, CI 0.47-0.84). Age, Hispanic ethnicity, gender, revision THA, use of immunosuppression medication, and elevated BMI were independent risk factors for S. aureus nasal colonization.

Nasal screening for methicillin-resistant Staphylococcus aureus does not reduce surgical site infection after primary lumbar fusion

BACKGROUND CONTEXT

Preoperative methicillin-resistant Staphylococcus aureus (MRSA) testing and decolonization has demonstrated success for arthroplasty patients in surgical site infections (SSIs) prevention. Spine surgery, however, has seen varied results.

PURPOSE

The purpose of this study was to determine the impact of nasal MRSA testing and operative debridement rates on surgical site infection after primary lumbar fusion.

STUDY DESIGN/SETTING

Retrospective cohort study and/or Consolidated medical enterprise PATIENT SAMPLE: Adult patients undergoing primary instrumented lumbar fusions from January 2015 to December 2019 were reviewed.

OUTCOME MEASURES

The primary outcome was incision and drainage performed in the operating room within 90 days of surgery.

METHODS

MRSA testing <90-day's before surgery, mupirocin prescription <30-day's before surgery, perioperative antibiotics, and Elixhauser comorbidity index were collected for each subject. Bivariate analysis used Wilcoxon rank-sum testing and logistic regression modeling Multivariable logistic regression modeling assessed for associations with MRSA testing, intravenous vancomycin use, and I&D rate.

RESULTS

The study included 1,884 patients for analysis, with mean age of 63.1 (SE 0.3) and BMI 29.5 (SE 0.1). MRSA testing was performed in 755 patients (40.1%) and was more likely to be performed in patients with lower Elixhauser index scores (OR 0.98, 95% CI 0.96-0.99, p=.021) on multivariable analysis. Vancomycin use increased significantly over time (OR 1.49 and/or year, 95% CI 1.3-1.8, p<.001) despite no change in mupirocin or I&D rates. MRSA testing, mupirocin prescriptions, perioperative parenteral vancomycin use, and intrawound vancomycin powder use had no impact on I&D rates. I&D risk was associated with higher BMI (OR 1.06, 95% CI 1.02-1.12, p=.009) and higher number of blood product units transfused (OR 1.23, 95% CI 1.03-1.46, p=.022).

CONCLUSIONS

The present study demonstrates no impact on surgical I&D rates from the use of preoperative MRSA testing. Increased BMI and transfusions were associated with operative I&D rates for surgical site infection. As a result of the hospital directive, vancomycin use increased over time with no associated change in infection rates, underscoring the need for focused interventions, and engagement with antibiotic stewardship programs.

Universal admission screening: a potential game-changer in hospitals with high prevalence of MRSA

INTRODUCTION

Despite the perception that meticillin-resistant Staphylococcus aureus (MRSA) is now under control in high-income countries, global prevalence remains high, even increasing in some regions. Universal admission screening and decolonization has been instituted in some hospitals to attempt control but the practice remains controversial.

METHODS

In 2014, Mater Dei Hospital in Malta introduced a universal admission screening policy, utilizing a novel, centralized and customized approach to achieve high compliance and low cost. Admissions are screened nasally by designated staff using chromogenic media, irrespective of risk factors. Carriers are decolonized without concurrent isolation or contact precautions. In this study, longitudinal, quasi-experimental evaluation was undertaken using time series analysis to analyse the impact of the intervention on the proportion of MRSA among clinical S. aureus isolates (%MRSA) and incidence per 1000 bed-days. A cost-utility analysis was also attempted to identify approximate quality-adjusted life years (QALYs) gained.

RESULTS

A transfer function model approach concluded that the intervention had a significant effect on both %MRSA and incidence. Six years following its introduction, the screening programme had led to an overall 43% long-term reduction in %MRSA from pre-screening levels [R²=0.687; Bayesian information criterion (BIC)=4.063], translating to a decrease in incidence of approximately 0.56 cases/1000 bed-days (R²=0.633, BIC=-3.063). No correlation was identified with consumption of antibiotics or alcohol hand rub. The annual cost-benefit of the programme was calculated at €1058 per QALY gain per year.

CONCLUSION

The universal admission screening and decolonization intervention was successful and cost-effective in this high-endemicity setting. It facilitated improvement in the prevalence of MRSA, achieving reduction levels rarely reported by Mediterranean hospitals.

Costs of outpatient and inpatient MRSA screening and treatment strategies for patients at elective hospital admission - a decision tree analysis

Background

Nosocomial infections are among the most common complications in hospitals. A major part is caused by multidrug-resistant organisms (MDRO). MRSA is still the most prominent and frequent MDRO. The early detection of carriers of multidrug-resistant bacteria is an effective measure to reduce nosocomial infections caused by MDRO. For patients who are planning to go to the hospital, an outpatient screening for MDRO and pre-hospital decolonization is recommended. However, the effectiveness of such pre-admission MDRO management in preparation for a planned hospital stay has not yet been sufficiently scientifically examined from an economic perspective.

Methods

A decision tree will be used to develop scenarios for MDRO screening and treatment in the context of the outpatient and inpatient sectors using MRSA-positive patients as an example. Subsequently, the expected costs for the respective strategy are presented.

Results

The decision tree analysis shows that the expected costs of outpatient MRSA management are €8.24 and that of inpatient MRSA management are €672.51.

Conclusion

The forward displacement of the MRSA screening to the ambulatory sector and any subsequent outpatient decolonization for patients with a planned hospitalization is the most cost-effective strategy and should become a standard benefit. Excluding opportunity costs, the expected costs of inpatient MRSA management are €54.94.

Assessing the opportunity costs of patients with multidrug-resistant organisms in hospitals

OBJECTIVES

The concept of opportunity cost can be applied to the utilization of hospital beds with special focus on patients colonized or infected with multidrug-resistant organisms. Blocked beds due to isolation measures or increased length of stay may result in opportunity costs if newly arriving patients have to be rejected and the hospital is confronted with revenue foregone. However, the amount of these costs is unclear, since different approaches are used in the literature to determine the respective costs. Our paper develops a concept to assess opportunity costs from the perspective of a hospital.

METHODS

The analysis is two-stage. In a first step, the probability of rejecting a patient due to over-occupancy in a hospital is calculated with a queuing model and a Monte Carlo simulation taking various assumptions into account. In a second step, the amount of the opportunity costs is calculated as an expected value applying a stochastic approach based on a potential patient pool.

RESULTS

Opportunity costs will occur only with a probability that is influenced, among others, by current bed occupancy rates. They have to be measured by average net revenue foregone, i.e., by the difference between average revenue foregone and average costs avoided.

CONCLUSIONS

Previous studies have a tendency of overestimating the occurrence or the size of opportunity costs with regard to the use of hospital beds. Nonetheless, its influence on the hospital budget is crucial and should be determined exactly.

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.

Nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) at a palliative care unit: A prospective single service analysis

BACKGROUND

The emergence of multidrug-resistant bacterial microorganisms is a particular challenge for the health care systems. Little is known about the occurrence of methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant Gram-negative bacteria (MDRGNB) in patients of palliative care units (PCU).

AIM

The primary aim of this study was to determine the carriage of MRSA among patients of a PCU at a German University Hospital and to assess whether the positive cases would have been detected by a risk-factor-based screening-approach.

DESIGN

Between February 2014 and January 2015 patients from our PCU were tested for MRSA carriage within 48 hours following admission irrespective of pre-existing risk factors. In addition, risk factors for MRSA colonization were assessed. Samples from the nostrils and, if applicable, from pre-existing wounds were analysed by standardized culture-based laboratory techniques for the presence of MRSA and of other bacteria and fungi. Results from swabs taken prior to admission were also recorded if available.

RESULTS

297 out of 317 patients (93.7%) fulfilled one or more MRSA screening criteria. Swabs from 299 patients were tested. The detection rate was 2.1% for MRSA. All MRSA cases would have been detected by a risk-factor-based screening-approach. Considering the detected cases and the results from swabs taken prior to admission, 4.1% of the patients (n = 13) were diagnosed with MRSA and 4.1% with MDRGNB (n = 13), including two patients with MRSA and MDRGNB (0.6%). The rate of MRSA carriage in PCU patients (4.1%) was elevated compared to the rate seen in the general cohort of patients admitted to our University Hospital (2.7%).

CONCLUSIONS

PCU patients have an increased risk to carry MRSA compared to other hospitalized patients. Although a risk factor-based screening is likely to detect all MRSA carriers amongst PCU patients, we rather recommend a universal screening to avoid the extra effort to identify the few risk factor-negative patients (<7%). As we did not perform a systematic MDRGNB screening, further studies are needed to determine the true prevalence of MDRGNB amongst PCU patients.

Identification of Staphylococcus spp. and detection of mecA by an oligonucleotide array

Phenotypic identification of coagulase-negative staphylococci (CoNS) is difficult and many staphylococcal species carry mecA. This study developed an array that was able to detect mecA and identify 30 staphylococcal species by targeting the internal transcribed spacer regions. A total of 129 target reference strains (30 species) and 434 clinical isolates of staphylococci were analyzed. Gene sequencing of 16S rRNA, gap or tuf genes was the reference method for species identification. All reference strains (100%) were correctly identified, while the identification rates of clinical isolates of S. aureus and CoNS were 98.9% and 98%, respectively. The sensitivity and specificity for mecA detection were 99% and 100%, respectively, in S. aureus isolates, and both values were 100% in isolates of CoNS. The assay takes 6 h from a purified culture isolate, and so far it has not been performed directly on patient samples.

Increasing the efficiency of a targeted methicillin-resistant Staphylococcus aureus screening program

An interdisciplinary team implemented a screening program targeting patients with a history of methicillin-resistant Staphylococcus aureus (MRSA), to reduce unnecessary contact isolation. After converting from a 2-step culture-based protocol to single polymerase chain reaction (PCR) testing, we increased the efficiency of the screening program from 77% to 100%. Despite the higher cost of PCR-based testing, this program remained cost-saving.

Impact of different diagnostic technologies for MRSA admission screening in hospitals - a decision tree analysis

BACKGROUND

Hospital infections with multiresistant bacteria, e.g., Methicillin-resistant Staphylococcus aureus (MRSA), cause heavy financial burden worldwide. Rapid and precise identification of MRSA carriage in combination with targeted hygienic management are proven to be effective but incur relevant extra costs. Therefore, health care providers have to decide which MRSA screening strategy and which diagnostic technology should be applied according to economic criteria.

AIM

The aim of this study was to determine which MRSA admission screening and infection control management strategy causes the lowest expected cost for a hospital. Focus was set on the Point-of-Care Testing (PoC).

METHODS

A decision tree analytic cost model was developed, primarily based on data from peer-reviewed literature. In addition, univariate sensitivity analyses of the different input parameters were conducted to study the robustness of the results.

FINDINGS

In the basic analysis, risk-based PoC screening showed the highest mean cost savings with 14.98 € per admission in comparison to no screening. Rapid universal screening methods became favorable at high MRSA prevalence, while in situations with low MRSA transmission rates omission of screening may be favorable.

CONCLUSION

Early detection of MRSA by rapid PoC or PCR technologies and consistent implementation of appropriate hygienic measures lead to high economic efficiency of MRSA management. Whether general or targeted screening is more efficient depends mainly on epidemiological and infrastructural parameters.

Performance of BD Max StaphSR for Screening of Methicillin-Resistant Staphylococcus aureus Isolates among a Contemporary and Diverse Collection from 146 Institutions Located in Nine U.S. Census Regions: Prevalence of mecA Dropout Mutants

This study determined the performance of BD Max StaphSR and the rate of methicillin-resistant Staphylococcus aureus (MRSA) with an unrecognized staphylococcal cassette chromosome mec (SCCmec) right-extremity junction (MREJ) region among 907 methicillin-resistant S. aureus (MRSA) and 900 methicillin-susceptible S. aureus (MSSA) isolates. The rate of mecA/mecC dropout mutants was also evaluated. Only three MRSA isolates (99.7% sensitivity; 904/907) were classified as MSSA by the BD Max StaphSR assay, due to negative results for MREJ. Eight MSSA isolates (99.1% sensitivity; 892/900) were assigned as MRSA. However, six of these MSSA isolates had the mecA gene confirmed by PCR and sequencing (99.8% sensitivity; 898/900). Overall, 7.1% (64/900) of MSSA isolates showed results compatible with a mecA dropout genotype.

Cost-benefit analysis from the hospital perspective of universal active screening followed by contact precautions for methicillin-resistant Staphylococcus aureus carriers

OBJECTIVE To explore the economic impact to a hospital of universal methicillin-resistant Staphylococcus aureus (MRSA) screening. METHODS We used a decision tree model to estimate the direct economic impact to an individual hospital of starting universal MRSA screening and contact precautions. Projected costs and benefits were based on literature-derived data. Our model examined outcomes of several strategies including non-nares MRSA screening and comparison of culture versus polymerase chain reaction-based screening. RESULTS Under baseline conditions, the costs of universal MRSA screening and contact precautions outweighed the projected benefits generated by preventing MRSA-related infections, resulting in economic costs of $104,000 per 10,000 admissions (95% CI, $83,000-$126,000). Cost-savings occurred only when the model used estimates at the extremes of our key parameters. Non-nares screening and polymerase chain reaction-based testing, both of which identified more MRSA-colonized persons, resulted in more MRSA infections averted but increased economic costs of the screening program. CONCLUSIONS We found that universal MRSA screening, although providing potential benefit in preventing MRSA infection, is relatively costly and may be economically burdensome for a hospital. Policy makers should consider the economic burden of MRSA screening and contact precautions in relation to other interventions when choosing programs to improve patient safety and outcomes.

Improving hospital hygiene to reduce the impact of multidrug-resistant organisms in health care--a prospective controlled multicenter study

BACKGROUND

Nosocomial infections are the most common complication during inpatient hospital care. An increasing proportion of these infections are caused by multidrug-resistant organisms (MDROs). This report describes an intervention study which was designed to address the practical problems encountered in trying to avoid and treat infections caused by MDROs. The aim of the HARMONIC (Harmonized Approach to avert Multidrug-resistant Organisms and Nosocomial Infections) study is to provide comprehensive support to hospitals in a defined study area in north-east Germany, to meet statutory requirements. To this end, a multimodal system of hygiene management was implemented in the participating hospitals.

METHODS/DESIGN

HARMONIC is a controlled intervention study conducted in eight acute care hospitals in the 'Health Region Baltic Sea Coast' in Germany. The intervention measures include the provision of written recommendations on methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE) and multi-resistant Gram-negative bacteria (MRGN), supplemented by regional recommendations for antibiotic prescriptions. In addition, there is theoretical and practical training of health care workers (HCWs) in the prevention and handling of MDROs, as well as targeted and critically gauged applications of antibiotics. The main outcomes of the implementation and analysis of the HARMONIC study are: (i) screening rates for MRSA, VRE and MRGN in high-risk patients, (ii) the frequency of MRSA decolonization, (iii) the level of knowledge of HCWs concerning MDROs, and (iv) specific types and amounts of antibiotics used. The data are predominantly obtained by paper-based questionnaires and documentation sheets. A computer-assisted workflow-based documentation system was developed in order to provide support to the participating facilities. The investigation includes three nested studies on risk profiles of MDROs, health-related quality of life, and cost analysis. A six-month follow-up study investigates the quality of life after discharge, the long-term costs of the treatment of infections caused by MDROs, and the sustainability of MRSA eradication.

DISCUSSION

The aim of this study is to implement and evaluate an area-wide harmonized hygiene program to control the nosocomial spreading of MDROs. Comparability between the intervention and control group is ensured by matching the hospitals according to size (number of discharges per year/number of beds) and level of care (standard or maximum). The results of the study may provide important indications for the implementation of regional MDRO management programs.

A primer on on-demand polymerase chain reaction technology

Efforts to reduce health care-associated infections (HAIs) have grown in both scale and sophistication over the past few decades; however, the increasing threat of antimicrobial resistance and the impact of new legislation regarding HAIs on health care economics make the fight against them all the more urgent. On-demand polymerase chain reaction (PCR) technology has proven to be a highly effective weapon in this fight, offering the ability to accurately and efficiently identify disease-causing pathogens such that targeted and directed therapy can be initiated at the point of care. As a result, on-demand PCR technology has far-reaching influences on HAI rates, health care outcomes, hospital length of stay, isolation days, patient satisfaction, antibiotic stewardship, and health care economics. The basics of on-demand PCR technology and its potential to impact health care have not been widely incorporated into health care education and enrichment programs for many of those involved in infection control and prevention, however. This article serves as a primer on on-demand PCR technology and its ramifications.

Cost Analysis of an Intervention to Prevent Methicillin-Resistant Staphylococcus Aureus (MRSA) Transmission

INTRODUCTION

Our objective was to assess the cost implications of a vertical MRSA prevention program that led to a reduction in MRSA bacteremia.

METHODS

We performed a matched historical cohort study and cost analysis in a single hospital in Israel for the years 2005-2011. The cost of MRSA bacteremia was calculated as total hospital cost for patients admitted with bacteremia and for patients with hospital-acquired bacteremia, the difference in cost compared to matched controls. The cost of prevention was calculated as the sum of the cost of microbiology tests, single-use equipment used for patients in isolation, and infection control personnel.

RESULTS

An average of 20,000 patients were screened yearly. The cost of prevention was $208,100 per year, with the major contributor being laboratory cost. We calculated that our intervention averted 34 cases of bacteremia yearly: 17 presenting on admission and 17 acquired in the hospital. The average cost of a case admitted with bacteremia was $14,500, and the net cost attributable to nosocomial bacteremia was $9,400. Antibiotics contributed only 0.4% of the total disease management cost. When the annual cost of averted cases of bacteremia and that of prevention were compared, the intervention resulted in annual cost savings of $199,600.

CONCLUSIONS

A vertical MRSA prevention program targeted at high-risk patients, which was highly effective in preventing bacteremia, is cost saving. These results suggest that allocating resources to targeted prevention efforts might be beneficial even in a single institution in a high incidence country.

Screening for methicillin-resistant Staphylococcus aureus … all doors closed?

PURPOSE OF REVIEW

To describe the latest evidence for methicillin-resistant Staphylococcus aureus (MRSA) infection control strategies, with particular emphasis on active surveillance cultures with contact precautions and targeted decolonization, and their impact.

RECENT FINDINGS

Several major trials published last year questioned the effectiveness of universal screening and contact precautions in controlling MRSA. These trials generally recommend universal decolonization as part of bundles to control MRSA, especially in ICUs, with some even concluding that universal decolonization should replace active screening and contact precautions. However, emerging resistance to agents used for decolonization, such as mupirocin and chlorhexidine, is a major concern. Several other studies confirmed a combination of hand hygiene enhancement, screening, contact precaution and targeted decolonization as a more viable MRSA infection control strategy for specific population groups.

SUMMARY

Universal decolonization is an acceptable MRSA control strategy for intensive care units; however, close monitoring of chlorhexidine and mupirocin resistance is warranted. As a strategy, screening and contact precautions are suitable for hospital-wide MRSA control. Targeted decolonization is a proven measure for patients undergoing clean surgery. Enhancement of hand hygiene is a core measure regardless of the strategy.

Low Yield of Methicillin-Resistant Staphylococcus aureus Screening in Hemodialysis Patients: 10 Years' Experience

OBJECTIVE

To determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization in hemodialysis patients and to analyze the cost-effectiveness of our screening approach compared with an alternative strategy. DESIGN Screening study and cost-effectiveness analysis.

METHODS

Analysis of twice-yearly MRSA prevalence studies conducted in the hemodialysis unit of a 950-bed tertiary care hospital from January 1, 2004, through December 31, 2013. For this purpose, nasal swab samples were cultured on MRSA screening agar (mannitol-oxacillin biplate).

RESULTS

There were 20 mass screenings during the 10-year study period. We identified 415 patients participating in at least 1 screening, with an average of 4.5 screenings per patient. Of 415 screened patients, 15 (3.6%) were found to be MRSA carriers. The first mass screening in 2004 yielded the highest percentage of MRSA (6/101 [6%]). Only 7 subsequent screenings revealed new MRSA carriers, whereas 4 screenings confirmed previously known carriers, and 8 remained negative. None of the carriers developed MRSA bacteremia during the study period. The total cost of our screening approach, that is, screening and isolation costs, was US $93,930. The total cost of an alternative strategy (ie, no mass screening administered) would be equivalent to costs of isolation of index cases and contact tracing was estimated to be US $5,382 (difference, US $88,548).

CONCLUSIONS

In an area of low MRSA endemicity (<5%), regular nasal screenings of a high-risk population yielded a low rate of MRSA carriers. Twice-yearly MRSA screening of dialysis patients is unlikely to be cost-effective if MRSA prevalence is low.

Methicillin-resistant Staphylococcus aureus prevention strategies in the ICU: a clinical decision analysis*

OBJECTIVES

ICUs are a major reservoir of methicillin-resistant Staphylococcus aureus. Our aim was to estimate costs and effectiveness of methicillin-resistant Staphylococcus aureus prevention policies.

DESIGN AND INTERVENTIONS

We evaluated three up-to-date methicillin-resistant Staphylococcus aureus prevention policies, namely, 1) nasal screening and contact precautions of methicillin-resistant Staphylococcus aureus-positive patients; 2) nasal screening, contact precautions, and decolonization (targeted decolonization) of methicillin-resistant Staphylococcus aureus carriers; and 3) universal decolonization without screening. We implemented a decision-analytic model with deterministic and probabilistic analyses. Methicillin-resistant Staphylococcus aureus infections averted, quality-adjusted life years gained, and incremental cost-effectiveness ratios were calculated. Cost-effectiveness planes and acceptability curves were plotted for various willingness-to-pay thresholds to address uncertainty.

MEASUREMENTS AND MAIN RESULTS

At base-case scenario, universal decolonization was the dominant strategy; it averted 1.31% and 1.59% of methicillin-resistant Staphylococcus aureus infections over targeted decolonization and screening and contact precautions, respectively, and saved $16,203/quality-adjusted life year over targeted decolonization and 14,562/quality-adjusted life year over screening and contact precautions. Results were robust in sensitivity analysis for a wide range of input variables. In probabilistic analysis, universal decolonization increased quality-adjusted life years by 1.06% (95% CI, 1.02-1.09) over targeted decolonization and by 1.29% (95% CI, 1.24-1.33) over screening and contact precautions; universal decolonization resulted in average savings of $172 (95% CI, $168-$175) and $189 (95% CI, $185-$193) over targeted decolonization and screening and contact precautions, respectively. With willingness-to-pay threshold per quality-adjusted life year gained ranging from $0 to $50,000, universal decolonization was dominant over targeted decolonization in 67.5-75.4% and dominant over screening and contact precautions in 66.0-75.4%.

CONCLUSIONS

In the ICU setting, universal decolonization outperforms the other two strategies and is likely to be cost-effective even at low willingness-to-pay thresholds. Assuming 700 annual ICU admissions in an average 12-bed ICU, the projected annual savings reach $129,500 to $135,100.

Clinical, patient experience and cost impacts of performing active surveillance on known methicillin-resistant Staphylococcus aureus positive patients admitted to medical-surgical units

BACKGROUND

There is a large and growing body of evidence that methicillin-resistant Staphylococcus aureus (MRSA) screening programs are cost effective, but such screening represents a significant cost burden for hospitals. This study investigates the clinical, patient experience and cost impacts of performing active surveillance on known methicillin-resistant S aureus positive (MRSA+) patients admitted to 7 medical-surgical units of a large regional hospital, specifically to allow discontinuation of contact isolation.

METHODS

We conducted mixed-methods retrospective evaluation of a process improvement project that screened admitted patients with known MRSA+ status for continued MRSA colonization.

RESULTS

Of those eligible patients on our institution's MRSA+ list who did complete testing, 80.2% (130/162) were found to be no longer colonized, and only 19.8% (32/162) were still colonized. Forty-one percent (13/32) of interviewed patients in contact isolation for MRSA reported that isolation had affected their hospital stay, and 28% (9/32) of patients reported emotional distress resulting from their isolation. Total cost savings of the program are estimated at $101,230 per year across the 7 study units.

CONCLUSION

Our findings provide supporting evidence that a screening program targeting patients with a history of MRSA who would otherwise be placed in isolation has the potential to improve outcomes and patient experience and reduce costs.

Dual-site sampling improved detection rates for MRSA colonization in patients with cutaneous abscesses

Extranasal sites are common reservoirs of Staphylococcus aureus colonization and may be relevant for methicillin-resistant S. aureus (MRSA) screening and infection control strategies. The objective here was to determine whether inguinal specimens could also be screened using Xpert SA Nasal Complete assay for MRSA. Results were compared to broth enrichment culture. Among 162 consented adults seeking care in the emergency department for cutaneous abscesses, inguinal specimens were found positive for MRSA more often than nares specimens, 24% and 26% by PCR or culture, respectively, compared to 19% each by PCR or culture. Overall, 6% of adults colonized with MRSA would have been missed by nares screening alone. Compared to culture, Xpert SA Nasal Complete assay demonstrated sensitivity and specificity of 89% and 97%, respectively, for detecting nares and/or inguinal MRSA colonization. In conclusion, inguinal specimens were a more common reservoir for MRSA than nares specimens in this population of patients.

Using electronic health record systems to optimize admission decisions: the Creatinine case study

Many medical organizations have implemented electronic health record (EHR) and health information exchange (HIE) networks to improve medical decision-making. This study evaluated the contribution of EHR and HIE networks to physicians by investigating whether health information technology can lead to more efficient admission decisions by reducing redundant admissions in the stressful environment of emergency. Log-files were retrieved from an integrative and interoperable EHR that serves seven main Israeli hospitals. The analysis was restricted to a group of patients seen in the emergency departments who were administered a Creatinine test. The assessment of the contribution of EHR to admission decisions used various statistical analyses and track log-file analysis. We showed that using the EHR contributes to more efficient admission decisions and reduces the number of avoidable admissions. In particular, there was a reduction in readmissions when patient history was viewed. Using EHR can help respond to the international problem of avoidable hospital readmissions.

Evaluation of reprocessing medical devices in 14 German regional hospitals and at 27 medical practitioners' offices within the European context - consequences for European harmonization

Safe reprocessing of medical devices through cleaning, disinfection, and sterilization is essential for the prevention of health care associated infections (HAI) and to guarantee patient safety. Several studies detected residual contamination and even severe infections of patients, despite carrying out reprocessing. To develop appropriate solutions, the existing situation in Germany and selected European countries was analyzed. Additionally, in 27 medical practitioners' offices and 14 hospitals, the true practice of reprocessing was analyzed using a questionnaire, a checklist, and inspection on site. A structured analysis of potential alternatives to the internal reprocessing was conducted within the German and European context. The results indicate that the conditions for the execution of the reprocessing process in the analyzed health facilities in southern Hesse (Germany) do not satisfy legal requirements. The detected deficiencies were consistent with other reports from Germany and Europe. The analysis gave insight into several reasons for the detected deficiencies. The three main reasons were the high costs for proper implementation, the subjective value assigned to the reprocessing unit in health care facilities, and deficits in monitoring by the health authority. Throughout the European Union, a similar regulatory framework for the performance of the reprocessing process exists, while the environment, structures of the health systems and administrative supervision vary significantly. The German states as well as selected European countries are currently discussing the challenges of increased quality-assured execution of the reprocessing process. For instance, the same supervisory system for hospitals and medical practitioners should be established at an equal standard. Alternatives such as the use of single-use medical devices, outsourcing the decontamination processes, or the cooperation of health facilities may be considered. This paper also discusses economic and ecological aspects. Finally, different options are recommended to ensure the exclusive use of reliable medical devices for surgical procedures that guarantee an adequate standard of patient safety within economic constraints.

[Multiresistant gram-negative bacteria. A bacterial challenge of the twenty-first century]

The incidence of human-pathogenic microorganisms with resistance or even complete insensitivity to broad-spectrum antibiotics is increasing. This poses a serious challenge to infection control in hospitals and to hygiene strategies in clinical areas with critically ill patients, particularly intensive care or transplant units. These microorganisms create problems that are seemingly impossible to solve at present. The management of gram-positive pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) has been facilitated by evidence-based recommendations resulting in a measurable decrease in the incidence of infection and, where treatment is concerned, in a selection of reliably effective drugs for clinicians. However, in the more frequent cases of multiresistant gram-negative (MRGN) pathogens, the only option is the use of poorly defined regimens with older drugs, which carry the risk of serious side effects and organ toxicities. This article presents a comparative analysis of hospital hygiene management for MRSA and MRGN pathogens, pointing out both similarities and features which are unique to MRGN pathogens.