Success and failures in MRSA infection control during the COVID-19 pandemic

Viewpoint: The impending pandemic of resistant organisms - a paradigm shift towards source control is needed

The United States needs a paradigm shift in its approach to control infectious diseases. Current recommendations are often made in a siloed feedback loop. This may be the driver for such actions as the abandonment of contact precautions in some settings, the allowance of nursing home residents who are carriers of known pathogens to mingle with others in their facility, and the determination of an intervention's feasibility based upon budgetary rather than health considerations for patients and staff. Data from both the U.S. Veterans Health Administration and the U.K.'s National Health Service support the importance of carrier identification and source control. Both organizations observed marked decreases in methicillin-resistant Staphylococcus aureus (MRSA), but not methicillin-susceptible Staphylococcus aureus infections with the implementation of MRSA admission screening measures. Facilities are becoming over-reliant on horizontal prevention strategies, such as hand hygiene and chlorhexidine bathing. Hand hygiene is an essential practice, but the goal should be to minimize the risk of workers' hands becoming contaminated with defined pathogens, and there are conflicting data on the efficacy of chlorhexidine bathing in non-ICU settings. Preemptive identification of dedicated pathogens and effective source control are needed. We propose that the Centers for Disease Control and Prevention should gather and publicly report the community incidence of dedicated pathogens. This will enable proactive rather than reactive strategies. In the future, determination of a patient's microbiome may become standard, but until then we propose that we should have knowledge of the main pathogens that they are carrying.

Impact of the implementation of the Intelligent Antimicrobial System (iAMS) on clinical outcomes among patients with bacteraemia caused by methicillin-resistant Staphylococcus aureus

OBJECTIVES

This study aimed to investigate the clinical impact of the Intelligent Antimicrobial System (iAMS) on patients with bacteraemia due to methicillin-resistant (MRSA) and methicillin-susceptible Staphylococcus aureus (MSSA).

METHODS

A total of 1008 patients with suspected SA infection were enrolled before and after the implementation of iAMS. Among them, 252 with bacteraemia caused by SA, including 118 in the iAMS and 134 in the non-iAMS groups, were evaluated.

RESULTS

The iAMS group exhibited a 5.2% (from 55.2% to 50.0%; P = 0.96) increase in the 1-year survival rate. For patients with MRSA and MSSA compared to the non-iAMS group, the 1-year survival rate increased by 17.6% (from 70.9% to 53.3%; P = 0.41) and 7.0% (from 52.3% to 45.3%; P = 0.57), respectively, both surpassing the rate of the non-iAMS group. The iAMS intervention resulted in a higher long-term survival rate (from 70.9% to 52.3%; P = 0.984) for MRSA patients than for MSSA patients. MRSA patients experienced a reduced length of hospital stay (from 23.3% to 35.6%; P = 0.038), and the 45-day discharge rate increased by 20.4% (P = 0.064). Furthermore, the intervention resulted in a significant 97.3% relative decrease in near miss medication incidents reported by pharmacists (P = 0.013).

CONCLUSIONS

Implementation of iAMS platform improved long-term survival rates, discharge rates, hospitalization days, and medical cost (although no significant differences were observed) among patients with MRSA bacteraemia. Additionally, it demonstrated significant benefits in ensuring drug safety.

Left ventricular assist device-associated driveline infections as a specific form of complicated skin and soft tissue infection/acute bacterial skin and skin structure infection - issues and therapeutic options

PURPOSE OF REVIEW

This review comments on the current guidelines for the treatment of wound infections under definition of acute bacterial skin and skin structure infections (ABSSSI). However, wound infections around a catheter, such as driveline infections of a left ventricular assist device (LVAD) are not specifically listed under this definition in any of the existing guidelines.

RECENT FINDINGS

Definitions and classification of LVAD infections may vary across countries, and the existing guidelines and recommendations may not be equally interpreted among physicians, making it unclear if these infections can be considered as ABSSSI. Consequently, the use of certain antibiotics that are approved for ABSSSI may be considered as 'off-label' for LVAD infections, leading to rejection of reimbursement applications in some countries, affecting treatment strategies, and hence, patients' outcomes. However, we believe driveline exit site infections related to LVAD can be included within the ABSSSI definition.

SUMMARY

We argue that driveline infections meet the criteria for ABSSSI which would enlarge the 'on-label' antibiotic armamentarium for treating these severe infections, thereby improving the patients' quality of life.

Synergistic Potential of α-Melanocyte Stimulating Hormone Based Analogues with Conventional Antibiotic against Planktonic, Biofilm-Embedded, and Systemic Infection Model of MRSA

The repotentiation of the existing antibiotics by exploiting the combinatorial potential of antimicrobial peptides (AMPs) with them is a promising approach to address the challenges of slow antibiotic development and rising antimicrobial resistance. In the current study, we explored the ability of lead second generation Ana-peptides viz. Ana-9 and Ana-10, derived from Alpha-Melanocyte Stimulating Hormone (α-MSH), to act synergistically with different classes of conventional antibiotics against methicillin-resistant Staphylococcus aureus (MRSA). The peptides exhibited prominent synergy with β-lactam antibiotics, namely, oxacillin, ampicillin, and cephalothin, against planktonic MRSA. Furthermore, the lead combination of Ana-9/Ana-10 with oxacillin provided synergistic activity against clinical MRSA isolates. Though the treatment of MRSA is complicated by biofilms, the lead combinations successfully inhibited biofilm formation and also demonstrated biofilm disruption potential. Encouragingly, the peptides alone and in combination were able to elicit in vivo anti-MRSA activity and reduce the bacterial load in the liver and kidney of immune-compromised mice. Importantly, the presence of Ana-peptides at sub-MIC doses slowed the resistance development against oxacillin in MRSA cells. Thus, this study highlights the synergistic activity of Ana-peptides with oxacillin advocating for the potential of Ana-peptides as an alternative therapeutic and could pave the way for the reintroduction of less potent conventional antibiotics into clinical use against MRSA infections.

Viewpoint: Patient safety in primary care - patients are not just a beneficiary but a critical component in its achievement

Promoting and maintaining patient safety in primary care requires different strategies and monitoring than utilized in large healthcare delivery systems. Maintenance of a culture of safety is key to providing patient safety but has been difficult to measure in primary care. This is particularly true in rural settings where practice size is a major barrier to measurement reliability. Primary care evaluates a wide range of patients, including those who are immunocompromised and others who have infectious diseases. Providing a safe environment with proper wearing of N95 masks, clean examination rooms, and adequate ventilation is important. Patients with infectious diseases should be separated from other patient populations. Primary care is often less bureaucratic than hospitals, but also has fewer resources to implement patient safety initiatives, along with detecting safety lapses and adverse events. However, monitoring the practice's safety practices and the culture of safety is of utmost importance and should be performed using both outcome and process measures. Because of the small size of many rural practices, effective monitoring of adverse events and maintenance of safety protocols should include patients. Patients are an important resource for reporting of adverse events and medical treatment outcomes. The aim of this manuscript is to underscore the importance of patient safety in primary care and to stimulate future research in developing a metric for the culture of safety in primary care, which also incorporates the patient perspective. Patients should be viewed not only as beneficiaries of patient safety but also as a critical component of its maintenance.