CDC Expert Commentary

Putting a Stop to MRSA: Active Detection and Isolation

John A. Jernigan, MD, MS

Disclosures

April 14, 2011

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Hello, I am Dr. John Jernigan, and I am an expert in healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) and the director of CDC's Office of Healthcare-Associated Infection Prevention Research and Evaluation.

I'm pleased to speak with you today as part of the CDC Expert Video Commentary Series on Medscape.

In recent years, much attention has been given to the importance of MRSA as a cause of healthcare-associated infections (HAIs). There has been controversy on how best for hospitals and other healthcare facilities to focus their MRSA prevention efforts, and in particular, whether the use of active detection and isolation (ADI) of patients colonized with MRSA should be routinely used in all inpatient populations and settings.

Despite ongoing research examining the issue, a simple answer has remained elusive. There is ongoing legitimate scientific debate on this practice and what you as a clinician should do to prevent the spread of multidrug-resistant infections, including MRSA, in your facility.

The results of 2 studies recently published in the New England Journal of Medicine[1,2] illustrate the complexities of the scientific evidence surrounding ADI. One of these studies, the STAR ICU [Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units] Trial,[1] was a large randomized controlled study designed to measure the effectiveness of a strategy that relies upon ADI. It found that ADI as implemented in the study was not effective in reducing transmission of MRSA or vancomycin-resistant enterococcus (VRE).

A separate observational study involving Veteran's Affairs (VA) hospitals and published in the same issue[2] found that after implementing a multifaceted MRSA prevention program that included ADI, MRSA transmissions and HAIs decreased significantly across the entire national VA system of hospitals. The fact that these studies seem to give different answers illustrates the complexities we as scientists face in making recommendations on how best to use limited prevention resources; sometimes the answers aren't as simple as we would like.

I do think there are some lessons we can take away from these studies. Together, the study findings are consistent with current belief that the MRSA problem is too complex to be controlled with any single intervention.

Focusing all prevention efforts on a single intervention like ADI does not appear to be an effective strategy. On the other hand, the VA study suggests that MRSA can be effectively controlled, even on a large scale involving hundreds of hospitals, using a multifaceted intervention strategy. While the strategy chosen by the VA did include use of ADI, the study design does not allow an assessment of the individual contribution of ADI to the overall success.

So what's the bottom line?

The most important message from these studies is that MRSA control, while difficult, is achievable, even if experts may still argue about the best way to do it.

In light of the conflicting evidence on the optimal role of ADI, some hospitals and healthcare settings may choose strategies that do not include ADI. Whatever strategy is chosen, rigorous measurement of the impact of the program should be in place, with the expectation that they should achieve results similar to those observed in the VA study. If not, the prevention strategy should be modified, and in some cases may benefit from use of ADI.

CDC guidelines are available to help hospitals develop a customized comprehensive strategy that will lead to effective control of MRSA and other multidrug-resistant infections.

Some of the major elements of those guidelines are as follows:

  • First and foremost, prevention of these infections should be given a high priority;

  • Perform surveillance for multidrug-resistant organisms incidence that is rigorous and capable of detecting changes over time;

  • Measure adherence to basic infection control practices designed to prevent transmission of pathogens such as hand hygiene, contact precautions, and environmental cleaning and make sure adherence is maintained at high levels; and

  • Assure that systems are in place to optimize antimicrobial use.

If, after implementing these steps, MRSA rates are not declining, implement additional measures until you are able to document effective control. Again, the most important message here is that MRSA control, while difficult, is achievable. For more information, please see the resources on this page.

Thank you.

Resources

CDC/HICPAC Management of Multidrug-Resistant Organisms in Healthcare Settings Guideline

CDC Methicillin-resistant Staphylococcus Aureus (MRSA) Infections

John Jernigan is currently the Director of the Office of HAI Prevention Research and Evaluation of the Centers for Disease Control and Prevention's (CDC's) Division of Healthcare Quality Promotion (DHQP). He is also a Clinical Associate Professor of Medicine at the Emory University School of Medicine in the Division of Infectious Diseases.

Jernigan attended medical school at Vanderbilt University, where he also completed his internship and residency in Internal Medicine, and served as Chief Medical Resident. Following his residency, he spent a year practicing medicine in East Africa. He later returned to the United States to complete his fellowship in Infectious Diseases at the University of Virginia, where he also earned a Master's Degree in Epidemiology.

He joined the faculty of Emory University in 1994, and became Hospital Epidemiologist at Emory University Hospital in 1995. In Spring 2000, he joined the Division of Healthcare Quality Promotion at the CDC but maintains his faculty appointment in the Emory Division of Infectious Diseases. He has served on the Board of Directors for both the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA). He was named the SHEA Investigator awardee in 2005.

His editorial activities have included service on the Editorial Board of Infection Control and Hospital Epidemiology and Hospital Epidemiology Section Editor for Current Infectious Disease Reports. He has authored/coauthored numerous peer-reviewed publications and textbook chapters dealing with the epidemiology of healthcare-associated infections and antimicrobial resistance and has a particular interest in the epidemiology of drug-resistant Staphylococcus aureus.

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