COMMENTARY

Decreasing MRSA in the Hospital

William R. Jarvis, MD

Disclosures

June 17, 2011

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Hi. This is Dr. William Jarvis, Medscape infectious disease expert advisor and President of Jason and Jarvis Associates. Today, I'd like to talk about a recent article from The New England Journal of Medicine by Jain and colleagues[1] that shows an incredibly impressive impact on reducing methicillin-resistant Staphylococcus aureus (MRSA) infections. A MRSA bundle was implemented in 150 hospitals in the Veterans Affairs (VA) system. Their bundle included universal nasal screening of patients on admission to one of the hospitals, and upon transfer within the hospital system. The screening was then processed using either a chromogenic agar or a polymerase chain reaction. If results were positive, the patients were placed in contact isolation. They reinforced the importance of hand hygiene, and then implemented culture change to make sure that everybody realized that infection control was their business. In the 2 years before this study, which started in October 2007, no significant change occurred in the MRSA rate. In fact, the healthcare-associated MRSA rate was slightly increased from 1.45 to 1.75/1000 patient days.

After implementation of this 32-month study (more than 2 years) of practice of MRSA control in 150 VA hospitals, they experienced a significant reduction in MRSA-healthcare associated infections.

They looked at the MRSA rate in the intensive care units (ICUs), which decreased from 1.64 to 0.62/1000 patient days. That is an impressive 62% reduction. In the non-ICUs (the rest of the hospital areas), the rate decreased from 0.47 to 0.26/1000 patient days, an almost 50% reduction. In the ICU:

  • Noncatheter-associated bloodstream infections were reduced by almost 79%;

  • Catheter-associated bloodstream infections decreased 62%;

  • Nonventilator-associated pneumonia decreased 37%;

  • Ventilator-associated pneumonia decreased 75%;

  • Urinary tract infections decreased 75%;

  • Skin and soft-tissue infections decreased 75%;

  • Ventilator-associated MRSA pneumonia decreased by 72%; and

  • MRSA bloodstream infections decreased by 33%.

Similar results occurred in the non-ICU setting.

  • Bloodstream infections decreased by almost 60%;

  • Pneumonia declined by almost 40%;

  • Urinary tract infections declined by almost 45%; and

  • Skin and soft-tissue infections were reduced by 53%.

This study had several important findings. The number of patients with bacterial colonization compared with those with bacterial infection was about 10 to 1, confirming what others have found -- that most patients with MRSA have bacterial colonization. If you depend only on clinical culture results, you will not find them. The researchers had almost 2 million admissions during this time -- more than 8 million patient days. Screening increased from approximately 82% to 96%. Of those admitted, and of those transferred, screening increased from 72% to 93%. These were very high rates of compliance with screening. The mean prevalence of MRSA was13.6% ± 3.7% and ranged by hospital from 5.4% to 28%.

This is a very long study -- a 32-month intervention study. Therefore, any Hawthorne effect is going to disappear. Compliance with screening was very high. With this very simple intervention that has been repeatedly documented to be effective, they were able to achieve significant reductions in healthcare- associated MRSA infections in their ICUs and in their non-ICUs in more than 150 hospitals.

This is the largest study of this type of intervention anywhere. These investigators should be complimented and all of us should look at this study and then implement the interventions. Thank you very much. Until next time, this is Dr. William Jarvis.

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