MRSA: Experts Question the Value of Some Control Precautions

Veronica Hackethal, MD

August 21, 2014

Uncertainties exist about the benefits of screening and contact isolation in controlling methicillin-resistant Staphylococcus aureus (MRSA), and some even contend these practices might be harmful, according to a viewpoint article published online August 21 in the Lancet.

"[L]egal mandates dictating specific infection-control practices for MRSA should be abandoned," write Gerd Fätkenheuer, MD, president of the German Society of Infectious Disease, from Department I of Internal Medicine, University Hospital Cologne, and the German Centre for Infection Research, Bonn-Cologne, Germany; Bernard Hirschel, MD, president of the Swiss Society of Infectious Disease, from the Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Switzerland; and Stephan Harbarth, MD, professor and chief of the Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Switzerland.

Standard MRSA control measures are usually bundled together and include contact isolation, screening for MRSA carriers, and hand hygiene. Many hospitals also strive to minimize device-associated and surgical infections as part of their MRSA control efforts.

During the last decade, rates of MRSA transmission have declined; however, evidence is limited regarding the effectiveness of individual components of MRSA bundles. These components need reevaluation, the authors argue, keeping in mind local hospital conditions, effectiveness, costs, and adverse effects.

For example, the relative benefits of MRSA screening have been muddied by potential confounding created by failure to separate screening from other parts of the MRSA bundle. Studies into the benefits of contact precautions and isolation have suffered from similar flaws.

Moreover, wearing masks, gowns, and gloves and placing patients in separate isolation rooms could interfere with patient care, the authors argue. Busy healthcare providers could be tempted to skip patients when confronted with the added burden of donning such equipment. Studies have linked isolation rooms with reduced quality of care and increased adverse effects. Isolation may also have psychological effects.

"Isolation is the prototypical punishment in all societies.... Some patients, unsurprisingly, do not like to be isolated, and feel depressed and resentful," the authors note.

Although "little evidence" from high-quality trials supports the effectiveness of screening and isolation, the authors argue, "much more evidence" supports hand hygiene and decolonization.

"[M]ost experts agree that hand hygiene during patient care is the most important measure to reduce the spread of MRSA in the health-care setting," the authors write. Even this is not without controversy, however, as some studies looking at hand hygiene also suffer from potential confounding created by evaluating the overall MRSA bundle, rather than its individual components.

"In view of the uncertainties about the efficacy of screening and the negative effects of contact isolation, the strategy of screening and isolation cannot be regarded as a gold standard to prevent the spread of MRSA in all health-care settings," the authors emphasize. "In the haste to do something against the rising tide of MRSA infection, measures were adopted that seemed plausible but were not properly assessed, bundling the effective and harmless with the ineffective and harmful."

"While some may consider screening and contact isolation as the gold standard for prevention of MRSA transmission, the number of publications investigating these methods argues against it," agreed John Lynch, MD, MPH, associate professor in medicine, allergy, and infectious diseases at the University of Washington, Seattle, when contacted by Medscape Medical News for an outside opinion. Dr. Lynch is also medical director of infection control at Harborview Medical Center in Seattle.

"Many hospitals, and the doctors who work in them, are required by state laws to adhere to specific standards. It will take more data on lack of effectiveness or evidence of patient harm to get these [laws] changed," Dr. Lynch added.

Preventing the spread of MRSA depends on adherence to hand hygiene and MRSA prevalence, according to Dr. Lynch, both of which vary widely from hospital to hospital and country to country.

"Where MRSA colonization and infection burden is high, backing off screening and isolation is hard to embrace, particularly in high-risk populations, like those found in [intensive care units], and where hand hygiene compliance is low," commented Dr. Lynch. "Hospitals with low MRSA prevalence and excellent adherence to hand hygiene can make a reasonable, economical, and patient-safety-oriented argument to do so."

Recent studies seem to back this up by suggesting no increase in MRSA transmission is seen after stopping such interventions, Dr. Lynch added.

"I agree with the authors that, as a research community, we need to move forward with studies designed to determine which individual interventions are most effective and, critically, lead to the best outcomes for patients," Dr. Lynch concluded.

Dr. Fätkenheuer reports consulting and/or fees from Astellas, AstraZeneca, and Pfizer. Dr. Harbarth reports consulting for bioMerieux, Da Volterra, and Destiny Pharma. Dr. Hirschel and Dr. Lynch have disclosed no relevant financial relationships.

Lancet. Published online August 21, 2014. Extract

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