A man dies of septic shock due to a methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI) only days after being admitted to your local hospital for a myocardial infarction. An initial quality improvement review reveals that the facility's rate of MRSA BSI is a lot higher than the national rate. What is going on?
S aureus is one of the most common pathogens in healthcare facilities and in the community, causing more than 100,000 BSIs and almost 20,000 deaths in 2017. Although the rates of hospital-onset (HO) MRSA BSIs had been decreasing up until 2012, the decline has slowed over the past 3 years.
Challenge yourself with this case representing a community hospital and see whether you would know what to do to reverse this trend.
A Distressing Finding
A 66-year-old man with a history of diabetes and coronary artery disease was admitted to a 400-bed suburban community hospital with chest pain, shortness of breath, and altered mental status. He was diagnosed with an ST-elevation myocardial infarction and underwent emergent cardiac catheterization with stent placement. He was subsequently admitted to the intensive care unit (ICU) and had a central venous catheter (CVC) placed. He remained hemodynamically unstable after his procedure.
On hospital day 7, he developed a fever and leukocytosis, and redness was noted at the insertion site of his CVC, which had remained in place since the day of admission. He was started empirically on vancomycin and cefepime; however, the patient rapidly decompensated several hours later. MRSA was isolated from blood cultures obtained before antibiotic administration.
After this event, as part of a quality improvement process, the facility's infection prevention supervisor completed a review of their standardized infection ratio (the observed number of infections divided by the expected number) for HO MRSA BSIs and came to a distressing conclusion: Their rate was not only greater than their goal for their facility but was also significantly above the national ratio. To better understand the problem and come up with possible interventions, the staff of the infection control program reviewed all episodes of HO MRSA BSIs over the past year to identify common risk factors and associated infectious syndromes.
Here are some of their key findings:
Many of the episodes occurred in the ICU or a single medical ward.
Infections in many of these patients met the definition for central line-associated BSI.
A smaller group of patients with HO MRSA BSIs had recently undergone orthopedic surgery and presented with a surgical-site infection that preceded the BSI. The surgeries had been performed by several different surgical teams, and patients received timely antibiotic prophylaxis with cefazolin before the procedure.
The facility placed patients who were known to be colonized or infected with MRSA in single rooms and on contact precautions.
The facility has not introduced chlorhexidine bathing into its ICU and does not perform active surveillance for MRSA carriers at admission.
Public Information from the CDC and Medscape
Cite this: New Strategies to Prevent MRSA Infections in Your Hospital - Medscape - Dec 23, 2019.