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VA hospitals cut MRSA with active surveillance
HAI rates in ICUs decline 77%
The Department of Veterans Affairs 153-hospital system has sharply reduced methicillin resistant Staphylococcus aureus (MRSA) infections through a nationwide program featuring active surveillance cultures (ASC), an epidemiologist reported recently in Atlanta at the Fifth Decennial Conference on Healthcare Associated Infections (HAIs).
Releasing some of the first national data on the ambitious national program, Martin Evans, MD, a health care epidemiologist in the VHA MRSA program office at the VA Pittsburgh health system, emphasized the importance of a less quantifiable "culture change" within the hospitals.
"Infection control became everyone's responsibility," he said. "...Of course I have to thank all the individuals who were very much involved in getting this program running and getting this data together including the MRSA coordinators and the infection preventionists that made all this happen."
The VA system implemented an MRSA bundle in all hospitals that included four key elements:
From October 2007 through June 2009 when the bundle was fully implemented, HAI rates declined 24% in the non-ICU settings. That included declines in bloodstream infections by 58%, pneumonias by 43%, urinary tract infections by 30%, and skin and soft-tissue infections by 26%. HAI rates in ICUs declined 77% after full implementation of the bundle, he added.
"MRSA ventilator-associated pneumonia (VAP) and central line-associated bloodstream infections (CLABSI) were the most common infections observed," he said. During the analysis period, MRSA VAPs decreased 53% and CLABSIs decreased 44%. In addition, non-device related MRSA bloodstream infections declined 58%, pneumonias 67%, urinary tract infections 79%, and skin and soft-tissue infections 32%.
"[Our] program of universal surveillance, contact precautions, hand hygiene, and culture change was associated with a decrease in MRSA transmissions and HAIs in both the ICU and non-ICU settings in a large health care system," Evans said. "The ratio of surveillance to clinical cultures was 10 to one, so if don't actively look for these infections you will miss probably 90% of the individuals in your institution that are carrying MRSA."
A contrary view
On the other hand, another study presented at the same meeting showed that a strong overall infection control program can reduce MRSA and other HAIs without ASCs.
"We demonstrated that a strategy that focuses on achieving high levels of compliance with multiple interventions reduces all HAIs including those that are caused by MRSA," said Michael Edmond, MD, MPH, MPA, a healthcare epidemiologist at Virginia Commonwealth University Medical Center in Richmond, VA. "I think we also show that active detection and isolation is not required to control MRSA and because of its high cost, [and] its association with adverse, unintended consequences... we believe it should be viewed as an option of last resort to control multidrug organisms in your facilities."
Beginning in 2004, a series of non-pathogen specific initiatives was implemented to reduce HAIs in the 820-bed, urban, teaching hospital. They included an increasingly aggressive hand hygiene program, a central line bundle, a ventilator bundle, chlorhexidine bathing of all adult ICU patients, and compliance monitoring and feedback via unit-specific posters. Active surveillance cultures were not performed. Over the seven-year period, Edmond and colleagues saw a 91% reduction in MRSA CLABSI; 62% reduction in MRSA UTI and a 92% reduction in MRSA VAP. The total number of MRSA infections in the three ICUs fell from 38 in 2003 to 5 in 2009.
"In the medical ICU our last MRSA infection was on Jan. 22, 2008 and in the surgical ICU June of 09," Edmond said.
The national focus on MRSA in general and ASC in particular, is ill advised given the rising threat of many other pathogens, he noted. "Despite the emergence of other important pathogens in the health care setting, media reports, advocacy groups and legislative activities remain focused on MRSA," Edmond said. "And identification of patients colonized with MRSA via active surveillance and subsequent contact precautions –has been widely touted as necessary for MRSA control."
Moreover, ASC programs are costly and involve unintended consequences like prolonged patient isolation. "Those programs are fairly labor intensive and unless you add employees to manage these programs they take away from other important infection control functions in your hospital," he said. "Surveillance cultures for MRSA in our hospital are limited to the NICU and they are targeted also to patients undergoing elective surgery."
In addition, the hospital has added a "bare below the elbows" policy for patient care givers to limit transmission via clothing while reinforcing hand hygiene.