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MRSA Infection of Leg

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MRSA Infection of Lower Lip
  
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MRSA Infection of Lower Lip

MRSA Infections
C. Diff. Infections
CLABSI Infections
CAUTI Infections
VAP Infections
Prevention of Events

Methicillin Resistant Staphylococcus Aureus is one of the most common hospital acquired infections.

Kentucky is one of the four states that has the highest percentage of Staph Aureus (on outpatient cultures) which is MRSA. Results were taken from Staph Cultures at State Laboratories. 
From The Center for Disease Dynamics, Economics & Policy.  

http://www.cddep.org/resistancemap/methicillin-saureus   

In northern European countries the percentage of Staph infections caused by MRSA is below  5% and falling.  Overall the incidence of MRSA in Staph infections is falling in Europe.   European Countries limit the use of antibiotics but also use extensive surveillance.  England and France also has public reporiting,1  

Great strides have been made in designing protocols for it's control but there has not been a uniform implementation in the United States Healthcare System. According to a 2008 GAO report, the CDC has many recommendations and they are not prioritized which may have inhibited adoption of major interventions.2

HW USA Policy Report on MRSA Surveillance Cultures

In Europe:  "A set of multimodal strategies was implemented in (Belgium, England and France) that involved structural and regulatory changes, to strengthen infection prevention and safe care in acute care hospitals; infection control measures, such as promotion of hand hygiene and antimicrobial stewardship; and measures to control MRSA transmission, such as screening for MRSA at hospital admission, use of contact isolation precautions and carrier decolonization." 3 

One of the first landmark initiatives in the US came out of the Veterans Administration Hospital System.  A bundled intervention approach was used which included but was not limited to, universal surveillance cultures, contact precautions and hand hygiene.   

Using this approach, the rates of MRSA in the VA System was lowered 76% in the ICU setting to 0.39 infections per 1000 bed care days and 28% in non-ICU settings to 0.33 infections per 1000 bed care days.   The VA national MRSA results involved 153 facilities and over 1 million patients (Dr Martin Evans, Hospital Infection Control & Prevention.  Vol7(48) Dec 2, 2010.)   

MRSA VA Results - Congressional Inquiry 10C1

MRSA VA Methodology - VHA Directive 2007-002

The Veterans Administration MRSA initiative data from Oct 2007 to June 2010 was published in the New England Journal of Medicine on April 14, 2011 and MRSA infections were observed to decrease a 62% in the ICUs and a 45% in the Non-ICU setting.  A bundle of surveillance cultures, contact isolation and hand hygiene was used.4   Dr William Jarvis on MRSA Surveillance and the Results of the National VA Study.
http://www.medscape.com/viewarticle/744830  

There is also evidence that optimal control of MRSA in any one facility is dependent upon control in all facilities.29  This is because the community or inter-facility patient transfers can be a major reservoir for infection.  
 

The following articles have found an MRSA Carrier Rate was associated with an Increase in Post-operative infections:

  • Feb., 2009:  Shukla, et al.,  reported that an MRSA carrier state is associated with an increased risk of post-operative infections.6 
     
  • Mar. 2008.  Harbarth found that 6.4% (693) of admitted patients were MRSA carriers (known and detected) and that these patients comprised 43% of all MRSA post operative infections (p < 0.0001 chi square) 
     
  • Jun. 2011: Schweickert, et al. MRSA-import into ICUs is an important predictor for the occurrence of nosocomial MRSA cases.20

As of Oct. 2012 there has been wide variation in the adoption of MRSA surveillance by facilities.  In one survey 59% of facility ICUs use admission surveillance in there routine screening protocols.30  Other studies have also supported the screening of patients for MRSA, these include:   

  • Oct. 2006:   Shitrit, et al. reported that universal active detection along with isolation and decolonization decreased MRSA bacteremia by 50% (p < 0.001)21

  • Oct 2006:  Clancy, et al. reported that screening of MRSA for patients admitted to the surgical and medical ICUs resulted in a 33% decrease in infections and was found to be cost effective.22

  • Feb. 2006: Harbarth reported that screening for MRSA (RPR Test) and isolation reduced infections in the non-surgical ICU.10

  • Oct. 2006:  Huang, et al. reported that screening for MRSA in ICU patients resulted in a large and statistically significant reduction in the incidence of MRSA bacteremia in the ICU and the  hospital.16  

  • Mar. 2008:  Robicsek, et al. found a 69% reduction of total MRSA infections in three facilities studied by Northwest University.5  

  • Mar. 2008:  Hacek, et al. calculated a four fold reduction in MRSA infections orthopedic infections in patients screened and decolonized with Mipirocin.25

  • Apr.  2008:  Roe, et. al.  Found no MRSA infections in 164 patients who were MRSA positive on preoperative screening for total joint arthroplasty and underwent decolonization as compared to a 12% infection rate in a control group.23  

  • May. 2009:  Pofahl reported that screening for MRSA in patients undergoing orthopedic surgery decreased post-operative MRSA infections.7 

  • Jan. 2010:  Bode, et al. found a decrease in MRSA infections by over 50% using universal screening and decolonization using Mupirocine.24

  • Jan. 2011:   Walsh, et al. reported that screening for MRSA in patients undergoing cardiothoracic surgery decreased post operative MRSA infections.8  

  • Jan-Mar: 2011:  Simmons found "Implementing an ICU-only active (MRSA) surveillance program is an effective method of controlling MRSA transmission on a hospital wide level" 19

  • Apr. 2011:  Jain, et al. found that a bundle of hand hygiene, universal MRSA surveillance and contact precautions decreased MRSA infections in ICU patients by 62% and in non-ICU patients by 45%.17 

  • Aug. 2011:  Haung, et al. reported that in the NICU "rates of MRSA colonization (8.6% vs. 41%, p<0.001) and infection (1.1% vs. 12%, p<0.001) decreased significantly during the period of surveillance and decolonization." 18 

  • Nov. 2012:   Schweizer, et al. reported that 17% of patients admitted to their ICU were MRSA carriers and they were a major reservoir for MRSA.   That interventions on preventing MRSA infections should focus on preventing transmission from MRSA carriers.28 

  • Jan. 2013.  MRSA Colonization Predicts GI Infections.32

  • Decolonization of MRSA Carriers prevents Surgical Infections:
    "Surgical programs that implement a bundled intervention including both nasal decolonization and glycopeptide prophylaxis for MRSA carriers may decrease rates of surgical site infections caused by S aureus or other Gram positive bacteria." http://www.bmj.com/content/346/bmj.f2743 

A widely quoted study, which has found no effect with screening for MRSA, was reported in the Feb. 2008 issue of JAMA.9  In this paper, Harbarth, et al, reported no effect of using universal screening in preventing post-operative infections.  However, this study also observe that no colonized patient who was identified on an outpatient basis and received appropriate prophylaxis developed an MRSA post-operative infection (p 1154).  In addition, the study had significant problems. 

  • Colonized patients who tested positive were only isolated in a "flagged side or single room whenever available" 9

  • Only 30% of MRSA Carriers that underwent surgery received antibiotics against MRSA prior to surgery. 

  • Only 43% (115) of the 266 MRSA surgical patients that were detected carriers prior to surgery received pre-operative antibiotics effective against MRSA.9

  • 120 of 386 MRSA carriers had emergency surgery and were identified as carriers only after the surgery.  These patients should not have been included in the study.9  

  • “… surgeons were reluctant to add Vancomycin to the standard prophylactic regimen”.9  

In an earlier study, Harbarth reported that screening for MRSA (RPR Test) and isolation reduced infections in the non-surgical ICU.10 

It is not enough to just identify patients.  MRSA has been shown to rapidly spread into the environment from a colonized patient   By the time screening results are obtained, up to 45% of patient MRSA carriers have already contaminated their environment.11  Universal screening has been shown to be cost effective12, 22 and should if possible be done prior to admission to the hospital.  If a patient is found to be positive, he/she needs to be placed in contact isolation and the environment decontaminated. 

The STAR MRSA Study13 found an opposite and conflicting result from the 2011 Veterans Administration data.  The editorial which followed the article, pointed out that the average of five days from the time the surveillance culture was taken to the results were obtained, certainly limited the usefulness of the surveillance.  Patient in the intervention group had full contact precautions less than 50% of the time.  A significant flaw since Chang, et al.,11 have shown the rapid spread of MRSA in the environment. Properly designed, the results should be available in less than 24 hours from admission. The danger is that this research may be used to cast doubt on well-designed major studies. 

Dr William Jarvis on MRSA Colonization and Risk of Infection:
This report discusses a study by Dr. Gupta (27) which found that the use of Vancomyin prophylaxis prior to surgery in the absence of MRSA colonization was associated with an increase risk in infections. 6.6% of patients were found to be MRSA carriers. And that MRSA carriage was associated with an increase risk of infection. States that the research data provides strong support for active MRSA Surveillance of preoperative patients. http://www.medscape.com/viewarticle/755905 

A recent article published in JAMA shows improvement in MRSA infection rates.  HW USA feels this can be viewed as a huge win for consumer advocates since all reporting metropolitan areas (except Atlanta) are in states that have public reporting laws. Atlanta is the home of the CDC and one would expect good results from this area. If it is measured it will be managed. If the measurement is made public it will be managed well.14 

A an article published in JAMA shows improvement in MRSA infection rates.  HW USA feels this can be viewed as a huge win for consumer advocates since all reporting metropolitan areas (except Atlanta) are in states that have public reporting laws. Atlanta is the home of the CDC and one would expect good results from this area. If it is measured it will be managed. If the measurement is made public it will be managed well.14   However, in a study published in Aug. 202 by David, et al. in Aug. 2012, found a two fold increase in MRSA infections infections per hospital discharges (community associated and healthcare associated) for the survey years 2003-2008.31  They also observed that community-associated MRSA was more likely to be captured using billing data than healthcare-associated MRSA. 

One facility can affect the outcomes of other facilities.  “Our simulation demonstrated that each hospital's decision to test for MRSA and implement contact isolation procedures could affect the MRSA prevalence in all other hospitals."33   Health Affairs 2012 PMID: 23048111   http://www.ncbi.nlm.nih.gov/pubmed/23048111
 

  1. Struelens MJ, Monnet DL.  Prevention of Methicillin-Resistant Staphyloccus aureus Infection:  Is Europe Winning the Fight? Infect Control Hosp Epidemiol. 2010 Nov;31 Suppl 1:S42-4.   http://www.journals.uchicago.edu/doi/pdf/10.1086/655997   

  2. GAO.  Health-Care-Associated Infections in Hospitals.  GAO-08-283 March 2008   http://www.gao.gov/new.items/d08283.pdf

  3. Struelens MJ, Monnet DL.  Prevention of Methicillin-Resistant Staphylococcus aureus Infection:  Is Europe Winning the Fight?  Infection Control and Epidemiology.  2010 Oct;31(51):
    http://www.journals.uchicago.edu/doi/pdf/10.1086/655997  

  4. Jain,R, Kralovic SM, Evans NE, AmbroseM, Simbartl LA, Obrosky DS, Render ML, Freyberg RW, Jernigan JA, Muder RR , Miller LJ, Roselle GA. Veterans Affairs Initiative to Prevent methicillin-Resistant Staphyloccus aureus Infections . NEJM Apr 2011:364:1419-1430.
    http://www.nejm.org/doi/full/10.1056/NEJMoa1007474

  5. Robicsek A, Beaumont JL, Paule SM, Hacek DM, Thomson RB Jr, Kaul KL, King P, Peterson LR. Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. Ann Intern Med. 2008 Mar 18;148(6):409-18.   http://www.ncbi.nlm.nih.gov/sites/entrez/18347349 

  6. Shukla S, Nixon M, Acharya M, Korim MT, Pandey R. Incidence of MRSA surgical-site infection in MRSA carriers in an orthopaedic trauma unit. J Bone Joint Surg Br. 2009 Feb;91(2):225-8.   http://www.ncbi.nlm.nih.gov/sites/entrez/19190058

  7. Pofahl WE, Goettler CE, Ramsey KM, Cochran MK, Nobles DL, Rotondo MF. Active surveillance screening of MRSA and eradication of the carrier state decreases surgical-site infections caused by MRSA. J Am Coll Surg. 2009 May;208(5):981-6; discussion 986-8. Epub 2009 Mar 26.   http://www.ncbi.nlm.nih.gov/pubmed/19476875  

  8. Walsh EE, Greene L, Kirshner R. Sustained reduction in methicillin-resistant Staphylococcus aureus wound infections after cardiothoracic surgery. Arch Intern Med. 2011 Jan 10;171(1):68-73. Epub 2010 Sep 13.  http://www.ncbi.nlm.nih.gov/pubmed/20837818

  9. Harbarth S, Fankhauser C, Schrenzel J, Christenson J, Gervaz P, Bandiera-Clerc C, Renzi G, Vernaz N, Sax H, Pittet D. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA. 2008 Mar 12;299(10):1149-57.   http://www.ncbi.nlm.nih.gov/pubmed/18334690 

  10. Harbarth S, Masuet-Aumatell C, Schrenzel J, Francois P, Akakpo C, Renzi G, Pugin J, Ricou B, Pittet D. Evaluation of rapid screening and pre-emptive contact isolation for detecting and controlling methicillin-resistant Staphylococcus aureus in critical care: an interventional cohort study. Crit Care. 2006 Feb;10(1):R25.   http://www.ncbi.nlm.nih.gov/pubmed/16469125

  11. Chang S, Sethi AK, Stiefel U, Cadnum JL, Donskey CJ. Occurrence of skin and environmental contamination with methicillin-resistant Staphylococcus aureus before results of polymerase chain reaction at hospital admission become available. Infect Control Hosp Epidemiol. 2010 Jun;31(6):607-12. http://www.ncbi.nlm.nih.gov/pubmed/20397963

  12. Lee BY, Bailey RR, Smith KJ, Muder RR, Strotmeyer ES, Lewis GJ, Ufberg PJ, Song Y, Harrison LH. Universal methicillin-resistant Staphylococcus aureus (MRSA) surveillance for adults at hospital admission: an economic model and analysis. Infect Control Hosp Epidemiol. 2010 Jun;31(6):598-606.   http://www.ncbi.nlm.nih.gov/pubmed/20402588   

  13. Huskins WC, Huckabee CM, O'Grady NP, Murray P, Kopetskie H, Zimmer L, Walker ME, Sinkowitz-Cochran RL, Jernigan JA, Samore M, Wallace D, Goldmann DA. Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care. NEJM. Apr 2011 364:1407-1428 http://www.nejm.org/doi/full/10.1056/NEJMoa1000373 

  14. Kallen AJ, Mu Y, Bulens S, Reingold A, Petit S, Gershman K, Ray SM, Harrison LH, Lynfield R, Dumyati G, Townes JM, Schaffner W, Patel PR, Fridkin SK; Active Bacterial Core surveillance (ABCs) MRSA Investigators of the Emerging Infections Program. Health care-associated invasive MRSA infections, 2005-2008. JAMA. 2010 Aug 11;304(6):641-8.   http://jama.ama-assn.org/cgi/content/full/304/6/641

  15. Jeyaratnam D, Whitty CJ, Phillips K, Liu D, Orezzi C, Ajoku U, French GL. Impact of rapid screening tests on acquisition of methicillin resistant Staphylococcus aureus: cluster randomized crossover trial. BMJ. 2008 Apr 26;336(7650):927-30. Epub 2008 Apr 16.  http://www.ncbi.nlm.nih.gov/pubmed/18417521

  16. Huang SS, Yokoe DS, Hinrichsen VL, Spurchise LS, Datta R, Miroshnik I, Platt R. Impact of routine intensive care unit surveillance cultures and resultant barrier precautions on hospital-wide methicillin-resistant Staphylococcus aureus bacteremia. Clin Infect Dis. 2006 Oct 15;43(8):971-8. Epub 2006 Sep 14. http://www.ncbi.nlm.nih.gov/pubmed/16983607 

  17. Jain R, Kralovic SM, Evans ME, Ambrose M, Simbartl LA, Obrosky DS, Render ML, Freyberg RW, Jernigan JA, Muder RR, Miller LJ, Roselle GA. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. N Engl J Med. 2011 Apr 14;364(15):1419-30. http://www.ncbi.nlm.nih.gov/pubmed/21488764

  18. Huang YC, Lien RI, Su LH, Chou YH, Lin TY. Successful control of methicillin-resistant Staphylococcus aureus in endemic neonatal intensive care units--a 7-year campaign. PLoS One. 2011;6(8):e23001. Epub 2011 Aug 12.  http://www.ncbi.nlm.nih.gov/pubmed/21857979 

  19. Simmons S. Effects of selective patient screening for MRSA on overall MRSA hospital-acquired infection rates. Crit Care Nurs Q. 2011 Jan-Mar;34(1):18-24. http://www.ncbi.nlm.nih.gov/pubmed/21160296 

  20. Schweickert B, Geffers C, Farragher T, Gastmeier P, Behnke M, Eckmanns T, Schwab F. The MRSA-import in ICUs is an important predictor for the occurrence of nosocomial MRSA cases. Clin Microbiol Infect. 2011 Jun;17(6):901-6. doi: 10.1111/j.1469-0691.2010.03409.x. Epub 2010 Dec 3.  http://www.ncbi.nlm.nih.gov/pubmed/20977541 

  21. Shitrit P, Gottesman BS, Katzir M, Kilman A, Ben-Nissan Y, Chowers M. Active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) decreases the incidence of MRSA bacteremia. Infect Control Hosp Epidemiol. 2006 Oct;27(10):1004-8. Epub 2006 Sep 20.  http://www.ncbi.nlm.nih.gov/pubmed/17006805  

  22. Clancy M, Graepler A, Wilson M, Douglas I, Johnson J, Price CS. Active screening in high-risk units is an effective and cost-avoidant method to reduce the rate of methicillin-resistant Staphylococcus aureus infection in the hospital. Infect Control Hosp Epidemiol. 2006 Oct;27(10):1009-17. Epub 2006 Sep 20.  http://www.ncbi.nlm.nih.gov/pubmed/17006806  

  23. Rao N, Cannella B, Crossett LS, Yates AJ Jr, McGough R 3rd. A preoperative decolonization protocol for staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res. 2008 Jun;466(6):1343-8. Epub 2008 Apr 11.  http://www.ncbi.nlm.nih.gov/pubmed/18404296 

  24. Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, Vandenbroucke-Grauls CM, Roosendaal R, Troelstra A, Box AT, Voss A, van der Tweel I, van Belkum A, Verbrugh HA, Vos MC. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010 Jan 7;362(1):9-17.  http://www.ncbi.nlm.nih.gov/pubmed/20054045 

  25. Hacek DM, Robb,WJ, Paule SM, Kudrna JC, Stamos, VP, and Peterson LR.  Staphylococcus aureus Nasal Decolonization in Joint Replacement Surgery Reduces Infection. Clin Orthop Relat Res. 2008 June; 466(6): 1349–1355.   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2384050/?tool=pubmed

  26. Jog S, Cunningham R, Cooper S, Wallis M, Marchbank A, Vasco-Knight P, Jenks PJ. Impact of preoperative screening for meticillin-resistant Staphylococcus aureus by real-time polymerase chain reaction in patients undergoing cardiac surgery. J Hosp Infect. 2008 Jun;69(2):124-30. Epub 2008 Apr 2.    http://www.ncbi.nlm.nih.gov/pubmed/18387695  

  27. Gupta K, Strymish J, Abi-Haidar Y, Williams SA, Itani KM. Preoperative nasal methicillin-resistant Staphylococcus aureus status, surgical prophylaxis, and risk-adjusted postoperative outcomes in veterans.  Infect Control Hosp Epidemiol. 2011 Aug;32(8):791-6.    http://www.ncbi.nlm.nih.gov/pubmed/21768763 

  28. Schweizer M, Ward M, Cobb S, McDanel J, Leder L, Wibbenmeyer L, Latenser B, Diekema D, Herwaldt L. The Epidemiology of Methicillin-Resistant Staphylococcus aureus on a Burn Trauma Unit. Infect Control Hosp Epidemiol. 2012 Nov;33(11):1118-25. doi: 10.1086/668032. Epub 2012 Sep 21.    http://www.ncbi.nlm.nih.gov/pubmed/23041810 

  29. Lee BY, Bartsch SM, Wong KF, Yilmaz SL, Avery TR, Singh A, Song Y, Kim DS, Brown ST, Potter MA, Platt R, Huang SS. Simulation shows hospitals that cooperate on infection control obtain better results than hospitals acting alone. Health Aff (Millwood). 2012 Oct;31(10):2295-303. doi: 10.1377/hlthaff.2011.0992. 
    http://www.ncbi.nlm.nih.gov/pubmed/23048111 

  30. Pogorzelska M, Stone PW, Larson EL. Wide variation in adoption of screening and infection control interventions for multidrug-resistant organisms: a national study. Am J Infect Control. 2012 Oct;40(8):696-700. doi: 10.1016/j.ajic.2012.03.014.   http://www.ncbi.nlm.nih.gov/pubmed/23021413

  31. David MZ, Medvedev S, Hohmann SF, Ewigman B, Daum RS. Increasing burden of methicillin-resistant Staphylococcus aureus hospitalizations at US academic medical centers, 2003-2008. Infect Control Hosp Epidemiol. 2012 Aug;33(8):782-9. Epub 2012 Jun 11.   http://www.ncbi.nlm.nih.gov/pubmed/22759545

  32. Ramirez MC, Marchessault M, Govednik-Horny C, Jupiter D, Papaconstantinou HT. The impact of MRSA colonization on surgical site infection following major gastrointestinal surgery. J Gastrointest Surg. 2013 Jan;17(1):144-52; discussion p.152. doi: 10.1007/s11605-012-1995-2. Epub 2012 Sep 5.
    http://www.ncbi.nlm.nih.gov/pubmed/?term=22948833   

  33. Lee BY, Bartsch SM, Wong KF, Yilmaz SL, Avery TR, Singh A, Song Y, Kim DS, Brown ST, Potter MA, Platt R, Huang SS. Simulation shows hospitals that cooperate on infection control obtain better results than hospitals acting alone. Health Aff (Millwood). 2012 Oct;31(10):2295-303. doi:  10.1377/hlthaff.2011.0992.  http://www.ncbi.nlm.nih.gov/pubmed/23048111