Saturday, May 15, 2010

MRSA active surveillance: It just doesn't make sense

A study in the June issue of Infection Control and Hospital Epidemiology takes a look at staphylococcal colonization in healthcare workers. Over 250 HCWs were cultured and nearly half (44%) were colonized with S. aureus. MRSA colonization was found in 7% overall and was highest in nurses (10.5%). If the findings of this study are generalizable to other hospitals, this study has two important implications. First, given that nearly half of HCWs were colonized with S. aureus, hand hygiene practiced at very high levels of compliance is warranted. It seems that in the hysteria surrounding MRSA it's been forgotten that MSSA is also a pathogen. Second, why should hospitals engage in active detection and isolation (ADI) when non-patients are a significant reservoir for MRSA in the hospital setting? For those who continue to truly believe in ADI it seems that to me that their logic should dictate that MRSA colonized HCWs be removed from practice. And then there are visitors who may be colonized. The solution there could be to ban all visitors to the hospital. Of course, all of this assumes that the ADI zealots are driven by logic. Here's my recommendation: let's stop focusing on who has what organism (see Eli's posting from a few days ago), and just get everyone to wash their hands before and after every patient contact. The key word here is every. And maybe if that happened, we wouldn't need contact precautions any more. Now here's an interesting thought experiment: what could we do with all the money that's been spent on MRSA surveillance cultures over the last 5 years?

9 comments:

  1. We could all hop aboard Virgin Galactic for a quick trip into space.

    http://www.virgingalactic.com/

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  2. Mike - I suffered a near-fatal deep surgical site MRSA and Strep infection after undergoing routine gallbladder surgery over two years ago and am still dealing with difficult physical complications that have left me disabled. There is little question about where I got the bacteria - at the hospital where there were other outbreaks. The sad truth about what happened to me is that more people probably got the infection on the surgical unit because when I was admitted, there wasn't any active surveillance and therefore no contact precautions were put into place until my cultures came back a week later (yes, a week - I had DIC and my INR was too high for the Interventional Radiologist to safely culture the large abscess in my gallbladder fossa - one of three large abscessed in my abdomen). They also lost the first culture and thus I waited far too long for targeted drugs to battle my specific pathogens.

    During this time, all of my visitors were exposed to a deadly bacteria because I was highly contagious given that I had a bloodline infection. The infection control officer at the hospital advised me to contact every one of my 13 visitors to advise them that they had been exposed to MRSA and to seek the advice of their personal physician. Could this have been prevented? Of course. Could my getting infected in the first place been prevented? Absolutely. Could I live a life free of chronic pain and other problems if someone would have detected and prevented MRSA from being spread to me? Of course.

    The fact that HCWs are often the ones spreading MRSA around at hospitals and in the community shouldn't get you fired from your jobs, but it should require you to undergo testing and decolonization and for you to not work (or not have direct patient contact) until you come back clear. That is the policy of many European hospitals and that system works well. But we Americans whine about instituting policy that actually saves people's lives if it inconveniences us. We call others who believe in patient protection "Zealots" even if those people have lost a loved one to preventable MRSA. How sad that an ID specialist doesn't see the logic in reducing HAIs through the simple step of doing a swab.

    And do you know how many other vulnerable surgical patients I exposed while on the unit? It's hard to know, but when I was first admitted, I walked the halls, touched the rails, and sat at the nurse's station looking at my labs on the computer. All the while spreading my deadly germs. I'll never now how many people I inadvertently exposed and it's probably best that I don't know. I have suffered enough already. I do know, however, that ADI could have prevented it.

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  3. You are right; the colonization is likely to be higher in healthcare workers mainly nurse. We know alcohol gel must be used generously on the hand and the nurse must wait for 30 sec before drying their hand, which they do not. Manufacturers also tell us that you should not use this more than twice before you wash your hands using soap and water. If the bugs are already colonised in the hand they do not die because the bugs know how to pump them out using a new “Efflux pump”. The most important fact is that the gel is only recommended for use in emergency and not for routine hand wash.

    The most important factor is that the MSSA will cross contaminate and soon become MRSA.

    My solution to this problem is to avoid visiting healthcare setting and the healthcare workers. Please check out my tools to help www.askmaya.net

    We must try to control the spread until some genius invents a new miracle drug.

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  4. Lana:
    Many thanks for sharing your story. There is no doubt that MRSA infections are serious. And I agree with you 100%--hospitals need to put time, resources and energy into controlling MRSA PLUS all the other organisms that are infecting patients. At least for MRSA we have several antibiotics that are effective. For some of the others, there are none. It's hard to believe but hospitals across the country now have organisms infecting patients which are not susceptible to any antibiotics. All the MRSA testing in the world won't prevent those. So I am arguing for a broader approach to infection control and the cornerstone of that is hand hygiene. After being a hospital epidemiologist for 20 years, I can tell you I would choose to have my surgery in a hospital with very high compliance with hand hygiene over a hospital with average hand hygiene and a MRSA screening program. See my recent posting about MRSA control at my hospital here: http://haicontroversies.blogspot.com/2010/05/no-mrsa-here-part-2.html

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  5. Authors seemed to not specify when the samples were obtained that is, they had an open-door policy over several weeks. I propose the majority of the participants may have come at the end of their shift rather than at the beginning. [I suggest this based on two things, the number of times I am running to get to work on time and the fact that direct care providers have to punch in within a short time window to avoid penalties].

    If they looked at percent positive in these two groups separately, I hypothesize that they would have seen different results between the two groups. Namely, HCWs may become transiently colonized during the course of their shift, leave, go home, take a shower, hug their kids and wake up negative. The patient impact of low-level, transient colonization in HCWs has not been evaluated. It would have been nice to see this done in more than one setting with hospital MRSA infection rates for comparison. Of course, then we would just been left with a chicken and the egg argument.

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  6. Trouble with my equations.

    I recently read an ICHE paper titled: Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals. The paper stated that admission prevalence of MRSA colonization should include patients with a history of MRSA as well as ASC/clinical cultures. With current literature showing that the "Once MRSA, always MRSA" is incorrect with patients resolving infection naturally or through decolonization (lab error too), why would patients with a distant history of MRSA that could conceivably be negative on their next admission be included in a period prevalence calculation (monthly/yearly)?

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  7. I would not include them but I don't believe in active surveillance, except in the outbreak setting.

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    1. I think we're on the same page. I'm in a system of hospitals and we are being asked to present our prevalence rates as part of our risk assessments in each individual hospital. Some of our rates look extraordinarily high with the inclusion of patients with a history of MRSA.

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  8. Dianna, I think you raise an excellent point. I have concerns that I am going to be cohorted with other patients who have very resistant strains of MRSA when I might be currently clear. I also agree that there are other, extremely deadly pathogens out there that can kill even more quickly and that hand-washing is the best defense. I am just not sure why we can't do all that is necessary to prevent the spread of these deadly pathogens, and if that means doing a nasal swab that costs a buck a patient, then let's do it if it helps us identify patients at risk of infection as well as patients at risk of spreading it. I was a funeral director many years ago, and can recall when universal precautions (as it was first called) came into effect because there was no telling who had deadly diseases and who didn't. I also hate to see the amount of MRSA that is getting spread around funeral homes to the general population because that profession doesn't have a good handle on preventing the spread of these diseases. Good comments, everyone - this is an issue that still impacts me daily, and one that we need to keep discussing until we get it right.

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