Sunday, February 6, 2011

Misguided mandates

Photo: New York Times
The Bangor Daily News is reporting that a bill being considered by the Maine legislature would mandate MRSA screening of high risk patients admitted to hospitals. I won't rehash all the writing we have done on active surveillance for MRSA, but you can see those posts here. So MRSA exceptionalism lives on, and more money will pour into the coffers of companies that produce MRSA test kits.


  1. Wow, it didn't take you long to criticize the work to prevent MRSA in Maine! Tell Mr Pacholski that mandates are misguided. He contracted his infection in a Maine medical center the same month that the Maine Infection Control Collaborative rolled out their new IC protocol for all Maine Hospitals and the same month that Maine Hospitals started the Maine MRSA Prevalence study to "define" high risk populations, as if we don't already know who is at high risk.(another delay tactic by the MHA) The study is now being declared "not very valuable" because apparently the Maine Hosptials and their association couldn't determine and follow simple rules. I know, I was in those meetings.
    Patients getting orthopedic implants were not included in that screening was a hospital Image thing...not a patient safety thing. Mr Pacholski, featured in this article, was not screened, and neither were any of the other Ortho patients he was roomed with, unless they fell under the "study" rules.
    ADI stops the infections, it is indisputable. I believe your argument against this is losing speed every day. By the way Mike, High Risk screening is already the law in Maine (June 2009). It is the rest of ADI, and public reporting that we are after now.

  2. Mike,

    How do you refute the significant reductions seen in the VA system due to screening/ADI?

    How do you refute the many non-VA hospitals who have implemented it and seen significant reductions in their rates of MRSA?

    How do you refute the fact that patients are choosing hospitals who do screening/ADI (especially for ortho procedures) because they know the word on the street is that these patients don't get infected or die?

    How do you refute the latest AJIC article about how screening saved $500 per hospital ICU patient?
    I could go on...

    To quote you in one of your previous posts:

    "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?"

    I'd be willing to hedge that the many patients/families who have suffered harm or lost a loved one to MRSA would answer:

    We could do a lot less with the money spent on nasal swabs than we could from the money we pay hospitals for the complications from Hospital Acquired MRSA and the money being poured into the growing number of wound care centers and home visiting programs that hospitals are building to profit off these infections.

    That doesn't even account for the lost employment, disability payments, loss of income to families; some forever because they lost a spouse or father to MRSA....

    Handwashing alone isn't working. Developing more antibiotics perpetuates the problem. Let's take a lesson from the great hospitals and the great COUNTRIES who are using screening/ADI and antibiotic stewardship programs (instead of developing more) and getting their MRSA rates down significantly.

    Thankfully consumers are getting more savvy and they are demanding screening/ADI from their surgeons/docs. They know if they don't make an issue out of it, that they cannot depend on consistent, safe hospital protocols to do it for them. Many patients are tired of the 'father knows best' mentality and they are assertively speaking up and deciding for themselves. What a great concept: patient-centered care.

    I will say that I'm glad you posted a photo of someone getting their nose swabbed so people can see how simple it is.

  3. I watched my mother die a slow agonizing death due to hospital acquired MRSA and failure to treat it. The physicians failed to treat even though the hospital was full of MRSA because they refused to acknowledge how many patients were infected in their hospital and the deaths/disabilities of MRSA.

    The evidence supporting ADI is growing daily. Other states are embracing laws and saving lives. Attitudes such as this blog belong in the dark ages of MRSA. If I knew what hospital any of you practiced at, I would not allow my family to be admitted there.

  4. I am new to this blog, but I wonder if Suzan and Lori could explain how ADI works?

    My understanding is that MRSA ADI acts to prevent transmission by identifying patients who have MRSA and then requiring nurses and doctors to wear gloves when seeing these patients. Couldn't there be other interventions that prevent MRSA spreading such as really good hand hygiene compliance or mandatory glove wearing?

    Many of my patients in residency died of VRE and now patients are dieing of C. diff and KPC and MRSA ADI does nothing to prevent these infections.

    I would recommend that you look at how low the MRSA infection rates are at a specific hospital and not just whether they utilize a marginally useful test that only targets one infection (MRSA) and not the dozens of other potential pathogens that can kill.

    Again, I am new here, but my sense of Dr. Edmonds is that he has spent his whole career preventing infections, studying infections and treating patients with MRSA and all other infections. I trust his judgment.

    Karl Newman, MD

  5. Part 1

    First, my thanks to those who took the time to send us comments. Secondly, I believe that pre-op MRSA testing for patients having cardiac surgery, joint implants, and neurosurgery is useful because decolonization and appropriate antibiotics can reduce the risk of infection.

    What I do not recommend is routine MRSA ADI for patients admitted to hospitals. My views on this are based on my clinical practice of infectious diseases, my experiences as a hospital epidemiologist, as well as my overall philosophical orientation. I’ll explain each.

    In my clinical practice, I have had the opportunity to see patients with all types of healthcare associated infections (HAIs), including those due to MRSA. There is no doubt that MRSA infections can be severe and have bad outcomes. However, MRSA is but one bad organism that can infect patients in the hospital, as pointed out by Dr. Newman. For MRSA we at least have several treatment options. For some of the other multidrug resistant (MDR) pathogens, we have no effective antibiotics. And if history tells us anything, it’s that if we don’t control these organisms now, they will become endemic in hospitals and we can expect high mortality rates without new antibiotics. Some of the hospitals that have led the MRSA ADI approach are now having severe problems with MDR-gram negative organisms, because their infection prevention strategies have narrowly focused on 1 or 2 specific pathogens.

    In clinical practice, I’m like the proverbial blind man with the elephant, experiencing one patient at a time, but when my epidemiologist hat is on, I see the whole elephant (all the HAIs that are occurring and their rends over time). At my hospital (and nationally), MRSA accounts for less than 10% of HAIs. So even if ADI were 100% effective and we eliminated MRSA, we would still be the left with the other 90% of HAIs due to other organisms.

    Lastly, my core philosophy is that of utilitarianism—for everything we do in infection prevention, for every dollar spent, and for every ounce of sweat expended, I want the absolute maximum achievable benefit.


  6. Part 2

    Putting these perspectives together, I believe that the best approach to reducing infections in the hospital is by focusing on interventions that reduce all HAIs. The most important intervention is hand hygiene. Some experts say hand hygiene doesn’t work, and they typically come from hospitals with low rates of hand hygiene compliance. I agree that hand hygiene doesn’t work when you don’t do it! Recently, we have begun to see hospitals reach very high rates of hand hygiene compliance. Some are doing this with technological advances (e.g., RFID, alcohol sensor badges, or videotaping). Several years ago hand hygiene compliance at my hospital was about 45%, and I didn’t believe that we would ever hit 60%. In 2010, we achieved 92% compliance hospital wide. We have also focused on other non-pathogen specific interventions, such as chlorhexidine bathing, meticulous IV line insertion, antibiotic stewardship, reduction of blood culture contamination (which improves antibiotic usage), amongst other interventions. But notice that none of these interventions mentioned any specific organism because our goal is to reduce HAIs from all organisms, not just MRSA. The result of our approach has been significant declines in HAIs due to all pathogens, including MRSA, but also C. difficile (which is increasing at many hospitals), VRE, and MDR-gram negatives.

    So if I were a doctor-epidemiologist-philosopher-king and could address the problem of MRSA and other pathogens causing infections in hospitals, here is what I would do:
    --Mandate antibiotic stewardship programs
    --Mandate resources for HAI prevention programs (i.e., staff these programs effectively based on the number and complexity of patients) but allow hospitals flexibility to address their unique problems
    --Mandate reporting of HAIs by anatomic site not by organism, introduced sequentially, one infection type at a time. The reported data should be validated before adding the next HAI to the list of reportables to ensure that consumers have excellent data.

    Losing a loved one to a MRSA infection is tragic, and I am inspired by how some channel grief into efforts to reduce these infections. But the question I must ask those of you who have lost family members to MRSA is this: would you feel differently if your loved one died of Acinetobacter or VRE? As a doctor and epidemiologist, I don’t want to see HAIs or deaths due to any pathogen, and as a patient, my goal is to avoid them all.


    This and about 200 other studies prove that ADI and decolonization stops MRSA. No one has ever suggested that ADI be used exclusively for MRSA (works great on VRE and likely many other MDROs) nor to the exclusion of handwashing and other infection prevention practices.
    We know how to stop MRSA and it's time to do it.
    Hanging our hats on handwashing alone for prevention has seen it's day. It's a great and necessary step, but will never work alone.

  8. "would you feel differently if your loved one died of Acinetobacter or VRE?"

    The answer is no.

    Who would ever give up preventing infections from any type of MDRO if they knew there were proven methods to reduce patient harm, save precious lives, reduce antibiotic use, reduce the MDRO load, & reduce costs?

    Imagine if firefighters took the approach that 'if I can't save everyone in the burning house I'm not saving anyone'

  9. To Dr. Newman,

    For a thorough explanation of ADI and current evidence that it works to reduce MRSA, you can use the following links. If you need additional resources, I'd be happy to provide them.

  10. MRSA is just the starting point. All HAI's must be eliminated. By the way. my mother caught 3 HAI's at the same time, including MRSA and Acinetobactor baumanii.

    Dr. Newman, I can explain how ADI works; thanks for asking. For a better explanation, read the study done at the VA, it is in physician speak!

    Mike, you stated, '...but allow hospitals flexibility to address their unique problems...'

    Mike, what did the hospitals do with this flexibility they have had for decades before the law (in some states) had to step in?

    What are they doing with this flexibility they have right now in regards to all the other bacteria you mentioned above that also cause hospital acquired infections?