Methicillin-resistant Staphylococcus aureus (MRSA) is an important pathogen both in the perioperative setting and within the community. Many studies have shown that it increases morbidity and mortality when compared with its less drug-resistant relative, methicillin-sensitive S. aureus.
Active surveillance testing
Vigorous academic debate has also focused on best practices, such as active surveillance testing (AST)—the screening of patients for MRSA prior to an operative procedure, usually via nasal cultures. This allows for patients with MRSA colonization to be identified and placed on contact precautions during their hospital stay.
Some facilities have embraced AST as a best practice, while others point out that MRSA still occurs in settings where AST has been practiced. Still, others have discussed the increased costs associated with the additional testing. In 2008, an article appeared in the Society for Healthcare Epidemiology of America journal stating that AST was a flawed infection control response.1 The authors noted that focusing on a single organism (MRSA) prevented far fewer healthcare-associated infections (HAIs) than did broader infection prevention approaches. The article discussed targeted approaches (AST for MRSA) versus universal approaches (such as central line insertion practice checklists) that impacted all infections related to a device or procedure. For example, reducing central line-associated bloodstream infections (CLABSIS) by 12.5% is the equivalent of reducing MRSA infections by 50%.1 A 25% reduction in CLABSIS would be equivalent to eliminating all MRSA infections. This population-based argument suggests that a new, broader approach is needed to handle MRSA as one of a number of pathogens rather than as an independent problem causing HAIs, including a push toward a universal infection control approach for dealing with all HAIs.
Universal infection prevention
Universal approaches that are best supported by the current literature include bundles, environmental cleaning, patient hygiene, healthcare worker hand hygiene, and antimicrobial stewardship.
Bundles. Bundles have gained visibility over the last few years. A bundle is an approach of implementing a number of interventions aimed at reducing a problem, such as reducing CLABSIS. These bundles can be introduced in a fashion that will allow a practitioner to create a checklist so that he or she may check off his or her adherence to these interventions and permit others to validate adherence to the intervention, allowing for both process (adherence to the bundle) and outcome measures (infections).
Now that the Centers for Medicare and Medicaid Services links reimbursement to bundles, such as the Surgical Care Improvement Project and central line insertion bundle, most institutions are very familiar with these approaches.2
The bundle to reduce surgical site infections (SSIs) includes the following measures3:
- appropriate antibiotics for prophylaxis for specific surgeries
- appropriate timing preoperatively to administer the antibiotic (within 1 hour before incision and within 2 hours for vancomycin or a fluoroquinolone)
- appropriate discontinuation of antibiotics (within 24 hours of surgery and within 48 hours of cardiac surgery)
- appropriate hair removal at the surgical site
- maintaining adequate warmth (normothermia) of the patient
- blood glucose control in cardiac surgical patients.
Some institutions have expanded on this bundle to include other elements supported in the literature, such as the use of 2% chlorhexidine gluconate (CHG) cloth bathing preoperatively to reduce SSIs.4
The bundle designed to reduce catheter-associated urinary tract infections focuses on removing unnecessary urinary drainage catheters, performing routine perioperative care, securing the catheter, maintaining a closed system, and keeping the bag off the floor and below the patient's bladder.5 The postoperative care bundle also includes elements to reduce catheter-associated urinary tract infections, such as removing the urinary drainage catheter within a set time period when no contraindications exist. Additional bundles have been developed to reduce late onset CLABSIS (catheter maintenance bundles) by focusing on removing the line as soon as possible (usually by verifying daily line necessity), scrubbing the hub before accessing a line, covering the site with a dressing, and changing the dressing every 7 days or as needed.6
Adherence to the ventilator-associated pneumonia (VAP) bundle is another way to reduce MRSA and other HAIs. The VAP bundle focuses on removing the patient from the ventilator as soon as possible (usually by encouraging daily assessment for readiness to extubate), reducing sedation for a period during the day, elevating the head of the bed between 30 degrees and 45 degrees, and performing daily chlorhexidine gluconate (CHG) oral care. It should be noted that one area of the original Institute for Healthcare Improvement VAP bundle, which uses histamine2-receptor blockers and proton pump inhibitors (PPIs) to prevent peptic ulcer disease, is controversial because PPIs may increase the likelihood of the patient developing C. difficile.7
Environmental cleaning. Occupying a room that previously housed a patient with MRSA or another multidrug-resistant organism (MDRO) is a known risk factor for acquiring that bacteria.8 Recently, studies have shown that rooms are cleaned much less than previously thought; one study noted that at over 40 hospitals, less than half of the high-touch surfaces in a patient's room were cleaned.9 The authors also noted that, until recently, there was no way of knowing whether something was actually clean.
The use of novel technology, such as luminescent gel or powder, has given clinicians the ability to see if items have been wiped with sufficient friction to remove bioburden. When this technology is used, environmental cleaning markedly improves.10 It's also been shown to be an effective teaching method for environmental service staff learning how and what to clean. It's widely thought that this technology should also be used for training and evaluating nursing staff members because they're frequently assigned cleaning responsibilities for patient-care equipment. In addition, clear roles about who cleans what equipment on a patient-care unit or in the OR need to be defined and reviewed with all staff on a regular basis.
Although novel technologies such as UV light and hydrogen peroxide plasma have shown some promise in preventing MRSA and other HAIs when employed in the patient's room post discharge, they still require a staff member to preclean a room. Additionally, the data aren't definitive regarding effectiveness, revealing that some technologies pose safety challenges and delays in room turnaround, which prolongs patients' stay in EDs where inappropriate cleaning and hand hygiene challenges are significant.
Patient hygiene. Patient hygiene is becoming an increasing focus for preventing the transmission of MRSA and other HAIs. The data to date have focused primarily, but not exclusively, on patients in the ICU and the use of CHG. As shown in the REDUCE MRSA Trial, MRSA and other HAI rates can decrease significantly when the patient is bathed daily.11 However, it should be noted that there are disparities in the literature; some studies have shown that using CHG in bath basins fails to reduce MRSA, whereas others have shown success with CHG.12,13
Nevertheless, given the repeated studies in different acute care settings demonstrating reduction in at least some HAIs (MRSA, C. difficile, CLABSIS, surgical site infections, and vancomycin-resistant enterococci) with CHG use and the marginal adverse reactions of such an approach, there's little rationale for not implementing it.
Healthcare worker hand hygiene. Hand hygiene has been recognized as an important step toward interrupting disease transmission. Studies have also been conducted that show increasing hand hygiene has reduced MRSA transmission on a unit.14,15 Unfortunately, very little data have been produced that demonstrate the ability to gain and maintain 100% hand hygiene adherence.
However, in the last few years, new technologies have been developed that allow for reminders and evaluation of healthcare worker hand hygiene at specific times, such as upon entering and exiting a patient's room. These products, although not infallible, allow unbiased and constant evaluation of units or, in some cases, specific healthcare worker hand hygiene adherence. This technology is promising but hasn't yet gained wide usage in acute care settings.
Antimicrobial stewardship. Antimicrobial stewardship has been noted to be an effective way to control MRSA and other MDROs.16 Antimicrobial stewardship is “a set of coordinated strategies to improve the use of antimicrobial medications with the goal of enhancing patient health outcomes, reducing resistance to antibiotics, and decreasing unnecessary costs.”17 In fact, the early literature supporting AST for reducing MRSA at one institution was mirrored by claims that antibiotic controls had also reduced MRSA at the same institution. Currently, The Joint Commission and several states are requiring that antibiotic stewardship be conducted by all acute care institutions.
However, this approach is ill defined at this time, and institutions with few resources, such as infectious disease pharmacists and/or infectious disease physicians, are less likely to implement this intervention than institutions that are considered resource rich. Nurses prompting physicians to be aware of negative culture results or responding to sensitivities can reduce inappropriate antibiotic or broad-spectrum antibiotic use, thus, helping to reduce MRSA and other HAIs.
This way to best practices
MRSA is still a very important and dangerous hospital pathogen. The best practice for reducing MRSA is to take approaches that will reduce other healthcare-associated pathogens, not solely focusing on MRSA-specific interventions. Although the use of active surveillance testing to reduce MRSA transmission in the acute care setting is of dubious value based on the current research, culturing patients for MRSA so that surgeons may prescribe the appropriate prophylactic antibiotic appears to still have some value in certain high-risk populations.
1. Wenzel RP, Bearman G, Edmond MB. Screening for MRSA: a flawed hospital infection control intervention. Infect Control Hosp Epidemiol. 2008; 29:(11):1012–1018.
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12. Rupp ME, Cavalieri RJ, Lyden E, et al. Effect of hospital-wide chlorhexidine patient bathing on healthcare-associated infections. Infect Control Hosp Epidemiol. 2012; 33:(11):1094–1100.
13. Climo MW, Sepkowitz KA, Zuccotti G, et al. The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and healthcare-associated bloodstream infections: results of a quasi-experimental multicenter trial. Crit Care Med. 2009; 37:(6):1858–1865.
14. Carboneau C, Benge E, Jaco MT, Robinson M. A lean Six Sigma team increases hand hygiene compliance and reduces hospital-acquired MRSA infections by 51%. J Healthc Qual. 2010; 32:(4):61–70.
15. Davis CR. Infection-free surgery: how to improve hand-hygiene compliance and eradicate methicillin-resistant Staphylococcus aureus from surgical wards. Ann R Coll Surg Engl. 2010; 92:(4):316–319.
16. Madaras-Kelly KJ, Remington RE, Lewis PG, Stevens DL. Evaluation of an intervention designed to decrease the rate of nosocomial methicillin-resistant Staphylococcus aureus infection by encouraging decreased fluoroquinolone use. Infect Control Hosp Epidemiol. 2006; 27:(2):155–169.
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