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Methicillin-Resistant Staphylococcus aureus Prevention Strategies in the ICU

A Clinical Decision Analysis*

Ziakas, Panayiotis D. MD, PhD1,2; Zacharioudakis, Ioannis M. MD1,2; Zervou, Fainareti N. MD1,2; Mylonakis, Eleftherios MD, PhD1,2

doi: 10.1097/CCM.0000000000000711
Clinical Investigations

Objectives: ICUs are a major reservoir of methicillin-resistant Staphylococcus aureus. Our aim was to estimate costs and effectiveness of methicillin-resistant Staphylococcus aureus prevention policies.

Design and Interventions: We evaluated three up-to-date methicillin-resistant Staphylococcus aureus prevention policies, namely, 1) nasal screening and contact precautions of methicillin-resistant Staphylococcus aureus–positive patients; 2) nasal screening, contact precautions, and decolonization (targeted decolonization) of methicillin-resistant Staphylococcus aureus carriers; and 3) universal decolonization without screening. We implemented a decision-analytic model with deterministic and probabilistic analyses. Methicillin-resistant Staphylococcus aureus infections averted, quality-adjusted life years gained, and incremental cost-effectiveness ratios were calculated. Cost-effectiveness planes and acceptability curves were plotted for various willingness-to-pay thresholds to address uncertainty.

Measurements and Main Results: At base-case scenario, universal decolonization was the dominant strategy; it averted 1.31% and 1.59% of methicillin-resistant Staphylococcus aureus infections over targeted decolonization and screening and contact precautions, respectively, and saved $16,203/quality-adjusted life year over targeted decolonization and 14,562/quality-adjusted life year over screening and contact precautions. Results were robust in sensitivity analysis for a wide range of input variables. In probabilistic analysis, universal decolonization increased quality-adjusted life years by 1.06% (95% CI, 1.02–1.09) over targeted decolonization and by 1.29% (95% CI, 1.24–1.33) over screening and contact precautions; universal decolonization resulted in average savings of $172 (95% CI, $168–$175) and $189 (95% CI, $185–$193) over targeted decolonization and screening and contact precautions, respectively. With willingness-to-pay threshold per quality-adjusted life year gained ranging from $0 to $50,000, universal decolonization was dominant over targeted decolonization in 67.5–75.4% and dominant over screening and contact precautions in 66.0–75.4%.

Conclusions: In the ICU setting, universal decolonization outperforms the other two strategies and is likely to be cost-effective even at low willingness-to-pay thresholds. Assuming 700 annual ICU admissions in an average 12-bed ICU, the projected annual savings reach $129,500 to $135,100.

1Infectious Diseases Division, Rhode Island Hospital, Providence, RI.

2Warren Alpert Medical School of Brown University, Providence, RI.

* See also p. 496.

The authors have disclosed that they do not have any potential conflicts of interest.

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