Rethinking the Evidence for Controlling ICU-Based MRSA Infections

Posted by The Evidence Blog on July 9, 2013

A recent study from the New England Journal of Medicine suggests that current practices to control the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and other blood infections in the hospital ICU may be wrong.

Healthcare–associated infection is a leading cause of preventable illness and death in the hospital environment. Among the pathogens causing healthcare–associated infection, MRSA is a targeted priority because of its virulence, multidrug-resistant profile, and increasing prevalence in healthcare settings—particularly among patients in the ICU. Hospitals commonly screen patients in the ICU for nasal carriage of MRSA and use contact precautions with carriers; in fact, 9 states mandate such screening.

But does it work?

Based on the data from this new study, hospitals can do better. The new study, funded by 2 government agencies, examined 3 different interventions to mitigate the rise of MRSA infections in the ICU in 43 hospital adult ICUs. The first intervention used a “vertical approach” of strategy of active screening and subsequent isolation of patients who tested positive for MRSA—the most common procedure used in hospitals today. The second used a strategy of targeted decolonization, with active detection and isolation plus intranasal mupirocin and chlorhexidine bathing for 5 days. The third strategy was a “horizontal approach”—universal decolonization, whereby all patients were treated given daily chlorhexidine baths for the entire ICU stay and intranasal mupirocin for 5 days, but no active detection and isolation.

Over 18 months, the ICUs that treated all admitted patients with the third intervention reported a 37% decline in the incidence of MRSA and a 44% decline in bloodstream infections of any kind. In contrast, none of the other groups showed a significant decrease in MRSA rates, although the second group—which isolated and treated MRSA-positive individuals—reduced the rate of blood-borne infections by 23%.

An accompanying editorial in the journal recommended that hospitals discontinue the current practice of screening and isolating MRSA-positive patients and that based on a lack of evidence, laws mandating screening should be repealed in favor of laws requiring universal treatment. The editorial points out that the current position of active detection and isolation came about as the result of a low quality of evidence and precluded the establishment of causality, and that contact precautions can interfere with quality of patient care. Nonetheless, most hospitals adopted programs of active detection and isolation, and 9 states mandated MRSA screening of inpatients.

What do you think? Is it time for hospitals and public health agencies to adopt a new, horizontal approach to infection control, even though it will require a complete paradigm shift? Can we afford to wait?

Topics: Hayes Blog

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