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MRSA Prevention Effective in a Large Healthcare System

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Désirée Lie, MD, MSEd
  • CME Released: 4/18/2011
  • Valid for credit through: 4/18/2012, 11:59 PM EST
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Target Audience and Goal Statement

This article is intended for primary care clinicians, infectious disease specialists, hospitalists, and other specialists who care for hospitalized patients.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe the rate of screening for MRSA infection and carrier state at hospital admission before and after an MRSA bundle intervention.
  2. Describe rates of MRSA colonization and healthcare-associated infection before and after an MRSA bundle intervention.


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  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.


  • Brande Nicole Martin

    CME Clinical Editor, Medscape, LLC


    Disclosure: Brande Nicole Martin has disclosed no relevant financial relationships.

CME Author(s)

  • Désirée Lie, MD, MSEd

    Clinical Professor; Director of Research and Faculty Development, Department of Family Medicine, University of California, Irvine at Orange


    Disclosure: Désirée Lie, MD, MSEd, has disclosed the following relevant financial relationship:
    Served as a nonproduct speaker for: "Topics in Health" for Merck Speaker Services

CME Reviewer(s)

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

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MRSA Prevention Effective in a Large Healthcare System

Authors: News Author: Laurie Barclay, MD CME Author: Désirée Lie, MD, MSEdFaculty and Disclosures

CME Released: 4/18/2011

Valid for credit through: 4/18/2012, 11:59 PM EST


April 18, 2011 — Universal surveillance, contact precautions, hand hygiene, and institutional culture change are linked to reduced transmissions and infections of methicillin-resistant Staphylococcus aureus (MRSA) in a large Veterans Affairs (VA) healthcare system, according to the results of a study reported in the April 14 issue of The New England Journal of Medicine.

These results are similar to those found in a study, as previously reported by Medscape Medical News, that showed enhanced cleaning of intensive care units (ICUs) with disinfectant-saturated cloths, an educational campaign, and targeted feedback could decrease transmission of MRSA or vancomycin-resistant enterococci.

"MRSA Bundles" Effective

The current study indicates that "Health care–associated infections with ...MRSA have been an increasing concern in ...VA hospitals."

"A 'MRSA bundle' was implemented in 2007 in acute care VA hospitals nationwide in an effort to decrease health care–associated infections with MRSA," write Rajiv Jain, MD, from the Veterans Health Administration MRSA Program Office, Patient Care Services, VA Central Office, and the VA Pittsburgh Healthcare System in Pittsburgh, Pennsylvania.

"The bundle consisted of universal nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, hand hygiene, and a change in the institutional culture whereby infection control would become the responsibility of everyone who had contact with patients."

At each facility, staff entered aggregate data into a central database each month on adherence to surveillance practice, prevalence of MRSA colonization or infection, and healthcare-associated transmissions of and infections with MRSA. The investigators evaluated the effect of the MRSA bundle on healthcare-associated MRSA infections from October 2007, when the bundle was fully implemented, through June 2010.

During this period, there were 1,934,598 admissions to or transfers or discharges from ICUs (n = 365,139) and non-ICUs (n = 1,569,459) and 8,318,675 patient-days, including 1,312,840 ICU patient-days and 7,005,835 non-ICU patient-days. The percentage of patients who were screened at admission increased from 82% to 96%, and those screened at transfer or discharge increased from 72% to 93%. At the time of hospital admission, the mean prevalence of MRSA colonization or infection was 13.6 ± 3.7%.

Although rates of healthcare-associated MRSA infections in ICUs did not change in the 2 years preceding October 2007 (P = .50 for trend), there was a significant 62% decrease associated with implementation of the bundle, from 1.64 infections per 1000 patient-days in October 2007 to 0.62 per 1000 patient-days in June 2010 (P < .001 for trend). Rates of healthcare-associated MRSA infections in non-ICUs also decreased (by 45%) from 0.47 per 1000 patient-days to 0.26 per 1000 patient-days (P < .001 for trend).

"A program of universal surveillance, contact precautions, hand hygiene, and institutional culture change was associated with a decrease in health care–associated transmissions of and infections with MRSA in a large health care system," the study authors write.

Limitations of this study include lack of data to determine the extent to which each component of the bundle or concomitant infection–control initiatives may have contributed to the overall reduction in healthcare-associated infections.

"Although we did not make a formal cost–benefit assessment of the VA MRSA Prevention Initiative, others have reported that programs of active surveillance are cost-effective over a wide range of prevalence and transmission rates," the study authors conclude. "Expanding elements of the program to long-term and ambulatory care settings may be necessary to deal with reservoirs of MRSA throughout the health care system."

Opposing Study Findings

Another study, published in the same issue of The New England Journal of Medicine as the current study, reached nearly opposite conclusions. A 6-month intervention in 18 ICUs was ineffective in reducing the transmission of MRSA and vancomycin-resistant enterococci, but the use of barrier precautions by providers was less than what the intervention required.

In an accompanying editorial, Richard Platt, MD, from the Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School in Boston, Massachusetts, suggests that the divergent results of the 2 current studies might be attributed to different study designs.

"It is also possible that the benefits Jain et al. observed were due to factors other than the MRSA bundle," Dr. Platt writes. "The VA system had introduced guidelines addressing ventilator-associated pneumonia and central-line–associated bloodstream infections in the previous year. It also issued a guidance document on decolonization of MRSA-colonized patients approximately 6 months after full implementation of the MRSA bundle, at about the time the dramatic drop in infections occurred. Interrupted time-series analyses incorporating the MRSA bundle and these other interventions might help elucidate the effect of the bundle."

Comments by Dr. John Jernigan, coauthor and the CDC's director of Healthcare-Associated Infection Prevention Research and Evaluation, are available as a CDC Expert Video Commentary on Medscape.

The study authors have disclosed no relevant financial relationships. Disclosure forms provided by Dr. Platt are available with the full text of this article at The New England Journal of Medicine Web site.

N Engl J Med. 2011;364:1419-1430, 1464-1465. Abstract Extract

Clinical Context

MRSA is one of the most common causes of ventilator-associated pneumonia, bloodstream infection associated with central venous catheters, and surgical-site infections. The VA system and the CDC in 2001 implemented an MRSA bundle that was shown to reduce MRSA-associated infection on surgical wards by 60% and 1 surgical ICU by 75%. Based on this pilot, a nationwide initiative was implemented by 2007 at all VA facilities admitting patients.

This is a report of the effect of the program on MRSA screening and infection rates at ICU and non-ICU facilities at VA facilities nationwide.

Study Highlights

  • VA medical centers were directed to implement the MRSA bundle, starting with 1 patient unit beginning in March 2007 and extending to all acute care units except mental health care units by October 2007.
  • The bundle consisted of universal nasal surveillance for MRSA colonization at admission, hand hygiene, contact precautions for carriers of MRSA, and institutional culture change, making everyone responsible for infection control with patients.
  • The goal of the culture change was to foster alterations in practice to become a natural component of patient care.
  • The project was performed as a quality improvement initiative.
  • Patients found to be colonized or infected with MRSA within the previous 12 months were assigned to contact precautions.
  • Patients negative for MRSA within 12 months who became infected at more than 48 hours were considered new events.
  • Healthcare-associated events were defined according to guidelines of the CDC's National Healthcare Safety Network.
  • Data from all facilities were pooled for analysis.
  • Follow-up occurred from 2007 to 2010.
  • The mean age of patients admitted to VA acute care facilities from 2007 to 2010 was 62.6 years, 95% were men, and median length of stay was 3.0 days.
  • There were 153 hospitals in the VA system, with 196 medical, coronary, and surgical ICUs and 428 medical, surgical, rehabilitation medicine, and spinal cord units involved in the bundle.
  • There were 1,934,598 admissions, transfers within, or discharges from units, and 8,318,675 patient-days.
  • A total of 1,712,537 surveillance screening tests were obtained from patients.
  • The prevalence of MRSA carriage among VA patients at admission was 13.5% compared with 1.5% in the general population and 6.3% among non-VA patients.
  • The percentage of patients screened at admission increased from 82% to 96%.
  • The percentage screened at transfer or discharge increased from 72% to 93%.
  • More non-ICU than ICU patients were colonized or infected at admission (15.7% vs 14.5%; P < .001).
  • During the analysis period, the rate of transmission of MRSA in the ICUs was reduced from 3.02 to 2.50 per 100 patient-days — a decrease of 17% (P < .001 for trend).
  • The rate of transmission in non-ICUs was reduced from 2.54 to 2.00 per 2000 patient-days — a decrease of 21% (P < .001 for trend).
  • Rate of healthcare-associated MRSA infections in the ICUs had not changed from 2005 to 2007, and after the bundle was implemented, the rate declined from 1.64 to 0.62 per 1000 patient-days in June 2010 — a decline of 62% (P < .001 for trend).
  • There was a decline in rate of MRSA infection related to a device from 0.14 to 0.03 per 1000 patient-days — a decrease of 79%.
  • The quarterly decline for infection related to a device was 62%.
  • The decline in quarterly rate of pneumonia not related to a device was from 0.35 to 0.22 per 1000 patient-days — a decrease of 37% (P = .001 for trend).
  • For pneumonia related to a device, the decline was 75%.
  • For urinary tract infection, the decline was from 0.16 to 0.04 per 1000 patient-days — a decrease of 75% (P < .001 for trend).
  • For soft tissue infection, the decline was 75%.
  • Between 2006 and 2007, there was no change in rate of MRSA-associated pneumonia and bloodstream infection.
  • In the period of analysis from 2007 to 2010, MRSA pneumonia declined from 1.17 to 0.33 per 1000 device-days — a decrease of 72% (P < .001 for trend).
  • The rate of bloodstream infection associated with a central venous catheter declined by 33%, and patient-days on mechanical ventilation declined by 14%.
  • During the same period, the rate of pneumonia in non-ICU settings fell from 0.08 to 0.05 per 1000 patient-days — a decrease of 38%.
  • Urinary tract infection fell by 44%, and skin and soft tissue infection by 53%.
  • The rate of MRSA healthcare-associated infections in non-ICUs fell by 45%.
  • The authors concluded that the MRSA bundle implemented at VA acute care facilities was effective at improving MRSA screening and in reducing MRSA colonization and healthcare-associated MRSA infection.

Clinical Implications

  • An MRSA bundle intervention implemented at multiple acute care facilities increased MRSA screening at admission.
  • The MRSA bundle is effective at reducing MRSA infection and healthcare-associated MRSA-infection.

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