Assigning responsibility: using feedback to achieve sustained control of methicillin-resistant Staphylococcus aureus

Epidemiology and clinical features of methicillin-resistant Staphylococcus aureus in the University Hospital, Jeddah, Saudi Arabia

OBJECTIVE

To describe the prevalence, demography and clinical characteristics of patients who were colonized or infected with methicillin-resistant Staphylococcus aureus (MRSA) in 1998 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

PATIENTS AND METHODS

Results of MRSA-positive cultures of clinical specimens obtained as part of investigations for suspected infections were retrieved from the King Abdulaziz University Hospital Infection Control Department's records. Charts of patients were reviewed.

RESULTS

Of 292 S aureus isolates identified, 111 (38%) were MRSA, or 6.0 MRSA isolates/1000 admissions, which represented a marked increase over MRSA prevalence in 1988 (less than 2%). Nosocomial acquisition occurred in 74.8% of isolates. All age groups were affected, but 45.9% of patients were in the 'extremes of age' group (younger than one or older than 60 years of age). The prevalence was highest in the medical ward (27%), followed by the paediatrics combined medical and surgical ward (20.7%), the outpatient department (18%), the adult surgical ward (17.1%) and the intensive care units (17.1%). Two-thirds (66.7%) of cases represented infection and the remainder represented colonization. Surgical wounds (31.1%), the chest (27%) and endovascular catheters (20.3%) were the most common sites of infection. Bacteremia occurred in 27% of patients. Local signs (68.9%) and fever (60.8%) were the most common clinical manifestations. Respiratory distress and septic shock occurred in 28.4% and 6.8% of cases, respectively. Of 74 patients with MRSA infection and 37 patients with MRSA colonization, 91.9% and 56.8% received antibiotics in the preceding six weeks, respectively (P<0.0001). The total mortality of patients with MRSA infection was 60.8%; 37.8% of deaths were the result of MRSA infection and 23% were the result of other diseases.

CONCLUSIONS

The prevalence of MRSA is high and rapidly increasing at King Abdulaziz University Hospital, as it is worldwide. Control measures to prevent the spread of MRSA in hospitals should continue with reinforcement of hygienic precautions and development of policies to restrict the use of antibiotics.

Epidemiology and virulence insights from MRSA and MSSA genome analysis

Staphylococcus aureus is a major human pathogen responsible for a wide diversity of infections ranging from localized to life threatening diseases. From 1961 and the emergence of methicillin-resistant S. aureus (MRSA), this bacterium has shown a particular capacity to survive and adapt to drastic environmental changes and since the beginning of the 1990s it has spread worldwide. Until recently, S. aureus was considered as the prototype of a nosocomial pathogen but it has now been recognized as an agent responsible for outbreaks in the community. Several recent reports suggest that the epidemiology of MRSA is changing. Understanding of pathogenicity, virulence and emergence of epidemic clones within MRSA populations is not clearly defined, despite several attempts to identify common molecular features between strains that share similar epidemiological and/or virulence behavior. These studies included: pattern profiling of bacterial adhesins, analysis of clonal complex groups, molecular genotyping and enterotoxin content analysis. To date, all approaches failed to find a correlation between molecular determinants and clinical outcomes. We hypothesize that the capacity of the bacterium to become more invasive or virulent is determined by genetics. The utilization of massively parallel methods of analysis is therefore ideal to study the contribution of genetics. Therefore, this article focuses on the entire genome including coding sequences as well as noncoding sequences. This high resolution approach allows the monitoring micro- and macroevolution of MRSA and identification of specific genomic markers of evolution of invasive or highly virulent phenotypes.

Clinical effectiveness of alcohol-based products in increasing hand hygiene compliance and reducing infection rates: a systematic review

Reducing the incidence of healthcare-associated infection represents a major challenge. This systematic review of the evidence base considers the clinical effectiveness of incorporating an alcohol-based hand hygiene product into procedures aimed at improving compliance with hand hygiene guidelines, and thereby reducing the incidence of healthcare-associated infections. Multi-component interventions that included alcohol-based products were as effective as those that did not, both in achieving sustained hand hygiene compliance and in reducing infection rates. However, a number of difficulties were encountered in assessing hand hygiene studies: the problem of attributing efficacy to an alcohol-based product when used in a multi-component intervention; the variability inherent in the design of such studies; and how to use data from uncontrolled, unblinded studies in the assessment.

Evidenced-based practice for control of methicillin-resistant Staphylococcus aureus

The increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) has become a global issue and affects nursing practice in many clinical areas. This article explores methods for effective control of MRSA in hospital settings. Based on infection control guidelines provided by the Centers for Disease Control and Prevention, the College of Nurses of Ontario, AORN, the World Health Organization, and several evidence-based studies, strategies for MRSA infection control measures include hand hygiene, contact isolation, and hospital environment hygiene.

Control of endemic MRSA-what is the evidence? A personal view

Although there is extensive literature on the control of MRSA, when that concerning epidemics is excluded, only a limited amount remains regarding the control of endemic MRSA. Several guidelines have been recently published recommending stringent control measures, which are often suggested based on their success in controlling MRSA outbreaks in hospitals with few MRSA or in containing MRSA cases introduced into a hospital with no MRSA. In these settings, multiple measures are usually introduced with apparently successful results. However, results may not be generalizable to other settings and we do not know the minimum effective measures required for MRSA containment. This paper aims critically to review the literature to determine whether evidence exists for the value of the infection control measures that are widely recommended in the endemic setting. Much of this literature is based on observational studies, with few randomized, controlled trials having been conducted. More well-designed studies are required before many of the principles on which we build infection control programmes can be regarded as evidence based.

Rapid detection of methicillin-resistant Staphylococcus aureus directly from sterile or nonsterile clinical samples by a new molecular assay

A rapid procedure was developed for detection and identification of methicillin-resistant Staphylococcus aureus (MRSA) directly from sterile sites or mixed flora samples (e.g., nose or inguinal swabs). After a rapid conditioning of samples, the method consists of two main steps: (i) immunomagnetic enrichment in S. aureus and (ii) amplification-detection profile on DNA extracts using multiplex quantitative PCR (5'-exonuclease qPCR, TaqMan). The triplex qPCR assay measures simultaneously the following targets: (i) mecA gene, conferring methicillin resistance, common to both S. aureus and Staphylococcus epidermidis; (ii) femA gene from S. aureus; and (iii) femA gene from S. epidermidis. This quantitative approach allows discrimination of the origin of the measured mecA signal. qPCR data were calibrated using two reference strains (MRSA and methicillin-resistant S. epidermidis) processed in parallel to clinical samples. This 96-well format assay allowed analysis of 30 swab samples per run and detection of the presence of MRSA with exquisite sensitivity compared to optimal culture-based techniques. The complete protocol may provide results in less than 6 h (while standard procedure needs 2 to 3 days), thus allowing prompt and cost-effective implementation of contact precautions.

Controlling methicillin-resistant Staphylococcus aureus: a feedback approach using annotated statistical process control charts

OBJECTIVES

To investigate the benefit of a hospitalwide feedback program regarding methicillin-resistant Staphylococcus aureus (MRSA), using annotated statistical process control charts.

DESIGN

Retrospective and prospective analysis of MRSA rates using statistical process control charts.

PARTICIPANTS

Twenty-four medical, medical specialty, surgical, intensive care, and cardiothoracic care wards and units at four Glasgow Royal Infirmary hospitals.

METHODS

Annotated control charts were applied to prospective and historical monthly data on MRSA cases from each ward and unit during a 46-month period from January 1997 through September 2000. Results were fed back from December 1999 and then on a regular monthly basis to medical staff, ward managers, senior managers, and hotel services.

RESULTS

Monthly reductions in the MRSA acquisition rate started 2 months after the introduction of the feedback program and have continued to the present time. The overall MRSA rate currently is approximately 50% lower than when the program began and has become more consistent and less variable within departments throughout Glasgow Royal Infirmary. The control charts have helped to detect rate changes and manage resources more effectively. Medical and nursing staff and managers also report that they find this the most positive form of MRSA feedback they have received.

CONCLUSIONS

Feedback programs that provide current information to front-line staff and incorporate annotated control charts can be effective in reducing the rate of MRSA.

Methicillin-resistant Staphylococcus aureus in two tertiary-care centers in Jeddah, Saudi Arabia

OBJECTIVE

To review clinical experience with methicillin-resistant Staphylococcus aureus (MRSA) in tertiary-care hospitals in Jeddah, Saudi Arabia.

DESIGN

Retrospective review for the year 1998.

SETTING

Two tertiary-care hospitals.

METHODS

Results of MRSA-positive cultures of clinical specimens obtained as part of investigations for suspected infections were retrieved from the microbiology laboratories' records. Charts of patients were reviewed, with standardized data collection.

RESULTS

Of 673 S. aureus isolates identified, 222 (33%, or 6.8 isolates/1,000 admissions) were MRSA. Overall MRSA prevalence was 2% in 1988. Nosocomial acquisition occurred in 84.2% of cases. All age groups were affected, and 52% of patients had at least one comorbidity. MRSA prevalence was highest in the intensive care units (26.6% of all isolates), the medical wards (24.8%), and the surgical wards (19.8%). Seventy-three percent of isolates caused infection; the rest represented colonization. Surgical wounds (35.2%), the chest (29%), and central venous catheters (13%) were the most common sites of infection. Bacteremia occurred in 15.4% of patients. Local signs (84%) and fever (75.9%) were the most common clinical manifestations. Respiratory distress and septic shock occurred in 30.2% and 13.6% of cases, respectively. Of 162 patients with MRSA infection and 60 patients with MRSA colonization, 95.7% and 70% received antibiotics in the preceding 6 weeks, respectively (P<.0001). The total mortality of patients with MRSA infection was 53.7%: 36.4% as a result of MRSA infection and 17.3% as a result of other causes.

CONCLUSIONS

The prevalence of MRSA is high and rapidly increasing in the two hospitals, as it is worldwide. Control measures to prevent the spread of MRSA in hospitals should continue, with reinforcement of hygienic precautions and development of policies to restrict the use of antibiotics.

Screening for methicillin-resistant Staphylococcus aureus in the endemic hospital: what have we learned?

Control of methicillin-resistant Staphylococcus aureus (MRSA) still generates controversy among infection control practitioners. Opponents claim that once MRSA becomes endemic in an institution, control efforts are no longer justified. This review examines the usefulness, feasibility and cost-effectiveness of control programmes in acute-care hospitals where eradication of MRSA has either failed or has never been attempted; hence, the pathogen has become endemic. High endemicity is associated with increased hospital-acquired infection rates, increased use of glycopeptides and subsequent risk of emergence of antibiotic-resistant Gram-positive bacteria, and additional healthcare costs. Thus, MRSA control has many advantages. Indeed, in many institutions the actual benefit of containment efforts was manifested through the resultant decrease in the incidence of hospital-acquired MRSA infections. Successful programmes are based on an early identification of the MRSA reservoir and prompt implementation of contact precautions. The most efficacious strategy to detect occult MRSA carriage is via the screening of high-risk patients on admission to the hospital which has proven to be cost-effective in varied acute-care endemic settings.

Methicillin-resistant Staphylococcus aureus (MRSA): is there a need to change clinical practice?

Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent organism that causes significant mortality and morbidity especially to patients in critical care areas (CCAs). MRSA can (and does in some cases) also contribute to an increased length of hospital stay and higher health care costs. The literature proposes that routine screening of patients in CCAs is an effective strategy to control MRSA. Furthermore, placing patients in contact isolation until screening results are confirmed can prevent the spread of MRSA. The policies for management of MRSA patients and the incidence of MRSA infection vary widely. The preliminary findings from this review suggest that a uniform policy regarding routine screening and infection control management for all CCA patients should be recommended. A uniform policy has the potential to reduce rates of infection, cross-contamination and associated health costs attributed to MRSA management. However, further research is required before changes to infection control policy can be recommended. The outcomes from this review will be used to increase staff awareness of current infection control practices for MRSA patients in critical care areas and encourage further research.

Methicillin-resistant Staphylococcus aureus in human milk

We collected and analyzed 500 samples of human milk, from five Brazilian cities (100 from each) to detect methicillin-resistant strains of Staphylococcus aureus (MRSA) producing enterotoxins. We found 57 strains of MRSA, and the mecA gene, responsible for resistance, was detected in all of them using a specific molecular probe. We examined 40 strains for the presence of four enterotoxins, after selecting a subset that included all strains from each region, except for the largest sample, from which 10 were randomly selected. Among these two presented enterotoxin B, and growth in human colostrum and trypicase soy broth. After 5 h of incubation at 37 degrees C, population sizes were already higher than 9.4 x 10(5) UFC/ml and enterotoxin was released into culture medium and colostrum. Our results stress the importance of hygiene, sanitary measures, and appropriate preservation conditions to avoid the proliferation of S. aureus in human milk.

Control of methicillin-resistant Staphylococcus aureus in the hospital setting

Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of nosocomial infections. Healthcare professionals in the United States should develop programs to prevent transmission of this organism within their institutions. Aggressive control efforts are justified for several reasons: (1) the incidence of nosocomial MRSA reflects the general effectiveness of infection control practice; (2) MRSA do not replace susceptible strains but instead increase the overall rate of nosocomial S. aureus infections; (3) MRSA infections cause substantial morbidity and mortality; (4) serious MRSA infections must be treated with vancomycin. Thus, in hospitals with high rates of MRSA, use of this antimicrobial agent increases, which in turn may increase the risk for selecting vancomycin-resistant enterococci. Hospitals have used numerous different approaches to control nosocomial spread of MRSA. Staff should choose a control method based on the prevalence of MRSA in their institution and in their referring facilities, the rate of nosocomial transmission of MRSA in their hospital, the risk factors present in their patient population, the reservoirs and modes of transmission specific to their hospital, and their resources. Any MRSA control plan must stress adherence to basic infection control measures, such as hand washing and contact isolation precautions. In addition, decolonization of patients and staff, control of antimicrobial use, surveillance cultures, and molecular typing may be helpful adjuncts.

Hospital-acquired pneumonia: methicillin resistance and intensive care unit admission

Although epidemiologic investigations of hospital-acquired pneumonia have certain intrinsic limitations because of the heterogeneity of the study populations, the difficulties in making a clinical diagnosis of nosocomial pneumonia, and the need for better microbiologic assays, recent studies have provided new and important data concerning the role of Staphylococcus aureus in this disease. This pathogen has now been identified as the most frequent cause of nosocomial pneumonia in hospitals in both Europe and the United States among patients in general hospital units as well as in the intensive care unit (ICU). Patients who have been treated with mechanical ventilation are at especially high risk for S. aureus pneumonia. The incidence of nosocomial pneumonia related to methicillin-resistant S. aureus (MRSA) has increased in recent years in many countries, especially among patients in the ICU. Because hospitalized patients with suspected nosocomial pneumonia often have many risk factors for MRSA infection, it seems advisable to include coverage of MRSA in the initial therapeutic regimen for these patients until MRSA infection is excluded.

Methicillin-resistant Staphylococcus aureus outbreak: a consensus panel's definition and management guidelines

OBJECTIVE

To provide medical personnel with a definition of an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) and guidelines for managing potential outbreaks.

PARTICIPANTS

Eighteen panel members were chosen from different specialties, types of institutions, and geographic regions. Representatives from the American Society of Consultant Pharmacists, the American Society of Health-Systems Pharmacists, the Society for Healthcare Epidemiology of America, and the National Association of Directors of Nursing Administration participated.

CONSENSUS PROCESS

In preparation for the conference, panel members reviewed the literature and wrote abstracts outlining their personal opinions on the core issues, which were circulated to all participants. During a weekend conference, the panel summarized the reviewed literature, defined an MRSA outbreak, and developed management guidelines.

EVIDENCE

Published literature, clinical experience, and expert opinion concerning the emergence and subsequent management of MRSA cases in health care institutions.

RESULTS

An outbreak of MRSA was defined as either an increase in the rate of MRSA cases or a clustering of new cases due to the transmission of a single microbial strain in the health care institution. An increased rate of cases can be defined statistically or experientially and includes both infected and colonized patients. A potential outbreak should trigger stepwise, multidisciplinary actions consisting of basic epidemiologic procedures (phase I) to form an initial epidemiologic hypothesis of an outbreak (phase II) followed by a standard epidemiologic workup (phase III) and microbiologic studies (phase IV) to confirm the hypothesis. Mupirocin calcium treatments should be considered to decolonize health care workers during the fourth phase, even before typing is completed.

CONCLUSIONS

Until studies can be conducted to delineate the effectiveness of different recommendations, the proposed guidelines may provide a useful starting point that can be adapted to meet an individual institution's specific needs.

The use of a ward-based educational teaching package to enhance nurses' compliance with infection control procedures

Obtaining study leave is becoming difficult for clinical nurses in the current economic climate, but the need to develop new clinical skills and to maintain existing good practice remains of prime importance to patient care and will become mandatory with the advent of post-registration education and practice (PREP) in the UK. The ward is widely acknowledged as the best venue for learning clinical skills by nurse educationalists and for many nurses is the preferred learning environment. The feasibility of using a ward-based teaching package to enhance nurses' compliance with key infection control precautions (hand decontamination, the use of gloves and the safe handling and disposal of sharp instruments) was tested in a quasi-experimental research study conducted on matched surgical wards in a teaching hospital, controlling for variables likely to influence performance (knowledge, availability of resources to perform infection control, previous opportunity to develop infection control expertise and nursing workload). Nurses on two wards received the intervention (experimental group). The remaining wards, which received no intervention, operated as controls. The ward-based sessions consisted of a carefully planned sequence of theory and practical demonstration delivered to qualified nurses in the clinical environment at convenient times selected by the ward managers. Performance of infection control precautions was audited before the intervention and 3 months afterwards. The sessions were well evaluated and the clinical environment was considered suitable for teaching by the nurses, but heavy and unpredictable workload prevented the teaching programme from being implemented as planned. The analysis of covariance failed to detect any changes in performance between nurses in the control and experimental groups. The implications of the study findings are discussed to help develop creative new ways of strengthening ward-based educational programmes.

Control of methicillin-resistant Staphylococcus aureus in a pediatric burn unit

BACKGROUND

Control of methicillin-resistant Staphylococcus aureus (MRSA) is particularly difficult in burn units, which are often cited as sources of hospital-wide MRSA outbreaks. We developed a successful MRSA control program and document here its apparent effectiveness in controlling MRSA transmission in a pediatric burn unit.

METHODS

An MRSA control program that included surveillance culturing, clinician feedback, flexible, site-specific isolation, and a list of known carriers was consistently applied in a pediatric burn unit through a 7-year period. Microbiology reports of MRSA isolates from patients and environmental surfaces and records of all patients from whom MRSA was isolated were reviewed.

RESULTS

During calendar years 1985 through 1991, a total of 991 acutely burned children were admitted to the Boston unit of the Shriners Burns Institute. Forty MRSA cases (4%) were identified. One patient both had MRSA at admission and met our criteria for nosocomial MRSA. Of the remaining 39 patients, 11 had MRSA at admission and 28 had nosocomial MRSA. There were 17 wound infections, two cases of pneumonia, and two bloodstream infections. No deaths were attributed to MRSA sepsis.

CONCLUSION

An MRSA control program including surveillance culturing, clinician feedback, flexible, site-specific isolation, and a list of known carriers is associated with a low rate of nosocomial MRSA in a pediatric burn unit.