Clinical, patient experience and cost impacts of performing active surveillance on known methicillin-resistant Staphylococcus aureus positive patients admitted to medical-surgical units

Patient Experiences and Perceptions with Infections Due to Multidrug-Resistant Organisms: A Systematic Review

Infections by multidrug-resistant organisms (MDROs) pose significant public health challenges, including increased mortality rates, healthcare costs, and significant impacts on the quality of life for patients. Utilizing a systematic review methodology adhering to PRISMA guidelines, we performed a comprehensive search across three databases, identifying 20 relevant studies that investigated the psychological effects of infections due to MDROs on hospitalized adults. The primary outcomes examined included depression, anxiety, and other psychosocial impacts, while secondary outcomes included patient and caregiver understanding of the infection. Findings revealed consistent associations between contact isolation due to MDRO infections and heightened levels of depression and anxiety among patients, although evidence regarding the impact on anger was mixed. Other psychological aspects, such as feelings of stigmatization and reduced healthcare provider interactions, were also recorded. The current systematic review highlights the importance of addressing these psychological effects through holistic, patient-centered care approaches, emphasizing the need for better communication and comprehensive education for both patients and healthcare providers. Our findings suggest that mitigating the psychological burden of MDROs can enhance overall patient care and outcomes and call for further research to optimize care strategies for patients hospitalized for infections due to MDROs.

The New Precision Stewards?

The precision health era is likely to reduce and respond to antimicrobial resistance (AMR). Our stewardship and precision efforts share terminology, seeking to deliver the “right drug, at the right dose, at the right time.” Already, rapid diagnostic testing, phylogenetic surveillance, and real-time outbreak response provide just a few examples of molecular advances we dub “precision stewardship.” However, the AMR causal factors range from the molecular to that of global health policy. Mirroring the cross-sectoral nature of AMR science, the research addressing the ethical, legal and social implications (ELSI) of AMR ranges across academic scholarship. As the rise of AMR is accompanied by an escalating sense of its moral and social significance, what is needed is a parallel field of study. In this paper, we offer a gap analysis of this terrain, or an agenda for “the ELSI of precision stewardship.” In the first section, we discuss the accomplishments of a multi-decade U.S. national investment in ELSI research attending to the advances in human genetics. In the next section, we provide an overview of distinct ELSI topics pertinent to AMR. The distinctiveness of an ELSI agenda for precision stewardship suggests new opportunities for collaboration to build the stewardship teams of the future.

Strategies for Effective Infection Prevention Programs: Structures, Processes, and Funding

Successful Infection Prevention Programs (IPPs) consist of a multidisciplinary team led by a hospital epidemiologist and managed by infection preventionists. Knowledge of the economics of health care-associated infections (HAIs) and the ability to make a business plan is now essential to the success of programs. Prevention of HAIs is the core function of IPPs with impact on patient outcomes, quality of care, and cost savings for hospitals. This article discusses the structure and responsibilities of an IPP, the regulatory pressures and opportunities that these programs face, and how to build and manage a successful program.

Justice in control of methicillin-resistant Staphylococcus aureus transmission: a fair question to ask?

Active surveillance cultures and contact precautions is a strategy to control the transmission of methicillin-resistant Staphylococcus aureus (MRSA) within healthcare facilities. Whether to implement this strategy to routinely screen and isolate inpatients with MRSA in non-outbreak (endemic) settings, or to remove it and use standard infection control precautions only is scientifically and ethically controversial, in view of the potential adverse effects of contact precautions on patients. To support the use of standard precautions only, it has been argued that active surveillance to identify patients who are asymptomatically colonised with MRSA to place them in contact precautions is unjust or unfair to these patients in various ways. This paper will unpack and examine four distinct arguments, which are advanced from a medical ethics or quality improvement ethical framework, for why this is so. Our analysis shows that while these arguments highlight the injustice of current practices, they do not provide strong ethical reasons for justifying the removal of active surveillance and contact precautions to control MRSA transmission and infection. An implication of our arguments is that the ethical frame for evaluating prevention and control strategies for MRSA, a multi-drug resistant bacteria, should shift from healthcare to primarily public health. From a public health ethics perspective, whether a strategy is unjust, or how ethically significant its lack of fairness is, depends on assessing the evidence for its public health effectiveness and necessity in a given setting, and the extent of the harms and burdens patients with MRSA bear when they are on contact precautions, which remain matters of scientific debate or uncertainty. As an ethical consideration in the debate, the chief normative implication of justice is to provide us further reasons to revise current active surveillance-contact precautions practices, and for the need for research and interventions to minimise their potential adverse effects on patients.

Limited multi-drug resistant organism related stigma in carriers exposed to isolation precautions: an exploratory quantitative questionnaire study

BACKGROUND

Isolation precautions are applied to control the risk of transmission of multi-drug resistant organisms (MDROs). These precautions have been associated with adverse effects, such as anxiety and depression. This study aimed to quantify stigma among MDRO carriers and its association with perceived mental health and experienced quality of care.

METHODS

A quantitative questionnaire study was performed in MDRO carriers exposed to ≥3 days of isolation precautions during hospitalization. Items derived from the Consumer Quality Index questionnaire (CQI) were used to assess perception of care. Stigma scores were calculated using the recently modified Berger Stigma Scale for meticillin-resistant Staphylococcus aureus (MRSA). Mental health was measured with the RAND Mental Health Inventory. The Spearman rank correlation test was used to assess the association between stigma score and RAND mental health score.

FINDINGS

Of the 41 included carriers, 31 (75.6%) completed both questionnaires. The experienced quality of care was 'good' according to CQI score. Twenty-four percent reported not to have received proper explanation about MDRO carriership from healthcare workers (HCWs). MDRO-associated stigma was reported in 1/31 (3.2%). Poor mental health was self-reported in 3/31 (9.7%). There was no correlation between stigma score and RAND mental health score (Spearman correlation coefficient: 0.347).

CONCLUSIONS

In this study, MDRO carriers exposed to ≥3 days of isolation precautions did not report stigma. This contrasts with a recent study that investigated MRSA-associated stigma and may be explained by contact plus airborne isolation protocols in MRSA compared with contact isolation alone in most other MDROs. Also, the psychological impact may be of a different magnitude due to as yet unknown reasons.

Screening for carriage of carbapenem-resistant Enterobacteriaceae in settings of high endemicity: a position paper from an Italian working group on CRE infections

Introduction

A variety of national and international guidelines exist around the management of carbapenem resistant Enterobacteriaceae (CREs), but some of these are several years old and do not reflect current epidemiology and they also do not necessarily give pragmatic advice around active surveillance of CREs in countries with a high burden of cases and limited resources. This paper aims to provide a best practice position paper to guide active surveillance in a variety of scenarios in these settings, and discusses which patients should be screened, what methods could be used for screening, and how results might influence infection prevention interventions.

Methods

This paper was developed as a result of a series of meetings of expert opinion leaders representing the major infectious disease and infection prevention societies in Italy and having the endorsement of AMCLI (Italian Association of Clinical Microbiology) and SITA (Italian Society for Anti-infective Therapy). There was no attempt to undertake a full systematic review of the evidence, as it was felt that this was inadequate to inform a pragmatic view on the best way forward based on current epidemiology and infection rates.

Key recommendations

Key recommendations focus on the urgent need to promote measures to prevent transmission and infection, focusing on high risk patients and clinical areas, as well as outbreak situations. Active surveillance leading to appropriate infection prevention precautions plays a major role in this.

Conclusions

There are limited national or international guidelines giving pragmatic advice on the most appropriate measures for active surveillance and management of colonized patients in a high-burden setting such as Italy. While individual hospitals and regions will need to formulate their own policies based on local epidemiology, this position paper attempts to highlight current best practice in this area and provide pragmatic advice for clinicians, infection prevention staff, and healthcare managers.

Assessment of current methicillin-resistant Staphylococcus aureus screening protocols and outcomes at an academic medical center

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for many hospital-associated infections. Both MRSA-colonized and MRSA-infected patients must be isolated on contact precautions per the Centers for Disease Control and Prevention guidelines. This study evaluates the current practice for removing MRSA-colonized patients from contact precautions and proposes a new protocol to decrease inconsistencies with screening methodologies.

METHODS

This was a retrospective chart review of MRSA screening swabs collected at an academic medical center between January 1, 2010 and December 31, 2017. Of those patients with MRSA screening swabs, extra-nasal cultures were also evaluated for MRSA infection. Screening swabs were analyzed for appropriateness of order and timing between swabs and active infections. Analysis of variance and the χ² tests were used to determine significance between groups.

RESULTS

This study included 8,310 patients with a combined total of 11,601 nasal swabs. Significantly more (P = .0159) patients with 2 negative nasal swabs returned with a recurrent MRSA infection or colonization than those who had 3 consecutive negative nasal swabs (27.8% vs 17.0%, respectively). Additionally, 47.8% of patients only had 1 appropriately ordered negative nasal swab, indicating that a nurse-driven protocol may be more effective in obtaining the full series of samples required to remove contact precautions.

CONCLUSIONS

The current practice for removing a patient from contact precautions for MRSA is insufficient. The number of negative nasal swabs required should be increased from 2 to 3 and a decolonization protocol should be implemented.

Experiences and consequences of living with extended-spectrum β-lactamase-producing bacteria: A qualitative study

BACKGROUND

The number of people who become carriers of antibiotic-resistant extended-spectrum β-lactamase (ESBL)-producing bacteria is steadily increasing. A carrier of ESBL can potentially be stressful for individuals, affecting their daily lives.

METHODS

The purpose of this study was to increase the understanding of experiences and consequences of being an ESBL carrier. A modified version of the grounded theory was used to analyze 16 open interviews.

RESULTS

The analysis resulted in the core category "to handle the new life situation." The results showed a lack of information being passed by attending doctors to study participants about ESBL and the consequences for their daily lives. This insufficient information initially caused fear and anxiety, leading to participants instead searching for information themselves using the Internet. Armed with this information, they developed strategies to continue with their lives as before. As patients they experienced staff that were respectful, showed no stigmatization toward ESBL carriership, and used correct hygiene routines.

CONCLUSIONS

When the information from the attending doctor about ESBL carriers is insufficient, patients often use the Internet to obtain additional information. With the use of this information, patients develop strategies to cope with their lives.

Experiences of carriers of multidrug-resistant organisms: a systematic review

OBJECTIVES

A comprehensive overview of the ways control measures directed at carriers of multidrug-resistant organisms (MDRO) affect daily life of carriers is lacking. In this systematic literature review, we sought to explore how carriers experience being a carrier and how they experience being subjected to control measures by looking at the impact on basic capabilities.

METHODS

We searched Medline, Embase and PsychINFO until 26 May 2016 for studies addressing experiences of MDRO carriers. Twenty-seven studies were included, addressing experiences with methicillin-resistant Staphylococcus aureus (n = 21), ESBL (n = 1), multiple MDRO (n = 4) and other (n = 1, not specified). We categorized reported experiences according to Nussbaum's capability approach.

RESULTS

Carriage and control measures were found to interfere with quality of care, cause negative emotions, limit interactions with loved ones, cause stigmatization, limit recreational activities and create financial and professional insecurity. Further, carriers have difficulties with full comprehension of the problem of antimicrobial resistance, thus affecting six out of ten basic capabilities.

CONCLUSIONS

Applying Nussbaum's capability approach visualizes an array of unintended consequences of control measures. Carriers experience stigmatization, especially in healthcare settings, and have limited understanding of their situation and the complexities of antimicrobial resistance.

Patient Involvement in Healthcare-Associated Infection Research: A Lexical Review

OBJECTIVEThis review examines patient involvement in healthcare-associated infection (HAI) research. Healthcare-associated infections represent an intractable issue with considerable implications for patients and staff. Participatory methodologies that involve patients in healthcare research are associated with myriad benefits.DESIGNLexical review.METHODSPubMed was searched to identify all publications on patient involvement in HAI research since 2000; publications were also identified from the cited references. A lexical analysis was conducted of the methods sections of 148 publications.RESULTSThe findings reveal that HAI research that actively involves patients and members of the public is limited.CONCLUSIONSPatient involvement is largely limited to recruitment to HAI studies rather than extended to patient involvement in research design, implementation, analysis, and/or dissemination. As such, there is considerable opportunity to further this important research area via alternative methodologies that award primacy to patient expertise and agency.Infect Control Hosp Epidemiol 2018;39:710-717.

Building a Successful Infection Prevention Program: Key Components, Processes, and Economics

Infection control is the discipline responsible for preventing health care-associated infections (HAIs) and has grown from an anonymous field, to a highly visible, multidisciplinary field of incredible importance. There has been increasing focus on prevention rather than control of HAIs. Infection prevention programs (IPPs) have enormous scope that spans multiple disciplines. Infection control and the prevention and elimination of HAIs can no longer be compartmentalized. This article discusses the structure and responsibilities of an IPP, the regulatory pressures and opportunities that these programs face, and how to build and manage a successful program.

Are Contact Precautions ethically justifiable in contemporary hospital care?

Hospital infection control practices known as Contact Precautions are recommended for the management of people with pathogens such as methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococci. Background: The patient is isolated, and staff are required to wear gloves, and a gown or apron when providing care. A notice is displayed to remind staff of these requirements and an 'alert' message is placed in the patient's medical record. Objective: The aim of this article is to discuss and explore whether practices used in hospitals to reduce the transmission of endemic antibiotic-resistant organisms are ethically justified in today's healthcare environment in the developed world. In order to do this, the history of the development of these practices is summarised, and the evidence base for their effectiveness is reviewed. Key bioethics principles are then discussed and contextualised from the perspective of hospital infection prevention and control, and an ethically superior model for the prevention and control of healthcare associated infection is proposed.

Utility of nasal swab and age in detecting methicillin-resistant Staphylococcus aureus in pediatric head and neck abscesses

OBJECTIVE

To identify risk factors associated with the presence of methicillin-resistant Staphylococcus aureus (MRSA) in surgical cultures taken from incision and drainage (I&D) of head and neck abscesses in the pediatric population.

STUDY DESIGN

Retrospective case series.

METHODS

All patients under 18 years of age with a head and neck abscess requiring I&D from 2009 to 2015 were reviewed. MRSA nasal swab cultures were taken from all patients upon hospitalization. Surgical cultures were obtained from all patients and correlated with MRSA nasal swab results. Univariate and multivariate logistic regression was performed, and odds ratios (ORs) along with descriptive statistics were analyzed.

RESULTS

Of a total of 272 patients, there were 68 (25%) MRSA-positive abscesses. The majority (86.8%) of these abscesses were in children under 2 years of age. Overall, 12 (4.4%) presented with positive admission MRSA nasal swabs. Of these, 91.7% had MRSA-positive abscess cultures. Decreasing age in years showed an OR of 1.650 (P < 0.001) for MRSA-positive abscess, with children less than 1 year old having the highest OR of 10.74 (P < 0.001).

CONCLUSION

Younger age and MRSA nasal colonization were two statistically significant risk factors for developing an MRSA abscess of the head and neck. This study demonstrates a high positive predictive value for MRSA-positive neck abscesses when nasal swab screenings were MRSA-positive (91.7%). Children under 2 years of age-especially those under 1 year of age-or those with MRSA nasal colonization can be considered a high-risk population that may benefit from empiric antibiotics against MRSA for head and neck abscesses.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2407-2412, 2017.

Research Methods in Healthcare Epidemiology and Antimicrobial Stewardship: Use of Administrative and Surveillance Databases

Administrative and surveillance data are used frequently in healthcare epidemiology and antimicrobial stewardship (HE&AS) research because of their wide availability and efficiency. However, data quality issues exist, requiring careful consideration and potential validation of data. This methods paper presents key considerations for using administrative and surveillance data in HE&AS, including types of data available and potential use, data limitations, and the importance of validation. After discussing these issues, we review examples of HE&AS research using administrative data with a focus on scenarios when their use may be advantageous. A checklist is provided to help aid study development in HE&AS using administrative data.

Infect Control Hosp Epidemiol 2016;1–10

Increasing the efficiency of a targeted methicillin-resistant Staphylococcus aureus screening program

An interdisciplinary team implemented a screening program targeting patients with a history of methicillin-resistant Staphylococcus aureus (MRSA), to reduce unnecessary contact isolation. After converting from a 2-step culture-based protocol to single polymerase chain reaction (PCR) testing, we increased the efficiency of the screening program from 77% to 100%. Despite the higher cost of PCR-based testing, this program remained cost-saving.

Economic features of antibiotic resistance: the case of methicillin-resistant Staphylococcus aureus

This paper analyses and updates the economic information regarding methicillin-resistant Staphylococcus aureus (MRSA), including information that has been previously reviewed by other authors, and new information, for the purpose of facilitating health management and clinical decisions. The analysed articles reveal great disparity in the economic burden on MRSA patients; this is mainly due to the diversity of the designs of the studies, as well as the variability of the patients and the differences in health care systems. Regarding prophylactic strategies, the studies do not provide conclusive results that could unambiguously orientate health management. The studies addressing treatments noted that linezolid seems to be a cost-effective treatment for MRSA, mostly because it is associated with a shorter length of stay (LOS) in hospital. However, important variables such as antimicrobial susceptibility, infection type and resistance emergence should be included in these analyses before a conclusion is reached regarding which treatment is the best (most efficient). The reviewed studies found that rapid MRSA detection, using molecular techniques, is an efficient technique to control MRSA. As a general conclusion, the management of MRSA infections implicates important economic costs for hospitals, as they result in higher direct costs and longer LOS than those related to methicillin-susceptible S. aureus (MSSA) patients or MRSA-free patients; there is wide variability in those increased costs, depending on different variables. Moreover, the research reveals a lack of studies on other related topics, such as the economic implications of changes in MRSA epidemiology (community patients and lineages associated with farm animals).