Infection Control
The drug-resistant bacterial infection MRSA has become so commonplace among the American populace in the last several years that most clinicians now diagnose and treat it as routinely as they do the flu. Still, tens of thousands of Americans with MRSA die each year, putting intense pressure on providers to do more.
Hospitals have instituted a multipronged approach. Certain strategies, like mandating and monitoring frequent hand washing by doctors and staff, are universally accepted, if not universally implemented. Others, such as testing all incoming patients, are much more controversial.
MRSA—full name methicillin-resistant Staphylococcus aureus—was first identified 50 years ago, but newly compiled data paints an alarming picture. For instance, a June study in the journal Pediatrics found that the number of children hospitalized with MRSA was 10 times higher in 2008 than in 1999, surging from two cases per 1,000 admissions to 21 cases per 1,000 admissions. All told, 30,000 children were hospitalized with MRSA during that 10-year period and 374 died.
Most of the infections were acquired in a community setting, not hospitals, according to the study, led by Jason Newland, M.D., an infectious-disease physician at Children's Mercy Hospitals and Clinics in Kansas City, Mo. The emergence of CA-MRSA—acquired in public places such as playgrounds and health clubs as opposed to health care settings—complicates experts' efforts to get their arms around the problem.
"What's new of late is we're seeing a blending of these strains," says Russ Olmsted, an epidemiologist at Saint Joseph Mercy Health System in Ann Arbor and president-elect of the Association for Professionals in Infection Control and Epidemiology. "As patients with community-acquired MRSA get admitted to hospitals, those strains are getting transmitted or are adapting to the environment and becoming more like health care-associated MRSA."
At the same time, hospitals are making progress on certain fronts. For example, researchers led by Deron C. Burton, M.D., reported in the Feb. 18, 2009, issue of The Journal of the American Medical Association that central-line catheter-associated bloodstream infections of MRSA declined significantly from 2001 through 2007 in all types of intensive care units except pediatric units, where rates remained static.
"There is some encouraging news," says John Jernigan, M.D., deputy chief of the Prevention and Response Branch of the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention. "We have begun to see, using various parameters, some movement in the right direction."
No one disputes that more needs to be done, but infection specialists worry that too much emphasis on MRSA may deflect attention from other drug-resistant infections, such as Clostridium difficile and Acinetobacter.
Jernigan says MRSA cases represent about 8 percent of the health care-acquired infections reported to the CDC's National Healthcare Safety Network surveillance system. "That means 92 percent are caused by other pathogens, and we don't want to forget about those other problems," he says.
"It is important to remember that MRSA is only one of the important challenges that we face," Jernigan says. "It's a poster child of a large group of problems that we have to deal with in hospitals every day in the United States."
Also complicating matters is a lack of consensus on two key issues: the value of universal MRSA testing of hospital patients, and whether it's fair for Medicare and private insurers to classify health care-acquired infections as "never events" and refuse to pay to treat them.
Amid all the controversy, hospitals have instituted stringent hand-washing campaigns and taken many other measures to keep MRSA and other infections at bay. Far from being complacent, hospital officials know that much work lies ahead of them in this ongoing struggle to protect the health of their patients.
Health care-acquired infections such as MRSA killed 48,000 Americans in 2006 and cost more than $8 billion to treat, according to a study released in February by Ramanan Laxminarayan, a visiting scholar at Princeton University, and Anup Malani, a professor at the University of Chicago.
MRSA most commonly attacks hospital patients via central-line-related bloodstream infections, urinary catheter-induced infections, ventilator-related pneumonia and surgical-site infections. The billions of dollars in added costs are mostly the result of longer lengths of stay, especially for patients in intensive care units.
Most MRSA cases are not life-threatening, consisting mainly of skin lesions that can be treated with a regimen of antibiotics that are carefully considered so as not to increase resistance. But the bacteria is never fully expunged from the body and infections are likely to recur.
"The qualified answer is, it depends," Olmsted says. "In the U.S. in general, I wouldn't say we have an epidemic, but we have a high endemic rate, which means the background frequency is high compared to other countries."
Olmsted says the prevalence of MRSA among American hospital patients may be three to four times higher than among Canadian hospital patients. "In addition, trends over time that look at frequency of MRSA infections in the entire U.S. population, and not just those in hospitals, indicate significant increases of MRSA over the past 10 years," he says.
"The good news is we still have reasonable susceptibility of MRSA strains to vancomycin, the antibiotic of choice, especially for very serious infection," Olmsted says. "The real concern on the horizon is called vancomycin-resistant Staph Aureus, or VRSA. Those are more difficult to treat."
Hospitals have been escalating the fight against MRSA. For example, the person who passes you in a corridor at Truman Medical Centers could very well be a designated observer watching to see if staff members wash their hands when entering and leaving a patient's room.
"Our infection control practitioners are out and about," says Mark Steele, M.D., chief medical officer at Truman Medical Centers in Kansas City, Mo. "We monitor the compliance of all segments of the hospital, with immediate feedback. We also educate the patients. One of the strategies is to have the patients participate in observation and speak up."
Other infection prevention practices at Truman include:
•Cleaning patient rooms and operating rooms with germ-killing bleach.
•Cleaning patients' skin before central-line catheters are inserted.
•Elevating the heads of ventilator patients by at least 30 degrees.
•Isolating patients known to be colonized with MRSA.
Truman also has made adjustments in the antibiotics it uses to treat infections. Keflex and oxacillin have been replaced by Bactrim or clindamycin for outpatients, and sicker patients requiring hospitalization are likely to be given vancomycin.
"I don't think it's becoming significantly more difficult to treat," Steele says, while acknowledging, "It's obviously less easy for hospitals to deal with what's being caught in the community."
In a 2006 report published in the New England Journal of Medicine, a team led by Gregory J. Moran, M.D., wrote that "the high prevalence of MRSA among patients with community-associated skin and soft-tissue infections has implications for hospital policies regarding infection control. Our results suggest that strategies used for patients with confirmed MRSA infections should be considered for all patients with purulent skin and soft-tissue infections in areas with a high prevalence of MRSA."
"We see many patients in the emergency department with cutaneous abscesses," Steele says. "Roughly three-quarters of those will be infected with MRSA. Fortunately, most of those are self-limited and amenable to treatment, the primary treatment being incision and drainage. We don't know if antibiotics help these to heal faster or not. That's the subject of an ongoing study I'm involved with now."
Olmsted says hospitals are employing infection prevention "bundles," such as a series of steps to follow when inserting a central-line catheter. He cites one study that says standardized use of CDC recommendations for central-line insertion has been shown to reduce bloodstream infections by 66 to 70 percent.
But knowing what best practices are and making sure they are implemented are two different things. "Many hospitals have the right policies in place," Jernigan says. "But we have learned that just having the right policy in place doesn't necessarily translate into effective implementation. Many of the gains we've been seeing have been achieved through better implementation of existing recommendations."
Despite all the efforts being put forth, not everyone thinks hospitals are doing enough to stop MRSA. Several states have passed laws requiring hospitals to screen high-risk patients.
"If hospitals won't take meaningful steps to stop drug-resistant infections, then we'll pass legislation to make sure they do," Washington State Rep. Tom Campbell told the Seattle Times last year.
APIC and the Society for Healthcare Epidemiology of America in 2007 issued a joint statement opposing MRSA screening mandates, saying they are too costly and limit the flexibility of hospital infection-control efforts.
Olmsted says universal MRSA screening legislation represents "a very cement approach to a problem that is fairly fluid and changing all the time. Detection of MRSA on admission is not a one-size-fits-all. You need to use your facility-specific data and decide what measures make sense. It varies considerably by facility."
Steele says "the jury is still out" on the effectiveness of universal MRSA screening. "Our infectious disease experts and infection control people have not felt that, based on the level of evidence we currently have, that's something we should do at this particular time."
Overall, Olmsted cautions that overly stringent measures could result in overtreatment with antibiotics, which would create yet more resistant strains.
Twenty-seven states now require public reporting of hospital-acquired infection rates. Olmsted says he originally was skeptical of public reporting requirements. "However, I will say that it has raised awareness significantly throughout the United States of the problem of health care-acquired infections. In that regard it's been a positive initiative."
In response to concerns about imposing a "severe burden" on hospitals, the CDC on May 7 notified hospitals that it had reversed course and would no longer require them to submit MRSA data to the Buccaneer Data Systems Clinical Data Abstraction Center that they previously reported to the CDC.
In 2008, the battle against MRSA took on a new dimension when Medicare implemented its "never events" policy. The policy states that Medicare will no longer pay hospitals for treatment of complications such as vascular catheter-associated infections, catheter-associated urinary tract infections and certain surgical-site infections.
"This is really about making hospitals and the health system just a safer place to be," former CMS Acting Administrator Kerry Weems said at the time.
Private insurers are following Medicare's example, but the policy continues to sir debate.
"Somebody who gets the wrong blood type, there's really no gray to that, that should be 100 percent preventable," Steele says. "But infections are a different deal, because there are different susceptibilities to infection. It's not clear that one can prevent 100 percent of infections."
Nonpayment should be decided on a case-by-case basis, Olmstead says, noting that while infections can be prevented in most usages of central-line and urinary-tract catheters, he says it is much more difficult to prevent ventilator-associated pneumonia.
Experts agree that a hard road lies ahead in the drive against MRSA and other drug-resistant infections. In its April report, AHRQ stated, "It is unfortunate that HAI rates are not declining. It is evident that more attention devoted to patient safety is needed to ensure that health care does not result in avoidable patient harm."
On the other hand, AHRQ earlier reported that the quality of care delivered in hospitals is improving faster than in any other care setting, and patients are more likely to receive quality of care in a hospital than in any other setting.
Olmsted says hospitals and epidemiologists will "continue to be challenged by new organisms. We can't culture every patient every day while they're in the hospital. If we put our resources into interrupting transmission, with good hand hygiene and cleaning the environment and the patient, that's going to give us a leg up and we'll be ready for whatever organism comes up next."
"There's a lot of work to be done," Jernigan says. "But I think we have come a long way."
Federal policymakers concur. In May, the CDC released The First State-Specific Healthcare-Associated Infections Summary Data Report. The report "demonstrates that the steps we're taking to reduce these often-preventable infections are working," Health & Human Services Secretary Kathleen Sebelius said. Citing the 18 percent reduction in the national CLABSI incidence rate, she said HHS, AHRQ and the CDC will work with hospital associations and others "to further reduce bloodstream infection rates through initiatives such as 'On the CUSP: Stop BSI.' "
The American Hospital Association is "committed to improving quality and sharing relevant information with the field," says spokesman Matthew Fenwick, adding, "infection control is a top priority." Though there are "no silver bullets here, we recognize that hospitals need to do more and we are focused upon areas where we can make the most difference," he says.
Julius Karash is a freelance writer in Kansas City, Mo.
This article 1st appeared in the July 2010 issue of HHN Magazine.
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