MRSA-control strategies in the ICU
MRSA-control strategies in the ICU
As healthcare workers, we become in need to realizing that yellow badge on the door meaning that the patient is on “Contact Precautions” to stop the spread of nosocmial methicillin-resistant Staph aureus (MRSA) . So we dutifully clean our hands and put on gown and gloves preceding to entering the room to see the patient. In the critical care units where I trained as a medical resident, all patients have a nasal swab testing for the colonization of MRSA. Patients who were MRSA negative could be disconnected from precautions.
This NEJM presents the results of a three-armed randomized trial aimed at reducing MRSA colonization and bloodstream infections. MRSA control measures are now standard at many ICUs across the world, still there is much debate as to how best to reduce nosocmial infections . The discussion for targeted cultuering for MRSA is that this pathogen is particularly nasty: it is MDRO, highly , and its incresing in both the community and healthcare settings has been clearly increaesing . In 2011, New England Journal of Medicince published the results of a large Veteran’s Affairs MRSA screening initiative which was able to reduce Nosocomial MRSA infections. also, an another analysis of the data recommend that the decrease in infections may have been due to other factors besides the MRSA screening and isolation of colonized persons . Another randomized trial of MRSA screening and infection control measures that was also published in NEJM in 2011 found no reduction in MRSA infections as a result of the study intervention . also , this study stated that compliance with the infection control measures was poor: hand hygiene was used only 2/3 of the time and gowns were worn only ¾ of the time.
instead of isolating MRSA-positive patients on contact precautions, also another option : dropping the bacterial load with intra-nasal mupirocin and chlorhexidine bathing. Arm 1 of the study underwent usual care with MRSA screening and contact precautions for those positive. Arm 2 also going for screening for MRSA and standard contact precautions, but those evaluating positive underwent decolonization process with mupirocin and CHG. Patients in the third arm of the research did not have MRSA culture , but they received decolonization with mupirocin and CHG. that is because the patients in the 3rd arm didn’t undergo MRSA screening, they were not on contact precautions unless they had a prior history of MRSA or their clinical cultures grew a pathogen requiring precautions.
This was a large study with more than 40 participating hospitals and over seventy thousand patients. The results stated that those in the universal decolonization group had a greater reduction in MRSA-positive clinical cultures as well as a greater reduction in all-pathogen bloodstream infections as compared with targeted decolonization or standard screening and isolation strategies. The study also tested rates of MRSA bloodstream infection and did not find any statistical difference between the groups.
In an accompanying editorial, Dr. Michael E. and Dr. Richard W. stated that the results of this study cast doubt on the benefits of MRSA screening and isolation strategies and “should encourage hospitals to discontinue practice for control of MRSA.”
While these data are compelling, the stakes are high – as many hospital-acquired infections are no longer reimbursed by some insurant Co.. also research are needed to corroborate the findings as well as to test whether a vision of universal decolonization with mupirocin and chlorhexidine may lead to more microbacterial resistance. Aalysis of cost-benefit will be helpful, given that MDRO Staph screening and isolation can exact both a direct financial cost and the labor cost of nursing and other staff who must implement such programs. More important than the probability for save cost is the possibility which moving towards a strategy of universal decolonization can reduce patients on contact precautions and remove barrier to visitation by health care workers , family, and friends.
Source: New England Journal of medicine
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