Got MRSA? APIC rallying ICPs to answer national prevalence survey

Landmark effort includes data on CA-MRSA

Infection control professionals throughout the country are being urged to participate in an unprecedented national prevalence survey this month as part of a long-range goal to eradicate the scourge of methicillin-resistant Staphylococcus aureus (MRSA) infections.

The Association for Professionals in Infection Control and Epidemiology (APIC) is asking ICPs from all types of inpatient health care facilities to participate in a national MRSA prevalence survey throughout the month of October. (See survey.) Moreover, APIC members are being asked to recruit non-APIC members at surrounding facilities to join in the survey. The baseline data will be used to target interventions and assess future progress in a subsequent national MRSA infection eradication campaign. The study is funded by a grant from the APIC Research Foundation, a division of APIC.

"We would like every ICP in an acute care, long-term care, inpatient and rehab facility to participate in the study," says Sue Slavish, RN, MPH, CIC, a member of the APIC research foundation board and an ICP at Queen's Medical Center in Honolulu. "Realistically, we know that that probably will not happen, but we are encouraging everybody to participate and we hope to get a good response."

APIC is asking one person per institution to complete the survey — either electronically or printed out and faxed back — on any single day in October 2006. The resulting snapshot of MRSA infection and colonization will only be as finely detailed as the response rate dictates, so participation is vital.

"Obviously, the success of this is going to be totally dependent on APIC members and their partners in infection control completing the survey," says William Jarvis, MD, lead investigator of the project and an infection control consultant in Hilton Head, SC. "The more people that do it, the better the estimate really is. We are trying to collect a number of pieces of information that none of the other [surveillance] sources can really get at."

Indeed, the survey could provide some much-needed national prevalence data on community-associated MRSA (CA-MRSA). For example, respondents will be asked to answer questions about whether MRSA was recognized within 48 hours of admission and whether the patient had been recently treated at another health care facility. "There are a lot of different pieces of information that we are pulling together to try to determine whether the patient had some exposure to the health care system — not just necessarily a hospital — that would be more indicative of a health care associated MRSA vs. a truly community-acquired isolate," Slavish says.

In addition, an attempt to differentiate between MRSA and CA-MRSA will be done through questions about the antibiotic susceptibility profile of the isolate. For example, community-acquired strains such as the predominant USA 300 clone tend to be susceptible to tetracycline, clindamycin and trimethoprim/sulfamethoxazole.

"We are doing a very simple antibiogram," explained Jarvis, a former medical epidemiologist in the hospital infections program at the Centers for Disease Control and Prevention. "So at least for the truly classical hospital-acquired and community-acquired we are going to be able to differentiate on the basis of that. We are going to have three ways of looking at this. Obviously, the best would be to get the isolate and genotype. That's impossible, but we will at least be able to look at time in the hospital before they have their positive culture, the site of infection and type of infection — whether it's skin, soft tissue, or invasive — and then antibiograms. So we have three of the four ways that you could tell whether they are community- or hospital-acquired."

The survey also will address the controversial issue of active surveillance cultures to detect MRSA in patients newly admitted to hospitals or to individual units such as intensive care. (See related story.) "We are asking some questions about who does surveillance cultures and who does not to get a sense of [whether] facilities that are doing active surveillance cultures are recognizing more or less than the others," he says. "We are asking if they do active surveillance cultures, are they done routinely or are they physician order-driven."

The survey has the potential to produce some unique regional data, with the results broken down by type of setting or other demographics, he explained. "We could look at MRSA in California vs. MRSA in New York," Jarvis says. "No one has been able to do that before, so we will have a little better sense regionally of what's going on. There are a number of ways that we could divide this. We are also asking about type of facilities, such as children's hospitals, women's hospitals, or long-term care acute care. There are a number of ways we could [analyze it]; and again, it is going to be largely driven by the magnitude of the response."

Given the apparent severity of the MRSA problem it is somewhat surprising to learn that the actual prevalence of the pathogen is based on relatively crude estimates and extrapolations. The primary sources have been discharge data and surveillance data from CDC sentinel hospitals. The CDC sentinel surveillance is biased somewhat toward large teaching hospitals and MRSA is likely underreported in discharge data, Jarvis notes.

"The [CDC sentinel hospital data] doesn't necessarily reflect what is going on in nonacute care facilities and perhaps not in smaller community hospitals," he says. "Secondly, with the national hospital discharge survey, we know from medical record reviews in the past that have looked at this that the noting in the chart of a health care-associated infection is often grossly under reported. So probably both of those really have major limitations."

Staph was one of the first targeted pathogens after antibiotics were discovered, but resistance appeared shortly after penicillin was first used in World War II. Likewise, staph became resistant to the first semi-synthetic penicillin — methicillin — only two years after its creation in 1959. MRSA — as we know it now — began causing hospital outbreaks, with the first in the United States occurring in Boston in 1968. Thus — in a manner of speaking — modern infection control was founded specifically to fight a single bug, one that shows no signs of surrender. No one will ever know how many lives have been saved by efforts of infection control professionals to stop its spread, but the cold truth is that MRSA appears to be winning the daily war being waged in this nation's hospitals and, increasingly, its communities.

It is estimated that MRSA currently accounts for more than 50% of all S. aureus health care-associated infections. MRSA currently is the most commonly identified antibiotic-resistant pathogen in many parts of the world, including Europe, the Americas, north Africa, the Middle East, and east Asia, according to a recently published study.1 "Of the expected 2 billion individuals carrying S aureus worldwide, conservative estimates based on either Dutch or U.S. prevalence figures would predict that between 2 million and 52 million carry MRSA," the authors conclude. ". . . The onus is therefore on health care authorities to develop not only surveillance systems that are able to monitor the clonal dynamics of MRSA over wide geographical areas but also to provide the resources for early recognition of MRSA carriers through rapid screening. Hospital staff have a responsibility to implement, maintain, and adhere to strict contact precautions, should hospitals remain places where citizens can aspire to positive health care outcomes with confidence."

Indeed, the days of begrudgingly accepting some endemic level of MRSA are growing shorter in an era of "zero tolerance" for infections, more transparency about adverse outcomes, and the continuing emergence of resistant staph infections in the community. Long the 400-pound gorilla of nosocomial pathogens, MRSA has a bit too high of a profile to be missed by the patient safety advocates and activists that are rallying patients and lawyers to fight hospital infections. In addition, the emergence of CA-MRSA has increased public awareness — and attendant outrage — about the old hospital nemesis. The lines between public health and clinical settings are blurring as CA-MRSA strains come into hospitals and begin spreading among patients. APIC is trying to sail out ahead of this perfect storm by calling for outright — if admittedly unrealistic — eradication. The nationwide prevalence survey is seen as good first step to find out what ICPs are up against.

"We clearly believe that organizations need to strive for zero infections," says Kathy Warye, executive director of APIC. "We know that zero infections is not a likely outcome, but unless our members and other health care workers strive for zero, they will never discover how low they can actually go. So our focus moving forward is on [MRSA] eradication as opposed to benchmarks. That is our message for administrators as well. It ties not only to the outcomes for patients but the economics of the facilities. These infections cost institutions huge sums of money. Striving for zero not only saves lives but dollars as well."

MRSA on Joint Commission's radar

The survey is actually part of a larger APIC rollout of MRSA initiatives, which will include creation of a toolkit or clinical "bundle" of best practices to prevent infections, she adds. "We are also going to have a series of regional conferences that concentrate not on the ICP but on health care administrators because we know that this is all about behavioral change in the facility," Warye says. "We really need CEOs, CFOs, and chief medical officers to understand the situation and support ICPs in their efforts. ICPs can't do it alone."

APIC isn't trying to do it alone either, instead forging a powerful partnership with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). "We are very intent on being aligned in terms of the processes and the standards with the Joint Commission," she says. "I think they can do a tremendous amount to enforce the types of behaviors and practices that are necessary if we are going to see a significant and sustained reduction in MRSA. They are a critical partner."

Indeed, the Joint Commission co-sponsored a recent MRSA conference with APIC that led to the prevalence survey and other initiatives.

"The whole issue of 'Can we do a better job with MRSA?' is of great interest to the Joint Commission," says Barbara Soule, RN, MPA, CIC, practice leader for infection prevention and control services at Joint Commission Resources and Joint Commission International. "They will see what [APIC] comes up with and then whether or not they integrate into an actual standard remains to be seen. The Joint Commission usually does not get that specific in standards. They give guidelines and expect the organizations to find the best pathway."

Current Joint Commission guidelines call for accredited facilities to conduct a risk assessment for infectious agents, reminds Carol O'Boyle, RN, PhD, an infection control consultant to the JCAHO and a faculty member in the school of nursing at the University of Minnesota in Minneapolis.

"The Joint Commission standard [requires] having an organizationwide infection prevention and control program that is based on a risk assessment," she says. "The data presented at the [APIC-JCAHO] conference clearly showed that the risks for MRSA are different now then they were 10 or 15 years ago. And the risks might not be the same in all areas of the country. [ICPs] can develop a program specific to the risk in their community."

Indeed, the result will not be a "one-size-fits-all" approach, but programs tailored to the MRSA risk in individual communities. Active surveillance cultures, for example, may be more cost-effective in some facilities than in others depending on the MRSA prevalence and patient population.

"For example, if a hospital provides care for prisoners from a state penitentiary and the rate of MRSA is very high there, how are they going to screen those individuals?," O'Boyle asks. "I think the struggle right now in the field is how do they operationalize [infection prevention], and is the degree of risk the same throughout the nation?"

Some answers to those questions may be gleaned from the data in the nationwide MRSA prevalence survey. Any release of the findings will be dependent on the number of responses and the demands of analyzing them, but Jarvis hopes to have something to report next June in San Jose, CA, at the annual APIC conference.


  1. Grundmann H, Aires-de-Sousa M, Boyce J, et al. Emergence and resurgence of methicillin-resistant Staphylococcus aureus as a public-health threat. Lancet 2006; 368:874-885.