With the focus on the emergence of multidrug-resistant gram negative pathogens, Clostridium difficle and the re-emergence of childhood diseases like measles, once-predominant methicillin-resistant Staphylococcus aureus (MRSA) has somewhat fallen off the radar — particularly as an occupational infection.

However, the CDC is revisiting MRSA and drug-susceptible staph strains in a major way in its comprehensive new guidelines, “Infection Prevention in Healthcare Personnel.”

Staph aureus MSSA/MRSA are certainly not talked about as much, and there have been a decrease in reports over time,” says David Kuhar, MD, medical officer in the CDC’s Division of Healthcare Quality Promotion, who is spearheading the development of the guidelines. “Other infections certainly get more press, but about a third of the population is colonized with Staph aureus and we still see these infections. It is still important.”

The CDC is updating employee health guidelines that were originally issued in 1998. The new guidelines will include a section on overall program elements and recommendations to protect workers from a broad range of infectious agents.

Two Questions

At a recent meeting of the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC), Kuhar said that two major questions about staph will be subject to a literature review and update. The questions are to inform guidance in healthcare settings without a concurrent MSSA/MRSA outbreak or evidence of ongoing transmission between patients and staff. Under these conditions, the CDC seeks evidence to answer the following questions:

  • For healthcare personnel (HCP) with laboratory-confirmed MSSA/MRSA infection, which interventions reduce MSSA/MRSA infections or colonization among patients and/or other HCP?
  • For asymptomatic HCP, does screening for MSSA/MRSA colonization lead to implementing interventions that prevent MSSA/MRSA infections or colonization among patients and/or other HCP?

To answer those questions and address other issues of occupational health and MRSA, the CDC is winnowing some 4,000 identified articles to about 460 papers that will be consulted in detail to inform the new guidance. Thus begins the update of individual pathogens in a part of the draft that will follow the first section on employee health program infrastructure, which is now under internal CDC review and clearance.

“Since putting the first section into clearance, we’re moving on to updating information about individual pathogens,” Kuhar explains to Hospital Employee Health. “We’re doing Staph aureus first for a few reasons. That section in the [1998] guideline has information that really needs to be updated. Some of it is really out of date, which isn’t the case for all of the pathogens. We thought that this one would be a good first test or ‘practice pathogen’ to update. It will inform how we approach all of the others.”

Regarding the aforementioned staph questions, the first question involving an infected healthcare worker is relatively straightforward, but the second question on asymptomatic colonization and screening of workers is more loaded. Screening of asymptomatic healthcare workers for MRSA in the absence of an outbreak has not generally been recommended and would likely be controversial if the new guidelines called for that. On the other hand, MRSA outbreaks have been traced to asymptomatic carriage by healthcare workers.

“We presented these questions to HICPAC because these were things that we wanted to approach with a systematic literature review — things that we had worried may have changed since 1998,” Kuhar says. “We wanted to make sure that HICPAC agreed that those were the important questions and that we weren’t missing anything.”

Program Support?

The draft section under current review for clearance is about “the infrastructure and routine practices of occupational infection prevention services,” he adds.

That includes the objectives of an occupational health service to prevent infections, as well as the needed program elements to provide medical evaluations and education to healthcare personnel.

“It is currently in CDC clearance and I think it will be in clearance for several months still,” Kuhar says. “Once it is done, the plan is to put it out for public comment.”

HEH asked Kuhar whether the CDC guidelines will stress the importance of employee health programs, even to the extent of underscoring they are appropriately budgeted and adequately staffed.

“These programs are absolutely important,” he says. “We know there are many documented outbreaks involving transmission of infectious disease among healthcare personnel and patients. Occupational health services provide critical preventive services to these personnel, from immunization to PEP and treatment for infections, as well as imposing work restrictions for infectious personnel. Without a doubt, occupational health administers these critical services, and having some discussion about the critical infrastructure [of these programs] is important.”

The next individual pathogen for literature review and update is measles, which has resurged to cause chaotic and expensive outbreaks and exposures in healthcare settings. Kuhar was the lead author of a study that found that 78 reported measles cases resulted from transmission in U.S. healthcare facilities in 2001-2014.1 That includes 29 healthcare workers who were infected from occupational exposures, one of whom transmitted measles to a patient. The economic impact of preventing and controlling measles transmission in healthcare facilities was $19,000–$114,286 per case.

“There have been several outbreaks involving hospitals in recent years, so we thought that measles was probably important to get to next,” he says. “It is labor-intensive and expensive when you have these outbreaks. I think a lot of these recent measles outbreaks have involved healthcare workers who got measles, and some of them had been immunized previously. That raises a lot of questions about how to appropriately approach measles, especially in the outbreak setting.”

REFERENCE

  1. Fiebelkorn AB, Redd SB, Kuhar DT. Measles in Healthcare Facilities in the United States during the Post-elimination Era, 2001-2014. Clin Infect Dis 2015;61(4):615–618.