An effective MRSA surveillance program in a NICU needs to address a question of balance. You must consider your resources, as one healthcare system found that “while more frequent monitoring led to greater use of a decolonization regimen, it also reduced the likelihood of isolation rooms being available.”¹

Preventing MRSA colonization in neonates is critical because some 30% colonized may develop invasive infection.

“Current practices for preventing invasive disease due to MRSA in the [NICU] include a ‘seek and destroy’ infection control program, whereby periodic surveillance cultures are obtained and colonized infants are decolonized and/or isolated,” the authors note.

The researchers conducted a simulation study to assess MRSA transmission in a NICU, with unit-wide surveillance occurring at periods of 1, 2, 3, and 4 weeks. This “was compared against the current NICU policy of dynamic surveillance,” which calls for weekly surveillance when there has been one or more positive MRSA cultures. If not, screening occurs every three weeks. At each surveillance period, colonized infants are decolonized with a regimen that is 56% effective and moved to isolation rooms, if available, they reported.

“Intuitively, a more frequent surveillance program sounds appealing but must be balanced with its corresponding risks and drawbacks,” they concluded.

Hospital Infection Control & Prevention interviewed the lead author of the paper, Neal D. Goldstein, PhD, MBI, an infectious disease epidemiologist at the Christiana Care Health System and an assistant research professor at Drexel University in Philadelphia.

HIC: You “observed that more frequent surveillance resulted in fewer MRSA colonized infants with shorter mean colonization times.” However, you cited the variables of hand hygiene efficacy and availability of isolation space. You note that not one size fits all, but can you comment further on what factors must be taken into account to seek a balanced approach to this clinical challenge?

Goldstein: Hand hygiene is probably the single most important factor in a clinical environment for staving off spread of organisms, like MRSA. But even with outstanding compliance, we have seen that MRSA can still spread. This brings into focus the other components of MRSA prevention: use of decolonization regimen, contact precautions, isolation (either in a dedicated room or in situ). A balanced approach means that an institution has all of these tools at their disposal. But they are not needed at all times — that is the point of surveillance.

HIC: Would you recommend that hospitals that set up a surveillance program for MRSA also monitor hand hygiene efficacy or have a good idea of their unit’s rate before implementing surveillance?

Goldstein: The first step that any institution should take is to be able to describe the burden of MRSA in their clinical setting over time. Then, the appropriate strategies can be adopted. We saw that colonization ebbed and flowed in the unit. This suggests that the right strategies are needed at the right time. That is the balance between costs and potential for harm. Our “dynamic” policy was created before we undertook this analysis, and the modeling demonstrated this was a reasonable approach to MRSA surveillance.

If an institution is observing a high burden of MRSA colonization — especially relative to comparable institutions or peers — the infection control program should examine compliance with hand hygiene. And not only compliance, but effectiveness [to ensure] it is being done correctly. Consider other prevention tools such as universal gloving for all patient interactions, decolonization regimens, contact precautions, use of isolation rooms, and so on. One of the main features of our model is we provided the framework for such infection control analyses. Any institution can adapt and apply our modeling approach to their site-specific characteristics.

HIC: Can you comment a little more on your decolonization protocol and whether it might be applicable for use by other hospitals?

Goldstein: The basic premise of a decolonization program is to actively identify patients who are colonized with a pathogenic organism, like MRSA, and prophylactically treat them to prevent development of invasive disease and the potential for spread to other people. Despite its documented success rate, a good proportion of NICUs still do not employ a decolonization program.

The program we use at Christiana Hospital is essentially the same as the one described in this article: bathing with chlorhexidine gluconate and intranasal mupirocin ointment. This is a protocol that we have had success with and can definitely be adapted and applied in a variety of settings, not just neonatal. In fact, many institutions follow a similar program in adult settings. The treatment for colonization is not expensive; rather, the expense incurred is from the active surveillance component of the program. Because in order to decolonize, you first need to identify those who are colonized. Nevertheless, we encourage other institutions to use our models to examine the patient care networks in their settings to estimate the effectiveness of an MRSA surveillance program.

REFERENCE

1. Goldstein ND, Jenness SM, Tuttle D, et al. Evaluating a neonatal intensive care unit MRSA surveillance programme using agent-based network modelling. Jrl Hosp Infect 2018; DOI: 10.1016/j.jhin.2018.05.002.