Once the undisputed tyrant of healthcare-associated infections, MRSA has been reduced in recent years through such highly effective measures as using checklists to aseptically insert central venous catheters.

Unfortunately, methicillin-resistant Staphylococcus aureus is back in a big way. Susceptible strains of staph — MSSA — are also still part of the problem. In 2017, 119,000 people acquired bloodstream staph infections in the U.S., and nearly 20,000 died, the Centers for Disease Control and Prevention (CDC) reports.¹

As a result, the CDC is no longer on track to meet the 2020 goal of a 50% reduction in hospital-onset MRSA bloodstream infections from the 2015 baseline.

“In healthcare settings, MRSA bloodstream infections decreased by approximately 17% each year between 2005 and 2012,” says Anne Schuchat, MD, principal deputy director at the CDC. “But our progress slowed after that, with no significant change during 2013 through 2016.”

While MRSA gains have stalled, bloodstream infections caused by MSSA in the community have actually increased 3.9% annually in 2012–2017. The national opioid epidemic is exacerbating the problem, Schuchat says.

“We’ve previously reported the rise in staph infections in the community may be linked to the opioid crisis,” she said at a recent press conference. “In fact, in 2016, 9% of all serious MRSA infections happened in people who inject drugs — rising from 4% in 2011.”

Infection preventionists should be aware that people who inject drugs are 16 times more likely to develop a serious staph infection. “Healthcare providers and community workers can also be on alert for infections among people who inject drugs and help facilitate those people getting the help they need,” she said.

Have Contact Precautions Lagged?

As IPs are aware, MRSA patients should be placed in contact isolation, including wearing gowns and gloves when entering the patient room.

“Overall, we think that the plateau we’re seeing may be related to reduced use of contact precautions and reduced following of CDC’s recommendations,” she said.

Asked to expand on this issue at the press conference, Schuchat said, “We strongly recommend that everybody use contact precautions and that they evaluate their data. Ideally, not just a single facility but a community pulling together the different facilities in the community, long-term care facilities as well as hospitals.”

The CDC data were gathered from its emerging infections program in six states and two electronic databases that included some 400 hospitals. The data also are consistent with infections being reported by IPs to the CDC National Healthcare Safety Network.

“The bottom line is we have prevented many staph infections,” Schuchat said. “But while we’ve made important progress, our data show that more needs to be done to stop all types of staph infections.”

There are success stories at reducing MRSA infections, including infection control teams that protect ICU patients by using decolonizing chlorhexidine baths and mupirocin in the nares. In addition, the Veterans Affairs (VA) hospital system has reduced MRSA by using active screening on admission, a measure the CDC does not routinely recommend unless warranted by the prevalence of MRSA in the patient population.

“We have an exception with the VA, which has continued to see progress, but we think the plateau may be that hospitals and healthcare providers perhaps have tired of instituting the intensive recommendations,” she says.

Time certainly has not mitigated MRSA infection severity, as the case fatality rates remain relatively unchanged, she added. “We don’t see a drop in the fatality of either MRSA or sensitive staph in terms of the electronic health record data that was looked at,” she said.

“So, we think that while individual hospitals, healthcare facilities, communities, and certainly the VA system may be continuing to make progress, the national plateau that we’re seeing probably stems from dropping off in using the intensive recommendations.”

The other factor is the rise in opioid addiction, with frequent use and reuse of needles contributing to staph infections. “We think that the national trend we’re seeing with the opioid epidemic and the extensive use of injecting drugs may be an additional burden that’s leading to the plateau,” she says.

One take-home point is that if IPs are continuing to see MRSA infections, consider adopting additional measures such as targeted screening of incoming patients and decolonizing patients before high-risk surgeries.

“We don’t at this time think there’s ‘one size fits all’ for the decolonization or some of the other steps like screening on admission,” Schuchat says.

“We certainly think it’s worth considering those steps in particular circumstances. This is a very serious infection, and we think it’s very much worth preventing.”

REFERENCE

1. Kourtis AP, Hatfield K, Baggs J, et al. CDC. Vital Signs: Epidemiology and Recent Trends in Methicillin-Resistant and in Methicillin-Susceptible Staphylococcus aureus Bloodstream Infections — United States. MMWR 2019;68:214–219. DOI: http://dx.doi.org/10.15585/mmwr.mm6809e1.