VA sharply reducing MRSA infections through patient screening pressure builds on CDC to follow suit
A 76% reduction in ICUs nationwide is an '800-lb. gorilla of data'
By Gary Evans, Senior Managing Editor
In this issue we conclude our two-part special report "MRSA Patient Stories" with comments from clinicians and public health officials, particularly in light of emerging data indicating MRSA infections can be sharply reduced through patient screening programs.
Methicillin-resistant Staphylococcus aureus (MRSA) infections are being reduced dramatically in the nation's Veterans Affairs hospitals through an aggressive eradication program that includes the controversial approach of screening all patients for the deadly pathogen.
In unpublished data involving more than 1 million patients at all 153 VA hospitals, MRSA infections have been reduced by a staggering 76% in intensive care units and 28% in non-ICUs, according to Martin Evans, MD, associate director of the VHA MRSA Prevention Program.
The VA findings are easily the most compelling evidence yet that there is nothing inevitable about the long-standing scourge of MRSA, which currently causes some 100,000 invasive infections annually and kills as many as 20,000 people.1
"This is not just the VA you're seeing this everywhere now. There is this whole new awareness now of infection control and its importance for patient safety and well being," Evans tells Hospital Infection Control & Prevention.
In that regard, the dramatic success of the VA program particularly the patient screening component is ratcheting up pressure on the Centers for Disease Control and Prevention to make a more aggressive recommendation to "seek and destroy" MRSA.
"Some of the VA hospitals are in fairly rural areas, some are in cities, some are in suburbs," says Jorge Parada, MD, MPH, chief of infection control at Loyola University Medical Center in Chicago. "We're talking about geographic dispersal around the whole country and absolutely huge amounts of patient data. And their data are not at the margins of a little decrease they had substantial decreases in infections. This to me, is a game changer. It is the 800-lb gorilla of data showing that [MRSA screening] works."
Parada has implemented a similar MRSA prevention program at Loyola, where he is compiling evidence that universal patient screening and isolation of those colonized or infected can save lives and dollars by stopping MRSA transmission to other patients.
The VA bundle consists of universal surveillance for MRSA via nasal swab on all admissions, in-hospital transfers, and discharges. Patients positive for MRSA are placed under contact isolation precautions to prevent spread to other hospitalized patients, which typically occurs via the unwashed hands of health care workers going from room to room. The VA MRSA program includes an emphasis on hand-hygiene as well as a "culture change" wherein infection control is everyone's responsibility.
"Overall averages for active surveillance are about 90% [at VA hospitals] throughout the country now," Evans says. "That's kind of an indirect measure of this culture change people are keyed in to these infection control issues."
In individual infection numbers compiled over a 21-month period, bloodstream infections declined by 58%, pneumonias by 43%, urinary tract infections by 30%, and skin and soft-tissue infections by 26% at the 153 hospitals. Though the data are unpublished, a portion abstracted for the CDC decennial conference earlier this year speaks to the enormous scope of the project. From October 2007 through June 2009, the ongoing effort included 1.2 million patents, including 230,470 in ICUs and 983,176 in non-ICUs.2
While the sheer numbers are impressive, VA investigators emphasize that the encouraging initial findings need to be subjected to peer review and formally published in a medical journal. The current CDC guidelines list patient screening as a "second tier" option for hospitals facing problems with MRSA or other multidrug-resistant organisms (MDROs), recommendations that fall well short of the universal testing approach the VA has undertaken.3
"I'm sure the CDC will want to see our data peer reviewed and in print before they recommend anything themselves," says Evans, an infectious disease physician at the University of Kentucky in Lexington. "And to be quite frank we can't tell you which part of the bundle is the absolute key one."
Moreover, the massive study does not include any cost-benefit analysis with which to weigh screening versus other approaches to MRSA prevention.
"You can imagine the difficulties of doing that," says Gary Roselle, MD, one of the principal investigators in the VA MRSA project and an infectious disease physician at the Cincinnati VA Medical Center.
"This type of program needs to be discussed and considered at hospitals across the country," Roselle says. "For instance, there may be hospitals that are doing other things that are also having a dramatic impact. And if they are then I don't think they need to switch to what we are doing. I do think that the moral imperative now is that you can't just say that MRSA is a hopeless problem that you can not fix. There may be modalities that can [prevent it]."
In that regard, the VA system saw no widespread evidence of the "unintended consequences" often cited as arguments against MRSA screening, including such issues as room shortages, patient admission backups and diminished care to patients under contact isolation precautions.
"Any time you have more patients in isolation there are always issues," Roselle says. "It requires more effort by the staff because you may end up moving patients around to ensure there are adequate rooms and beds, but there was not a groundswell of problems."
You get what you pay for?
Ultimately, when it comes to MRSA prevention it may be a case of you get what you pay for. To achieve such dramatic reduction of infections, the federal VA system funded a salaried position for an MRSA prevention coordinator at each of the hospitals, Evans explained. In addition, the hospitals received funding for laboratory supplies and lab support personnel. For the most part the MRSA admissions were done using rapid test kits, another expense that afforded much quicker test results than a traditional culture.
"All of that put in an infrastructure that wasn't present before," Evans says. "And of course, the active surveillance [component] is expensive. So what other places might do is try to target the patients you are doing active surveillance on, like admissions from other hospitals, people who have been re-hospitalized recently or on antibiotics recently. I think the best [scenario] is to screen everybody, but again it costs money and in these days and times people don't have the money to do that."
In its 2006 guidelines that many are now calling to be amended, the CDC specifically warned that screening programs to prevent MRSA would require such infrastructure and additional resources. The CDC recommended conducting a risk assessment and going to such aggressive measures "if other control measures have been ineffective." The CDC is currently analyzing the VA data, but will not make any immediate changes to its recommendations, says Michael Bell, MD, deputy director of the CDC division of Healthcare Quality Promotion. Bell is the CDC executive secretary to the Healthcare Infection Control Practices Advisory Committee, the body ultimately responsible for reviewing and amending official CDC guidelines.
"That is a study that we are quite involved with and we are close partners with the VA," Bell says. "We are very interested in not only this work but the work that it is going to lead to. It may come to a point where we will consider [revising recommendations], but I don't think we are there yet."
However, the CDC may incorporate elements of screening as specific recommendations are updated, with the most likely candidate being recommending patients be screened for MRSA prior to elective surgery.
"There are very good data that show the specific procedures benefit hugely from preoperative screening and decolonization," Bell says.
However, an overall change to the MDRO guidelines is a considerably different question, particularly as it would involve emphasizing one pathogen over the multitude of others. As important as MRSA is, Bell says the CDC must develop strategies that address a formidable array of emerging MDROs. For example, New Delhi metallo-beta-lactamase (NDM-1) a virtually untreatable gram negative bacterial enzyme that originally emerged in hospitals in India continues to spread globally.
"Do we really want to be saying in this day and age where we are seeing almost entirely untreatable gram-negative rods spreading in our hospitals focus most of your attention on MRSA?," Bell says. "I don't think the organism-by-organism approach is very wise. Don't get me wrong, I'm very aware of and empathetic to the fact that individuals who have experienced an infection from a specific organism feel the need to be vocal about that and want to raise the issue. Our job here at CDC is to make sure that all health care is safe not to tackle a specific organism at the exclusion of others."
In that regard, a risk assessment at the local level should determine the target MDROs for a facility, he adds.
"It's important to be doing risk assessments at the facility level," Bell says. "There is a huge range in terms of what facilities are dealing with the burden of different pathogens, the different populations affected and so on. Given that there is not an infinite amount of time and resources, there needs to be a specific and targeted approach. The reasons for our tiered approach is that there are places that don't need to be doing [MRSA screening] on a routine basis for all patients. What they do need to do is to assess whether there is a population like an ICU or some other aspect for whom that would be beneficial, and if so, then they should do it."
Indeed, many infection preventionists and epidemiologists similarly caution against tailoring infection control efforts against a single pathogen, arguing instead for standard precautions approach that includes flexibility to go to more enhanced measures.
"Just speaking generically I don't think there is anything wrong with people looking at the data and thinking about [this issue] again," says William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University Medical Center. "I would like more information about implementation [of the VA program] and some acknowledgement that there are institutions as the CDC has suggested that have large MRSA problems and others that do not. The question really is does one size fit all?"
The answer to that question is an unequivocal "no", adds Patti Grant, RN, infection preventionist at Medical City in Dallas. "If I come into a hospital whether I have MRSA, VRE or multidrug resistant acinetobacter it doesn't matter how you label me. It matters how you care for me. This [screening approach] is taking us all back to relying on an isolation sign or a patient label to practice basic good infection prevention and control. We need to put our resources where we can actually start preventing infections at the bedside. I don't think labeling people with MDROs is going to be the answer."
Data may spur more state laws
However, state legislators may increasingly think that it is a politically attractive answer, particularly given the VA data and increasing activism and outcry of consumer groups. Four states (CA, PA, IL, NJ) have laws in place that call for MRSA screening of "high-risk" patients according to varying definitions. Such risk groups would likely include patients coming in from other hospitals and nursing homes and possibly communal settings like prisons. In any case the VA data will likely prompt more legislative interest even as it increases consumer calls for the CDC to adopt more stringent MRSA control measures.
"The CDC should definitely put active screening for MRSA and isolation of colonized patients into their first tier recommendations, based on the results that we have seen in the VA hospitals as well as many other private hospitals that have adopted this practice," says Lisa McGiffert, senior policy analyst on health issues at the Consumers Union, publishers of the influential magazine Consumer Reports.
Though CDC guidelines are voluntary, the level of emphasis given them by the agency has a direct relationship to how widely they are ultimately implemented, she argues.
"Whether a strategy is ranked as 'first tier' is critical, as hospitals generally pay the most attention to those," McGiffert says. "Why is it important to screen? Because we know that the colonized population is growing, thus more incoming patients are carrying MRSA into the facility where those patients are at a higher risk for developing an infection. They increase the risk of spreading this superbug to other patients, which happens when health care workers and doctors fail to take precautions and carry the bug from patient to patient. We know that studies consistently show that hand hygiene [compliance] by doctors and nurses between patients is 50% or lower."
The CDC is well aware that such arguments will be compelling to patients and family members who gather at events like World MRSA Day to tell their stories and remember lost loved ones. Whether by logic or emotion, they have attached themselves to the notion that universal patient screening is at least part of the answer because it would show more of the true prevalence of MRSA in patient populations.
"How can you change what you do not acknowledge?" says Jeanine Thomas of Hinesdale, IL, founder of the MRSA Survivors Network.
As a doctor, Bell finds the patient MRSA stories "heart-wrenching" but the call for universal screening misplaced.
"These are the people I take care of in hospitals who are threatened by each of these different infections," he says. "It is a 360-degree fulltime battle to make sure that every individual gets through without complications. We make our recommendations in the context of a risk assessment, so it gets back to the fact that the individuals responsible for dealing with infection prevention at the facility level really need to have the due diligence to determine what things need to be done, and which things perhaps don't."
- Klevens RM, Morrian MA, Nadle J. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA 2007;298:1763-1771.
- Evans ME, Jain R, Roselle GA, et al. Results of a Veterans Affairs initiative to prevent health care associated Methicillin-resistant Staphylococcus aureusinfections. Abstract 75. Fifth Decennial International Conference on Healthcare-Associated Infections 2010. Atlanta, March 18-22, 2010.
- Siegal JD, Rhinehart E, Jackson L, et al. Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006. On the web at: http://www.cdc.gov/ncidod/dhqp/.