Infection control 'bundle' key in reducing MRSA

A targeted infection control strategy universally instituted at U.S. Veterans Affairs hospitals dramatically increased number of patients actively cultured for methicillin-resistant Staphylococcus aureus and reduced the number of hospital-associated infections during a three-year period.

Health care-associated MRSA incidence in ICUs decreased more than 60% and rates in non-ICU settings declined 45% compared with the two years prior to implementation, data indicate.

The ‘MRSA bundle' consisted of the following strategies:

  • Universal nasal surveillance for MRSA
  • Contact precautions for patients colonized or infected with the bacteria
  • Hand hygiene
  • Institutional policy change emphasizing personal responsibility for infection control among all employees in contact with hospital patients

“Preventing transmission and subsequent colonization with MRSA reduces the risk of infection which may occur in more than a third of recently colonized patients, and decreases the reservoir of patients who can transmit MRSA during future health care encounters,” Rajiv Jain, MD, of the Veterans Health Administration MRSA Program office, and colleagues from several other U.S. sites wrote in the New England Journal of Medicine.

From Oct. 2007 — when the program was fully implemented — through June 2010, the percentage of patients screened for MRSA at admission increased from 82% to 96% and the percentage of those who were screened before transfer to another facility or discharge increased from 72% to 93%.

The VHA issued a directive requiring all medical centers nationwide, with the exception of mental health units to institute the MRSA bundle after a successful pilot study instituted at the VA Pittsburgh Healthcare system in 2001 reduced MRSA rates.

Each VA hospital was assigned a MRSA-prevention coordinator who was educated and trained in the various components of the bundle, and then disseminated the information to other employees at his or her institution.

Data were recorded for 1,934,598 admissions, transfers, and discharges from ICUs and non-ICU areas and 8,318,675 patient-days; 1.7 million surveillance-screening tests were performed, consisting of 329,903 swabs from ICUs and 1,382,634 from non-ICU areas.

MRSA-infection rates, which had not changed in the two years prior to the study, decreased from 1.64 to 0.62 per 1,000 patient-days (62%, P<0.001) in ICU areas. In non-ICU units MRSA rates decreased from 0.47 to 0.26 per 1,000 patient days, a 45% reduction (P<0.001).

Larger decreases may have been possible if initial MRSA infection rates had been lower, the researchers noted. Baseline rates of MRSA colonization or infection at admission were 13.6% compared with 6.3% at non-VA hospitals and 1.5% among the general population.

"Although we did not make a formal cost-benefit assessment of the VA MRSA Prevention Initiative, others have reported that programs of active surveillance are cost-effective over a wide range of prevalence and transmission rates,” the researchers wrote.

They suggested that initiating similar strategies at acute care hospitals outside of the VA system, as well as long-term care and ambulatory care settings, could help eliminate MRSA reservoirs throughout the health care system, but that further studies are needed before this can be done.

“A phased-in approach targeting high-risk patients may be reasonable initially but optimal control of health care-associated MRSA infections and the best ratio of cost to benefit may be realized only with universal surveillance.”

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