OBJECTIVE:
To measure the effectiveness of an industrial systems-engineering approach to a methicillin-resistant Staphylococcus aureus (MRSA) prevention program.SETTING:
An intensive care unit (ICU) and a surgical unit that was not an ICU in the Pittsburgh Veterans Administration hospital.RESULTS:
The rate of healthcare-associated MRSA infection in the surgical unit decreased from- 1.56 infections per 1,000 patient-days in the 2 years before the intervention to
- 0.63 infections per 1,000 patient-days in the 4 years after the intervention (a 60% reduction; P = .003).
- 5.45 infections per 1,000 patient-days in the 2 years before to the intervention to
- 1.35 infections per 1,000 patient-days in the 3 years after the intervention (a 75% reduction; P = .001).
CONCLUSIONS:
Sustained reduction in the incidence of MRSA infection is possible in a setting where this pathogen is endemic. An industrial systems-engineering approach can be adapted to facilitate consistent and reliable adherence to MRSA infection prevention practices in healthcare facilities.Sustained Reduction in the Clinical Incidence of Methicillin
Infection Control Measures in the MGH ICU
Strategies to decrease transmission
Proven
or Proposed Strategies
–Antibiotic
stewardship
–Proper
hand hygiene
–Cohorting
patients
–Reducing
LOS
–Gowns
and gloves
–Isolation
of patients
–Appropriate
staffing ratios
–Antibiotic
crop rotation
–Surveillance
cultures
–Decolonization
of patients (chlorhexidine body washes, muciprocin)
–Decolonization
of health care worker carriers
•Paucity
of RCTs on efficacy of individual approaches
•Efficacy
of an individual approach may vary by pathogen
•Near
eradication of a pathogen from a hospital (or a country) requires a bundle of
approaches (eg. “Search and Destroy” in the Netherlands)
Infection Control in the ICU.pdf
Nosocomial infections (NIs) now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to ICUs. The most common causes are pneumonia related to mechanical ventilation, intra-abdominal infections following trauma or surgery, and bacteremia derived from intravascular devices. This overview is targeted at ICU physicians to convince them that the principles of infection control in the ICU are based on simple concepts and that the application of preventive strategies should not be viewed as an administrative or constraining control of their activity but, rather, as basic measures that are easy to implement at the bedside. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective. The principles of general preventive measures such as the implementation of standard and isolation precautions, and the control of antibiotic use are reviewed. Specific practical measures, targeted at the practical prevention and control of ventilator-associated pneumonia, sinusitis, and bloodstream, urinary tract, and surgical site infections are detailed. Recent data strongly confirm that these strategies may only be effective over prolonged periods if they can be integrated into the behavior of all staff members who are involved in patient care. Accordingly, infection control measures are to be viewed as a priority and have to be integrated fully into the continuous process of improvement of the quality of care. (CHEST 2001; 120:2059 –2093)
Infection Control in the ICU: MRSA Control - Springer
MRSA
Methicillin-resistant Staphylococcus aureus (MRSA) is characterized by its resistance to beta-lactam antibiotics, including methicillin, dicloxacillin, and oxacillin. MRSA
is an important nosocomial pathogen in terms of its virulence and
survival fitness. In acute care facilities, there is selective advantage
for MRSA survival as a result of antibiotic use and selection pressure. Multidrug-resistant pathogens, including MRSA, are being isolated at increased frequency in intensive care units (ICUs). National surveillance data has shown that MRSA is recovered in greater than 60% of S. aureus isolates from US intensive care units (ICUs) [1] and 24% of isolates from German ICUs.
Horizontal infection control strategy decreases methicillin-resistant Staphylococcus aureus infection and eliminates bacteremia in a surgical ICU w... - PubMed - NCBI
MEASUREMENTS AND MAIN RESULTS:
The prevalence of methicillin-resistant S. aureus infection fell from 2.66 to 0.69 per 1,000 patient days from 2005 to 2012, an average decrease of 21% per year. The biggest decline in rate of infection was detected in 2008, which may suggest that the catheter-associated bloodstream infection prevention program was particularly effective. Among 4,478 surgical ICU admissions over the last 5 years, not a single case of methicillin-resistant S. aureus bacteremia was observed.CONCLUSIONS:
Aggressive multifaceted horizontal infection control is an effective strategy for reducing the prevalence of methicillin-resistant S. aureus infection and eliminating methicillin-resistant S. aureus bacteremia in the ICU without the need for active surveillance and decontamination.Targeted versus universal decolonization to prevent ICU infection. - PubMed - NCBI
RESULTS:
A total of 43 hospitals (including 74 ICUs and 74,256 patients during the intervention period) underwent randomization. In the intervention period versus the baseline period, modeled hazard ratios for MRSA clinical isolates were 0.92 for screening and isolation (crude rate, 3.2 vs. 3.4 isolates per 1000 days), 0.75 for targeted decolonization (3.2 vs. 4.3 isolates per 1000 days), and 0.63 for universal decolonization (2.1 vs. 3.4 isolates per 1000 days) (P=0.01 for test of all groups being equal). In the intervention versus baseline periods, hazard ratios for bloodstream infection with any pathogen in the three groups were 0.99 (crude rate, 4.1 vs. 4.2 infections per 1000 days), 0.78 (3.7 vs. 4.8 infections per 1000 days), and 0.56 (3.6 vs. 6.1 infections per 1000 days), respectively.CONCLUSIONS:
In routine ICU practice, universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen. (Funded by the Agency for Healthcare Research and the Centers for Disease Control and Prevention; REDUCE MRSA ClinicalTrials.gov number, NCT00980980).Cost-effectiveness of Strategies to Prevent Methicillin-Resistant Staphylococcus Aureus Transmission and Infection in an Intensive Care Unit | RAND
- OBJECTIVE: To create a national policy model to evaluate the projected cost-effectiveness of multiple hospital-based strategies to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection.
- DESIGN: Cost-effectiveness analysis using a Markov microsimulation model that simulates the natural history of MRSA acquisition and infection.
- PATIENTS AND SETTING: Hypothetical cohort of 10,000 adult patients admitted to a US intensive care unit.
- METHODS: We compared 7 strategies to standard precautions using a hospital perspective:
- (1) active surveillance cultures;
- (2) active surveillance cultures plus selective decolonization;
- (3) universal contact precautions (UCP);
- (4) universal chlorhexidine gluconate baths;
- (5) universal decolonization;
- (6) UCP + chlorhexidine gluconate baths; and
- (7) UCP+decolonization.
- For each strategy, both efficacy and compliance were considered. Outcomes of interest were:
- (1) MRSA colonization averted;
- (2) MRSA infection averted;
- (3) incremental cost per colonization averted;
- (4) incremental cost per infection averted.
- RESULTS: A total of 1989 cases of colonization and 544 MRSA invasive infections occurred under standard precautions per 10,000 patients. Universal decolonization was the least expensive strategy and was more effective compared with all strategies except UCP+decolonization and UCP+chlorhexidine gluconate. UCP+decolonization was more effective than universal decolonization but would cost $2469 per colonization averted and $9007 per infection averted. If MRSA colonization prevalence decreases from 12% to 5%, active surveillance cultures plus selective decolonization becomes the least expensive strategy.
- CONCLUSIONS: Universal decolonization is cost-saving, preventing 44% of cases of MRSA colonization and 45% of cases of MRSA infection. Our model provides useful guidance for decision makers choosing between multiple available hospital-based strategies to prevent MRSA transmission.
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