Every time someone is admitted to the Veterans Health Administration hospital in Pittsburgh, a nasal swab is taken to check for methicillin-resistant Staphylococcus aureus (MRSA). If the test comes back positive, the patient is placed in isolation.
Since the hospital began screening patients five years ago, the incidence of hospital-acquired MRSA infections has gone down by 50%, from 1.0 per 1,000 days of patient care to 0.5 per 1,000 days of patient care, according to Rajiv Jain, FACP, chief of staff at the VA Pittsburgh Healthcare System. “Once the word spreads that it's possible to reduce and control and prevent these infections—we have the tools to do it—more and more hospitals will get into screening patients,” he said.
Making screening mandatory
Already, the entire VA health system is getting into the act. It began phasing in MRSA testing at its 155 medical centers in March and plans to test all patients, both in acute care and long-term care, starting next year, Dr. Jain said.
“The decision was made that this is an important safety initiative, and because we have been successful in Pittsburgh, we want to offer the same high-quality care to all of our patients around the system,” said Dr. Jain, who serves as national director for the VA's MRSA prevention initiative.
The VA's program comes amid growing concern over the threat of drug-resistant organisms, especially MRSA, in health care settings. MRSA infections accounted for just 2% of staph infections in 1974 but 22% in 1995 and 63% in 2004, according to the CDC. John Jernigan, MD, a medical epidemiologist in the CDC's Division of Healthcare Quality Promotion, reported that at least 126,000 persons are infected by MRSA in U.S. hospitals each year and at least 5,000 die as a result, leading to at least $4 billion in excess health care costs. And recent findings from the Association for Professionals in Infection Control and Epidemiology suggest that the problem might be even more widespread: In a survey of 1,237 health care facilities across the U.S., 46 of every 1,000 patients were found to be infected or colonized with MRSA on a given day.
The threat of MRSA has also captured the attention of some consumer health groups, which want testing to become standard. The availability of new, speedier tests for MRSA could help make screening more attractive to hospitals.
“The evidence is copious that nearly all hospital infections are preventable,” said Betsy McCaughey, PhD, founder of the Committee to Reduce Infection Deaths. “Very few administrators realize that infection prevention is not a cost center, it's a profit center,” she said, noting that hospital administrators can save money, and also avoid legal troubles, by reducing the number of infections.
“Hospital infection is the next asbestos. It is the next major cause of class action lawsuits,” Dr. McCaughey said. She said countries such as Denmark, Holland and Finland aggressively target MRSA with “search and destroy” tactics. “Even the cash-strapped British national health service is implementing screening.”
The debate over whether MRSA screening should be mandatory is popping up in state legislatures around the United States. Illinois, for instance, recently passed legislation requiring hospitals to test at-risk persons (including ICU patients and nursing home residents). Varying approaches are under consideration in several other states, including Maryland, New Jersey and New York, Dr. McCaughey said.
The critical view
While no one in health care disputes that MRSA is a problem to be taken seriously, there is disagreement over whether universal screening of hospital patients for MRSA colonization or infection, in conjunction with the use of isolation and other barrier precautions, is the best way to reduce the threat.
“It does sound appealing, but there is a big hole in the literature that I'm very concerned about,” said Daniel J. Diekema, FACP, an infectious disease specialist and hospital epidemiologist at the University of Iowa in Iowa City. “Everyone has the same goal to reduce MRSA transmission in hospitals—that's a critical goal and I fully support it—but I'm concerned that people are not taking into account the complexity of this intervention.”
He and some other experts say there is not sufficient evidence to recommend universal screening, noting that the bulk of the research used to support it is based on the experiences of individual institutions, often in response to a MRSA outbreak, and not on data from well-designed or randomized, controlled trials. In fact, a new government-funded multicenter randomized trial suggests that MRSA screening, combined with contact precautions, is not enough to bring down infection rates.
Dr. Diekema said there is a troubling downside to screening because patients who are placed in isolation tend to get less attention from doctors and nurses, putting them at risk for other problems, such as pressure ulcers or falls. They may also become depressed or anxious.
“You have to know how this is going to affect your patients,” he said. “You have to have your eyes wide open to the potential negative impact.”
Moreover, the skeptics say, a screening program can't compensate for lapses in hand washing and other infection control practices.
“When there is an emphasis on screening and then isolating patients, there's a hidden promise of increased infection control in general,” said Richard P. Wenzel, MACP, an infectious disease specialist and chairman of the department of internal medicine at the Medical College of Virginia in Richmond. “Even if you put someone in isolation, there is no guarantee there will be strict adherence [to the use of gown and gloves] 100% of the time.”
“There is too much not known and too many downsides” to recommend the adoption of universal MRSA testing, noted Dr. Wenzel.
The CDC includes active surveillance of patients as one of numerous tactics hospitals can adopt to reduce MRSA infections, but the agency does not recommend routinely screening all patients.
“We think the approaches that are likely to have success in addressing this problem are going to be multifaceted and multi-discipline in nature,” the CDC's Dr. Jernigan said. “There is no single intervention that is going to solve this problem. Active surveillance should be viewed as just one component of a multifaceted approach.”
Experts on both sides of the MRSA screening debate have been waiting for the results of a just-completed study funded by the National Institutes of Health (NIH), in which 19 intensive care units around the country were randomly assigned to one of two groups. In the first group of ICUs, patients who tested positive for MRSA or vancomycin-resistant enterococci (VRE) on admission were placed in isolation and staff used gowns and gloves when caring for them. In the second group of ICUs, staff followed each hospital's standard infection control practices. Preliminary results were presented in April at the annual meeting of the Society for Healthcare Epidemiology of America.
“There was really no difference between the two groups,” said Naomi O’Grady, MD, a staff clinician in the department of critical care at the NIH's clinical center, who was on the study's protocol team. “The preliminary thing we can say, and we're still in the middle of data analysis, is that the intensive infection control strategy alone was not effective in reducing the incidence density of either MRSA or VRE.”
However, Dr. O’Grady urged caution in interpreting the results, in part because data are still being analyzed. “These results should not be interpreted to say that active surveillance is useless or efforts to control MRSA or VRE are futile,” she said.
But the results do suggest that simply implementing screening will not solve the problem. “Intuitively it does make sense,” she said. “But not everything in medicine is intuitive, which is why you need to test things with rigorous randomized, controlled studies.”
For hospitals interested in MRSA screening, there are many issues to be considered. For starters, there are questions of whether the hospital laboratory can handle the demands of the added testing and whether the hospital has enough single rooms to accommodate patients who test positive, or at least available double rooms to pair those with MRSA. At the Pittsburgh VA, that's 10% of patients.
“When you're going through a high-volume time, people will look at you and say, ‘How am I going to do that?’ “ Dr. Jain said. “It's a nursing challenge that needs to be addressed up front.”
The cost of screening varies depending on what test is used. Polymerase chain reaction (PCR)-based screening costs $25 to $30 per test (the advantage is a turnaround time of two to four hours), for instance, while chromogenic agar-based screening costs about $5 per test (turnaround time is 18 to 24 hours), according to Dr. Diekema. Those costs don't include laboratory overhead and personnel costs, and they may be even higher at some hospitals.
There is also the expense of additional gloves and gowns. Dr. Jain said his program costs about $100 to $175 per patient, which he said still adds up to less than the cost of caring for patients who get infections. “But we want to be careful interpreting the numbers,” Dr. Jain said. “This has to be seen as a quality initiative more so than a cost-saving initiative.”
Hospitals also need to make sure that workers are trained in the importance of always using gloves and gowns when going into isolation rooms. Lawrence Gerber, ACP Member, a hospitalist at the Pittsburgh VA, said he is careful to explain to residents and medical students what the isolation precautions entail, including the necessity of using a designated red stethoscope kept in the rooms of patients in isolation. He also explains to patients what the precautions mean.
Dr. Gerber said that while the MRSA screening program took some getting used to, it is not much trouble. “The only time it would add to the workload is that occasionally a red stethoscope will be missing from the rooms, and you have to ask a nurse to go look for one. You're talking about just seconds for putting on the gown and gloves,” he said.
Critics worry that hospital staff will skip over patients in isolation, perhaps because they don't want to don gown and gloves. “You have to make sure they go in and see those patients as much as they would a patient outside isolation,” Dr. Diekema said. A study published in the Oct. 8, 2003 Journal of the American Medical Association found that patients in isolation for infection control were more likely than non-isolated patients to experience preventable adverse events, had less documented care and were more likely to formally complain to the hospital about their care.
Hospitals must also decide what treatment, if any, to give patients who are colonized with MRSA. Some hospitals use nasal antibiotic ointment (mupirocin) and body washes with chlorhexidine, Dr. Diekema said, while others add an oral antibiotic depending on the circumstances. However, Dr. Diekema does not recommend routine use of “decolonization,” pointing out that most patients recolonize with MRSA over time and that resistance to mupirocin is likely to emerge with increased use. A protocol for retesting patients must also be determined.
“I don't think we know all the answers about what the optimal approach is, and the answer may be different for different hospitals and different health care settings,” said the CDC's Dr. Jernigan. “It's quite possible that one size does not fit all.”