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Tip of the week: Look beyond a universal approach when screening for MRSA

Contemporary Long-Term Care Weekly, December 4, 2008

Is universal screening the answer to reducing Methicillin-resistant Staphylococcus aureus (MRSA) infections at your facility? Two new studies have offered very different conclusions on the subject.

The first study, “Universal Screening for Methicillin-Resistant Staphylococcus aureus at Hospital Admission and Nosocomial Infection in Surgical Patients,” published in the March 12 Journal of the American Medical Association (JAMA), found that screening all patients when they were admitted to 12 surgical wards did not reduce MRSA infections.

But several days later, a study published in the March 18 Annals of Internal Medicine, “Universal Surveillance for Methicillin-Resistant Staphylococcus aureus,” found the opposite: that the “introduction of a universal admission surveillance for MRSA was associated with a large reduction in MRSA disease during admission and 30 days after discharge,” according to study authors.

So what does this mean for your facility? Is universal screening a worthwhile intervention or a waste of time and money?

The answer may vary from facility to facility, says Daniel J. Diekema, MD, who wrote the editorial accompanying the JAMA study.

“I think the bottom line is that screening for MRSA can be an effective measure, but it’s not a one-size-fits-all approach,” Diekema says.

Screening may be beneficial at some facilities, but there are facilities that have been able to control MRSA just as effectively without using universal screening. Ebbing Lautenbach, MD, MPH, MSCE, the author of the editorial accompanying the Annals study, says the two studies create a “confusing landscape” regarding universal surveillance.

What is clear from the two studies is that facilities have different patient populations, and what works in one won’t necessarily work in another, says Lautenbach.

Although MRSA may be the No. 1 problem at some facilities, it may be less prominent at others, and allocating substantial time and resources to it would detract from other, equally critical infection control efforts.

“Recommending that all facilities begin universal MRSA screening on admission is certainly premature,” wrote Lautenbach.

Even though the results of the Annals study were certainly promising—screening was attributed to a 70% reduction in MRSA infections—Lautenbach said it’s not clear whether other interventions, such as decolonization, played a role in the results. A “one-size-fits-all approach is probably not sensible for MRSA screening,” and further study on this issue is certainly warranted and necessary, he wrote.

A closer look at the studies

The JAMA study was conducted at a Swiss teaching hospital. Researchers used a rapid screening test to look for MRSA in patients being admitted to 12 surgical wards. Overall, 515 MRSA-positive patients were identified, and 93 of them developed an infection. However, screening did not significantly reduce rates at the facility, where the infection rate was low to begin with. In the end, the infection rate among patients in screening wards did not differ significantly from the control group, according to the study.

The Annals study was conducted at a three-hospital organization in the United States. The study compared the outcomes when MRSA surveillance was conducted solely for ICU admissions and later for all hospital admissions. Although the ICU surveillance did not appear to be effective in reducing the number of MRSA infections, universal surveillance cut the infections by about 70%. There are some important differences to note between the JAMA and Annals papers, says Lautenbach, including the following:

The JAMA paper focused on one institution and focused only on surgical patients.

The Annals paper focused on a hospitalwide population and took place at three hospitals.

The JAMA study was European, whereas the Annals study took place in the United States. Therefore, the epidemiology of MRSA was different in the two settings.

It’s important to consider how the facilities treated patients who they identified as MRSA carriers, says Lautenbach, adding that although few of the patients in the JAMA study were decolonized, approximately two-thirds of the patients in the Annals study were.

The papers don’t offer enough information to serve as an endorsement of decolonization, but decolonization may have played a role in the results and should be explored further, Lautenbach says.

Both authors say that the studies, although contradictory, appear to confirm that facilities should not be forced, through legislation or other initiatives, to adopt a cookie-cutter approach to MRSA infections.

Decide for yourself

To decide whether screening is right for your facility, it’s important to assess your local epidemiology by asking:

• How much of a problem is MRSA?
• How many infections does your facility have?
• Where in the facility is MRSA a problem?
• Can you reduce and control MRSA by focusing on tried-and-true approaches to hand hygiene promotion?

“If you have limited resources, as most [facilities] do, my suggestion is that you first invest heavily in approaches that target all pathogens,” says Diekema. MRSA infections represent only 8% of hospital-associated infections. If you throw a majority of your resources at this problem, you’re leaving other areas unprotected, he says.

“No one disputes that MRSA is an important pathogen. But if you reduce your bloodstream infections to zero by following recommended interventions, you won’t have any MRSA either,” he says. This applies to ventilator-associated pneumonia and surgical site infections as well.

The downside of early detection

There is another issue to consider when it comes to screening: the effect it will have on patients.

With early detection of MRSA comes an increase in the number of patients placed on isolation precautions, says Diekema.

These patients may suffer from depression and feelings of isolation. They have less contact with healthcare workers during a hospital stay, and that can lead to complications.

In addition, these patients also report lower satisfaction with their care. These points are often overlooked, says Diekema, but must be weighed by facilities that are considering the pros and cons of universal screening.

When to opt for screening

There are times when screening is not only appropriate, it’s necessary, Diekema says. You should use screening to assess the scope of your facility’s MRSA problem and to create a strategy for reducing the infection rate.

“Your [facility] has to tailor its approach to its unique set of circumstances and implement what works,” adds Diekema.

You should also screen in the event of an outbreak or if standard infection control methods aren’t getting your MRSA problem under control. Begin screening in high-risk units in these instances, Diekema says.

Focusing screening on the ICU has been an effective tactic at some institutions.

Being placed on contact precautions will have less of an effect on these patients, Diekema says, adding that “patients already have private rooms. They aren’t likely to be up walking around, so keeping them isolated will be less burdensome.”

In the end, it all boils down to the needs of the individual facility.

“Some [facilities] may need to resort to screening to control MRSA,” says Diekema. For others, particularly those with low numbers of MRSA infections, it may not be worth the time or the effort.
 

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