Comparison of strategies to reduce meticillin-resistantStaphylococcus aureusrates in surgical patients: a controlled multicentre intervention trial

Abstract

ObjectiveTo compare the effect of two strategies (enhanced hand hygiene vs meticillin-resistant Staphylococcus aureus (MRSA) screening and decolonisation) alone and in combination on MRSA rates in surgical wards.DesignProspective, controlled, interventional cohort study, with 6-month baseline, 12-month intervention and 6-month washout phases.Setting33 surgical wards of 10 hospitals in nine countries in Europe and Israel.ParticipantsAll patients admitted to the enrolled wards for more than 24 h.InterventionsThe two strategies compared were (1) enhanced hand hygiene promotion and (2) universal MRSA screening with contact precautions and decolonisation (intranasal mupirocin and chlorhexidine bathing) of MRSA carriers. Four hospitals were assigned to each intervention and two hospitals combined both strategies, using targeted MRSA screening.Outcome measuresMonthly rates of MRSA clinical cultures per 100 susceptible patients (primary outcome) and MRSA infections per 100 admissions (secondary outcome). Planned subgroup analysis for clean surgery wards was performed.ResultsAfter adjusting for clustering and potential confounders, neither strategy when used alone was associated with significant changes in MRSA rates. Combining both strategies was associated with a reduction in the rate of MRSA clinical cultures of 12% per month (adjusted incidence rate ratios (aIRR) 0.88, 95% CI 0.79 to 0.98). In clean surgery wards, strategy 2 (MRSA screening, contact precautions and decolonisation) was associated with decreasing rates of MRSA clinical cultures (15% monthly decrease, aIRR 0.85, 95% CI 0.74 to 0.97) and MRSA infections (17% monthly decrease, aIRR 0.83, 95% CI 0.69 to 0.99).ConclusionsIn surgical wards with relatively low MRSA prevalence, a combination of enhanced standard and MRSA-specific infection control approaches was required to reduce MRSA rates. Implementation of single interventions was not effective, except in clean surgery wards where MRSA screening coupled with contact precautions and decolonisation was associated with significant reductions in MRSA clinical culture and infection rates.Trial registrationclinicaltrials.gov identifier: NCT00685867

Methicillin-Resistant Staphylococcus aureus Control in the 21st Century: Laboratory Involvement Affecting Disease Impact and Economic Benefit from Large Population Studies

“…For patients undergoing clean surgery, there was a significant reduction in MRSA clinical infection for the AST and decolonization (15% per month) arm and for the combined AST and decolonization plus enhanced hand hygiene arm (18% per month). After multivariable analysis, the only significant reduction in clinical MRSA nosocomial infection was for patients undergoing clean surgery in the AST and decolonization (17% per month) arm (15). The results are summarized in Table 1.…”

“…A large multicenter, multinational trial that studied approaches to reduce MRSA in surgical patients was reported by Lee and colleagues (15). The study included 10 hospitals in 9 countries using 33 surgical wards with a total of 126,750 patients and was designed as a prospective trial with a 6-month baseline, a 12-month intervention, and 6-month washout study periods.…”

“…Based on the data discussed, there are two practices with the potential to lower MRSA clinical infection rates: universal decolonization (11) and active surveillance testing (9,(13)(14)(15). AST, combined with contact precaution isolation or with isolation plus decolonization, was reported to achieve the lowest endpoint rates of clinical MRSA disease: between 0.21 and 0.48 clinical infections per 1,000 patient days for 5,032,023 enrollees (9,(13)(14)17), compared to 2.1 cases per 1,000 patient days for universal decolonization in a 122,464-patient study (11).…”

“…The study included 10 hospitals in 9 countries using 33 surgical wards with a total of 126,750 patients and was designed as a prospective trial with a 6-month baseline, a 12-month intervention, and 6-month washout study periods. The interventions were enhanced hand hygiene training and MRSA AST with contact precautions and decolonization of positive carriers (15). AST was conducted with chromogenic agar culture for universal surveillance and PCR for targeted (risk-based) surveillance.…”

A Perspective on How the United States Fell behind Northern Europe in the Battle against Methicillin-Resistant Staphylococcus aureus

“…In contradistinction, on the basis of the strength of the literature, one could argue that legislative mandates should be expanded from ICU to facility-wide surveillance (9,13). This position is further supported by a recent multicenter study coauthored by Stephan Harbarth (the JAMA Swiss study's lead author) that found screening coupled with contact precautions and decolonization to be effective in preventing MRSA infections in surgical wards (30).…”