By Annette M. Boyle
LEXINGTON, KY—When the VHA implemented a nationwide prevention initiative against methicillin-resistant Staphylococcus aureus (MRSA), healthcare facility-associated infections (HAIs) were unacceptably high.
Eight years later, the healthcare system continued to make notable progress, according to a study published last month in the American Journal of Infection Control, the official journal of the Association for Professionals in Infection Control and Epidemiology (APIC).1
Martin E. Evans, MD, of the Lexington, KY, VAMC, and colleagues from the VHA MRSA/MDRO Program Office, National Infectious Diseases Service reported that, between October 2007 and September 2015, monthly HAI rates dropped 87% in intensive care units (ICUs), 80.1% in non-ICUs and 80.9% in spinal-cord injury units (SCIUs).
In long-term care facilities (LTCFs), meanwhile, institutionally-acquired infection rates fell 49.4% from July 2009 to September 2015.
“Understanding how and why rates of MRSA have diminished in recent years is essential for the continued progress of effective prevention programs,” Evans explained. “As we seek to protect patients from MRSA and other resistant organisms, our study supports the need for strong infection prevention programs at every healthcare facility.”
In fact, during the last month of the reporting period, only two MRSA HAIs were reported in ICUs, 20 in non-ICUs—three of those in SCIU—and 31 in LTCFs nationwide.
“SCIU patients are very challenging because of their debility and dependence on devices for feeding, management of urine, sometimes breathing, etc. They have multiple admissions, multiple infections and over time are exposed to multiple courses of antibiotics,” Evans told U.S. Medicine. “The VA SCIUs have actually done an amazing job decreasing MRSA HAIs and keeping them low in their patients as documented in our publications.”
Results from previous studies published by the researchers demonstrated a significant decline in MRSA transmissions and MRSA HAIs between October 2007 and June 2012 in acute care medical centers, between October 2007 and June 2011 in SCIUs and between July 2009 and December 2012 in LTCFs. The current report brings the MRSA transmission and HAI trends up to eight years since implementation of the program.
Among the features of the VA program were dedicated MRSA prevention coordinators at each facility to oversee a bundle of interventions which included:
- universal active surveillance (screening) on admission, unit-to-unit transfer and discharge;
- contact precautions for those colonized or infected with MRSA; adherence to hand hygiene; and
- institutional culture change where infection prevention was considered the concern of the entire staff.
“We speculate that active surveillance was the primary driver of the downward trends seen in the VA, because MRSA HAI rates had not changed prior to October 2007 when the initiative was fully implemented, even though formal recommendations for hand hygiene and device-related infection control bundles had been in place for several years,” study authors wrote.
For the update, researchers used monthly reports generated by nationally-distributed software, which extracts MRSA nares screening, clinical culture and patient movement data, to analyze MRSA and HAI data from the VA between October 2007 and September 2015.
The VA’s MRSA Prevention Initiative was shown to be success when initial results in 2011 demonstrated significant decreases in the transmission of MRSA—a 17% decline within intensive care units and a 21% decline for non-ICUs—as well as reductions in healthcare-associated infection (HAI) rates within the hospitals, 62% for ICUs and 45 for non-ICUs.
With the most recent update, study authors note that, in the ICUs over the eight-year period, the nondevice bloodstream infection (BSI) rate fell significantly faster than those not associated with a central line, supporting the idea that the declines were not due solely to implementation of a formalized approach to placing and maintaining central line intravascular catheters. x6Pronovost, P., Needham, D., Berenholtz, S., Sinopoli, D., Chu, H., Cosgrove, S. et al.
The report also addressed why transmission rates did not decline as much in SCIUs as in ICUs and acute care non-ICUs. “The lack of a significant decrease in the SCIUs may be because of the high admission prevalence (around 33%) resulting in a higher MRSA colonization pressure making transmissions more likely x8Jones, M., Ying, J., Huttner, B., Evans, M., Maw, M., Nielson, C. et al.
Relationship between the importation, transmission and nosocomial infections of methicillin-resistant Staphylococcus aureus: an observational study of 112 Veterans Affairs medical centers. Clin Infect Dis. 2013; 58: 32–39
Crossref | PubMed | Scopus (9)See all References8or may be related to the lower compliance with discharge screening (67%) at the baseline level (April 2008),” study authors wrote.
As for why MRSA HAIs dropped so dramatically overall after the implementation of the “bundle” of initiatives, the team said it was impossible to cite one cause because the prevention initiative was a quality improvement project rather than a prospectively designed, randomized controlled trial.
However, they wrote, “We speculate that active surveillance was the primary driver of the downward trends seen in the VA because MRSA HAI rates had not changed before October 2007 when the Initiative was fully implemented, even though formal recommendations for hand hygiene and device-related infection control bundles had been in place for several years.”
“If universal screening played an important role in decreasing rates, it may be because obtaining nasal surveillance on patients at admission, unit-to-unit transfer, and discharge served to constantly remind staff of MRSA and the need to prevent MRSA transmissions and HAIs through good compliance with hand hygiene and contact precautions,” study authors added.
The report noted continued high compliance with nasal surveillance at admission of more than 92%, as well as the greater than 89% rate at transfer and discharge at VA facilities nationwide throughout the eight-year analysis period underscores “that health care workers continued to be fully engaged with the Initiative.”
The institutional culture change, which was the fourth component of the VA MRSA bundle, might have had an unexpected benefit, they added, by leading to better overall compliance with infection control and, subsequently, decreases in Clostridium difficile infectionsx14Evans, M.E., Kralovic, S.M., Simbartl, L.A., Jain, R., and Roselle, G.A.
Effect of a Clostridium difficile infection prevention initiative in Veterans Affairs acute care facilities. Infect Control Hosp Epidemiol. 2016; 37: 720–722
Crossref | PubMedSee all References14 and gram-negative rod bacteremiasx15Goto, M., O’Shea, A., Livorsi, D.J., McDanel, J.S., Jones, M., Richardson, K.K. et al.
The effect of a nationwide infection control program expansion on hospital-onset gram-negative rod bacteremia in 130 Veterans Health Administration medical centers: an interrupted time series analysis. Clin Infect Dis. 2016; 63: 642–650
Crossref | PubMedSee all References15 observed in the VA system over the past several years.
The update also pointed out that, given the apparent success of the VHA MRSA Prevention Initiative, VA has changed its policy in acute care to make swabbing on unit-to-unit transfer and facility discharge optional except for ICUs, although the three remaining components of the intervention bundle remain unchanged.
“We reduced the amount of swabbing required because HAI rates have gotten so very low. We wished facilities to have the latitude to use funds that would have been spent on MRSA swabbing to deal with the more prevalent pathogen, C. difficile, and emerging carbapenem-resistant Enterobacteriaceae (CRE),” Evans explained. “Facilities can opt to continue nasal swabbing as originally implemented in 2007, if they wish. We are continuing to track MRSA HAIs each month as we have always done to see if the change in recommendations makes a difference. So far, the trends in MRSA HAIs have continued to decrease.”
- Evans ME, Kralovic SM, Simbartl LA, Jain R, Roselle GA. Eight years of decreased methicillin-resistant Staphylococcus aureus health care-associated infections associated with a Veterans Affairs prevention initiative. Am J Infect Control. 2017 Jan 1;45(1):13-16. doi: 10.1016/j.ajic.2016.08.010. PubMed PMID: 28065327.
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