By Annette M. Boyle

CINCINNATI — The VA’s methicillin-resistant Staphylococcus aureus (MRSA) prevention initiative reduced healthcare-associated MRSA infections 69% in VA acute care facilities and 81% in spinal cord injury units in five years. The VA hopes to see similar success in preventing infections with Clostridium difficile (CDI) and carbapenem-resistant Enterobacteriaceae (CRE) — and the MRSA bundle itself may help them do that.

A medical supply technician at the VA Roseburg, OR, Healthcare System, cleans scopes.  The VA is using enhanced environmental management to control resistant infections at VAMCs. VA photo.

A medical supply technician at the VA Roseburg, OR, Healthcare System, cleans scopes. The VA is using enhanced environmental management to control resistant infections at VAMCs. VA photo.

“The MRSA bundle was so effective, it seemed reasonable to move on,” said Gary Roselle, MD, director, National Infectious Diseases Service of the VHA. “We were a little ahead of other organizations in tackling MRSA and then CDI. CRE looks like the next big thing and we want to stay ahead.”

While the MRSA focus achieved dramatic results, Roselle hesitated to state similar numeric goals for the expanded program. “We definitely want to decrease the number of healthcare-associated infections, but I’m nervous about stating an arbitrary goal. Achieving a 20%-30% drop is not as important as promoting continuous improvement,” he told U.S. Medicine.

The MRSA bundle includes active surveillance with nares swabs for all patients on admission, aggressive hand hygiene, contact precautions for all MRSA positive patients as well as cultural transformation that makes everyone responsible for infection control. The CDI/MDRO bundle looks very similar, with enhanced environmental management, hand hygiene, contact precautions and appropriate diagnostic testing. C. difficile can persist on inadequately cleaned surfaces for up to five months, and MRSA can survive for more than nine months, according to VA materials.

The MDRO bundle also calls for special attention to cleaning reusable medical equipment. Inadequate cleaning of reusable equipment contributed to a number of outbreaks of CRE infections in patients who had procedures that used difficult-to-clean duodenoscopes in the last few years. Common items such as pulse oximeters, EKG leads and wires, glucometers, and blood pressure cuffs also require careful cleaning before and after each patient, note MDRO program training materials.

The prevalence of CRE has quadrupled in the last decade, with 4% of acute care hospitals and 18% of long-term care facilities in 42 states now reporting having had a patient infected with either carbapenem-resistant Klebsiella or E. coli, according to the Centers for Disease Control and Prevention. The U.S. has 9,300 such cases annually and about 610 reported deaths. More than half of patients with CRE bloodstream infections die. The few remaining antibiotic options for treating patients with CRE — polymyxins, aminoglycosides, tigecycline and fosfomycin — all have serious toxicity issues.

While not yet resistant to common drugs, C. difficile most commonly occurs in patients who have recently used antibiotics and carries high rates of morbidity and mortality. Among VA patients, the estimated incidence of CDI in 2010 was 10.4 cases per 1,000 discharges, with an estimated 2% of all patients over age 65 receiving the diagnosis, noted in a memo introducing the VA prevention program. Nationwide, C. difficile sickens a quarter of a million patients every year and causes 14,000 deaths, according to the CDC.

Unintended Consequences

A surprising bonus from the MRSA program might provide additional help in controlling CRE and other resistant pathogens. A recent study in the American Journal of Infection Control found that the VA’s screening for MRSA might also limit the spread of other MDROs.

The study found that up to 44.3% of patients diagnosed with multidrug-resistant (MDR) gram-negative bacteria (GNB) within 30 days of admission to a VA hospital would have been in contact precautions because they had a positive nasal screen for MRSA. Patients with positive MRSA screens were 2.5 more likely to have a MDR GNB than those who tested negative.

Of patients subsequently diagnosed with any MDR GNB, 30.7% had tested positive for MRSA on admission. That percentage rose as high as 44.3% for those with an Acinetobacter diagnosis.

The researchers examined MRSA screening and MDR GNB culture results from a database that included all admissions to VA acute care facilities from January 2009-December 2012. During the period reviewed, 759,759 patients had more than 1.6 hospital admissions and MRSA nasal screens. Of those, 14.7% had positive results at admission or in the previous year and 6.3% had been diagnosed with an MDRO in the 12 months prior to admission; 3.3% had been positive for both.

Patients positive for MRSA had 2.4 times the risk of infection with multidrug-resistant Enterobacteriaceae (including CRE and extended-spectrum beta-lactamase producing bacteria), 2.7 times the risk of MDR Pseudomonas aeruginosa and were 4.3 times more likely to have MDR Acinetobacter spp than patients who had negative screens.

For the VA’s MDRO Prevention Initiative, the results of this study should reinforce its educational focus. As the authors wrote, “education of health care workers regarding the risk of transmitting not only MRSA, but also more difficult-to-treat organisms (e.g., carbapenem-resistant Enterobacteriaceae) could potentially improve compliance with contact precautions and hand hygiene practice.”

The identification of an association between resistant gram-negative infections and MRSA also might inform the selection of empirical antibiotic therapy, guiding clinicians to use broader spectrum drugs when co-infection is likely and narrower spectrum antibiotics for patients who test negative for MRSA, they note.

The good news for the VA and the MDRO program, the authors conclude, is that “screening and identification of patients carrying MRSA may have value with respect to reducing exposure to high-risk MDR GNB with minimal or no added cost.”

And that could significantly help the VA achieve its overall goal. “It’s not a goal of reducing x or not using y,” Roselle noted. “There will probably be some decrease and shift in use of certain drugs as we enhance the appropriate use of antibiotics. The real goal is using the right drug for the right patient for the right duration through the right route at the right dose.”

To promote appropriate use of antimicrobials, antibiotic stewardship programs now operate in every VA hospital. The national office has provided guidelines to help local MDRO coordinators and antimicrobial stewardship teams educate healthcare workers, select policies and promote cultural change, Roselle said.

All of the tools and programs advance the VA’s primary aim of “improving health for patients,” said Roselle. “It’s very straightforward and a goal for which there is universal agreement.”

1 Jones M, Nielson C, Gupta K, Khader K, Evans M. Collateral benefit of screening patients for methicillin-resistant Staphylococcus aureus at hospital admission: Isolation of patients with multidrug-resistant gram-negative bacteria. Am J Infect Control. 2015;43:31-34.