States consider requiring hospitals to screen for MRSA

As the drug-resistant staph rate grows, lawmakers call for a more aggressive response. But doctors question mandates.

By Kevin B. O’Reilly — Posted Feb. 16, 2009

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The rate of patients entering the hospital with methicillin-resistant Staphylococcus aureus increased eightfold between 1999 and 2006. Politicians in statehouses around the country say hospitals need to take a more active approach to stopping MRSA's spread.

Since 2007, four states -- California, Illinois, New Jersey and Pennsylvania -- have enacted laws requiring hospitals to screen high-risk patients for MRSA infection or colonization and follow precautions to prevent other patients from becoming infected. Eight states considered similar legislation last year, and as of late January, new bills had been filed in Washington and Kentucky.

The Washington bill, sponsored by Republican State Rep. Tom Campbell, was spurred by a Seattle Times investigation that found cases of patients in the state with MRSA jumped 33-fold from 1997 to 2007. Six in seven patients with MRSA infections contract it during a stay in a health care facility, according to the Centers for Disease Control and Prevention.

"If hospitals won't take meaningful steps to stop drug-resistant infections, then we'll pass legislation to make sure they do," Campbell told the newspaper.

But infectious-disease-control experts say the matter is not so simple. Most studies on the clinical effectiveness of widespread MRSA testing, known as active surveillance, were conducted during outbreaks and may not apply in other circumstances.

More recent studies have clashed.

An active surveillance program at three U.S. hospitals reduced MRSA by 36% when intensive care unit patients were screened and by 70% when all patients were tested, according to a March 18, 2008, Annals of Internal Medicine study. But a Swiss active surveillance program of 10,000 patients, reported the same month in the Journal of the American Medical Association, made no significant difference in hospital-acquired MRSA rates compared with 10,000 patients for whom standard infection-control procedures were followed.

Sizing up right approach

The Society for Healthcare Epidemiology of America and the Assn. of Professionals in Infection Control and Epidemiology issued a joint position statement in 2007 opposing MRSA screening mandates, saying they limit hospital infection-control programs' flexibility and are too costly.

"The science is somewhat limited, and no one really knows how to best go about preventing these infections," said Mark E. Rupp, MD, SHEA's president. "We think that this prescriptive, one-size-fits-all approach is not the right way to go at the present time."

Dr. Rupp, professor of infectious diseases at the University of Nebraska Medical Center, said whether widespread MRSA screening is called for depends on the hospital and whether its other infection-control approaches, such as hand hygiene, have been successful.

"Active surveillance cultures are a prominent part of what hospitals should be considering when other approaches don't seem to be working," Dr. Rupp said.

SHEA and the Infectious Diseases Society of America endorsed a compendium of MRSA strategies, published in the October 2008 Infection Control and Hospital Epidemiology. The guidelines list active surveillance as a "special approach," alongside bathing adult ICU patients with the antiseptic chlorhexidine, to be instituted when "basic practices" such as proper disinfection of equipment fail to effectively control MRSA.

But this strategy does not satisfy advocates pushing for mandates.

"The experts say, 'We shouldn't be mandated to do these things. We're handling it. Everybody has some kind of program and that's good enough for us,' " said Lisa McGiffert, director of the Consumers Union's Stop Hospital Infections campaign. "But I think the public is saying, 'Well, it's not good enough for us. We need something visible. We need something aggressive.' "

Matthew Fenwick, a spokesman for the American Hospital Assn., said the organization is taking the issue seriously. The AHA partnered with infectious-disease-control groups on the MRSA strategies compendium.

"We recognize that hospitals need to do more and we are focused upon areas where we can make the most difference," Fenwick said in a statement. "Active surveillance is not a silver bullet, but hospitals are actively seeking ways to prevent the spread of infections."

January did see some apparently good news in the battle against MRSA.

The Food and Drug Administration approved for market a blood test that takes only two hours to distinguish between MRSA and staph susceptible to methicillin. Currently available tests take 24 to 48 hours or longer. Also, an FDA panel approved an injectable drug to combat MRSA infections.

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A MRSA battle plan

Two leading infection-control groups recently recommended that hospitals and other health care organizations implement a staged approach to reducing MRSA prevalence. Here is a condensed version of the guidelines:

Step 1: Institute basic practices such as a MRSA risk-assessment program, hand-hygiene compliance, contact precautions, health personnel education, and a monitoring program.

Step 2: Continue to monitor MRSA rates.

Step 3: If MRSA is not effectively controlled, double-check to make sure the basic practices are being implemented correctly.

Step 4: If MRSA still is not under control, institute one or more special approaches such as active surveillance testing for MRSA colonization among patients and decolonization therapy for MRSA-colonized patients.

Source: "Supplement Article: SHEA/IDSA Practice Recommendation: Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals," Infection Control and Hospital Epidemiology, October 2008 (link)

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