23 October 2008

Much new news on hospital-acquired infections

There's a ton of new, and conflicting, findings on prevention and detection of hospital-acquired MRSA and other infections.

First: Today, in the journal Infection Control and Hospital Epidemiology, three researchers from Virginia Commonwealth University add to the ferocious debate on "search and destroy," the colloquial name for active surveillance and testing: that is, checking admitted patients for MRSA, isolating them until you have a result, and and if they are positive, treating them while continuing to isolate them until they are clear. "Search and destroy" has kept in-hospital MRSA rates very low in Europe, and has proven successful in some hospitals in the United States; in addition, four states (Pennsylvania, Illinois, California and New Jersey) have mandated it for some admitted patients at least. Nevertheless, it remains a controversial tactic, with a variety of arguments levelled against it, many of them based on cost-benefit.

Comes now Richard P. Wenzel, M.D., Gonzalo Bearman, M.D., and Michael B. Edmond, M.D., of the VCU School of Medicine, to say that the moment for MRSA search and destroy has already passed, because hospitals are now dealing with so many highly resistant bugs (Acinetobacter, vancomycin-resistant enterococci (VRE), and so on). They contend that hospitals would do better to pour resources into aggressive infection-control programs that broadly target a spectrum of HAIs.

The abstract is here and the cite is: Richard P. Wenzel, MD, MSc; Gonzalo Bearman, MD, MPH; Michael B. Edmond, MD, MPH, MPA. Screening for MRSA: A Flawed Hospital Infection Control Intervention. Infection Control and Hospital Epidemiology 2008 29:11, 1012-1018.

Meanwhile, the US Government Accountability Office recently released a substantive examination of HAI surveillance and response programs, in states and in hospitals, that looks at:
  • the design and implementation of state HAI public reporting systems,
  • the initiatives hospitals have undertaken to reduce MRSA infections, and
  • the experience of certain early-adopting hospitals in overcoming challenges to implement such initiatives. (from the cover letter)
The report is too thick to summarize here, but here are some key points:
  • No two places are doing this the same way — which means that data still does not match state to state
  • Experts are still divided about how much MRSA control is necessary
  • Hospitals that have undertaken MRSA-reduction programs have taken different paths
  • But MRSA control does work: It does reduce in-hospital infections, but at a cost.
This report is an important bookend to an earlier GAO report from last April that explored the poor state of MRSA surveillance nationwide. Read it if you wonder why we don't really know how much MRSA - in hospitals or in the community - we have.

I am stillworking my way through the new Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, released a week ago by a slew of health agencies (Joint Commission, CDC, et al.) and health organizations (American Hospital Association, ACIP, SHEA, IDSA et al.), to see how much the MRSA strategies have actually changed. If anyone has any comments, please weigh in!


Unknown said...

"...But MRSA control does work: It does reduce in-hospital infections, but at a cost."

The last point can be interpreted in different ways.

Does this mean that a hospital commits business suicide to try to reduce in-hospital infections? Therefore, a hospital can't afford to make the effort (so they don't) or they must pass this cost to the patient for providing this service?

Or does it mean that the costs tied to the causes of MRSA (some potential candidates: agricultural use of antibiotics; challenging the pathogen with more potent antibiotic drugs; over-prescribing antibiotics; ignorance of hygiene; antibiotic soaps and socks...) is no longer sustainable and we need to look at WHERE MRSA is coming from, and therefore focus on causes instead of sucking up the burden and allowing the cause to continue?

Depends on your skills of critical thinking, I suppose.

daedalus2u said...

I think it depends on who bears the cost and who derives the benefit. If the costs and benefits accrue to different parties, there is no rational economic system that allows a cost/benefit ratio to be calculated.

What you have then is cost/zero and zero/benefit.