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!

More about hospital-acquired infections

As I said earlier, a panel of heavy hitters (and me, just the moderator) will meet later this month to debate the trend of states forcing hospitals to fess up to hospital-acquired infections. Nineteen states now require it and an additional handful have additional laws that specifically require MRSA reporting.

The unstated assumption behind those laws is that hospitals both should and can control hospital-acquired (AKA nosocomial) infections. But in the real world, the strategies for doing that are still being argued about. This is surprising, to say the least, since hospital-acquired MRSA has been brewing in the United States for 40 years. (First cite, for medical-history geeks: Barrett FF, McGehee RF Jr, Finland M.Methicillin-resistant Staphylococcus aureus at Boston City Hospital. Bacteriologic and epidemiologic observations. N Engl J Med. 1968 Aug 29;279(9):441-8.)

The tactic that has worked the best — in hospital units, whole hospitals, geographic areas and in Europe entire countries — goes by the jargon name "Active detection and isolation (ADI)" and the shorthand description "Search and destroy." Briefly, it calls for identifying new hospital patients whose recent history puts them at risk of being infected or colonized, testing them for the bug, and putting them under isolation until they are cleared of the bug.

It sounds straightforward, and currently there are about 150 studies to prove that it works. (Here is one of the most recent, about Evanston Northwestern Healthcare in Illinois.) But in the United States, hospitals take their infection-control cue from several official authorities, including the Healthcare Infection Control Practices Advisory Committee (HICPAC) chartered by the Centers for Disease Control; and a joint task force of the members of two professional organizations, the Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control (APIC). And those two groups do not agree: The task force says ADI should be used routinely — but HICPAC delinks detection from isolation and makes isolation just one of many options a hospital can try as a means of curbing a bug's spread.

The difference provokes furious debate among infection-control professionals, leaves hospitals confused, and has sparked a grassroots movement among families of victims of nosocomial infections. For a great overall exploration, check out Arthur Allen's recent article at the newly launched Washington Independent.