Management of MRSA and other Hospital acquired infections

Introduction

Data, information and opinions surrounding the management of MRSA are as numerous and varied as the frequency of occurrence in community and hospital settings. To that point, this review captures much of the current tenor of the discussion and introduces a potentially game changing capability that provides timely actionable information to better guide the management and prevention of future outbreaks. I wish to thank the authors and publishers whose work allowed this review to be created.

With the exception of a few Northern European countries, hospital acquired infections, or HAIs, are widespread throughout the developed world. These infections are significant contributors to morbidity and mortality. In the United States alone, the CDC estimates that about 90,000 people each year die from these infections. An estimated additional 1.9 million patients spend anywhere from 1 to 30 additional days in the hospital for treatment of these infections .

This situation will become even more important as a public health problem with increasing economic and human impact because of:

• Increasing numbers and crowding of people
• More frequent impaired immunity (age, illness, treatments)
• High nursing staff turnover and heavy workload
• New microorganisms (not previously considered human pathogens)
• Increasing bacterial resistance to antibiotics
• Wide spread colonization of our live stock and pet animals with resistant bacterial strains

Role of Hospital Management

People are at the center of the Hospital Acquired Infection phenomenon because:

• They are a reservoir and source of microorganisms
• They are the main transmitter, notably during treatment
• They are the receptor for microorganisms, thus becoming a new reservoir.

Therefore, administration and hospital management must provide leadership by supporting the hospital infection prevention program. Historically they are responsible for:

• Establishing a multidisciplinary Infection Control Committee, identifying appropriate resources for a program to monitor infections, and applying the most appropriate methods for preventing infection
• Ensuring education and training of all staff through support of infection prevention programs by disinfection and sterilization techniques
• Delegating technical aspects of hospital hygiene to appropriate staff, such as: nursing, housekeeping, maintenance, clinical microbiology laboratory

Real-time Direct Molecular Admissions Screening for MRSA

Recently, PCR- based tests from Becton Dickinson and Cepheid have come on the market replacing the overnight culture and providing a result in hours. This capability has interested a growing number of hospitals in the USA because it allows for immediate isolation of the patient on admission. NorthShore University HealthSystem in Evanston Illinois screens all admissions to its three hospitals using a molecular assay, which provides results in two hours. At the end of the program's first year, Northshore had reduced nosocomial MRSA bloodstream infections by 70 percent system wide. While these methods are effective in preventing the introduction of MRSA into the hospital, they provide little information about the indigenous pathogens or their vectors of transmission amongst the patients, wards and staff.

Role of Strain Typing in Hospital Acquired Infections

In order to track down and eradicate the source of an outbreak isolates which are clones or clonally-related must be identified quickly and accurately. Contact screening of suspected carrier sources allows the epidemiologist to determine when to initiate additional investigation. Related organisms may be derived from a point source such as the patient himself, another patient, visiting relative, or colonized health care worker. They could also be transmitted from patient-to-patient via health care worker hands, medical equipment, or hand-touch areas. To have a complete picture for investigative purposes, strain characterization of pathogens, including those from non-patient sources, are necessary in helping the infection control team plan and undertake appropriate interventions in outbreak settings.

In addition to outbreak investigation, strain typing can help the epidemiologist track a particular strain within a given institution and through the wider health care community. Clinicians have also applied these techniques to assess whether multiple infections with the same species over time represents persistent infection or acquisition of a new strain. Determining whether multiple positive blood cultures are caused by the same organism or several different strains of a skin contaminant is another clinical use for these methods.

Opportunity for a Real-time MRSA Strain Identification from Culture: SpectraCell RA®

The opportunity for improving the effectiveness of the Infection Control Committee and subordinate Corrective Action Teams rests in providing timely actionable information that specifically addresses the source or root cause of a particular infection or outbreak for both gram positive and gram negative pathogens.

The SpectraCell RA^® Bacterial Strain Analyzer can provide just such a capability. Now a laboratory can identify the strain of a pathogen and match it to a database of known isolates that have appeared before in the hospital, community or are new and unique to the institution. This information, available in less than 24 hours from the positive molecular test, gives the Corrective Action Team a specific path to follow to the location and ultimately eradication of the pathogen. Furthermore, the availability of this precise information changes the paradigm for management of HAIs with a goal of reducing the costs associated with increased length of stay and closure of wards.

The opportunity to bring a new value proposition to the issue exists today because of the introduction of SpectraCell RA. This approach to combating HAIs applies to several key bacterial pathogens including Acinetobacter, Vancomycine resistant Enterococci, Klebsiella, and ESBL producing E. coli isolates. The timeliness of the result provides hospital management with the opportunity to take action preemptively.

The SpectraCell SCRA technology provides hospitals with actionable information at the time of the outbreak, not days or weeks later; information to track down and eradicate the source and alter the pathway through which the infection was transmitted. For the first time, administration has a tool to measure, monitor and prevent future outbreaks. For the first time the Infection Control team has evidence of the spread, vectors of transmission and the ability to search and destroy the source of and HAI. To take full advantage of the significance and power of this data, it has to be embraced by the hospital administration. It is this group that will ultimately have to manage the resources, budget and enforce a new way management will respond to and be measured by HAIs.