Community hospitals hit hard by MRSA
Failed empiric therapy fuels increase
Kaye, KS, Anderson DJ, Choi Y, et al. The deadly toll of invasive methicillin-resistant Staphylococcus aureus infection in community hospitals. Clin Infect Dis 2008; 46:1,568-1,577.
Once primarily a problem for large tertiary care hospitals, methicillin-resistant Staphylococcus aureus (MRSA) infections increasingly are a patient safety hazard in community settings. One of the primary reasons is failed empiric therapy in these smaller hospital settings that may be less familiar with MRSA, the authors of a new study report.
In the study, empirical treatment choices for patients with invasive infections due to MRSA and mortality rates due to these infections were poor. Antimicrobial therapy and outcomes were particularly poor among patients cared for at community hospitals. Approximately 40% of patients with SSI and/or BSI in community hospitals (123 patients; 41%) did not receive an antimicrobial agent active against MRSA during the first seven days after their infection was diagnosed, the authors report. Patients with BSI due to MRSA who were cared for in community hospitals were more than twofold less likely to receive an agent active against MRSA at seven days after diagnosis, compared with patients in the tertiary care hospital. Patients cared for at community hospitals were less frequently discharged to home and had higher rates of one-year mortality, compared with patients at the tertiary care hospital. However, compared with patients who were cared for in the tertiary care hospital, patients treated in community hospitals had poorer functional status, were more likely to be incontinent of urine, and were more likely to have dementia. The presence of these patient characteristics might explain why patients treated in community hospitals had higher mortality rates, they noted.
The cohort study was conducted at one tertiary care hospital and eight community hospitals in the southeastern United States. "The explanation for the high frequency of administration of inappropriate antimicrobial therapy for BSI and SSI due to MRSA is unclear." The authors conclude. "The high rate of administration of inappropriate treatment for BSIs due to MRSA [which occurred in more than one-third of study patients] was alarming."
The results reflect a significant lack of understanding, particularly in community hospitals, regarding three important issues: the emergence of MRSA as a community and SSI pathogen, the importance of administering early effective therapy, and the need for effective, culture-based, and prolonged (i.e., administered for at least two weeks) systemic therapy for serious MRSA infections, they concluded. "Health care providers must become more familiar with patients who present with invasive "community-onset" infection due to MRSA and must provide early, optimal treatment modalities," they said.
ASC: Does it work?
Low existing infection rate a likely explanation
Harbarth S, Fankhauser C, Schrenzel J, et al. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA 2008; 299(10):1,149-1,157.
Researchers in Switzerland have rained on a parade that was starting to resemble Macy's at Thanksgiving: using active surveillance cultures (ASC) to detect and isolate patients with methicillin-resistant Staphylococcus aureus (MRSA). According to the paper, "patients admitted to the intervention wards for more than 24 hours were screened before or on admission by rapid, multiplex polymerase chain reaction. Infection control measures "consisted of contact isolation of MRSA carriers, use of dedicated material (e.g., gown, gloves, mask if indicated), adjustment of perioperative antibiotic prophylaxis of MRSA carriers, computerized MRSA alert system, and topical decolonization (nasal mupirocin ointment and chlorhexidine body washing) for five days. Their conclusion: "A universal, rapid MRSA admission screening strategy did not reduce nosocomial MRSA infection in a surgical department with endemic MRSA prevalence but relatively low rates of MRSA infection."
Indeed, one possible explanation for the findings is that if your rates are already low, no single intervention is likely to make them evaporate completely. In that sense, the study may have more implications for the "getting to zero" debate than the lively ongoing exchange on ASC. The authors concede, "MRSA infection rates at our center were relatively low for a surgical department at a tertiary care hospital with endemic MRSA prevalence. Recently, published data from the United Kingdom indicated that the MRSA bacteremia rate in most surgical specialties varies between 0.5 and 1.5 cases per 10,000 patient-days; whereas, it was 0.36 cases per 10,000 patient-days in our surgical department. This made a significant intervention effect less likely."
Once primarily a problem for large tertiary care hospitals, methicillin-resistant Staphylococcus aureus (MRSA) infections increasingly are a patient safety hazard in community settings.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content