Methicillin Resistant Staphylococcus Aureus is one of the most common hospital acquired infections.

Kentucky is one of the four states that has the highest percentage of Staph Aureus (on outpatient cultures) which is MRSA. Results were taken from Staph Cultures at State Laboratories. 
From The Center for Disease Dynamics, Economics & Policy.  

http://www.cddep.org/resistancemap/methicillin-saureus   

In many European countries the percentage of Staph infections caused by MRSA is between 5%  to 10% and falling.  European Countries limit the use of antibiotics but also use extensive surveillance.  England and France also has public reporiting,¹  

Great strides have been made in designing protocols for it's control but there has not been a uniform implementation in the United States Healthcare System. According to a 2008 GAO report, the CDC has many recommendations and they are not prioritized which may have inhibited adoption of major interventions.²

In Europe:  "A set of multimodal strategies was implemented in (Belgium, England and France) that involved structural and regulatory changes, to strengthen infection prevention and safe care in acute care hospitals; infection control measures, such as promotion of hand hygiene and antimicrobial stewardship; and measures to control MRSA transmission, such as screening for MRSA at hospital admission, use of contact isolation precautions and carrier decolonization." ³ 

One of the first landmark initiatives in the US came out of the Veterans Administration Hospital System.  A bundled intervention approach was used which included but was not limited to, universal surveillance cultures, contact precautions and hand hygiene.   

Using this approach, the rates of MRSA in the VA System was lowered 76% in the ICU setting to 0.39 infections per 1000 bed care days and 28% in non-ICU settings to 0.33 infections per 1000 bed care days.   The VA national MRSA results involved 153 facilities and over 1 million patients (Dr Martin Evans, Hospital Infection Control & Prevention.  Vol7(48) Dec 2, 2010.) 

The Veterans Administration MRSA initiative data from Oct 2007 to June 2010 was published in the New England Journal of Medicine on April 14, 2011 and MRSA infections were observed to decrease a 62% in the ICUs and a 45% in the Non-ICU setting.  A bundle of surveillance cultures, contact isolation and hand hygiene was used.⁴ 

 Other studies have also supported the screening of patients for MRSA, these include:

• Mar., 2008:  A 69% reduction of total MRSA infections in three facilities studied by Northwest University.⁵

• Feb., 2009:  Shukla, et al.,  reported that an MRSA carrier state is associated with an increased risk of post-operative infections.⁶ 

• Feb., 2009:  Pofahl reported that screening for MRSA in patients undergoing orthopedic surgery decreased post-operative MRSA infections.⁷ 

• Jan. 2011.  Walsh et. al. reported that screening for MRSA is patients undergoing cardiothoracic surgery decreased post operative MRSA infections.⁸

A widely quoted study, which has found no effect with screening for MRSA, was reported in the Feb. 2008 issue of JAMA.⁹  In this paper, Harbarth, et. al, reported no effect of using universal screening in preventing post-operative infections.  However, this study did show that 6.4% (693) of patients were MRSA carriers (known and detected) and that these patients comprised 43% of all MRSA infections (p < 0.0001 chi square) and this study also observe that no colonized patient who was identified on an outpatient basis and received prophylaxis developed an MRSA post-operative infection(p 1154).  Similarly, no MRSA positive patient undergoing elective surgery that received proper prophylaxis and decolonization developed an MRSA infection (pgs 1155-1156).   In addition, the study had significant problems. 

• Colonized patients who tested positive were only isolated in a "flagged side or single room whenever available"

• Less than half of the 266 MRSA surgical patients that were detected carriers received pre-operative antibiotics effective against MRSA.5
  -- Among the 382 patients, 120 had emergency surgery and were identified only after the surgery.
  -- Among the remaining 266 patients, 151 patients did not receive appropriate prophylaxis for MRSA.
  -- 34% of patients with MRSA surgical site infections did not receive prophylaxis to cover MRSA. “… surgeons were reluctant to add Vancomycin to the standard prophylactic regimen”.

In an earlier study, Harbarth reported that screening for MRSA (RPR Test) and isolation reduced infections in the non-surgical ICU.¹⁰ 

It is not enough to just identify patients.  MRSA has been shown to rapidly spread into the environment from a colonized patient   By the time screening results are obtained, up to 45% of patient MRSA carriers have already contaminated their environment.¹¹  Universal screening has been shown to be cost effective¹² and should if possible be done prior to admission to the hospital.  If a patient is found to be positive, he/she needs to be placed in contact isolation and the environment decontaminated. 

The STAR MRSA Study¹³ found an opposite and conflicting result from the 2011 Veterans Administration data.  The editorial which followed the article, pointed out that the average of five days from the time the surveillance culture was taken to the results were obtained, certainly limited the usefulness of the surveillance.  Patient in the intervention group had full contact precautions less than 50% of the time.  A significant flaw since Chang, et al.,¹¹ have shown the rapid spread of MRSA in the environment. Properly designed, the results should be available in less than 24 hours from admission. The danger is that this research may be used to cast doubt on well-designed major studies.

A recent article published in JAMA shows improvement in MRSA infection rates.  HW USA feels this can be viewed as a huge win for consumer advocates since all reporting metropolitan areas (except Atlanta) are in states that have public reporting laws. Atlanta is the home of the CDC and one would expect good results from this area. If it is measured it will be managed. If the measurement is made public it will be managed well.¹⁴ 

At least one review article has referenced Jeyanatnam et. al.¹⁵ as showing no impact of performing admission cultures, when actually the article dealt with surveillance of admitted patients using "rapid polymerase chain reaction based screening test for MRSA compared with conventional culture".  This article did find an over all MRSA carrier rate on admission of 6.7%. 

1. Struelens MJ, Monnet DL.  Prevention of Methicillin-Resistant Staphyloccus aureus Infection:  Is Europe Winning the Fight? Infect Control Hosp Epidemiol. 2010 Nov;31 Suppl 1:S42-4.   http://www.journals.uchicago.edu/doi/pdf/10.1086/655997   

2. GAO.  Health-Care-Associated Infections in Hospitals.  GAO-08-283 March 2008   http://www.gao.gov/new.items/d08283.pdf

3. Struelens MJ, Monnet DL.  Prevention of Methicillin-Resistant Staphylococcus aureus Infection:  Is Europe Winning the Fight?  Infection Control and Epidemiology.  2010 Oct;31(51):
   http://www.journals.uchicago.edu/doi/pdf/10.1086/655997  

4. Jain,R, Kralovic SM, Evans NE, AmbroseM, Simbartl LA, Obrosky DS, Render ML, Freyberg RW, Jernigan JA, Muder RR , Miller LJ, Roselle GA. Veterans Affairs Initiative to Prevent methicillin-Resistant Staphyloccus aureus Infections . NEJM Apr 2011:364:1419-1430.
   http://www.nejm.org/doi/full/10.1056/NEJMoa1007474

5. Robicsek A, Beaumont JL, Paule SM, Hacek DM, Thomson RB Jr, Kaul KL, King P, Peterson LR. Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. Ann Intern Med. 2008 Mar 18;148(6):409-18.   http://www.ncbi.nlm.nih.gov/sites/entrez/18347349 

6. Shukla S, Nixon M, Acharya M, Korim MT, Pandey R. Incidence of MRSA surgical-site infection in MRSA carriers in an orthopaedic trauma unit. J Bone Joint Surg Br. 2009 Feb;91(2):225-8.   http://www.ncbi.nlm.nih.gov/sites/entrez/19190058

7. McNamara D.  MRSA Screening Used to Decrease SSIs   Surgery News  Vol 5(2) Feb 2009.    http://www.facs.org/surgerynews/0209.pdf 

8. Walsh EE, Greene L, Kirshner R. Sustained reduction in methicillin-resistant Staphylococcus aureus wound infections after cardiothoracic surgery. Arch Intern Med. 2011 Jan 10;171(1):68-73. Epub 2010 Sep 13.  http://www.ncbi.nlm.nih.gov/pubmed/20837818

9. Harbarth S, Fankhauser C, Schrenzel J, Christenson J, Gervaz P, Bandiera-Clerc C, Renzi G, Vernaz N, Sax H, Pittet D. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA. 2008 Mar 12;299(10):1149-57.   http://www.ncbi.nlm.nih.gov/pubmed/18334690 

10. Harbarth S, Masuet-Aumatell C, Schrenzel J, Francois P, Akakpo C, Renzi G, Pugin J, Ricou B, Pittet D. Evaluation of rapid screening and pre-emptive contact isolation for detecting and controlling methicillin-resistant Staphylococcus aureus in critical care: an interventional cohort study. Crit Care. 2006 Feb;10(1):R25.   http://www.ncbi.nlm.nih.gov/pubmed/16469125

11. Chang S, Sethi AK, Stiefel U, Cadnum JL, Donskey CJ. Occurrence of skin and environmental contamination with methicillin-resistant Staphylococcus aureus before results of polymerase chain reaction at hospital admission become available. Infect Control Hosp Epidemiol. 2010 Jun;31(6):607-12. http://www.ncbi.nlm.nih.gov/pubmed/20397963

12. Lee BY, Bailey RR, Smith KJ, Muder RR, Strotmeyer ES, Lewis GJ, Ufberg PJ, Song Y, Harrison LH. Universal methicillin-resistant Staphylococcus aureus (MRSA) surveillance for adults at hospital admission: an economic model and analysis. Infect Control Hosp Epidemiol. 2010 Jun;31(6):598-606.   http://www.ncbi.nlm.nih.gov/pubmed/20402588   

13. Huskins WC, Huckabee CM, O'Grady NP, Murray P, Kopetskie H, Zimmer L, Walker ME, Sinkowitz-Cochran RL, Jernigan JA, Samore M, Wallace D, Goldmann DA. Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care. NEJM. Apr 2011 364:1407-1428 http://www.nejm.org/doi/full/10.1056/NEJMoa1000373 

14. Kallen AJ, Mu Y, Bulens S, Reingold A, Petit S, Gershman K, Ray SM, Harrison LH, Lynfield R, Dumyati G, Townes JM, Schaffner W, Patel PR, Fridkin SK; Active Bacterial Core surveillance (ABCs) MRSA Investigators of the Emerging Infections Program. Health care-associated invasive MRSA infections, 2005-2008. JAMA. 2010 Aug 11;304(6):641-8.   http://jama.ama-assn.org/cgi/content/full/304/6/641

15. Jeyaratnam D, Whitty CJ, Phillips K, Liu D, Orezzi C, Ajoku U, French GL. Impact of rapid screening tests on acquisition of methicillin resistant Staphylococcus aureus: cluster randomised crossover trial. BMJ. 2008 Apr 26;336(7650):927-30. Epub 2008 Apr 16.  http://www.ncbi.nlm.nih.gov/pubmed18417521