Healthcare-Associated Infections _ ______________________________________________________________
SUMMARY OF STRATEGIES FOR PREVENTION OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS AND OTHER DRUG-RESISTANT MICRO-ORGANISMS
Conduct MRSA risk assessment and implement an MRSA monitoring program a System to identify patients with MRSA colonization or infection Feedback of information to clinicians a
Implement laboratory-based alert system to timely notify HCP of new MRSA-colonized or MRSA-infected patients Implement alert system that identifies readmitted or transferred MRSA-colonized or MRSA-infected patients Provide MRSA data/outcome measures to key stakeholders Education Hand hygiene Environmental and equipment cleaning and decontamination Dedicated equipment Use Contact Precautions for MRSA-colonized and MRSA-infected patients Masks b Cohorting c Antimicrobial stewardship Active surveillance testing c (Can be performed in setting of MRSA outbreak or evidence of ongoing MRSA transmission) Decolonization therapy d Compliance with CDC or WHO hand hygiene recommendations Compliance with cleaning protocols e a Not discussed in the guidelines by the Society for Healthcare Epidemiology of America (SHEA). b Recommended in SHEA guidelines but not in guidelines by the Centers for Disease Control and Prevention (CDC). c Recommended by the CDC and SHEA only for specific subpopulations or circumstances in conjunction with decolonization and contact precautions. d Recommended by both CDC and SHEA only for specific subpopulations or circumstances. e Recommended by the CDC only for specific subpopulations or circumstances. Source: [25; 33; 41] Table 19
Antimicrobial Stewardship The principles underlying the judicious use of antibiotics are the limitation of unnecessary antibiotics, obtaining timely cul- ture and sensitivity data, selecting the most appropriate treat- ment, and prescribing the appropriate dose [316]. In addition, studies have shown that antimicrobial use can be decreased by using explicit criteria to identify patients with HAIs as well as those at highest risk for infection [317]. Antibiotic stewardship programs provide guidance to clinicians and have been shown to improve patient outcomes, reduce the burden of antibiotic resistance, and save healthcare dollars [2; 318]. In their “Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship,” SHEA and IDSA recommend that two core strategies of such a program are a prospective audit with intervention and feedback and formu- lary restriction and preauthorization [72]. Other elements of an effective antimicrobial stewardship program include [72]: • Education to supplement interventions • Guidelines and clinical pathways that incorporate local microbiology and resistance patterns • Antimicrobial order forms • Policy to avoid routine antimicrobial cycling • Selective use of combination therapy
Since the publication of the guideline, conflicting data have been reported. In a prospective study of surgical patients at a Swiss teaching hospital, a rapid MRSA screening test at the time of hospital admission did not reduce the rate of MRSA infections [312]. In contrast, a universal MRSA screening pro- gram at a three-hospital organization in the United States led to a large reduction in MRSA infection during hospitalization and at 30 days after discharge [313]. Rates of MRSA infection have been reduced when universal MRSA surveillance was incorporated into a bundle of interventions that included adherence to Standard Precautions and recommendations for hand hygiene, adherence to Contact Precautions for patients who have MRSA-positive cultures, and efforts to change the environmental culture through briefings on patient care units, leadership involvement, and other similar strategies [314]. In one study, implementation of such a bundle resulted in significant decreases in transmission of MRSA (from 5.8 per 1,000 bed-days to 3.0 per 1,000) and overall MRSA HAIs (from 2.0 per 1,000 bed-days to 1.0 per 1,000), as well as a 65% decrease in MRSA surgical site infections after orthopedic operations [180]. Three independent factors have been found to correlate with previously unknown MRSA carriage: recent treatment with antibiotics, history of hospitalization, and age older than 75 years. Predictive models with these factors may enhance MRSA screening by better targeting patients at risk for MRSA carriage [315].
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