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Looking for MRSA
Whatís the cost of identifying MRSA in your facility? Whatís the cost of not doing so?

If bugs are in a race against humans, pessimists are placing their bets on MRSA, or methicillin-resistant Staphylococcus aureus.

MRSA is what infection control professionals call a multidrug-resistant bacterium. By adapting to just about any antibiotic, MRSA is doing what most organisms do - adapting and surviving against great odds, according to Marcia Patrick, RN, MSN, CIC, infection control director, MultiCare Health System, Tacoma, Wa., and contributor to a March 2007 report by the Association for Professionals in Infection Control and Epidemiology (APIC) entitled "Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings." Just as cockroaches can quickly adapt to Raidģ, so too can bacteria adapt to the latest antibiotic deployed to kill them, she says. Overuse and misuse of antibiotics, poor hygiene practices and the susceptibility of immunocompromised patients all play a role in the spread of multidrug-resistant bacteria.

MRSA has been a topic for infection control journals and textbooks for some time. But today, itís talked about in newspaper articles and TV news segments. Thatís because MRSA is showing up more frequently in hospitals and communities.

Whatís the price tag?
At staff meetings around the country, hospital epidemiologists and infection control professionals are weighing their options. Should they screen all patients upon admission, or only those considered at high risk of carrying the bug? Perhaps they should just screen ICU patients. How about patients scheduled for elective surgery, or just those who are exhibiting symptoms of infection?

Traditional lab tests, in which cultures are grown in Petri dishes, are relatively cheap to administer. But they donít yield results for two or three days. By that time, the patient has exposed others to the bacteria, and has further compromised himself or herself. In some cases, he or she may already have been discharged from the hospital. Newer tests, which examine the DNA of bacteria (using a technology called PCR, or polymerase chain reaction), yield results in just a couple of hours, but they cost more money. So, what is the price of infection control?

The price of not monitoring MRSA could be high, however. Studies show that the average cost of treating an MRSA infection exceeds $35,000, according to APIC. The annual cost to the United States of treating MRSA in hospitalized patients is somewhere between $3.2 and $4.2 billion. The Centers for Medicare and Medicaid Services has already informed healthcare facilities that come October 2008, it will stop reimbursing hospitals for caring for at least two conditions related to hospital-associated infections (catheter-associated urinary tract infections and Staph aureus blood infections). Many infection control experts expect hospital-associated MRSA to be on the non-reimbursable list in 2009.

One hospital - Evanston Northwestern Healthcare in suburban Chicago - screened 25,139 individuals for MRSA upon admission and found that 1,307 (5.2 percent) were MRSA-positive, according to hospital epidemiologist Ari Robicsek, M.D. To screen every patient upon admission with the new molecular diagnostics, Evanston would incur a cost somewhere between $600,000 and $1 million, he figured. But by catching MRSA early, the hospital would actually avoid approximately $1 million a year in costs associated with treating patients.

"Not only is there a tremendous impact on the quality of patient care, but thereís a very positive financial impact," says Glen MacKenzie, director of marketing GeneOhm platform, BD Diagnostics, a subsidiary of BD. The companyís GeneOhm StaphSR Assay, which was cleared for marketing by the Food and Drug Administration in December 2007, uses molecular methods to identify within two hours whether a blood sample contains genetic material from the MRSA bacterium or the more common and less dangerous staph bacterium, which can be treated with methicillin. The company has submitted applications to the FDA to add nasal swab and wound claims.

Hospital-by-hospital approach
While APIC has long supported mandatory public reporting of infection rates as a way of leading to better patient outcomes, the association avoids advocating legislation calling for screening for specific microorganisms, says APIC CEO Kathy Warye. "Such regulations will hard-wire the way facilities spend their money and the way they direct their resources," she says. By "hard-wiring," Warye means that such legislation could deny hospitals the flexibility to direct their resources where they are most needed.

"Some hospitals have a big problem, while others might not have any MRSA issues at all," she says. "We want hospitals to maintain the flexibility to address their specific issues. Weíre concerned that weíre doing this in an organism-of-the-month manner. Weíd rather see legislation that acknowledges the importance of having really robust, fully resourced infection control programs across the nation. Itís a more complicated solution, but itís a complex problem, and it needs a comprehensive solution."

"Screening has to be based on local risk assessment," adds Patrick. "All hospitals are different; our communities are different. A rural access hospital has different issues than an inner-city hospital. So everything should be based on risk assessment. If youíre doing no screening at all, how do you know whatís going on? If youíre just monitoring infections and you donít have a lot of patients who get infected, you donít know the rate of colonization. A certain amount of testing isnít a bad idea, but thatís a local decision. That has to be the linchpin - local risk assessment."

Low-tech measures still work
In its 2007 report on the elimination of MRSA transmission in hospitals, APIC emphasized the need for a thorough risk assessment followed by a surveillance (screening) program based on it. But the association urged hospitals to continue to follow basic infection control practices: hand hygiene, thorough cleaning and decontamination of equipment, hospital rooms, etc.; and appropriate contact precautions.

Perhaps the most important component is what Warye refers to as antibiotic stewardship. "One reason weíre in this situation is that weíve overused and misused antibiotics for many years," she says. "We need to be judicious and cautious in our use of antibiotics, and not prescribe them so often Ö. [O]ur arsenal is thin, and it will only get worse if we canít improve our antibiotic stewardship."

MRSA: How prevalent is it?

MRSA caused more than 94,000 life-threatening infections and nearly 19,000 deaths in the United States in 2005, reported the Centers for Disease Control and Prevention (CDC) in October 2007. Eighty-five percent of all invasive MRSA infections were associated with healthcare settings, of which two-thirds surfaced in the community among people who were hospitalized, had undergone a medical procedure or had resided in a long-term care facility within the previous year. In contrast, about 15 percent of reported infections were considered to be community-associated, which means that the infection occurred in people without documented healthcare risk factors, including athletes, military personnel, prisoners and others. (Community-associated MRSA often presents itself as lesions on the skin, or wounds that resist healing. Healthcare-associated MRSA, on the other hand, often presents itself as a component of other infections, such as bloodstream infections, urinary tract infections or surgical site infections. Elderly patients, people with chronic illnesses and those with tubes penetrating their bodies, such as catheters, appear to be particularly susceptible to infection.)

Data from the National Nosocomial Infections Surveillance System data analysis for 1992 to 2003 showed that the percentage of Staph isolates that were methicillin-resistant increased from 35.9 percent in 1992 to 64.4 percent in 2003 in participating adult and pediatric ICUs. According to the 2007 APIC report, in the early 1990s, MRSA was reported to account for 20 to 25 percent of Staphylococcus aureus in hospitalized patients in the United States. By 2005, many hospitals experienced MRSA percentages in the range of 50 to 70 percent of total Staph isolates. (S. aureus is the most common hospital pathogen.) In a study conducted in October and November 2006, the Association for Professionals in Infection Control and Epidemiology found that 46 out of every 1,000 patients in the study were either infected or colonized with MRSA. That rate was between eight and 11 times greater than previous MRSA estimates.

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