Looking for MRSA

What’s the cost of identifying MRSA in your facility? What’s 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 Raid®, 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, it’s talked about in newspaper articles and TV news segments. That’s because MRSA is showing up more frequently in hospitals and communities.

What’s 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 don’t 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 there’s a very positive financial impact,” says Glen MacKenzie, director of marketing GeneOhm platform, BD Diagnostics, a subsidiary of BD. The company’s 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. We’re concerned that we’re doing this in an organism-of-the-month manner. We’d rather see legislation that acknowledges the importance of having really robust, fully resourced infection control programs across the nation. It’s a more complicated solution, but it’s 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 you’re doing no screening at all, how do you know what’s going on? If you’re just monitoring infections and you don’t have a lot of patients who get infected, you don’t know the rate of colonization. A certain amount of testing isn’t a bad idea, but that’s 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 we’re in this situation is that we’ve 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 …. [O]ur arsenal is thin, and it will only get worse if we can’t improve our antibiotic stewardship.”

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