Prevention and Control of Multidrug-Resistant Organisms

The Centers for Disease Control and Prevention (CDC) reported that approximately 99,000 patients die per year from approximately 2 million health care–associated infections (HAIs).¹ These are infections caused mostly by multidrug-resistant organisms (MDROs), which include methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Most of these HAIs are preventable by employing basic infection prevention and control methodologies. The 2003 Society for Healthcare Epidemiology of America (SHEA) “Guideline for Preventing Nosocomial Transmission of Multi-Drug Resistant Strains of Staphylococcus aureus and Enterococcus” stated, “(m)ore than 70% of the bacteria that cause hospital-acquired infections are resistant to at least one of the drugs commonly used to treat these infections.”² SHEA further recognized that MRSA and VRE have been successfully “controlled with rigorous infection control practices” supporting the “premise that transmission is the major factor contributing to the increasing prevalence of MRSA.”²

Many prevalence studies have shown that MRSA accounts for approximately 60% of all staphylococcal HAIs, and when MRSA results in a bloodstream infection, mortality rates can range from 23% to 50%.^2,3 Not all HAIs occur from new or first-time exposures to these resistant microbes in health care settings. Many patients are colonized with community-acquired (CA-) strains of MRSA or health care–associated (HA-) MRSA or VRE that are due to events occurring and conditions existing in the community or during previous admission(s) into health systems (i.e., acute care and long-term care). Upon subsequent readmissions, patients may proceed on to infection with these colonizing strains. Through transmission in the health care setting, patients with unidentified colonization or infection can transmit these strains to previously uncolonized or uninfected patients. Typical public health methodologies employ program concentration both in the communities and as those community members gain access to health care. Therefore, this is a unique issue encompassing exposure and colonization or infection of CA-MRSA and its manifestation into HA-MRSA. Again, a subsequent infection can occur not only in those patients being admitted with colonization or infection from the community but also new (previously uncolonized or uninfected) patients who have exposure (either directly or indirectly by contaminated healthcare worker hands or environmental surfaces).

Mortality associated with HAIs (~90,000 per annum) exceeds that associated with breast cancer (40,870), prostate cancer (30,350), and AIDS (15,798).^4,5 HAIs result in more than 8 million excess hospital days, often times taking critically needed intensive care unit beds, and cost the health care system more than $4.5 billion annually.⁶ In 2004, the Pennsylvania Health Care Cost Containment Council (PHC4) estimated, after implementing mandatory public reporting of HAIs, that in Pennsylvania alone, of 1.8 million total hospitalizations, 13,722 patients had an MRSA infection. Of those, 8.9% died, compared with a mortality of only 2.1% of those patients without an MRSA infection. Patients with MRSA infections averaged $87,990 to treat, compared with $28,711 for those patients without an MRSA infection.⁷ PHC4 estimated that private-payer insurance payments for MRSA infections in Pennsylvania could total $613.7 million; this did not include payment from Medicare and Medicaid, which pay for more than 60% of all patients.⁷ The burden on federal payers outweighs the burden on private payers, by nature of the fact that a great majority of HAIs occur in high-risk patients, who are 65 years of age or older or disabled. Some infection prevention leaders have argued that because PHC⁴ data were based on billing data, they are not as accurate as they could have been, but several cost–benefit analyses, using multiple data sources, will be published in 20078 to add to the long list of studies referenced in the SHEA guidelines.²

European studies confirmed that MRSA is transmitted from pigs to pig farmers, their families, veterinarians, and hospital staff treating them. MRSA strains of farm origin have caused human skin and wound infections, mastitis, endocarditis, and pneumonia. One study found farms using antibiotics routinely were more likely to have MRSA detected.^9–15

National Guidelines and Public Health Focus
CDC guidelines, “Management of Multidrug-Resistant Organisms in Healthcare Settings,” were developed by internationally recognized experts in infection control in conjunction with CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC).¹⁶ The guidelines seek to halt the rising rates of drug-resistant infections by calling on hospitals and other healthcare facilities to make comprehensive infection control programs a priority and to take aggressive steps to reduces rates of drug resistance.^16,17

The American Public Health Association (APHA) has a mandate to address emergent public health issues from the perspective of protecting the public health and welfare from MDRO-related HAIs and the high morbidity and mortality associated with them. This document sets forth the APHA policy statement regarding MRSA, VRE, and other emerging MDROs as it relates to HAIs, whether acquired in or outside of the health care setting.

APHA

1. Encourages and promotes rigorous infection prevention and control practices in health care settings with a focus on implementing clinically proven methodologies, including contact precautions, hand hygiene, appropriate use of personal protective equipment, active surveillance and diagnostic testing, proper invasive medical device care, environmental cleaning and disinfection, and antimicrobial stewardship. At a minimum, health care facilities should implement the SHEA² or CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) MDRO Guidelines.¹⁶
   a. Society for Healthcare Epidemiology of America (SHEA) Guideline for Preventing Nosocomial Transmission of Multi-Drug Resistant Strains of Staphylococcus aureus and Enterococcus (2003)²
   b. CDC HICPAC Management of Multi-Drug Resistant Organisms in Healthcare Settings (2006)¹⁶ 
2. Encourages and promotes the use of infection prevention and control prevention “bundles” and “how to” implementation guidelines set up and established by professional associations such as the Association of Professionals in Infection Control and Epidemiology and quality organizations such as the Institute for Healthcare Improvement.
3. Stresses the need for health care quality and standards setting organizations (e.g., Joint Commission for Accreditation of Healthcare Organizations and National Quality Forum) to create additional infection prevention and control standards, alerts, and patient safety goals focused on MDRO prevention, identification, and control.
4. Encourages an international effort, in collaboration with the infection prevention community (e.g., CDC, Association of Professionals in Infection Control and Epidemiology, SHEA, Infectious Disease Society of America) and global health leaders (World Health Organization, International Federation of Infection Control) to provide guidance on the application of active surveillance testing as an integral part of MDRO prevention practices.
5. Urges the Centers for Medicare and Medicaid Services to examine the cost to the Medicare and Medicaid programs and societal burden of HAIs related to MDROs and reimburse for screening tests, rapid diagnostics, and relevant medical devices (e.g., closed intravenous systems, single-use devices) that minimize HAIs associated with MDROs, as well as the transmission of those microbes.
6. Encourages the US Department of Health and Human Services to allocate funds to the National Institute of Occupational Safety and Health (minimum of $500,000) to research the impact of occupational MDRO exposure among health care workers.
7. Encourages the US Department of Labor to allocate funds to the Occupational Safety and Health Administration (minimum of $500,000) to develop a safety and health information bulletin, other supporting publications, and enforcement guidance for the protection of health care workers with occupational exposure to MDROs.

References

1. Klevens RM, Edwards JR, Richards CL Jr., et al. Estimating Healthcare-Associated Infections and Deaths in US Hospitals. Public Health Rep. 122:160–166;2007.
2. Muto C, Jernigan JA, Ostrowsky BE, et al. SHEA guideline for preventing nosocomial transmission of multi-drug resistant strains of Staphylococcus aureus and Enterococcus. Infect Control Hosp Epidemiol. 2003;24:362–386. 
3. Peterson, L. Improved MRSA Management for Illinois. Evanston Northwestern Healthcare. PowerPoint Presentation. Evanston, IL. September 11, 2006.
4. American Cancer Society. Cancer Facts & Figures 2005. Available at: www.cancer.org/downloads/STT/CAFF2005f4PWSecured.pdf. Accessed December 10, 2007.
5. Centers for Disease Control and Prevention. A Glance at the HIV/AIDS Epidemic. Available at: www.cdc.gov/hiv/resources/factsheets/At-A-Glance.htm. Accessed December 10, 2007. 
6. McKibben L, Horan T, Tokars J, et al. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Am J Infect Control. 33:217–226; 2005.
7. PHC4 Research Briefs. MRSA in Pennsylvania Hospitals. 2006;10. Available at: www.phc4.org/reports/researchbriefs/082506/docs/researchbrief2006report_mrsa.pdf. Accessed December 10, 2007.
8. Murphy D, Whiting J. Dispelling the Myths: The True Costs of Healthcare-Associated Infections. Washington, DC: Association for Professionals in Infection Control and Epidemiology; 2007. Available at: www.sealshield.com/apic.pdf. Accessed January 24, 2008.
9. de Neeling AJ, van den Broek MJ, Spalburg EC, et al., High prevalence of methicillin resistant Staphylococcus aureus in pigs. Vet Microbiol. 2007;122:366–372. Eighty-one percent of Dutch pig farms had pigs carrying MRSA and 39% of pigs at slaughter carried MRSA. All MRSA were tetracycline resistant, and many of the bacteria were resistant to other antibiotics. 
10. Ekkelenkamp MB, Sekkat M, Carpaij N, Troelstra A, Bonten MJ. Endocarditis due to methicillin-resistant Staphylococcus aureus originating from pigs [in Dutch]. Ned Tijdschr Geneeskd. 2006;150:2442–2447. A 63-year-old transplant patient was admitted with endocarditis with pig strain MLST type 398.
11. Hanselman BA, Kruth SA, Rousseau J, et al. Methicillin-resistant Staphylococcus aureus colonization in veterinary personnel. Emerg Infect Dis. 2006;12:1933–1938. Available at: www.cdc.gov/ncidod/EID/vol12no12/06-0231.htm. Accessed December 10, 2007. Vets averaged 7% MRSA colonization, with large-animal vets at 16% and small-animal vets at 4% colonization. No MRSA was detected in non-vets. 
12. Huijsdens XW, van Dijke BJ, Emile Spalburg, et al. Community acquired MRSA and pig farming. Ann Clin Microbiol Antimicrob. 2006;5:26–29. Mother was detected with MRSA mastitis. Later, the baby was admitted to hospital for another cause, but MRSA was detected. Three family members were positive, and 3 coworkers and 8 of 10 pigs tested positive. 
13. van Duijkeren E, Ikawaty R, Broekhuizen-Stins MJ, et al. Transmission of methicillin-resistant Staphylococcus aureus strains between different kinds of pig farms. Vet Microbiol. 2008;126:383–389. Epub Jul 25, 2007. Eleven percent of pigs from 31 farms were positive for MRSA, with antimicrobial medication of pigs a risk factor. 
14. Voss A, Loeffen F, Bakker J, Klaassen C, Wulf M. Methicillin-resistant Staphylococcus aureus in pig farming. Emerg Infect Dis. 2005;11:1965–1966. Pig farmers had 760 times as much MRSA as patients admitted to hospital. Transmission was demonstrated between animal and human, family members, and nurse and patient in hospital.
15. Witte W, Strommenger B, Stanek C, Cuny C. Methicillin-resistant Staphylococcus aureus ST398 in humans and animals, Central Europe. Emerg Infect Dis. 2007;13:255–258. Described human infections, skin, wound, and 3 nosocomial pneumonia infections with ST398.
16. Siegel JD, Rhinehart E, Jackson M, Chiarello L, the Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention; 2006. Available at: www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf. Accessed December 13, 2007.
17. Centers for Disease Control and Prevention. CDC Urges Hospitals and Healthcare Facilities to Increase Efforts to Reduce Drug-Resistant Infections [press release]. October 19, 2006. Available at: www.cdc.gov/od/oc/media/pressrel/r061019.htm?s_cid=mediarel_r061019_x. Accessed December 11, 2007.

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