MRSA in Decline: England Edition

Don't know what I want
But I know how to get it
I wanna destroy passerby

-Sex Pistols "MRSA? in the UK"

MRSA rates have just reached their lowest levels in recorded history. Per a BBC report, there were 97 cases in the entire NHS in June, which represents the first time rates have been below 100. 25 hospitals had no MRSA cases in the month. C. difficile cases are also falling, so the decline is likely due to an overall emphasis on infection prevention including hand hygiene, which would impact both infections. Good news, overall.

BBC report
Guardian report

See you at Starbucks!

There is a very interesting study in the July/August issue of the Annals of Family Medicine from the Medical University of South Carolina (free full text here). Investigators there analyzed data from the 2003-2004 NHANES study, a survey designed to assess the health and nutritional status of the US populace, using an interview and physical examination on approximately 5,000 persons selected as a representative sample of the population. This study also included a nasal swab done on each participant, which found that 1.4% of persons in the sample were colonized with MRSA.

Using the NHANES dataset, the South Carolina  investigators found that persons who drank coffee or hot tea were half as likely to be colonized with MRSA, even when controlling for age, race, socioeconomic status, health status, hospitalization in the last year and antibiotic use in the last month.

Now it's important to remember that this is an observational study, which doesn't allow us to determine causation, as we know that these studies can be plagued by bias and confounding. Nonetheless, the authors do elaborate on the biologic plausibility for their tantalizing finding.

I'm just saying it sure beats squirting mupirocin up your nose!

The new ICHE is here, the new ICHE is here!!!

Congrats to all of the authors who had articles published in this August's ICHE. Now that ICHE has a massive new impact score, I suspect most of them now feel like Navin when he says, "Page 73 - Johnson, Navin R.!  - I'm somebody now! Millions of people look at this book everyday! This is the kind of spontaneous publicity - your name in print - that makes people. I'm in print! Things are going to start happening to me now."  Well, I hope all the things that happen to these fine authors are a little more positive.

Highlights:

Page 737, Boyce, John M et al. looked at the impact of an automated mobile UV-C light unit on environmental contamination in 25 rooms after patient discharge. They report the unit significantly reduced aerobic colony counts and C. difficile spores.

Page 743, Rutala, William A et al. wrote an accompanying editorial that concluded that "there is now ample evidence that no-touch systems such as UV-C light or hydrogen peroxide can reduce environmental contamination...(however) only a single study using a before-after design has been published that demonstrated that such a system can reduce healthcare-associated infections." There we go again, hospital infection prevention: the queen (or king) of intermediate outcomes. Would be pretty cool if there were more independent (federal or foundation) resources to study HAI prevention interventions, such as these.

Page 791, Gupta, Kalpana et al. report the results of a cohort of all patients at the VA Boston Health Care System that had clean or clean-contaminated in 2008-2009 and a nasal MRSA PCR test less than 31 days prior to surgery. 6.6% of the patients were MRSA+ and were at significantly higher risk for postoperative MRSA infections (RR, 8.46; 95% CI, 1.70–42.04). Interestingly, vancomycin prophylaxis was associated with higher SSI risk in those negative for nasal MRSA (RR, 4.34; 95% CI, 2.19–8.57) but not in MRSA+ patients.

Page 818, Tohme, Rania A et al. reviewed hepatitis B vaccination rates and immunity among healthcare students during a 10-year period at Emory University. They report that among 4,075 students, only 60% had documented vaccination and 84% had anti-HBs concentration greater than or equal to 10 mIU/mL. It is interesting that despite CDC and ACIP (1995) recommendations of routine vaccination of children aged 11-12 years, and for all less than 18yo in 1999, the majority of students were only recently vaccinated.

If I left you off this list, sorry! You are still awesome!

Nosing around for staphylococci

In my last post about the newly described MRSA strains that carry the mecA_LGA251, I referred again to the “empty cassette variants” (or “mecA dropouts”) that are missed by commercial MRSA PCR tests that target the orfX gene but don’t contain mecA primers. I also mentioned that we’d soon be publishing our first year of experience with this. Well, here is the short report I was talking about, describing our ~8% rate of false positivity due to empty cassette variants, and characterizing the strains in question. We found substantial genetic diversity among the “drop-out” strains, meaning that the problem wasn’t due to the introduction of a single clone. When we tested these MSSA isolates using the newer GeneXpert MRSA/SA Nasal Assay (the “Nasal Complete” assay), they were correctly identified as S. aureus but not MRSA (this new assay has primers for the mecA gene). Even the “Nasal Complete” assay is susceptible to false positives, though, from the simultaneous presence of an MSSA and a methicillin-resistant coagulase-negative staphylococcus (MR-CoNS) in the same nose (the prevalence of MR-CoNS + MSSA co-colonization was 3.4% in one study). Indeed, the package insert describes a PPV of about 75% for the Nasal Complete—for MRSA, the 25% “false positives” divide equally between those for which culture was negative (which might reflect increased sensitivity of PCR) and those for which the culture grew only MSSA (which may reflect MR-CoNS/MSSA co-colonization). Who knew the nares would be such a vexing place for those who design and market PCR tests?

Always playing catch-up

Reports of the emergence of novel MRSA strains bearing mecA_LGA251, discussed in Eli’s excellent post, were published just as I finished a pro-con session at ASM on the use of culture versus PCR for clinical detection of MRSA. I pointed to the ongoing evolution of MRSA as a drawback to existing PCR methods, and included reference to the "empty cassette variants" that I previously discussed.

Because I think the "empty cassette" or "mecA dropout" story is instructive here. When the orfX-based assays were initially released, the published data described a very low incidence of these variants (in the case of the "mecA dropouts", isolates of MSSA that tested positive by the GeneOhm-GeneXpert-BD test...the opposite problem we see with the mecA_LGA251 isolates, which are MRSA that test negative....). So the potential problem was minimized, mainly for lack of good data and an assumption that clinical labs wouldn't run across these strains very often. Of course, some labs (including ours) did run across them quite often (“empty cassette variants” constitute almost 8% of our positive tests, a finding we'll soon publish (manuscript "in press" at JCM)).

Similarly, we are going to hear about how rare these mecA_LGA251 isolates are, how clinical labs are not likely to run across them, the tests still perform well, etc., etc. But how will we know when we start running across them? Of the hundreds of labs doing MRSA nares screening by PCR, how many are doing culture in parallel (not just on positives, but on negatives as well)? Of the labs that do only culture, how many are also doing confirmatory mecA PCR and following up on any phenotypic MRSA that test PCR negative?

More to come on this topic, and what is says about the future of PCR testing for MDRO detection, in future posts...

Super Sneaky MRSA (but only if you use PCR)

Lost in the din of our Rice Crispies or even the E. Coli outbreak in Europe, are a couple papers out of UK/Denmark and Ireland reporting novel mecA containing MRSA in human and bovine populations.  The concern here, of course, is that in many centers these novel MRSA strains would be missed by static PCR tests, which is what actually happened in these reports. 

The report out of Ireland discusses two clinical MRSA isolates that were PBP2a-positive but mecA negative by conventional mecA PCR - ie they were called MSSA by GeneXpert. The first strain was isolated from a 64-year old in a Dublin acute care hospital, while the second was isolated from an 85 year-old in a South-East Ireland regional hospital. Evaluation determined that these strains contained a novel SCCmec element (Similar to SCCmec XI) with divergent mecA, mecI, mecRI, blaZ and ccr genes. 

In the second report, investigators out of England noticed bovine MRSA strains which tested negative after standard PCR tests for mecA. They determined that they contained a novel mecA homologue, mecALGA251. They then searched collections in Scotland, England and Denmark for similar strains and 51 human isolates with the same mecALGA251. 14 of 25 from London, 12 of 16 from Glasgow and 24 of 32 clinical strains from Copenhagen contained the novel mecA. One human strain dated back to 1975, although detection increased substantially between 2007 and 2010. 54% (13/24) of the bovine isolates were also positive. The distribution of cattle and human isolates in England is shown above.

The authors of this paper suggest that new PCR primers will solve the problem. It is true that it will solve this particular problem, but is it a good long term solution?  Do we think MRSA evolution will stop here? Also, they suggest that dairy cows could be a reservoir of infection, but I would think that humans could also be the reservoir.

What this suggests to me is that if you isolate/decolonize patients using a static PCR for mecA, it is not surprising to me that other novel strains could emerge.  Hand hygiene would not be so easily circumvented, nor would simpler culture-based microbiology methods.

Hopefully our resident microbiologist Dan will chime in too...

UK and Denmark report: Garcia-Alvarez et al. Lancet ID June 3, 2011

Ireland report: Shore AC et al. AAC, June 2, 2011

Tara Smith's take can be found here and Scientific American's report by Katherine Harmon here

Should you shake your patient's hand? Not if she owns a cellphone!

A recent AJIC article is getting a lot of press attention. Investigators cultured the cellphones (mobile phones) of patients, visitors and health care workers for hospital pathogens.  The study out of Medicine Inonu University in Malatya, Turkey reported that 40% of patients' phones were contaminated with pathogens while fewer HCW's phones were contaminated (20%). Patients' phones were more likely to be contaminated with MDR-bacteria including MRSA, ESBLs, and carabepenem-resistant Acinetobacter.  Yikes!  And I only thought cellphones caused brain cancer. A bad week to be a cellphone, for sure.

Tekerekoglu, et al. AJIC June 2011

Off to ASM

I'm off to New Orleans today, to attend the ASM General Meeting. I'm scheduled to give a talk Monday morning as part of a "pro-con" session on rapid diagnostic testing. Even though the world might end today, I prepared a talk in advance. My task is to argue that culture is just as good (or in some ways even better) than rapid PCR-based techniques for MRSA screening. Fun! Next week I'm giving another talk at our local library. I'll be explaining why a typewriter is just as good as a computer if you're writing something that is expected to have little impact.

Bedbugs and superbugs and bears, oh my!

Combine superbugs and bedbugs and what do you get? At least one publication, and a lot of media attention, that’s what. I was trying my hardest to ignore this story, but our stat counter shows that we now have a sizable readership—how can I let them down? My solution to this problem: we should try to destroy bedbugs wherever we find them (oh, we’re already doing that? OK). As for the over 4 million people in the U.S. who carry MRSA in their noses, let's let them live.

Using viruses to detect bacteria!

The FDA just approved a new rapid detection test for MRSA and MSSA from blood cultures that are positive for Gram positive cocci (GPC). The most widely used tests for rapid MRSA or Staphylococcus aureus detection from blood cultures are real-time PCR tests by BD and Cepheid. These tests are limited by both cost and by some performance issues, one of which I referred to here.

The interesting thing about the new Microphage test is that it utilizes bacteriophages specific for S. aureus. The advantage of the test is that it is a simple immunoassay, requiring no special equipment or platform—the immunoassay detects phage antigens, which accumulate only if their target (S. aureus) is present. The MRSA/MSSA distinction is made in a similar manner, but using cefoxitin to inhibit the MSSA that the phages would otherwise feast upon. From the data in the package insert and in this ICAAC abstract from last year, the main limitation is a sensitivity of 91.8% for detection of S. aureus. If the result is positive for S. aureus, the assay is very accurate for distinguishing MRSA from MSSA (accurate enough to meet FDA standards for any commercial susceptibility test). So positive results should be useful, while negative results may not be (negative predictive value will vary based upon the proportion of all blood cultures positive for GPC that are S. aureus).

I could find no peer-reviewed literature on this test (point me to it if you can find anything), so we’ll have to see if real-life performance matches the trial data presented in the package insert. Cost will also be a big issue, and my understanding is that they haven’t settled on a price at this point.

Regardless of how it pans out, you have to love the concept of using bacteriophages for diagnostic purposes…compared with our nucleic acid detection tests, proteomics, etc., it just seems so…..old school!

Those deviants!

Photo: OpenIDEO

I have a bookshelf that is filled with many books on leadership and management that I read while working on my Master of Public Administration degree. While each of them might have a kernel or two of unique insights, most of these books contain a great deal of fluff. The basic formula for these books is to take concepts that are often common sense, give them a new name, and create the illusion of a totally new discovery about human behavior.These books often focus on a magic number--7 principles, 10 milestones, 12 steps (wait, that's something else!), and they continue to be steadily churned out (just take a look at any airport bookstore). Of all of these books that I've read, one did stand out as different and important, and that was Robert Greenleaf's Servant Leadership.

One recent book in this genre caught my eye given it's potential application to HAI prevention: The Power of Positive Deviance: How Unlikely Innovators Solve the World's Toughest Problems. Positive deviance was a part of the interventions implemented in the Veteran Affairs initiative to reduce MRSA that was recently reported in the New England Journal of Medicine (see Dan's comments here and here). My colleague in Sao Paulo, Alex Marra, has published on his use of positive deviance to improve compliance with hand hygiene. You can read an interview with Alex focusing on the use of positive deviance here.

In a nutshell, the concept of positive deviance is to simply involve not just experts but everyone in identifying solutions to problems. And it recognizes that a few individuals (the positive deviants) devise solutions to problems that the vast majority of people never realize. The deviants then share their successes with others and in doing so previously intractable problems are solved. Importantly, change is driven bottom-up, not top-down. The book uses several case studies, including the Pittsburgh VA hospital MRSA initiative.

Like the overwhelming majority of leadership/management books, this is another one that essentially follows the same formula as many others--a relatively simple, commonsense concept is given a new name, and presto, problems appear to be solved. I have no doubt that positive deviance can be used successfully in infection prevention, but it's simply another way to achieve the outcomes we want. It's not magic and it's not the be-all, end-all. But it's another tool, and if it works for your organization, well, you go girl!

Pre-emptive contact precautions of intubated patients: effective??

One of the odd things about contact precautions is that they are typically used to isolate patients colonized or infected with MDROs like MRSA. What this does is protect the healthcare worker from being contaminated with the MDRO but does little to protect the uncolonized patients.  The contact "event" we should MOST care about is contact between the contaminated or colonized healthcare worker and the uncolonized patient. So, current active detection and isolation programs have it all wrong. Please read that paragraph again.

Thus, I read with interest a paper just e-published in the JHI by Matsushima et al.  The authors noticed, using surveillance data, that ventilated patients in their ICU were 8 times as likely to acquire MRSA compared to non-ventilated patients.  Based on this finding they decided to place all ventilated patients on contact precautions throughout their stay to see if it reduced MRSA acquisition.  This intervention is close to a universal contact precautions intervention (or close to the STAR*ICU study that was a study of barrier precautions - gloves or gowns/gloves).

The study was completed in a 19-bed ICU in Osaka, Japan.  A unique (for the US at least) characteristic of this ICU was that only 2 rooms were single-bed rooms while the remaining 17 beds were in a single open ward. There were 2 study periods.  Period 1 occurred during 2004 and period 2 was a 3-year period from 2005-2007. During period 1, contact precautions were only used if the patients was found to be colonized with an MDRO. Surveillance cultures were obtained on all admissions and weekly using sputum, nasal and urine sources. During period 2, the same practices existed as period 1, but all patients who were intubated were placed on contact precautions for their entire stay.  MRSA acquisition occurred when a patient negative for MRSA on admission culture became positive on a subsequent surveillance or clinical culture.  They actually completed segmented Poisson regression looking for changes in slope/intercept of HA-MRSA rates. Woo woo!

The main difference between period 1 and period 2 was that many more people were placed on contact precautions during period 2. In period 1, 2.9% of patients were MRSA+ on admission and isolated while in period 2, 6.1% of patients were MRSA+ on admission, but fully 43% of patients were placed on contact precautions. Importantly, the colonization pressure was 2x greater in period 2.  Keep that in mind...

Interestingly, HA-MRSA infection in all patients declined from 3.6 to 2.3 per 1000 patient-days, p<0.05. The incidence of HA-MRSA in the intubated patients greatly decreased from 12.2% to 1.1%. I have pasted the key figure -->.  What it shows is that while HA-MRSA colonization and infection declined in intubated patients it actually slightly increased in non-intubated patients (who could be considered a non-equivalent control group).  Very cool.

Usual caveats: single center with somewhat unique bed arrangement in the ICU, and of course the control group wasn't random.  However, this is a fairly strong quasi-experimental study with good epi and statistical methods. And it points out that isolating patients actually PROTECTS them, so if there are downsides associated with contact precautions, like fewer visits from healthcare workers, at least the patients isolated directly benefit from the isolation.  This sort of study could actually help flip how we think about contact precautions. Isolate the uncolonized!

Matsushima et al. JHI 2011, doi:101016/j.jhin.2011.02.010

h/t Marin Schweizer

Good news, bad news

Here’s a nice “good news, bad news” report by Becky Miller and colleagues from DICON (the Duke infection control network). First the bad news: Clostridium difficile has now replaced MRSA as the most common HAI in this 39 hospital network in the southeastern United States. The good news? This development is driven largely by a steady and substantial decline in healthcare-associated MRSA infections between 2005-2009. Check it out:

We’ve discussed this trend before, a trend documented by CDC investigators in the NHSN and EIN programs, and confirmed in the VA system as well. The challenge now is to find a way to make the C. difficile trend line resemble that for MRSA….

FDA Warns: OTC products caught making false MRSA claims

Today, I was off searching the interweb for news at sites not named The New York Times, when I came across this piece in the LA Times. Apparently, the FDA has issued four warning letters to companies making false claims that their products prevent MRSA infection.  These products, which include some 'natural' hand sanitizers, had little data to back up these claims.  The companies/products include:

• Tec Laboratories for Staphaseptic First Aid Antiseptic/Pain Relieving Gel;
• JD Nelson and Associates for Safe4Hours Hand Sanitizing Lotion and Safe4Hours First Aid Antiseptic Skin Protectant;
• Dr. G.H. Tichenor Antiseptic Co. for Dr. Tichenor’s Antiseptic Gel;
• Oh So Clean, Inc dba CleanWell Company for CleanWell All-Natural Foaming Hand Sanitizer, CleanWell All-Natural Hand Sanitizer, CleanWell All-Natural Hand Sanitizing Wipes, and CleanWell All-Natural Antibacterial Foaming Handsoap

My recommendation:  stick with alcohol hand rub or just plain-olde soap-n-water (TM)

Source: FDA News Release 4/20

MRSA in veterinarians

Scott Weese's blog has a great piece on MRSA in veterinarians. You can view it here.

MRSA Video - If this doesn't get you excited "almost" nothing will

The video was made by The University Hospital of South Manchester.

Things to note:
1) They start off by washing their hands and not swabbing their noses
2) Ties are tucked, sleeves are rolled up and they're mostly bare below the elbows.

Source: BBC News

Control groups are for losers

That’s what I learned from today’s New York Times editorial. In their review of the two NEJM studies we covered last week (here and here), they describe the VA study as “broader” (true, if by broader they mean larger) and “possibly more rigorous” (untrue). They also point out that “if other hospitals could replicate the effort, thousands of patients might be saved from needless infections”. The editorial board at the NY Times should know that hospitals across the country are already saving thousands as MRSA HAI rates drop nationwide! And many of these hospitals are saving lives without also stimulating the economy by doing universal MRSA screening. A bundle with multiple interventions, one of which is unproven and hugely resource intensive, doesn’t seem in keeping with the spirit of health care reform. And sadly, determining the proper role of the most expensive element in the VA's MRSA bundle requires studies that use something we epidermatologists like to call a “control group”.

VA reduces HAIs! In other news, VA spends millions on MRSA screening

Jain and colleagues just published data from the VA healthcare system implementation of the "MRSA directive". For those who are still unaware, in 2007 the VA began mandating the IHI MRSA bundle system-wide, with MRSA screening (active detection and isolation, or "ADI") applied to all VA admissions. The results? From October 2007 until June 2010, the MRSA transmission rate decreased by 17% in ICUs and 21% in non-ICUs, and the incidence of healthcare associated MRSA infections in ICUs fell by 62%. Very impressive indeed.

But that's not the whole story. During the same time period, a subset of these VA hospitals also reported their rates of healthcare-associated VRE and C. difficile infections, and guess what? VRE HAIs fell by 100% in ICUs and 70% in non-ICUs, and C. difficile HAIs fell by 57% in non-ICUs. It seems that HAIs are falling across the VA system, probably as a result of an important culture change, and improved application of so-called "horizontal" approaches to infection prevention. Bravo to the VA!

Here's the problem: because the VA jumped right into universal ADI, utilizing the most expensive screening technology available, they've poured millions of dollars into one specific intervention (ADI), and we still have no idea if ADI had anything to do with their MRSA reductions. After all, MRSA HAI rates have been falling across the country, both inside and outside of ICUs, including in hospitals that do no ADI, or that do targeted ADI. And of course Mike's hospital, where no ADI is done, would scoff at a mere 60% rate of decrease, having reduced MRSA HAIs by almost 90% using horizontal approaches.

My conclusions? First, the VA is to be congratulated for demonstrating real and sustained progress in HAI prevention (disclaimer: I was a VA hospital epidemiologist for 10 years, including during the first 2 years of implementation of the MRSA directive). Second, VA policy makers should consider the possibility that universal MRSA screening is now doing more harm than good, if only because it costs millions of dollars annually that could be used to improve other infection prevention programs. By all means, continue the MRSA initiative. But consider relaxing the "universal" ADI directive to allow individual hospitals the latitude to tailor ADI practices to best address their current risk assessment.

STAR*ICU study published: Barrier precautions not effective

It's only one study. Everybody take a deep breath. OK, exhale.

You might have already heard about this study and you might even know the results.  Someday, someone might discuss how this study was designed, and why the investigators decided to ship all of the microbiology specimens to NIH for processing resulting in a 5-day test turn-around time.  Someday, someone might explain why this study took 4 years to publish and the saga behind its eventual publication in the NEJM.  Someday, someone might even discuss how the difficulties completing this study might be hindering NIAID from funding other infection prevention clinical studies.  Someday, someone.

What can I say about the study?  Barrier precautions (ie. gloves or gowns/gloves) are ineffective in halting the transmission of MRSA and VRE in ICU settings.

Methods: The cluster-randomized trial (ie a largish quasi-experimental study but with a cool fancy name - see my "Random note" below) was completed in 2006 with the intervention lasting 6 months from March to August 2006. There were 10 intervention ICUs and 8 control ICUs.

Random note: There were 18 ICUs in this study, so it's somewhat like an 18-person RCT.  With such small numbers you can't expect that all measured and unmeasured confounders to be randomly distributed between the intervention and control ICUs. Thus, this is more like a large QE study than a standard RCT and needs to be analyzed as a QE study using multivariable regression controlling for known sources of confounding. Don't believe me? Check out Table 2 to see how different the intervention and control arms were in regards to topical and systemic antimicrobial exposure. You would not typically expect these "significant" differences in a large RCT (or large cluster-RCT).

Microbiology: Nasal swabs for MRSA surveillance cultures and stool or perianal swabs for VRE surveillance cultures were obtained from all patients within 2 days after their admission to the ICU, weekly thereafter, and within 2 days before or after their discharge from the ICU. Swabs were shipped overnight, 6 days a week, to the NIH. The mean number of days from obtaining surveillance cultures to reporting of results was 5.2 days.  I would have liked to see this reported in median days and I would also have liked this number to be reported from time of admission and not time from obtaining the culture since 2 days could pass between admission and obtaining the culture.

Planned Intervention: Known colonized or infected patients were placed on contact precautions. All other patients were placed on universal gloving from the time of admission until their discharge or until the results of surveillance cultures results returned. If surveillance cultures were positive, patients were upgraded to contact precautions (gowns/gloves) and if they were negative, they were downgraded to standard precautions.

Actual intervention as implemented: In the intervention ICUs, 92% of the ICU-days were spent under barrier precautions (51% contact precautions and 43% universal gloving) while in the control ICUs, 38% of ICU-days were spent under contact precautions.  Thus, indepedent of what anyone says, this study is about whether increasing barrier precautions from 38% to 92% reduces transmission. Also, 4 times as many patients in the intervention group were exposed to a topical antimicrobial (e.g. mupirocin), 12% vs 3.2%. Now, some will say that there wasn't 100% compliance with these interventions. I agree, this is not an efficacy trial.  As Ebb and I said in our JAMA commentary yesterday, cluster-randomized trials are real-world effectiveness trials in the domain of infection prevention.

Compliance: Overall, 47% of contacts in the intervention arm occurred with clean gloves and exit hand hygiene compliance vs 25% in the control ICUs. Compliance with contact precautions was relatively good in the intervention ICUs: gloves 82% and gowns 77%. Hand-hygiene compliance was also higher in the intervention vs. control ICUs (69% vs 59%)

MRSA or VRE colonization or infection: The mean incidence of MRSA or VRE per 1000 patient days at risk was actually higher in the intervention arm than the control arm (40.4 vs 35.6, p=0.35) but this was not statistically significant.

My thoughts:  How can this study not find a benefit when so many others have? Since most of the previous studies were uncontrolled quasi-experimental studies and we know that uncontrolled QE studies can over-estimate the measure of effect, it is possible that barrier precautions don't work.  It is also possible that other factors need to be included in any MDRO prevention program including attention to environmental cleaning and far higher compliance with the hand hygiene and contact precautions. However, the compliance rates reported in this study are not abnormally low (at least at the mean/median). Finally, perhaps decolonization is needed to achieve the results (at least for MRSA) that we've seen in other studies.

Another criticism that we've heard and will hear again is that the turn-around time for the microbiology was too-long.  This is mostly a red herring.  Since we have little evidence that gowns add much to gloves, and 92% of contacts in the intervention arm occurred with gloves, this study had FAR better glove compliance than we would expect with any typical ADI program in the real world.  The use of universal gloves in the pre-result period in the intervention arm really saved this study and, thus, it provides VERY useful information and should not be discounted. A quicker test turn-around would not have magically led to reduced transmission. Sorry.

Again, this is one study and it shouldn't be the last.  AHRQ is funding some very important MRSA (and VRE) prevention trials that many of us are involved with and I hope the publication of this paper won't discourage AHRQ (or NIH or CDC or VA) from funding these large and important studies.

What this study really tells us is that we can't fall back on legislative mandates in MDRO prevention and we must continue to search for the right combination of interventions along with developing better implementation strategies. Don't stop with the STAR*ICU study. Let this be the beginning.


Huskins W.C. et al. NEJM April 14, 2011

Anti-MRSA N95 mask?

I don't get this.  FDA has just approved an antibacterial N95 mask. The SpectraShield mask is labeled as an N95 surgical respirator with activity against S. pyogenes, MRSA, and H. influenzae when the bacteria are exposed to the outer surface of the mask.  When should these be used and why?  Is there evidence that in settings where an N95 should be used (i.e. caring for TB+ patients) that healthcare workers are contracting MRSA or Group A Strep? Are surgeons acquiring MRSA in the OR from their patients?  I probably missed the publications where they compared HCW acquisition rates between standard N95 and antibacterial N95. Please forward them along. 


PR Newswire, April 8, 2011