Treating all patients in a hospital ICU as if they were infected with methicillin resistant staphylococcus aureus reduces positive bacterial cultures and bloodstream infections by 44%, research shows.
The relatively rare practice of universally treating all intensive care unit patients as if they were infected, and not screening them for pathogens first, reduces positive bacterial cultures and bloodstream infections dramatically more than screening patients and isolating those who test positive, according to a surprising study published Thursday.
"We now have a very large trial with strong evidence that universal decolonization is better, and it would behoove many hospitals to consider moving to that strategy," says Susan Huang, MD, principal investigator and medical director of epidemiology and infection prevention at the University of California Irvine Health. The study was published in the New England Journal of Medicine.
"What we found, a 44% reduction, represents a remarkable difference" when compared with two other strategies tested, she says. "This has been a really long-standing debate in medicine: Whether we should target high-risk germs or target high-risk people, and this trial answers that question. It's much better to target high-risk patients.
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"A strategy that looks to screen and find people who have MRSA, and then do something for them then, is inferior to treating everybody in an ICU as if they are critically ill."
Huang adds that the study is unusual because among the three strategies tested, "results weren't even close. A 44% reduction is pretty remarkable compared with what we had already been able to achieve in the last five or 10 years."
John Jernigan, MD, an author of the paper who is director of the Centers for Disease Control and Prevention's Office of HAI Prevention Research and Evaluation, called the study's results "dramatic," and the most significant finding on ways hospitals can reduce infections, especially MRSA, methicillin resistant staphylococcus aureus, to come out this year. A CDC committee is working on issuing guidelines.
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The study also was unusual because it was federally funded by the U.S. Department of Health and Human Services in 43 non-academic community hospitals owned by Hospital Corporation of America, not the traditional cohort of academic medical centers. It included 74,256 patients treated at 74 adult intensive care units between 2009 and 2011.
As a result of the trial, HCA officials said they are making universal decolonization in the ICU, without screening, standard practice in all of their 160 hospitals.
Hospitals were randomly assigned to one of three strategies.
In Group 3, which had the winning strategy, patients in the ICU received twice-daily doses of an antibiotic ointment, mupirocin, in the nose as well as daily baths with chlorhexidine-impregnated cloths during their ICU stay. The strategy did not involve screening patients for MRSA on admission to the ICU.
The Group 1 strategy, in most hospitals today, in which patients' nasal passages were screened for MRSA on admission to the ICU, and if positive, placed in isolation with glove and gown precautions. This protocol is so common, it is required by law in eight states, which may reconsider their regulations, Huang says.
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In Group 2, all ICU patients were screened and received contact precautions similar to Group 1. But patients known to have MRSA colonization or infection received a five-day regimen of twice-daily mintranasal mupirocin and daily bathing with chlorhexidine cloths
It's unclear whether the cost of administering mupiricin, at about $3 to $4 for the generic version for a course of treatment, and giving a $3 to $5 chlorhexidine daily bath to all ICU patients, will be less expensive compared with screening all ICU patients, which costs $25 to $30 per patient.
Huang and colleagues are working on a cost-effectiveness study, but she pointed out that the cost of treating a patient with a MRSA infection is also high, between $5,000 to $30,000.
In an accompanying editorial, Michael B. Edmond, MD, and Richard P. Wenzel, MD, of the Division of Infectious Diseases at Virginia Commonwealth University School of Medicine in Richmond, noted that the issue has been "one of the most controversial concepts in healthcare epidemiology during the past decade."
This study, he said in an interview, should change practice. 'This study shows that testing people for MRSA and isolating them is not an effective way to control MRSA in the hospital, which we've been arguing all along."
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In an interview, however, Edmond said he is "a little worried, because I think that widespread use of mupirocin will likely lead to development of a lot of resistance." His hospital uses routine chlorhexidine baths in the ICU, but not mupirocin.
MRSA colonization is a major target in quality measurement because bloodstream infections are common and are lethal in more than 20% of cases. Increased length of stay can add costs of as much as $30,000 per patient.
A decade ago, the CDC estimated 90,000 invasive MRSA infections, most of them acquired in hospitals, with 19,000 deaths per year. Hand hygiene and other strategies have reduced those rates by 28% between 2005 and 2008 and again 28% in 2011.