Methicillin-resistant Staphylococcus aureus Infections: It's Time to Get Tough

In 1982 Boyce and Causey reported in Infection Control the results of a survey conducted to determine the magnitude of methicillin-resistant Staphylococcus aureus (MRSA) infections in the United States. From responses to that questionnaire, it was apparent that the number of hospitals reporting MRSA dramatically increased from 1975 to 1980, that larger hospitals were encountering the problem more frequently than smaller ones, and that it was more common in university and federal hospitals than community, community teaching, and municipal hospitals.' In this issue of Infection Control, Preheim and colleagues have determined that the problem has not abated, at least in the Federal Veterans Administration system. Since 1980, the hospitals identifying the problem have continued to increase. This increase is geographically widespread and involves hospitals of all sizes.2 Federal hospitals in general have a high incidence of nosocomial infections compared with community hospitals.3 The reasons for this are not absolutely known but are probably multiple. VA hospitals provide care for primarily indigent patients, a group that may delay therapy longer and have more severe underlying conditions. The patients are frequently older and stay somewhat longer than those in other hospitals. Fixed hospital budgets often produce shortages in personnel, a problem aggravated by the scarcity of nurses in many areas of the country. Perhaps more important, there is an increased number of physicians and students per patient in the medical school-affiliated VA hospitals, as in university hospitals, each increasing the chances of spread of resistant pathogens from one patient to another. So it is in this type of setting, whether a university, VA, county, or community hospital, that the spread of resistant organisms such as MRSA can quickly get out of hand. It is in this type of setting that we must be particularly careful to prevent this from occurring. The presence of these organisms in the hospital is costly. Vancomycin, the only parenteral antibiotic for therapy of severe infections from this organism, costs our hospital $900 for a 2-week regimen. Likewise, the cost of isolation is not insignificant. But more important than cost are the morbidity and mortality caused by this organism in the hospital and its potential spread into chronic care facilities, nursing homes, and the community. As Preheim and colleagues have indicated, 41% of Veterans Administration Medical Centers reported sending known MRSA colonized patients to nursing homes-sometimes, I suspect, without forewarning the receiving institution that the patient has the resistant pathogen. Indeed, community identification has now been reported in Boston and New York, and has been noted in Baltimore and, I am sure, other communities as well.4,5,6 That the organism is in the community population is not only possible but appears to be a fact. It is our responsibility to prevent this from occurring or minimize it as much as we possibly can. The following are recommendations we have found helpful in maintaining control of an MRSA outbreak in a 291From Division of Infectious Diseases, Department of Medicine, Baltimore Veterans Administration Medical Center and the University of Maryland School of Medicine, Baltimore, Maryland. Address reprint requests to Harold C. Standiford, MD, Chief Section of Infections Diseases, Baltimore Veterans Administration Medical Center, 3900 Loch Raven Boulevard, Baltimore, MD 21218.