A Tiered Approach for Preventing Methicillin-Resistant<i>Staphylococcus aureus</i>Infection
Authors: Kyle J. Popovich, Shannon Davila, Vineet Chopra, Payal K. Patel, Shelby Lassiter, Russell N. Olmsted, David P. Calfee
Journal: Annals of Internal Medicine (2019)

Supplement: STRIVE1 October 2019A Tiered Approach for Preventing Methicillin-Resistant Staphylococcus aureus InfectionFREEKyle J. Popovich, MD, MS, Shannon Davila, MSN, RN, CIC, CPHQ, Vineet Chopra, MD, MSc, Payal K. Patel, MD, MPH, Shelby Lassiter, BSN, RN, CPHQ, Russell N. Olmsted, MPH, CIC, and David P. Calfee, MD, MSKyle J. Popovich, MD, MSRush University Medical Center, Chicago, Illinois (K.J.P.), Shannon Davila, MSN, RN, CIC, CPHQHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.D., S.L.), Vineet Chopra, MD, MScUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (V.C., P.K.P.), Payal K. Patel, MD, MPHUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (V.C., P.K.P.), Shelby Lassiter, BSN, RN, CPHQHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (S.D., S.L.), Russell N. Olmsted, MPH, CICIntegrated Clinical Services Team, Trinity Health, Livonia, Michigan (R.N.O.), and David P. Calfee, MD, MSWeill Cornell Medicine, New York, New York (D.P.C.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-3468 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Methicillin-resistant Staphylococcus aureus (MRSA) remains a significant cause of health care–associated infections (HAIs) (1, 2). A nationwide survey estimating the total number of HAIs in U.S. acute care hospitals in 2015 demonstrated that Staphylococcus aureus remained the second most common causative pathogen of HAI (2). To reduce MRSA infections in acute care settings, several evidence-based infection prevention strategies, such as conducting MRSA risk assessment and ensuring compliance with hand hygiene, have been recommended (3). National surveillance studies have demonstrated significant reductions in hospital-onset MRSA bloodstream infections in U.S. hospitals (4, 5) and intensive care units (ICUs), largely due to the successful implementation of these infection control strategies in hospitals (6, 7).Despite this progress, many U.S. hospitals continue to experience higher than expected rates of hospital-onset MRSA infection (8). Reasons for persistently elevated rates of HAI due to MRSA include poor compliance with recommended infection prevention practices, lack of support from frontline personnel and administration, and financial challenges (9). To assist hospitals that continue to have hospital-onset MRSA bloodstream infections despite recommendations of best infection control practices, strategies that address these barriers and provide clear, pragmatic, and concise direction for implementation are needed.In response to persistently elevated rates of HAI, in particular Clostridioides difficile, the Centers for Disease Control and Prevention (CDC) funded a prospective, interventional, nonrandomized, quality improvement project that was implemented at 443 short-stay and long-term acute care hospitals in 28 U.S. states and the District of Columbia. The overall project was titled CDC STRIVE (States Targeting Reduction in Infections via Engagement) and focused on Clostridioides difficile and MRSA infections, central line–associated bloodstream infection, and catheter-associated urinary tract infection. Program planning for the project occurred in September 2015, and there were 4 cohorts of hospitals, with recruitment occurring in waves: cohort 1 (June 2016 to April 2017), cohort 2 (November 2016 to October 2017), cohort 3 (April 2017 to March 2018), and cohort 4 (June 2017 to May 2018). This article outlines the evidence underlying and rationale for creation of a 2-tiered intervention approach that was developed to reduce rates of hospital-onset MRSA bacteremia.Program StructureThe STRIVE program brought together subject-matter experts, national health care professional societies, and state-level health care organizations to identify hospitals struggling to reduce HAIs. Subject-matter experts created educational materials for several infection prevention topics, including MRSA bacteremia, via in-person meetings and conference calls. The program was rolled out to 4 cohorts of hospitals across the country with the curriculum, divided into 1) onboarding, 2) foundational infection prevention strategies, and 3) education targeted to the program's 4 HAIs of interest.To develop an intervention, subject-matter experts on the national STRIVE team began by performing comprehensive literature reviews of existing systematic reviews, pertinent guidelines, practice recommendations, and expert guidance documents. Two systematic reviews were identified: one funded by the Agency for Healthcare Research and Quality that examined the comparative effectiveness of MRSA screening (10) and a Cochrane review of gloves, gowns, and masks for reducing the transmission of MRSA in hospital settings (11).Multiple guidelines that included randomized studies, observational studies, quasi-experimental studies, and expert opinion were also reviewed. We evaluated the quality of evidence behind recommendations in guidelines and gave preference to recommendations with high-quality evidence. In addition, we factored in recommendations that were based on long-standing accepted infection control practices. The guidelines reviewed were the 2014 Society for Healthcare Epidemiology (SHEA)/Infectious Diseases Society of America (IDSA) practice recommendation on prevention of MRSA transmission and infection in acute care hospitals (3), the SHEA/Healthcare Infection Control Practices Advisory Committee (HICPAC) recommendations for metrics for multidrug-resistant organisms in health care settings (12), the HICPAC guideline for hand hygiene in health care settings (13), the 2007 guideline for isolation precautions to prevent transmission of infectious agents in health care settings (14), and SHEA expert guidance on the duration of contact precautions in acute care settings (15).On the basis of prior collaborative work (3), our team believed that a tiered approach would be optimal for implementing interventions in STRIVE hospitals. The premise behind a tiered approach was to include high-evidence, low-cost, and high-impact interventions in tier 1 and more labor-intensive, often with less supporting data, interventions in tier 2. Given the myriad approaches to reducing MRSA transmission in the hospital, the team prioritized interventions that focused on 1) prevention of MRSA acquisition and 2) strategies to reduce risk for infection among individuals colonized with MRSA. We used this framework when reviewing pertinent documents and developing and organizing the 2 tiers.Tier FrameworkA 2-tiered intervention approach was developed for each HAI in the STRIVE project (Figure). Foundational elements were the main components across tier 1 strategies and were considered practices that are standard of care and should be routinely implemented in all hospitals. Tier 1 interventions therefore included foundational elements that targeted multiple HAIs (horizontal strategies, such as hand hygiene) as well as interventions specific for a given HAI (vertical strategies, such as conducting a MRSA risk assessment). Conversely, tier 2 interventions were defined as those that are more labor intensive or costly and less supported by current scientific evidence but could be considered if rates of an HAI remained elevated despite implementation of tier 1 practices. An incremental approach was taken for tier 2 interventions, with additional strategies used if rates of an HAI remain elevated.Figure. MRSA bacteremia tier 1 and 2 interventions.GPS = guide to patient safety; HO = hospital-onset; MRSA = methicillin-resistant Staphylococcus aureus; NHSN = National Healthcare Safety Network. Download figure Download PowerPoint MRSA Tier 1 InterventionsTier 1 components (Figure) are strategies recommended for implementation in all hospitals. Hospitals were encouraged to review and audit compliance with each intervention in tier 1 before moving to tier 2. Tier 1 interventions involved both vertical MRSA-specific prevention strategies as well as horizontal strategies to prevent infections due to MRSA as well as other pathogens (3).Tier 1, Intervention 1: MRSA Risk AssessmentA critical component that all hospitals should have in place is a risk assessment strategy to determine MRSA infection burden and transmission risk (3). A risk assessment allows a hospital to understand the extent to which that facility is able to control MRSA spread and, potentially, highlight specific hospital populations or units where infection prevention improvements are needed. For example, an assessment tool could determine the rates of MRSA transmission and infection, describe the local epidemiology of these events at an individual facility, and identify opportunities for MRSA transmission for a specific unit or hospital-wide. Results from a risk assessment can allow hospitals to develop and optimize an infection prevention plan for reducing MRSA transmission in the facility, as well as serve as a comparator for future assessments (12).Tier 1, Intervention 2: Case Review of Hospital-Onset MRSA Bloodstream EventsFor each National Healthcare Safety Network–defined case of hospital-onset MRSA bacteremia, hospitals should conduct a case review to identify patient and population-level risk factors in which these events occur (16–18), building an understanding of the path to infection. A case review tool is helpful for several reasons. First, it allows a systematic assessment of events, including the route through which infection may have occurred. Second, by using the created epidemiologic profile, a hospital can identify the source of and contributing factors for each MRSA bacteremia event. Finally, these data can inform preventive measures that need to be reinforced or implemented. For example, if case reviews identify that MRSA bacteremia is occurring in patients with ventilator-associated pneumonia (VAP), introduction or compliance with evidence-based VAP prevention strategies, such as subglottic secretion suction or chlorhexidine oral rinses, can be considered in high-risk populations (19). Similarly, in cases of other sites, hospitals may use data from the case review to ensure that evidence-based prevention guidelines are consistently being followed for surgical-site infections, peripheral intravenous catheter and central line–associated bloodstream infections, and dialysis-related infections, because these are the most common sources of MRSA bacteremia in health care settings (20, 21).Tier 1, Intervention 3: Monitor and Alert Health Care Personnel About Patients With MRSAIn addition to audit of cases, tier 1 recommended institution of a prospective monitoring program for MRSA (3). Hospitals should establish a program to identify and track patients from whom MRSA has been identified (3). Components of this program may include a mechanism for rapid recognition of patients with MRSA so as to enforce MRSA prevention strategies in accordance with a hospital's policy. For instance, a hospital should have in place a laboratory alert system that can rapidly notify appropriate personnel (such as care providers or infection prevention and control) when MRSA is identified in a specimen sample. Intra- and interfacility communication is an important component of alerting health care personnel of a patient's MRSA status (3). Engaging leadership and frontline health care personnel with feedback about rates of hospital-onset MRSA can help foster continued vigilance in reducing MRSA and motivate personnel to encourage adherence to infection control policies in place at that facility.Tier 1, Intervention 4: Promote and Monitor Hand Hygiene ComplianceHand hygiene (with soap and water or an alcohol-based hand gel) before and after patient contact or contact with the patient care environment remains an essential cornerstone of any hospital's infection control program (22, 23). Nevertheless, compliance by health care personnel with hand hygiene is known to be variable (24). Health care personnel need to be educated on the importance of hand hygiene compliance and how breaches in hand hygiene can promote transmission of MRSA, particularly in settings with high carriage rates of MRSA, because there is increased opportunity for health care workers to contaminate themselves and transmit MRSA to other patients (25). Regular audits of health care personnel compliance should be performed. Providing feedback on hand hygiene compliance to health care workers has been associated with significant increases in compliance (26, 27), and a reduction in MRSA bacteremia has been observed with increased adherence with hand hygiene (28). An added benefit to ensuring high compliance of health care personnel with hand hygiene is that the beneficial effects extend to prevention of transmission of other organisms (that is, it is a horizontal infection control strategy). However, because multiple methods are available to measure compliance and it remains unclear what the most effective strategy is, no single approach was emphasized (22, 29).Tier 1, Intervention 5: Initiate Contact Precautions for Patients Colonized or Infected With MRSAPatients who are colonized or infected with MRSA may be placed in private, single-occupancy rooms or cohorted with similar patients to reduce the spread of MRSA (3, 14). Contact precautions (gloves and gowns) are used during clinical encounters with patients who are colonized or infected with MRSA because these may reduce the risk for spread of MRSA to health care workers and other patients (14, 30, 31). One study observed health care worker contamination rates for gloves, gowns, and gloves and/or gown with MRSA of 17.7%, 6.2%, and 18.5%, respectively, suggesting that an infection control practice, such as contact precautions, might be beneficial for reducing spread of MRSA (32).If hospital policy recommends contact precautions for patients colonized or infected with MRSA, appropriate personal protective equipment (PPE) should be readily available (33). In addition, facilities need to confirm that health care personnel have received training on proper use of PPE and consider audits of adherence with feedback provided to personnel (3, 27). Of note, there is variation among facilities regarding use of contact precautions for patients colonized with MRSA, particularly for asymptomatic carriers (15, 34). Some before–after studies have called into question the effectiveness of contact precautions as a means to control spread of MRSA and have observed that discontinuation of contact precautions in the setting of endemic MRSA is not associated with an increase in the rate of MRSA infections (35, 36). It has therefore been suggested that hospitals choosing to forgo contact precautions should emphasize compliance with various horizontal infection control strategies (for example, hand hygiene or device bundles) to help control endemic MRSA (37).Tier 1, Intervention 6: Ensure Thorough Environmental Cleaning of Hospital Environment and Patient Care EquipmentBecause MRSA can survive on hospital surfaces and contaminate the hospital environment as well as patient care equipment (38–40), dedicated medical equipment for a single patient known to carry or be infected with MRSA, or cleaning and disinfection of equipment before use with another patient, was recommended as a tier 1 strategy (33). Environmental cleaning and disinfection reduces opportunities for contamination of health care workers' hands; consequently, risk for MRSA acquisition by subsequent room occupants has been reduced through improvements in cleaning (41, 42). Thorough cleaning and disinfection ensures that high-touch environmental surfaces are cleaned and disinfected with an Environmental Protection Agency–registered disinfectant regularly (for example, daily), when spills occur, when there is visible contamination, and at the time of discharge (3). Engaging environmental service personnel should therefore be an important component of a hospital's infection prevention and control efforts. Indirect methods that assess the thoroughness of cleaning and disinfection are available and have been used for regular audit and feedback (43).MRSA Tier 2 InterventionsTier 2 strategies (Figure) were practices considered for implementation if hospital-onset MRSA bacteremia rates remained high, despite implementation and compliance with tier 1 strategies. Tier 2 interventions were recognized to require more effort from staff, be more costly, and (in some cases) to have less supporting data; therefore, from an implementation perspective, they were not recommended as the first step in reducing MRSA HAI. Tier 2 strategies were introduced incrementally as needed, depending on the impact of prior interventions on rates of hospital-onset MRSA bacteremia.Tier 2, Intervention 1: Use a Guide to Patient Safety to Perform an MRSA Needs AssessmentWhen hospitals struggle with infection prevention, understanding where they are going wrong in terms of practice and policy is a critical first step. This "pause" in the problem-solving process could benefit from a structured approach. A guide to help hospitals ask and answer critical questions related to infection prevention has been shown to be useful and helpful when tracking HAIs, such as catheter-associated urinary tract infection (44, 45). Therefore, for MRSA, a guide to patient safety (GPS) comprising 7 key questions that hospitals should ask when examining sustained MRSA rates was created for this project (46). Questions included assessing whether dedicated personnel existed for focusing on MRSA prevention, support from leadership, collection of MRSA-related data, and feedback to frontline staff. A hospital-onset MRSA bacteremia GPS was considered the first step that hospitals would take among the tier 2 interventions.Tier 2, Intervention 2: Daily Chlorhexidine Gluconate Bathing for Patient Populations at Risk for MRSA Bloodstream InfectionsDaily bathing of ICU patients with chlorhexidine gluconate (CHG) serves as a means of "source control" and has been shown to significantly reduce potential pathogens (47), including MRSA (6), on patients' skin. Downstream benefits of decreasing the burden of patient skin contamination include 1) preventing infections due to potential pathogens on patient skin, 2) reducing the opportunity for health care workers to contaminate their hands during patient care activities, 3) reducing environmental contamination, and 4) decreasing spread of potential pathogens to other patients. Daily patient bathing with CHG has been examined in a variety of units, with data showing reduction in risk for acquisition of multidrug-resistant organisms and hospital-acquired bloodstream infections (48, 49).Linking back to tier 1, hospitals can use results of the MRSA risk assessment and hospital-onset MRSA bacteremia case reviews to identify which patient population may benefit from targeted daily CHG bathing. Although several studies support routine use of daily CHG bathing in ICUs, other high-risk populations, such as those with indwelling central venous catheters (even in non-ICU settings), may also be candidates for this infection prevention intervention (50).Key aspects to implementation of this intervention are 1) ensuring adequate education of health care personnel who will be performing the daily CHG baths; 2) ensuring product compatibility of other skin care products on that medical unit; 3) developing standardized protocols or order sets to maximize adherence of CHG bathing; 4) ensuring adequate supplies for CHG bathing and, if dilutions of CHG soap are being used rather than impregnated cloths, ensuring appropriate dilutions of products and application techniques; and 5) performing routine audits of adherence with real-time feedback to frontline personnel (3).Tier 2, Intervention 3: Decolonization for Patients With MRSA Colonization at High Risk for InfectionShould rates of hospital-onset MRSA bacteremia remain elevated despite implementation of tier 1 and early tier 2 strategies, a hospital can consider decolonization for patients identified as having MRSA colonization, particularly those at high risk for infection (for example, patients undergoing surgery or admitted to an ICU) (3). Decolonization regimens vary and include such agents as intranasal mupirocin or povidone iodine, with or without CHG bathing or systemic oral antimicrobial therapy. In a multicenter study of adult ICUs, universal decolonization with intranasal mupirocin in conjunction with daily CHG bathing was the most effective strategy for reducing rates of MRSA clinical isolates (6).When implementing decolonization, consideration should be given to the possible emergence of resistance, particularly with mupirocin (51, 52). Furthermore, in studies examining the durability of decolonization regimens, a large proportion of individuals have been found to be colonized again several months after the intervention (53), suggesting the limited durability of decolonization regimens. Nevertheless, in situations with ongoing MRSA infections despite adherence to tier 1 interventions, decolonization of at-risk patients should be a consideration.Tier 2, Intervention 4: Active Surveillance Among High-Risk Patient PopulationsActive surveillance is a strategy used to detect previously unrecognized asymptomatic MRSA carriers so that additional infection control measures (such as placement of these patients into contact isolation) can be implemented (3). Active surveillance programs can be instituted for high-risk populations (such as those in ICUs) as a strategy to help reduce cross transmission of MRSA in the unit and, ultimately, to attempt to reduce nosocomial MRSA infections (54). Often, active surveillance programs for MRSA involve screening the anterior nares for MRSA carriage. However, not all studies of active surveillance have observed a reduction in new colonization with MRSA or nosocomial MRSA infections after implementation of active surveillance (55, 56). Of note, significant planning is involved with instituting an active surveillance program in a unit or among high-risk populations in a hospital (3). Consideration is needed of the resources that would be allocated for efficient laboratory processing and reporting of results, notifying frontline staff of MRSA-positive results, implementing contact precautions if in accordance with hospital policy, and ensuring sufficient space is available for cohorting MRSA-positive patients or placing MRSA-positive patients in private rooms.Tier 2, Intervention 5: Gowning and Gloving for All ICU PatientsIf MRSA in an ICU remains prevalent, implementing a universal gown and glove policy when caring for all patients in the ICU (not just those in contact precautions or those known to be colonized or infected with MRSA) may be considered (3, 57). A cluster randomized trial compared universal glove and gown use with usual care in medical and surgical ICUs at several U.S. hospitals (57). The intervention did not result in a decrease in the primary outcome of acquisition of MRSA or vancomycin-resistant enterococci but did lead to fewer acquisitions of MRSA alone (difference, –2.98 acquisitions per 1000 person-days; P = 0.046). In addition, universal gown and glove use decreased frequency of room entry, increased room-exit hand hygiene compliance, and did not lead to a difference in adverse events (preventable and nonpreventable). Whether there is an increased risk for adverse effects among patients who are placed on contact isolation remains an unresolved issue (58). Should a strategy of universal gowning and gloving for all ICU patients be implemented, adherence to the intervention and to hand hygiene is key.ConclusionA tier-based intervention to reduce hospital-onset MRSA infections was developed to assist hospitals struggling with MRSA HAI. Tier 1 strategies included fundamental infection control practices that all hospitals should implement. 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