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MRSA SCREENING:
THEORETICAL VS. PRACTICAL
Nancy Alfieri, March 5, 2008
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Why Screen?
PROs:• MRSA has increased (in CHR) from 2.2 to
9.4/10,000 patient days since 2003
• CMRSA (new cases) is rising as quickly as health-care associated MRSA in the CHR
• U.S. data indicates an MRSA infection costs an additional $35,000 (while other nosocomial infections add $14,000 to $15,000)
• Patients with unidentified MRSA act as reservoirs for transmission
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CONs:
• Screening programs are expensive…
$100,000 allows 5,000 persons to be screened (average of 2.5 screens/person)
3 averted infections = $105,000
• Isolation precautions challenge systems already stretched to capacity
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CHR Universal Screening Pilot Project
• 3 months, 3 units(orthopedic surgery, palliative/medicine, medical teaching)
• Methods:• All patients admitted to these units were screened
• Prevalence screens conducted prior to beginning screening and on termination of the pilot
• Anatomical sites screened were: – Nasal culture– Z body swab (axilla and torso)– Up to three wounds
• Suppression: CHG bath/shower
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Results• 89.2% of eligible patients were screened
PREVALENCE SCREEN RESULTS
FMC (%) PLC (%) RGH (%) Total
Previously unknown MRSA positive patients detected during Prevalence Screen #1 1/37 (2.7) 4/26 (15.3) 0/33 5/96(5.2)
Previously unknown MRSA positive patients detected during Prevalence Screen #2 1/33 (3.0) 2/29 (6.7) 0/27 3/89(3.3)
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New Cases Admitted During Pilot
FMC (%) PLC (%) RGH (%)
Positive screening at admission to study unit 8/445 (1.8) 20/238(8.4) 11/246 (4.5)
Positive clinical isolate* at admission 0 1/238(0.4) 0
Positive clinical isolate >72 hrs in hospital 0 1/238(0.4) 0
Total 8/445 (1.8) 22/238 (9.2) 11/246 (4.5)
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Acquisition of Newly Detected MRSA
Positive Cases
FMC PLC RGH Total (%)
Nosocomial* 3 12 2 17 (41.5)
LTC 1 0 4 5 (12.2)
Community 4 10 4 18 (43.9)
Unknown 0 0 1 1 (2.4)
Total 8 22 11 41 (100.0)
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The Last Table is Important! Why?
• An equal number of cases are hospital-acquired and community-acquired
• This means up to 44% of the positive patients would have been “missed” using an admission screening protocol based on previous hospitalization or living in “institutional” settings
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What Did We Learn…
• For the CHR, traditional admission screening would not capture a large proportion of the MRSA-colonized clients
• Medically complex patients with multiple co-morbidities and frequent health care encounters are to be considered “high risk” for MRSA
• Some surgical patient populations may be low risk
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What did we learn…(cont’d)
• “Universal” screening is challenging to units facing significant staffing shortages
• Housekeeping workload increases as the burden of patients on isolation increases
• Suppression regimes may be an effective way to decrease transmission risk
• Streamlining screening processes is key to sustainability
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Next Steps…
• In the CHR we are proposing expansion of the “universal” screening process and staging implementation
• Screening programs require regular analysis for efficiency and effectiveness
• Screening combined with interventions to reduce transmission requires further study
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GO OUT ON A LIMB…
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Recommendations1. Go ‘out on a limb’, test your population appropriately
2. Engage the front-line care providers and measure workload, transmission/ acquisition rates in screening programs
3. Question, Question, Question….if the screening protocols don’t impact nosocomial acquisition…then what?
4. Test interventions:• Effective screening specimens• Decolonization• Suppression• Isolation• Environmental controls• Hand hygiene