Rajiv Jain

Sustained Reduction in the Clinical Incidence of Methicillin- Resistant Staphylococcus aureus Colonization or Infection Associated with a Multifaceted Infection Control Intervention

OBJECTIVE To assess the impact and sustainability of a multifaceted intervention to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission implemented in 3 chronologically overlapping phases at 1 hospital. DESIGN Interrupted time-series analyses. SETTING A Veterans Affairs hospital in the northeastern United States. PATIENTS AND PARTICIPANTS Individuals admitted to acute care units from October 1, 1999, through September 30, 2008. To calculate the monthly clinical incidence of MRSA colonization or infection, the number of MRSA-positive cultures obtained from a clinical site more than 48 hours after admission among patients with no MRSA-positive clinical cultures during the previous year was divided by patient-days at risk. Secondary outcomes included clinical incidence of methicillin-sensitive S. aureus colonization or infection and incidence of MRSA bloodstream infections. INTERVENTIONS The intervention--implemented in a surgical ward beginning October 2001, in a surgical intensive care unit beginning October 2003, and in all acute care units beginning July 2005--included systems and behavior change strategies to increase adherence to infection control precautions (eg, hand hygiene and active surveillance culturing for MRSA). RESULTS Hospital-wide, the clinical incidence of MRSA colonization or infection decreased after initiation of the intervention in 2001, compared with the period before intervention (P = .002), and decreased by 61% (P < .001) in the 7-year postintervention period. In the postintervention period, the hospital-wide incidence of MRSA bloodstream infection decreased by 50% (P = .02), and the proportion of S. aureus isolates that were methicillin resistant decreased by 30% (P < .001). CONCLUSIONS Sustained decreases in hospital-wide clinical incidence of MRSA colonization or infection, incidence of MRSA bloodstream infection, and proportion of S. aureus isolates resistant to methicillin followed implementation of a multifaceted prevention program at one Veterans Affairs hospital. Findings suggest that interventions designed to prevent transmission can impact endemic antimicrobial resistance problems.

Implementation of an industrial systems-engineering approach to reduce the incidence of methicillin-resistant Staphylococcus aureus infection.

OBJECTIVE To measure the effectiveness of an industrial systems-engineering approach to a methicillin-resistant Staphylococcus aureus (MRSA) prevention program. DESIGN Before-after intervention study. SETTING An intensive care unit (ICU) and a surgical unit that was not an ICU in the Pittsburgh Veterans Administration hospital. PATIENTS All patients admitted to the study units. INTERVENTION We implemented an MRSA infection control program that consisted of the following 4 elements: (1) the use of standard precautions for all patient contact, with emphasis on hand hygiene; (2) the use of contact precautions for interactions with patients known to be infected or colonized with MRSA; (3) the use of active surveillance cultures to identify patients who were asymptomatically colonized with MRSA; and (4) use of an industrial systems-engineering approach, the Toyota Production System, to facilitate consistent and reliable adherence to the infection control program. RESULTS The rate of healthcare-associated MRSA infection in the surgical unit decreased from 1.56 infections per 1,000 patient-days in the 2 years before the intervention to 0.63 infections per 1,000 patient-days in the 4 years after the intervention (a 60% reduction; P = .003). The rate of healthcare-associated MRSA infection in the ICU decreased from 5.45 infections per 1,000 patient-days in the 2 years before to the intervention to 1.35 infections per 1,000 patient-days in the 3 years after the intervention (a 75% reduction; P = .001). The combined estimate for reduction in the incidence of infection after the intervention in the 2 units was 68% (95% confidence interval, 50%-79%; P < .001). CONCLUSIONS Sustained reduction in the incidence of MRSA infection is possible in a setting where this pathogen is endemic. An industrial systems-engineering approach can be adapted to facilitate consistent and reliable adherence to MRSA infection prevention practices in healthcare facilities.

Nationwide reduction of health care-associated methicillin-resistant Staphylococcus aureus infections in Veterans Affairs long-term care facilities.

The Veterans Affairs methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative was implemented in its 133 long-term care facilities in January 2009. Between July 2009 and December 2012, there were ~12.9 million resident-days in these facilities nationwide. During this period, the mean quarterly MRSA admission prevalence increased from 23.3% to 28.7% (P < .0001, Poisson regression for trend), but the overall rate of MRSA health care-associated infections decreased by 36%, from 0.25 to 0.16/1,000 resident-days (P < .0001, Poisson regression for trend).

Veterans Affairs methicillin-resistant Staphylococcus aureus prevention initiative associated with a sustained reduction in transmissions and health care-associated infections

Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative was associated with significant declines in MRSA transmission and MRSA health care-associated infection rates in Veterans Affairs acute care facilities nationwide in the 33-month period from October 2007 through June 2010. Here, we show continuing declines in MRSA transmissions (P = .004 for trend, Poisson regression) and MRSA health care-associated infections (P < .001) from July 2010 through June 2012. The Veterans Affairs Initiative was associated with these effects, sustained over 57 months, in a large national health care system.

Clostridium difficile Infections in Veterans Health Administration Long-Term Care Facilities.

OBJECTIVE A nationwide initiative was implemented in February 2014 to decrease Clostridium difficile infections (CDI) in Veterans Affairs (VA) long-term care facilities. We report a baseline of national CDI data collected during the 2 years before the Initiative. METHODS Personnel at each of 122 reporting sites entered monthly retrospective CDI case data from February 2012 through January 2014 into a national database using case definitions similar to those used in the National Healthcare Safety Network Multidrug-Resistant Organism/CDI module. The data were evaluated using Poisson regression models to examine infection occurrences over time while accounting for admission prevalence and type of diagnostic test. RESULTS During the 24-month analysis period, there were 100,800 admissions, 6,976,121 resident days, and 1,558 CDI cases. The pooled CDI admission prevalence rate (including recurrent cases) was 0.38 per 100 admissions, and the pooled nonduplicate/nonrecurrent community-onset rate was 0.17 per 100 admissions. The pooled long-term care facility-onset rate and the clinically confirmed (ie, diarrhea or evidence of pseudomembranous colitis) long-term care facility-onset rate were 1.98 and 1.78 per 10,000 resident days, respectively. Accounting for diagnostic test type, the long-term care facility-onset rate declined significantly (P=.05), but the clinically confirmed long-term care facility-onset rate did not. CONCLUSIONS VA long-term care facility CDI rates were comparable to those in recent reports from other long-term care facilities. The significant decline in the long-term care facility-onset rate but not in the clinically confirmed long-term care facility-onset rate may have been due to less testing of asymptomatic patients. Efforts to decrease CDI rates in long-term care facilities are necessary as part of a coordinated approach to decrease healthcare-associated infections.

Clinical incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection as a proxy measure for MRSA transmission in acute care hospitals.

BACKGROUND The incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection has been used as a proxy measure for MRSA transmission, but incidence calculations vary depending on whether active surveillance culture (ASC) data are included. OBJECTIVE To evaluate the relationship between incidences of MRSA colonization or infection calculated with and without ASCs in intensive care units and non-intensive care units. SETTING A Veterans Affairs medical center. METHODS From microbiology records, incidences of MRSA colonization or infection were calculated with and without ASC data. Correlation coefficients were calculated for the 2 measures, and Poisson regression was used to model temporal trends. A Poisson interaction model was used to test for differences in incidence trends modeled with and without ASCs. RESULTS The incidence of MRSA colonization or infection calculated with ASCs was 4.9 times higher than that calculated without ASCs. Correlation coefficients for incidences with and without ASCs were 0.42 for intensive care units, 0.59 for non-intensive care units, and 0.48 hospital-wide. Trends over time for the hospital were similar with and without ASCs (incidence rate ratio with ASCs, 0.95 [95% confidence interval, 0.93-0.97]; incidence rate ratio without ASCs, 0.95 [95% confidence interval, 0.92-0.99]; P = .68). Without ASCs, 35% of prevalent cases were falsely classified as incident. CONCLUSIONS At 1 Veterans Affairs medical center, the incidence of MRSA colonization or infection calculated solely on the basis of clinical culture results commonly misclassified incident cases and underestimated incidence, compared with measures that included ASCs; however, temporal changes were similar. These findings suggest that incidence measured without ASCs may not accurately reflect the magnitude of MRSA transmission but may be useful for monitoring transmission trends over time, a crucial element for evaluating the impact of prevention activities.

Targeted decolonization to prevent ICU infections.

To the Editor: Huang and colleagues (June 13 issue)1 report that universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of methicillin-resistant Staphylococcus aureus (MRSA) clinical isolates. However, the study protocol indicates that patients with a history of MRSA infection who underwent universal decolonization were still isolated; of the patients undergoing universal decolonization, 10.6% had a MRSA history during the observation period and 3.7% had such a history during the intervention period. This suggests that one third of patients with positive tests for MRSA in this group may have been isolated and that universal decolonization meant more than simply decolonization. The protocol describes extensive training and regular input in hospitals that were randomly assigned to targeted or universal decolonization, but the facilities that were assigned to screening and isolation (standard of care) did not appear to receive this training and input. It is conceivable that training led to improved infection control and reduced infection rates that were independent of the studyspecific interventions. The protocol indicates that resistance to mupirocin or chlorhexidine was a secondary outcome. These data are not reported but are required to weigh the gains from universal decolonization against the emergence of resistance.

289Occurrence of Methicillin-Resistant Staphylococcus aureus (MRSA) Surgical Site Infections (SSIs) of Total Knee and Total Hip Arthroplasty (TKA and THA) Procedures within Veterans Health Administration Medical Centers

289. Occurrence of Methicillin-Resistant Staphylococcus aureus (MRSA) Surgical Site Infections (SSIs) of Total Knee and Total Hip Arthroplasty (TKA and THA) Procedures within Veterans Health Administration Medical Centers Stephen Kralovic, MD, MPH; Martin Evans, MD; Loretta Simbartl, MS; Judith Whitlock, RN, MSN, APRN; Marla Clifton, RN, MSN, CIC; Rajiv Jain, MD; Gary Roselle, MD; National Infectious Diseases Service, Department of Veterans Affairs Central Office, Cincinnati, OH; Division of Infectious Diseases, University of Cincinnati, Cincinnati, OH; Cincinnati VA Medical Center, Cincinnati, OH; Department of Veterans Affairs Central Office National Infectious Diseases Service MRSA/MDRO Prevention Office, Lexington, KY; Lexington VA Medical Center, Lexington, KY; Department of Veterans Affairs, Veterans Health Administration Central Office Patient Care Services, Washington, DC