Sally Stewart

Should healthcare workers be screened routinely for meticillin-resistant Staphylococcus aureus? A review of the evidence

Meticillin-resistant Staphylococcus aureus (MRSA) is considered endemic in the UK National Health Service (NHS), and routine MRSA screening of hospital inpatients has recently been introduced in both Scotland and England. The UK National Screening Committee states that public pressure for widening the eligibility criteria of a proposed screening programme should be anticipated and any related decisions scientifically justifiable. A literature review was conducted to examine whether MRSA screening in Scotland should be expanded to include the routine screening of healthcare workers (HCWs). There are no published prevalence studies reporting the overall MRSA carriage rate in HCWs in NHS hospitals. Estimates of HCW carriage from the worldwide literature vary widely depending on the country, hospital specialty and setting (endemic, non-endemic or outbreak). Recent studies conducted in endemic hospital settings report non-outbreak carriage rates of 0-15%. The role of HCW carriage in the transmission of MRSA is not well understood. Persistent carriage could act as a reservoir for infection and HCWs have been implicated as the source in a number of published outbreak reports. There are no published controlled trials examining the impact of routine HCW screening as an intervention in the prevention and control of MRSA infections in the endemic hospital setting. Most of the evidence for HCW screening comes from outbreak reports where the outbreak was brought to an end following the introduction of staff screening as part of a suite of infection control measures. Further research is required before a recommendation could be made to introduce routine MRSA screening of HCWs in the NHS in Scotland.

Universal screening for meticillin-resistant Staphylococcus aureus: interim results from the NHS Scotland pathfinder project

Following recommendations from a Health Technology Assessment (HTA), a prospective cohort study of meticillin-resistant Staphylococcus aureus (MRSA) screening of all admissions (N=29 690) to six acute hospitals in three regions in Scotland indicated that 7.5% of patients were colonised on admission to hospital. Factors associated with colonisation included re-admission, specialty of admission (highest in nephrology, care of the elderly, dermatology and vascular surgery), increasing age, and the source of admission (care home or other hospital). Three percent of all those who were identified as colonised developed hospital-associated MRSA infection, compared with only 0.1% of those not colonised. Specialties with a high rate of colonisation on admission also had higher rates of MRSA infection. Very few patients refused screening (11 patients, 0.03%) or had treatment deferred (14 patients, 0.05%). Several organisational issues were identified, including difficulties in achieving complete uptake of screening (88%) or decolonisation (41%); the latter was largely due to short duration of stay and turnaround time for test results. Patient movement resulted in a decision to decolonise all positive patients rather than just those in high risk specialties as proposed by the HTA. Issues also included a lack of isolation facilities to manage patients with MRSA. The study raises significant concerns about the contribution of decolonisation to reducing risks in hospital due to short duration of stay, and reinforces the central role of infection control precautions. Further study is required before the HTA model can be re-run and conclusions redrawn on the cost and clinical effectiveness of universal MRSA screening.

Results from the Scottish National HAI Prevalence Survey

A national point prevalence survey was undertaken over the period of one calendar year in Scotland from October 2005 to October 2006. The prevalence of healthcare-associated infection (HAI) was 9.5% in acute hospitals and 7.3% in non-acute hospitals. The highest prevalence of HAI in acute hospital inpatients was found in the following specialties: care of the elderly (11.9%), surgery (11.2%), medicine (9.6%) and orthopaedics (9.2%). The lowest prevalence was found in obstetrics (0.9%). The most common types of HAI in acute hospital inpatients were: urinary tract infections (17.9% of all HAI), surgical site infections (15.9%) and gastrointestinal infections (15.4%). In non-acute hospitals one in ten inpatients in two specialties (combined) - medicine (11.4%) and care of the elderly (7.8%) - was found to have HAI, and one in 20 inpatients in psychiatry (5.0%) had HAI. In non-acute hospital patients, urinary tract infections were frequent (28.1% of all HAI) and similarly skin and soft tissue infection (26.8% of all HAI). When combined, these two HAI types affected 4% of all the inpatients in non-acute hospitals. This is the first survey of its kind in Scotland and describes the burden of HAI at a national level.

Universal screening for meticillin-resistant Staphylococcus aureus in acute care : risk factors and outcome from a multicentre study

BACKGROUNDnA Health Technology Assessment (HTA) model on effectiveness of meticillin-resistant Staphylococcus aureus (MRSA) screening in Scotland suggested that universal screening using chromogenic agar was the preferred option in terms of effectiveness and cost.nnnAIMnTo test the models validity through a one-year pilot-study.nnnMETHODnA large one-year prospective cohort study of MRSA screening was carried out in six acute hospitals in NHS Scotland, incorporating 81,438 admissions. Outcomes (MRSA colonization and infection rates) were subjected to multivariable analyses, and trends before and after implementation of screening were compared.nnnFINDINGSnThe initial colonization prevalence of 5.5% decreased to 3.5% by month 12 of the study (Pxa0<xa00.0001). Colonization was associated with the number of admissions per patient, specialty of admission, age, and source of admission (home, other hospital or care home). Around 2% of all admissions with no prior history of MRSA infection or colonization tested positive. Those who were screen positive on admission and not previously known positive were 12 times more likely than those who screened negative to develop infection, increasing to 18 times if they were both screen positive and previously known positive. MRSA infections (7.5 per 1000 inpatient-days overall) also reduced significantly over the study year (Pxa0=xa00.0209).nnnCONCLUSIONnThe risk factors identified for colonization and infection indicate that a universal clinical risk assessment may have a role in MRSA screening.

The Prevalence of Health Care–Associated Infection in Older People in Acute Care Hospitals

OBJECTIVEnTo determine the prevalence of health care-associated infection (HAI) in older people in acute care hospitals, detailing the specific types of HAI and specialties in which these are most prevalent.nnnDESIGNnSecondary analysis of the Scottish National Healthcare Associated Infection Prevalence Survey data set.nnnPATIENTS AND SETTINGnAll inpatients in acute care (n = 11,090) in all acute care hospitals in Scotland (n = 45).nnnRESULTSnThe study found a linear relationship between prevalence of HAI and increasing age (P<.0001) in hospital inpatients in Scotland. Urinary tract infections and gastrointestinal infections represented the largest burden of HAI in the 75-84- and over-85-year age groups, and surgical-site infections represented the largest burden in inpatients under 75 years of age. The prevalence of urinary catheterization was higher in each of the over-65 age groups (P<.0001). Importantly, this study reveals that a high prevalence of HAI in inpatients over the age of 65 years is found across a range of specialties within acute hospital care. An increased prevalence of HAI was observed in medical, orthopedic, and surgical specialties.nnnCONCLUSIONSnHAI is an important outcome indicator of acute inpatient hospital care, and our analysis demonstrates that HAI prevalence increases linearly with increasing age (P<.0001). Focusing interventions on preventing urinary tract infection and gastrointestinal infections would have the biggest public health benefit. To ensure patient safety, the importance of age as a risk factor for HAI cannot be overemphasized to those working in all areas of acute care.

Evidence-based infection control planning based on national healthcare-associated infection prevalence data.

This study identifies factors associated with a high prevalence of healthcare-associated infection (HAI) in the Scottish inpatient population, on the basis of the Scotland National HAI Prevalence Survey data set. The multivariate models developed can be used to predict HAI prevalence in specific patient groups to help with planning and policy in infection control.

Understanding the patient experience of health care–associated infection: A qualitative systematic review

HIGHLIGHTSQualitative research synthesis of patients experiences across different health care–associated infections (HAIs).Continuum to enhance understanding of physical and emotional responses across HAIs.Importance of practitioner‐patient communication to minimize distress.New perspectives on how contemporary understanding of contagion produces stigma.Analysis of patients HAI experiences to inform care quality improvement. Background: The global burden of health care–associated infection (HAI) is well recognized; what is less well known is the impact HAI has on patients. To develop acceptable, effective interventions, greater understanding of patients experience of HAI is needed. This qualitative systematic review sought to explore adult patients experiences of common HAIs. Methods: Five databases were searched. Search terms were combined for qualitative research, HAI terms, and patient experience. Study selection was conducted by 2 researchers using prespecified criteria. Critical Appraisal Skills Programme quality appraisal tools were used. Internationally recognized Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines were applied. The Noblit and Hare (1988) approach to meta‐synthesis was adopted. Results: Seventeen studies (2001–2017) from 5 countries addressing 5 common types of HAI met the inclusion criteria. Four interrelated themes emerged: the continuum of physical and emotional responses, experiencing the response of health care professionals, adapting to life with an HAI, and the complex cultural context of HAI. Conclusions: The impact of different HAIs may vary; however, there are many similarities in the experience recounted by patients. The biosociocultural context of contagion was graphically expressed, with potential impact on social relationships and professional interactions highlighted. Further research to investigate contemporary patient experience in an era of antimicrobial resistance is warranted.

Estimating excess length of stay due to healthcare-associated infections: a systematic review and meta-analysis of statistical methodology

BACKGROUNDnHealthcare-associated infection (HCAI) affects millions of patients worldwide. HCAI is associated with increased healthcare costs, owing primarily to increased hospital length of stay (LOS) but calculating these costs is complicated due to time-dependent bias. Accurate estimation of excess LOS due to HCAI is essential to ensure that we invest in cost-effective infection prevention and control (IPC) measures.nnnAIMnTo identify and review the main statistical methods that have been employed to estimate differential LOS between patients with, and without, HCAI; to highlight and discuss potential biases of all statistical approaches.nnnMETHODSnA systematic review from 1997 to April 2017 was conducted in PubMed, CINAHL, ProQuest and EconLit databases. Studies were quality-assessed using an adapted Newcastle-Ottawa Scale (NOS). Methods were categorized as time-fixed or time-varying, with the former exhibiting time-dependent bias. Two examples of meta-analysis were used to illustrate how estimates of excess LOS differ between different studies.nnnFINDINGSnNinety-two studies with estimates on excess LOS were identified. The majority of articles employed time-fixed methods (75%). Studies using time-varying methods are of higher quality according to NOS. Studies using time-fixed methods overestimate additional LOS attributable to HCAI. Undertaking meta-analysis is challenging due to a variety of study designs and reporting styles. Study differences are further magnified by heterogeneous populations, case definitions, causative organisms, and susceptibilities.nnnCONCLUSIONnMethodologies have evolved over the last 20 years but there is still a significant body of evidence reliant upon time-fixed methods. Robust estimates are required to inform investment in cost-effective IPC interventions.

Right Here Right Now (RHRN) pilot study: testing a method of near-real-time data collection on the social determinants of health

Background Informing policy and practice with up-to-date evidence on the social determinants of health is an ongoing challenge. One limitation of traditional approaches is the time-lag between identification of a policy or practice need and availability of results. The Right Here Right Now (RHRN) study piloted a near-real-time data-collection process to investigate whether this gap could be bridged. Methods A website was developed to facilitate the issue of questions, data capture and presentation of findings. Respondents were recruited using two distinct methods – a clustered random probability sample, and a quota sample from street stalls. Weekly four-part questions were issued by email, Short Messaging Service (SMS or text) or post. Quantitative data were descriptively summarised, qualitative data thematically analysed, and a summary report circulated two weeks after each question was issued. The pilot spanned 26 weeks. Results It proved possible to recruit and retain a panel of respondents providing quantitative and qualitative data on a range of issues. The samples were subject to similar recruitment and response biases as more traditional data-collection approaches. Participants valued the potential to influence change, and stakeholders were enthusiastic about the findings generated, despite reservations about the lack of sample representativeness. Stakeholders acknowledged that decision-making processes are not flexible enough to respond to weekly evidence. Conclusion RHRN produced a process for collecting near-real-time data for policy-relevant topics, although obtaining and maintaining representative samples was problematic. Adaptations were identified to inform a more sustainable model of near-real-time data collection and dissemination in the future.

An adjusted funnel plot methodology for benchmarking targeted local healthcare associated prevalence surveys

We report the development of a local healthcare associated infection prevalence survey methodology that uses multivariate adjustment and funnel plots to facilitate benchmarking of local survey results against Scottish National HAI Prevalence Survey data. The tool provides robust and consistent results that can be used to inform infection control strategy.