Loading...
Please wait, while we are loading the content...
Similar Documents
Choosing Between Methods to Prevent Methicillin-Resistant Staphylococcus aureus in ICUs*
| Content Provider | Scilit |
|---|---|
| Author | Morgan, Daniel J. |
| Copyright Year | 2015 |
| Description | Journal: Critical Care Medicine |
| Abstract | Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of infections, annually accounting for over 62,000 invasive healthcare-associated infections in the United States (1). In this issue of Critical Care Medicine, Ziakas et al (2) present a decision analysis estimating costs related to MRSA prevention methods examined in the Randomized Evaluation of Decolonization vs. Universal Clearance to Eliminate MRSA (REDUCE MRSA) trial (3). The REDUCE MRSA cluster trial randomized 74 ICUs in 43 hospitals to active surveillance culturing (ASC) with isolation of patients found to be positive, ASC with targeted decolonization of those found to be positive, or universal decolonization of all patients without ASC. Decolonization was performed with daily chlorhexidine bathing and intranasal mupirocin antibiotic. The REDUCE MRSA trial found that universal decolonization was the most effective strategy, reducing MRSA clinical cultures and all-cause bacteremia, the biggest effect being on skin commensals (3). A similar ICU randomized cluster trial of chlorhexidine bathing without mupirocin found a 23% decrease in MRSA or vancomycin-resistant Enterococcus (VRE) colonization by screening cultures and a decrease in bacteremia, with the biggest effect on skin commensals again (4). Finally, a cluster trial of universal use of gown and glove use without ASC in all ICU patients (that I helped conduct) found a 40% decrease in MRSA colonization by screening cultures (5). How should an ICU allocate limited resources between these and the other methods of infection control (hand hygiene, environmental cleaning, healthcare-associated infection prevention bundles, etc.)? It is from this perspective that one reads the decision analysis by Ziakas et al (2) modeling the expected financial costs associated with adoption of the different interventions of the REDUCE MRSA trial. Notably, there is no assessment of the standard Centers for Disease Control and Prevention recommended practice of Contact Precautions for patients with MRSA or VRE identified by clinical cultures (and not ASC). As with any model, there are many assumptions, terms, and data-rich tables that induce heavy eyelids in clinicians. To understand the model, it is key to focus on the assumptions. These include 1) 9% admission prevalence for MRSA, which lower than in many regions, and 2) costs associated with identifying MRSA by ASC, they choose the less expensive culture versus polymerase chain reaction test ($75 vs $311, per authors). The most important assumption is the estimated effect of MRSA clinical cultures on length of stay. Estimates were based on a study finding a 0.3–1.2 day increased length of stay with the more rigorous definition of MRSA infection and not MRSA clinical cultures (6). These assumptions lead to the conclusion that the more effective strategy for MRSA clinical culture reduction is also more cost-effective. Universal decolonization was less expensive, saving $189 per patient over ASC with Contact Precautions and $172 over ASC with targeted decolonization. Given chlorhexidine and mupirocin is generally less expensive than gowns, gloves, and admission MRSA screening, and this has face validity. Recently, the investigators who performed the REDUCE MRSA trial published a decision analysis of their trial that included costs of each intervention and instead of examining the impact of MRSA clinical cultures, looked at the impact of overall bacteremia (7). This makes an interesting comparison to the decision analysis by Ziakas et al (2) focused on MRSA clinical cultures. Huang et al (7) estimate per patient savings of $171 over ASC with Contact Precautions and $100 over ASC with targeted decolonization. The assumptions of the models were similar, beyond the assumption by Huang et al (3, 7) that each bacteremia resulted in a 3. |
| Related Links | http://europepmc.org/articles/pmc4299917?pdf=render https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4299917/pdf |
| Ending Page | 497 |
| Page Count | 2 |
| Starting Page | 496 |
| ISSN | 00903493 |
| e-ISSN | 15300293 |
| DOI | 10.1097/ccm.0000000000000779 |
| Journal | Critical Care Medicine |
| Issue Number | 2 |
| Volume Number | 43 |
| Language | English |
| Publisher | Ovid Technologies (Wolters Kluwer Health) |
| Publisher Date | 2015-02-01 |
| Access Restriction | Open |
| Subject Keyword | Journal: Critical Care Medicine Critical Care Medicine Methicillin-resistant Staphylococcus Aureus (mrsa) Active Surveillance Infection Prevention |
| Content Type | Text |
| Resource Type | Article |
| Subject | Critical Care and Intensive Care Medicine |
