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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).

      Key Words

      The Department of Veterans Affairs (VA) administers 133 long-term care facilities (Community Living Centers [CLCs]) throughout the United States that provide services for up to 12,000 veterans daily. These services include geriatric evaluation, skilled nursing, rehabilitation, restorative, psychiatric, dementia, hospice, palliative, and respite care.
      Between 26% and 62% of residents in VA and non-VA long-term care facilities may be colonized with methicillin-resistant Staphylococcus aureus (MRSA),
      • Stone N.D.
      • Lewis D.R.
      • Johnson T.M.
      • Hartney T.
      • Chandler D.
      • Byrd-Sellers J.
      • et al.
      Methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage in residents of Veterans Affairs long-term care facilities: role of antimicrobial exposure and MRSA acquisition.
      • Mody L.
      • Kauffman C.A.
      • Donabedian S.
      • Zervos M.
      • Bradley S.F.
      Epidemiology of Staphylococcus aureus colonization in nursing home residents.
      • Lee B.Y.
      • Singh A.
      • Bartsch S.M.
      • Wong K.F.
      • Kim D.S.
      • Avery T.R.
      • et al.
      The potential regional impact of contact precaution use in nursing homes to control methicillin-resistant Staphylococcus aureus.
      with the highest rates seen in those with indwelling devices.
      • Mody L.
      • Kauffman C.A.
      • Donabedian S.
      • Zervos M.
      • Bradley S.F.
      Epidemiology of Staphylococcus aureus colonization in nursing home residents.
      The risk of infection is significantly higher in residents colonized with MRSA compared with those not colonized with MRSA and those colonized with methicillin-susceptible S aureus.
      • Muder R.A.
      • Brennen C.
      • Wagener M.M.
      • Vickers R.M.
      • Rihs J.D.
      • Hancock G.A.
      • et al.
      Methicillin-resistant staphylococcal colonization and infection in a long-term care facility.
      The management of MRSA infections increases the costs associated with long-term care,
      • Capitano B.
      • Leshem O.A.
      • Nightingale C.H.
      • Nicolau D.P.
      Cost effect of managing methicillin-resistant Staphylococcus aureus in a long-term care facility.
      and colonized individuals may spread MRSA to other patients after admission to acute care facilities.
      • Manzur A.
      • Gudiol F.
      Methicillin-resistant Staphylococcus aureus in long-term-care facilities.
      A MRSA Prevention Initiative was implemented in all VA acute care hospitals in 2007. This initiative featured a “bundle” consisting of (1) nasal surveillance for MRSA on all hospital admissions, in-hospital transfers, and discharges; (2) contact precautions for patients carrying MRSA; (3) hand hygiene; and (4) an institutional culture change in which infection prevention and control became everyone's responsibility. Implementation of the initiative in the acute care setting was associated with a 62% decline in MRSA health care–associated infection (HAI) rates in intensive care units and a 45% decline in non–intensive care units nationwide.
      • Jain R.
      • Kralovic S.M.
      • Evans M.E.
      • Ambrose M.
      • Simbartl L.A.
      • Obrosky D.S.
      • et al.
      Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.
      By September 2010, more than 70% of acute care facilities reported zero MRSA HAIs each month.
      • Kralovic S.M.
      • Evans M.E.
      • Simbartl L.A.
      • Ambrose M.
      • Jain R.
      • Roselle G.A.
      Zeroing in on methicillin-resistant Staphylococcus aureus: US Department of Veterans Affairs' MRSA Prevention Initiative.
      Based on concerns regarding MRSA in the VA CLCs, the MRSA Prevention Initiative was expanded into these facilities in January 2009. Here we report declines in MRSA HAIs from July 2009 through December 2012 associated with implementation of the initiative in this setting.

      Methods

      Resources for the MRSA Prevention Initiative, training of MRSA Prevention Coordinators (MPCs) at each facility, and Institutional Review Board approval have been described previously.
      • Jain R.
      • Kralovic S.M.
      • Evans M.E.
      • Ambrose M.
      • Simbartl L.A.
      • Obrosky D.S.
      • et al.
      Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.
      A CLC-specific MPC was added to CLCs with more than 200 beds with expansion of the initiative into CLCs.
      MRSA admission prevalence was calculated as the number of CLC admissions with MRSA, either from nasal surveillance or a clinical culture within 48 hours of admission, as a percentage of the total number of admissions for the CLC. MRSA HAIs were defined according to guidelines of the Center for Disease Control and Prevention's National Healthcare Safety Network (NHSN) with modifications noted previously.
      • Jain R.
      • Kralovic S.M.
      • Evans M.E.
      • Ambrose M.
      • Simbartl L.A.
      • Obrosky D.S.
      • et al.
      Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.
      Data on admission prevalence and MRSA HAIs were entered into the VA Inpatient Evaluation Center national database (Cincinnati, OH) each month by MPCs at each CLC. Data were analyzed quarterly beginning in July 2009 (the first month of the first quarter with complete data) and extending through December 2012.
      All statistical data analyses were performed using SAS version 9.2 (SAS Institute, Cary, NC). Descriptive statistics were examined for data normality. Poisson regression models, using resident-days as an offset variable, were used to compare the change in infection rate over time. All P values were based on 2-tailed tests, and P ≤ .05 was considered statistically significant.
      VA CLCs promote a home-like environment in which residents do not “live in their bedrooms,” but rather are encouraged to leave their rooms to socialize with others in the facility. At the same time, infection prevention and control policies are in place to prevent transmission of pathogens within the CLC. For the MRSA Prevention Initiative, colonized or infected residents were categorized as low risk or high risk based on their likelihood of transmitting MRSA to other residents. Low-risk residents were those who were cognitive, willing and able to consistently follow instructions regarding personal hygiene, and had no active MRSA infection, and in whom all wounds, drainage, and body fluids could be consistently covered or contained. High-risk residents were those who did not meet all of these criteria. Low-risk residents were to be given a private room or cohorted with other low-risk residents, with gloves and gowns used during their care. These residents could leave the bedroom if they observed good hand hygiene, wore clean clothing, and kept all wounds, drainage, and body fluids covered and contained. Residents deemed at high risk were managed under contact precautions.
      • Siegel J.D.
      • Rhinehart E.
      • Jackson M.
      • Chiarello L.
      Guideline for isolation precautions: preventing transmission of infectious agents in health care settings 2007.

      Results

      During the 42-month analysis period of July 2009 through December 2012, there were a total of ∼12.9 million resident-days in VA CLCs nationwide. The mean quarterly MRSA admission prevalence increased from 23.3% to 28.7% (P < .0001, Poisson regression for trend) (Fig 1). The ratio of residents with MRSA colonization or infection who were identified by active surveillance to those identified by clinical cultures alone was 37:1. The overall MRSA HAI rate decreased by 36%, from 0.25 to 0.16/1,000 resident-days (P < .0001, Poisson regression for trend), during the analysis period (Fig 2).
      Figure thumbnail gr1
      Fig 1Quarterly prevalence of MRSA detected by clinical cultures or surveillance screening on admission to VA CLCs nationwide from July 2009 through December 2012.
      Figure thumbnail gr2
      Fig 2Quarterly MRSA HAIs per 1000 resident-days in the 133 VA CLCs nationwide from July 2009 through December 2012. P values are for trend in HAI rates. The inset shows the distribution of CLC MRSA HAIs other than pneumonia by type during the 42-month analysis period. PNA, pneumonia; GI, gastrointestinal; ENT, ear, nose, and throat; LRT, lower respiratory tract.
      The distribution of MRSA HAIs during the analysis period was 45% skin and soft tissue infections, 25% urinary tract infections (UTIs), 9% pneumonias, 8% bloodstream infections (BSIs), 7% ear, nose, and throat infections, 3% lower respiratory tract infections other than pneumonia, 2% bone infections, and 1% gastrointestinal infections (Fig 2). Rates of health care–acquired MRSA lower respiratory tract infections and non–catheter-associated UTIs decreased significantly (P = .001 and P < .0001, respectively, Poisson regression for trend), but rates of non–device-associated MRSA BSI (P = .30), pneumonia (P = .10), and skin and soft tissue infections (P = .09) remained unchanged.
      Approximately one-half (51%) of the MRSA BSIs recorded during the analysis period were central line–associated and 58% of MRSA UTIs were catheter-associated. Nationwide, during the analysis period, MRSA central line–associated BSI rates decreased from 0.07 to 0.02/1,000 device-days (P = .27), whereas MRSA catheter-associated UTI rates decreased from 0.34 to 0.28/1,000 device-days (P = .001).

      Discussion

      We previously reported that a MRSA Prevention Initiative was associated with significant decreases in MRSA HAIs in acute care facilities over a 33-month period in a large health care system.
      • Jain R.
      • Kralovic S.M.
      • Evans M.E.
      • Ambrose M.
      • Simbartl L.A.
      • Obrosky D.S.
      • et al.
      Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.
      Here we show that the initiative was also associated with decreased rates of MRSA HAIs in VA CLCs without a corresponding decrease in MRSA admission prevalence. To our knowledge, declines in MRSA HAIs such as this have not been reported in other large long-term care settings.
      A recent survey of 10 California nursing homes found that the prevalence of residents carrying MRSA was 18% on admission but 31% after admission. The 67% increase in prevalence after admission could not be accounted for by differences in length of stay between the MRSA-positive and -negative residents, suggesting that the increased prevalence was related to residents congregating in common areas or having roommates, or to a lack of standard contact isolation policies in the nursing homes.
      • Reynolds C.
      • Quan V.
      • Kim D.
      • Peterson E.
      • Dunn J.
      • Whealon M.
      • et al.
      Methicillin-resistant Staphylococcus aureus (MRSA) carriage in 10 nursing homes in Orange County, California.
      Recent computer simulations have demonstrated the benefit of using contact precautions for all MRSA colonized and infected residents in long-term care settings.
      • Lee B.Y.
      • Singh A.
      • Bartsch S.M.
      • Wong K.F.
      • Kim D.S.
      • Avery T.R.
      • et al.
      The potential regional impact of contact precaution use in nursing homes to control methicillin-resistant Staphylococcus aureus.
      The VA's experience with MRSA in both acute care and long-term care settings is consistent with the concept that health care networks obtain better results when they cooperate in infection control. This may be because efforts to control MRSA infections by an individual hospital might be adversely affected when patients are transferred from another facility with less rigorous infection control practices. Simulations of the effect of cooperation among regional hospitals have demonstrated that each hospital's decision to test for MRSA and implement contact isolation can affect the prevalence of MRSA in all other hospitals in the region.
      • Lee B.Y.
      • Bartsch S.M.
      • Wong K.F.
      • Yilmaz S.L.
      • Avery T.R.
      • Singh A.
      • et al.
      Simulation shows hospitals that cooperate on infection control obtain better results than hospitals acting alone.
      When VA patients access their health care within the VA system, they encounter the MRSA Prevention Initiative in many of the venues that serve them. This is because the initiative was implemented nationwide in all acute care ICUs and non-ICUs in October 2007, in all spinal cord injury units in July 2008, with modifications in all CLC units in January 2009, in all inpatient mental health units in July 2009, and in all ambulatory care venues in April 2010. This approach of encompassing all components of a health care system in a single overarching infection prevention and control strategy may be a factor underlying the documented success associated with the VA's MRSA Prevention Initiative in acute care settings,
      • Jain R.
      • Kralovic S.M.
      • Evans M.E.
      • Ambrose M.
      • Simbartl L.A.
      • Obrosky D.S.
      • et al.
      Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.
      spinal cord injury units,
      • Evans M.E.
      • Kralovic S.M.
      • Simbartl L.A.
      • Obrosky D.S.
      • Hammond M.C.
      • Goldstein B.
      • et al.
      Prevention of methicillin-resistant Staphylococcus aureus infections in spinal cord injury units.
      and CLCs.
      Antibiotic resistance in long-term acute care hospitals is high,
      • Won S.Y.
      • Munoz-Price L.S.
      • Lolans K.
      • Hota B.
      • Weinstein R.A.
      • Hayden M.K.
      Emergence and rapid regional spread of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae.
      and residents in long-term facilities are at risk for infections with multidrug-resistant organisms. The nursing home may serve as a nidus for dissemination of these pathogens throughout a referral network.
      • Won S.Y.
      • Munoz-Price L.S.
      • Lolans K.
      • Hota B.
      • Weinstein R.A.
      • Hayden M.K.
      Emergence and rapid regional spread of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae.
      Our experience suggests that adherence to a simple bundle of infection prevention and control strategies may be of value in controlling MRSA HAIs in CLCs, especially if the program is implemented widely throughout the network of health care venues in which an individual may seek care.

      Acknowledgments

      The authors thank Robert A. Petzel, MD, Under Secretary for Health; Madhulika Agarwal, MD, MPH, Deputy Under Secretary for Health for Policy and Services; Christa M. Hojlo, PhD, RN, NHA, Director, VA Community Living Centers; and Lisa Minor, RN, Chief, Facility-Based Programs, Geriatrics and Extended Care Operations, for support of the VA MRSA Prevention Initiative. The authors acknowledge the efforts of Dr Suzanne Bradley, Patricia Burke, Cheryl Creen, Linda Danko, Christy Galbreath, Elizabeth Hegel, Pamela Higdem, Ona Montgomery, and Dr James Tischler in the initial development of the CLC MRSA guidelines for VA and to Kathy Risa and Rosie Fardo for bringing the final guidance to fruition through a field-based beta-testing process with VA CLCs. They also thank the MRSA Taskforce, the MRSA Prevention Coordinators, Infection Prevention and Control Professionals, Infectious Disease specialists, and clinical laboratory personnel at each facility for their hard work and dedication to improving the health care of America's veterans.

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