A Big Step in the Fight Against Superbugs Our Study Zeroed in on an Effective Way to Prevent Deadly MRSA Infections in Hospitals. JONATHAN B. PERLIN And RICHARD PLATT
http://online.wsj.com/article/SB10001424127887324492604579083742106373398.html?mod=opinion_newsreel
In the U.S. and abroad, humans are at risk of increasingly weak antibiotics and increasingly strong superbugs. Before the discovery of penicillin in the early 20th century, a significant portion of people unlucky enough to contract a bacterial infection died. With increasing antibiotic resistance, we risk a post-antibiotic era every bit as frightening.
A report out this month from the Centers for Disease Control and Prevention highlights multidrug-resistant bacteria as one of the world’s most serious and pressing health threats. “Antibiotic Resistance Threats in the United States, 2013” notes that drug resistance is often the result of poor stewardship, defined as the lack of careful use of antibiotics in humans and animals.
When antibiotics are used unnecessarily or inappropriately, we kill the most susceptible organisms and, in their void, create a more favorable environment for the selection of more-resistant bacteria. This has resulted in a scary alphabet soup of superbugs, including C. diff, CRE, MRSA, multidrug-resistant TB, and VRE, that can be deadly to those with suppressed immune systems and are threatening even the healthiest patients.
The CDC’s strategies to address resistance include tracking resistant bacteria, improving uses of antibiotics, and developing new antibiotics and diagnostic tests for resistant bacteria. But success also means reducing the overuse of antibiotics and requires a commitment from more than health professionals. Patients need to change their expectations for receiving an antibiotic when an illness is likely viral—in which case it will never respond to an antibiotic—or self-limited, like a cold that will go away on its own. Doctors need to feel supported by patients, not pressured, when they exhibit prudent stewardship in prescribing only those medicines that will be effective.
Preventing infection is another critical piece of the CDC’s national strategy, and we still have a lot to learn on that front. That is why Hospital Corporation of America, in partnership with researchers from the CDC, Harvard Pilgrim Health Care Institute and Harvard Medical School, University of California Irvine School of Medicine, Rush Medical College and Washington University, recently conducted a study known as Reduce MRSA (short for the Randomized Evaluation of Decolonization Versus Universal Clearance to Eliminate MRSA).
The study set out to address the question: What could hospitals do right now to dramatically reduce their infection rates? The answer turned out to be a surprisingly simple intervention to cleanse patients who potentially carry the virulent organism.
Methicillin-resistant Staphylococcus aureus, more commonly known as MRSA, was identified in the CDC report as a serious threat to human health. MRSA is a common organism, and individuals who have been exposed to it can become carriers. In the hospital, carriers are at particular risk of developing MRSA infections. MRSA may be transmitted to other patients and can cause bloodstream infections known as sepsis. There are some 80,000 cases of invasive MRSA infections per year, resulting in about 11,000 deaths annually. MRSA, and staphylococcus in general, account for approximately one-quarter of the 80,000 deaths from hospital-acquired infections in the U.S.
The Reduce MRSA trial, conducted across 74 intensive-care units at 43 hospitals, involved more than 74,000 patients over an 18-month period. Results show that hospitals urgently need to better define their standards for infection prevention.
Before this trial, the CDC didn’t have enough information to determine which of three alternative approaches is truly best: Would it be most effective to screen patients for MRSA and, if they test positive, isolate them from other patients, or to screen patients for MRSA and, if they test positive, isolate them and apply the “decolonization,” which means eradicating bacteria by using antimicrobial soap and nasal ointment to prevent bacteria from entering the bloodstream? Or would it be better to decolonize all patients immediately on admission to intensive-care units?
The third approach proved unequivocally best. Universal decolonization reduced all bloodstream infections, including those caused by MRSA, by 44%. The other approaches were not nearly as successful. There was negligible change in the reduction of bloodstream infections using the first approach; the second approach saw a 22% reduction.
While this study was notable for its outcome, it was also notable for its efficiency. It didn’t take a single hospital dozens of years to amass the power of this study—it took 43 hospitals collaborating for 18 months. It didn’t take a research team focused only on answering one question. The research was implemented by nurses and infection-prevention professionals during routine patient care, and not in a laboratory, but within the real-world environment of community hospitals. This suggests the prevention strategy can be implemented in hospitals everywhere, as it already has been by all HCA facilities.
The stakes are high. Breeding superbugs threatens a return to the vulnerability of the pre-antibiotic era, when untreatable bacterial diseases and TB were responsible for countless deaths. The Reduce MRSA study demonstrated that government, the private sector and academia, by conducting research collaboratively, can accelerate creating the best scientific evidence for practice. By using that evidence, we can change outcomes for patients, and maybe even the way history records our fate.
Dr. Perlin is president, Clinical & Physician Services of Hospital Corporation of America. Dr. Platt, an infectious diseases specialist, is a professor at the Harvard Pilgrim Health Care Institute.
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