Is screening for MRSA and decolonization therapy in the hospital useful?

So you’re about to be admitted into the hospital for a surgical procedure? Hopefully its something small…maybe a little nose job or a colonoscopy, but maybe its something a little more serious like a hip replacement or a cardiac bypass procedure? Depending on where you live and what hospital you go to you might be asked to give samples from various parts of your body for MRSA analysis prior to being admitted. Don’t worry…this only consists of a nurse or medical assistant running a cotton swab lightly across your skin in the nasal, armpit, and/or groin regions and then sending it on to the lab where they will use one of various techniques to identify whether MRSA is present. The end result is that in as little as a few hours or as long as about a day later they will know whether you are going to be bringing some unwanted “little friends” into their facility, putting yourself and others at risk for infection. If you happen to be a carrier, you may be put through a couple extra measures or treatments prior to surgery designed to reduce the chances that you or others will develop an infection.

There’s a healthy debate in the North American medical field currently regarding whether it is useful to screen and decolonize patients for MRSA in this way prior to hospital admission. Detractors cite the costs of screening and subsequent measures as prohibitive to the potential benefits of eliminating a few infections. Proponents wave pharmacoeconomic studies suggesting that the prevention of just a few major infections per year in a hospital can recoup the investment in screening equipment and effort. So what’s the truth? Why are some US states legislating that patients must be screened on admittance, while other regions scarcely seem to recognize it as an issue? The answer is usually quite complicated and driven by factors as diverse as funding availability, healthcare structure, infection control dogma, and presence of local studies/support literature. Other times, I’m ashamed to admit, it simply boils down to the beliefs (right or wrong) of the clinicians in charge of infection control in that region.

The fact is, all North American hospitals have both patients within their walls carrying MRSA and some number of MRSA infections occurring annually. Without screening, it becomes very difficult (impossible) to estimate how many patients are colonized and what impact that has on baseline infection rate for the facility. Hospital reports of overall low MRSA infection incidence rates can be deceiving – US based studies1 have reported the cost of a Staphylococcal infection in patients who have had orthopedic, cardiovascular, or neurological surgeries to be well above $100,000, triple the cost of caring for the same patient without an infection. At those cost levels it doesn’t take too many infections to impose a major burden on the healthcare system. Not to mention the even more important statistic of a roughly 10% increase in mortality rate (ie. deaths) among post-surgical patients with infections1. If MRSA monitoring and intervention can make an impact on these numbers, surely it can be justified from both a cost and public health standpoint?

To be fair, the small body of scientific research to date is somewhat split on whether screening and decolonization of patients for MRSA colonization prior to admission leads to a significant reduction in MRSA infection rate. There are a few studies that failed to show a large benefit after adoption of screening2. However, a larger body of literature is growing suggesting that applying MRSA screening followed by targeted decolonization in well controlled studies has a significant and measurable effect on infection rate3-5. A recent meta-analysis of several studies6 also concluded that screening and decolonization significantly reduced the rate of Staphylococcal infection in post-operative patients. (Keep in mind that the references I’ve given in this paragraph for and against MRSA screening are just a few examples, and don’t even come close to covering the full body of work in this area)

So back to the original question: Is screening in the hospital for MRSA useful? The bulk of scientific evidence says that screening, combined with some form of intervention to reduce subsequent transmission, does have the effect of reducing MRSA infection rate in hospitals. Certainly widespread adoption of MRSA screening in countries like the United Kingdom (see my previous blog) appears to have had a measurable and sustained impact on hospital-acquired infections. Continued resistance among North American hospitals to institute MRSA intervention practices likely relates more to concerns about costs of getting the program up and running as opposed to pessimism about the potential benefits. After all, the hospital business in the US is cut-throat just like any other. Of course, all that matters to you going in for your nose job or bypass is that you are given the best care possible with the least chance of developing a life-threatening infection. So you decide….do you want to live in a place where MRSA screening and decolonization in hospitals is required, or somewhere where you have no idea if your roommate is carrying something that can kill you?…

1 Noskin et al. (2005) Archives of Internal Medicine 165: 1756-1761

2 Kurup et al. (2010) American Journal of Infection Control 38: 361-367

3 Awad et al. (2009) The American Journal of Surgery 198: 607-610

4 Fraser et al. (2010) Infection Control and Hospital Epidemiology 31(8): 779-783

5 Bode et al. (2010) The New England Journal of Medicine 362(1): 9-17

6 van Rijen et al. (2008) Journal of Antimicrobial Chemotherapy 61: 254-261

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4 Responses to “Is screening for MRSA and decolonization therapy in the hospital useful?”

  1. Gary Lampman says:

    I want to thak you for your contribution to this important issue. I live in the Nashville Tn and I know of many advocates across the United States that are heading the fight on MRSA in their home towns. Keep up the Great Work.

  2. heidi wightman says:

    YES!!!! Speaking from alot of experience on MRSA…I have had it twice after a C-Section. Both times it was inside me, not just on the skin. My infectious disease doctor said that the hospital gave it to me the first time, and after the 2nd c-section I got it again. I should have been treated the 2nd time beforehand so It would not have happened again. My OB dropped the ball on that one! Now I guess I am a carrier and will have to be treated from now on before I have any kind of surgery. I consider myself very lucky, though, that it did not get into my bloodstream. But I was so sick for a month both times and in the hospital instead of enjoying my newborn babies. It was horrible. My babies never got it. Thank God!!

  3. Cynthia says:

    I’ve contracted MRSA in two separate hospitalizations. Once of the heart and blood when I contracted endocarditis from an infected PICC line; and the last time during a hip transplant. I had been tested and been cleared of it in the interim between the two. I think that decolonization proceedings are a good idea. The misery that I went through in both circumstances would have been perhaps easily avoidable had they been done. NOw, as I face my second hip replacement, I’ve been told that I will be decolonized prior to the second operation. I already had a history of MRSA…and am immunocompromised from another illness and the treatment I am receiving for that…why wasn’t it done the first time?

  4. Rhonda says:

    Cynthia, I asked the same thing. After having a “minor” surgery to release a tendon causing grief to my resurfaced left hip, I ended up with a deep tissue MRSA infection and went through a year of hell. We still do not know for sure that it is gone and I live in fear that one day I will wake up with that excruciating pain and have to start treatment all over.

    A simple MRSA test BEFORE my surgery would have found that I was colonized and saved me the suffering and the health system hundreds – yes, hundreds of thousands of dollars!

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