We Typically Don’t Treat MRSA-Colonized Patients. Instead, We Let Them Run The Risk of Acquiring A Serious Infection. Why Is That?
Canada has the second highest health-care associated infection rate in the world compared to other high-income countries. Every year at least 200,000 people become infected after they go to a hospital. Somewhere between 8,000 and 12,000 of those people will die as a result. And Canada’s Chief Public Health Officer says it appears that these numbers are rising. For example, the healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) infection rate increased more than 1,000% from 1995 to 2009. If we were at war and suffering these kinds of casualties it would be front page news and we would be doing all we could to stop the bleeding.
Whether we’re doing all we can to stop the harm caused by infections contracted at hospitals has arisen in the context of the MRSA-colonized patient. Infection is a 2-step process that begins with the patient being “colonized” by the bad bug: the bug gets into open areas of the body’s exit sites such as the tips of the nostrils but the patient isn’t yet infected – they haven’t become ill – so far. But since studies show that between 1 in 4 and 1 in 7 patients who become colonized also become infected, good health care practice would suggest that you should get rid of the bad bug as soon as you know it’s there – you “decolonize” the patient.
Surprisingly, though, most hospitals do no such thing. For example, Prairie Mountain Health Authority in western Manitoba does not recommend treatment for colonization by MRSA. Dr. Greg Large, a general physician there, explains that the golden rule in medicine is “First, do no harm.” So if someone isn’t infected it means that no harm is being caused by the colonization – so leave the person alone. Because when you treat/decolonize you run the risk of creating irritation, toxicity, and antibiotic resistance; and it taxes hospital resources. Therefore, since 75 – 85% of the patients who are colonized never become infected, why risk harming them?
Hospitals covered by the Winnipeg Regional Health Authority confirmed by email that they do not have a policy specific to the decolonization of MRSA-colonized patients: “The decision to decolonize MRSA from a patient would be made by the clinical team on a case by case basis in order to protect the most vulnerable patients from infection. Those patients who present to hospital repeatedly with invasive infections would be significantly more at risk of becoming infected and, as a result, would be most likely to be decolonized.”
The most recent research on the subject demonstrates the high stakes that are involved. It found that of the 840 patients studied, 125 died (1 in 7) within six months of MRSA acquisition. Of patients surviving to discharge, 1 in 4 required multiple admissions for complications due to their MRSA infection. And surgery within 30 days as well as admission to an ICU were associated with MRSA infection.
Accordingly, the researchers conclude that “targeting interventions such as decolonization therapy and enhanced efforts to prevent device-associated infection to reduce development of infection in patients who newly acquire MRSA colonization may also have a key role.”
The Vancouver General Hospital took an important step in this direction. In 2012 they began decolonizing all of the roughly 7,000 surgical patients they have every year. As a result, surgical-site infections are down by almost 40%, which also saves the hospital about $2 million a year that it would otherwise have to spend to treat those infections.
Changing how we conceptualize the colonization issue may help as well. For example, we vaccinate healthy people all the time so they don’t run the risk of catching a disease, some a lot less serious than what a MRSA infection can do to you. So why not think of a policy of decolonization as a kind of “vaccination,” a way of preventing the risk of serious harm?
Finally, what about involving the patient in the decision to decolonize? If you were told you were MRSA-colonized and therefore faced a significantly increased risk of multiple hospital admissions, surgery, the need for care in an ICU, and even death, what would you do?