SHEA/IDSA/APIC Answer to Diekema, et al, Study on Prevention of MRSA Infection and Transmission

Safety equipment sign and labels: A patient with MRSA wears a mask and goggles.

(Adobe Stock 569752761 by Pog)

In a recent article published in the American Journal of Infection Control (AJIC), Dr. Daniel J. Diekema and his colleagues conducted a comprehensive analysis of infection prevention recommendations, focusing on the prevention of methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection in acute care hospitals.

Infection Control Today^® (ICT^®) covered it: “Challenging the Universality of Contact Precautions in MRSA Prevention: A Critical Appraisal of Recent Infection Control Guidelines.”

The study by Diekema, et al, prompted a response from the authors of the "2022 Update of the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America/Association for Professionals in Infection Control and Epidemiology Practice Recommendations for Prevention of MRSA Infection and Transmission in Acute Care Hospitals."

Kyle J. Popovich, MD, MS

To shed light on these critical updates, Kyle J. Popovich, MD, MS, the lead author of the 2022 Update, recently shared insights in an interview with ICT. This discussion delves into key changes in the guidelines, areas of agreement, the introduction of MRSA-specific risk assessments, challenges related to discontinuing contact precautions, and tailoring MRSA prevention measures to individual health care facilities' specific contexts. The interview provides valuable insights for health care professionals seeking to enhance MRSA prevention strategies and adapt them to their unique settings.

ICT: Can you provide an overview of the key changes and updates made in the 2022 practice recommendations for preventing MRSA infection and transmission in acute care hospitals?

Kyle J Popovich, MD, MS: Key changes in the Essential (formerly known as Basic) Approaches include reclassifying antimicrobial stewardship from an unresolved issue to an essential practice. One significant change from the 2014 document is now including considerations for hospitals with strong horizontal prevention measures in place and neither ongoing MRSA outbreaks nor high or increasing rates of MRSA to modify contact precautions for some or all MRSA-colonized or infected patients.

Key updates in the Additional Approaches include a discussion for use of active surveillance testing in several specific patient populations. In addition, decolonization therapy for MRSA colonization has been updated to include recommendations for universal or targeted decolonization for several specific populations.

ICT: In your response to the Viewpoints article by Diekema et al., you mentioned that there is more agreement than disagreement between the recommendations. Could you elaborate on the areas of agreement and how the new recommendations address conflicting conclusions about contact precautions?

KJP: We believe that our recommendations and the Viewpoints article both acknowledge that the burden of MRSA and the risk for MRSA transmission varies substantially among hospitals and that the benefits and risks of contact precautions also vary among and within hospitals. The updated recommendations encourage risk assessments to assist hospitals in making informed decisions on various infection control measures targeting MRSA, including the use of contact precautions. We agree with Diekema and colleagues that some hospitals may be able to successfully prevent MRSA transmission without the use of contact precautions for some or all patients with MRSA, but that it is imperative that facilities assess their horizontal infection control strategies (eg hand hygiene [adherence]) and MRSA epidemiology before modifying the use of contact precautions and to periodically reassess these factors and MRSA transmission and infection rates if contact precautions are discontinued or modified.

ICT: The updated recommendations introduce the concept of conducting MRSA-specific risk assessments. Can you explain how MRSA-specific risk assessments work and what factors hospitals should consider when evaluating the need for contact precautions?

KJP: An MRSA risk assessment examines the opportunity for MRSA transmission and estimates the facility-specific MRSA burden and rates of MRSA transmission and infection. This assessment assists hospitals in choosing and implementing strategies and provides a baseline for subsequent assessments and other data comparisons. Factors considered could include internal infection rates, special patient populations (eg neonatal ICU, burn ICU), local epidemiology, hospital infrastructure (eg, proportion of single patient rooms versus multipatient rooms) that may contribute to patient-to-patient transmission of MRSA if contact precautions are not used, and other factors. 

ICT: One of the challenges highlighted is the potential risk of mass de-implementation of contact precautions. How do you propose balancing the discontinuation of contact precautions in some cases while ensuring patient safety and infection control?

KJP: I think this is a key issue, especially at a time when a lot of hospitals are still struggling with higher MRSA rates that occurred during the pandemic. Hospitals that have discontinued contact precautions or are planning to ensure that their hospital has robust horizontal infection control strategies with excellent [adherence] don’t have high or increasing MRSA rates and are not experiencing an MRSA outbreak. Therefore, hospital-specific risk assessments are important to assist in decision-making.

ICT: The 2022 Compendium emphasizes the diversity in epidemiology and risk within hospitals. Could you share some strategies or considerations that health care facilities should consider when tailoring MRSA prevention measures to their specific context?

KJP: A risk assessment is critical for hospitals so they can make individualized decisions that work for that institution and ensure patient safety. Not all hospitals are the same, and several may have their own set of challenges. Resources and staffing for infection control programs in various health care settings are variable. Hospitals need a robust system to monitor MRSA rates and implement a response should rates increase (eg bring back contact precautions).

ICT: Do you have anything else you’d like to add?

KJP: We agree with Diekema and colleagues in that it would be ideal if all acute care settings in the US had excellent adherence to basic infection control practices to keep rates of MRSA transmission and infection in their hospitals low and share their interest in pursuit of a “precision-based approach” to infection prevention strategies, including contact precautions. However, there is variation in compliance for infection control strategies (eg historic hand hygiene compliance rates are low) and different challenges across health care facilities. We structured the updated document to account for these differences and challenges and provide some flexibility for hospitals to tailor their interventions based on a risk assessment.