MRSA and 'Search and Destroy'

I have discussed the "search and destroy" strategy for controlling and reducing methicillin resistant Staphylococcus aureus (MRSA) before. Search-and-destroy involves the screening of every patient and hospital worker for MRSA.

Patients with MRSA are isolated to prevent spread to other patients. In the Netherlands, hospital workers with MRSA are sent home with pay, and are treated with muriopicin nasal drops (MRSA usually lives up your nose). In addition, the workers' family is screened along with any pets, and those that have MRSA are also treated. Because of this program, the Netherlands has kept its MRSA infection rate below one percent (in the U.S., it's roughly 50%).

In Slate, there is a very good article about some of hurdles search-and-destroy faces in the U.S. First, some background on MRSA:

In the United States, MRSA kills an estimated 13,000 people every year, which means that a hospital patient is 10 times as likely to die of MRSA as an inmate is to be murdered in prison. The latest survey by the Centers for Disease Control and Prevention found that 64 percent of the Staphylococcus aureus strains in American hospitals were MRSA--that is, resistant to the powerful antibiotic methicillin and other antibiotics--which makes them difficult to treat....

Given the dimensions of the threat, you'd think that the CDC would be making a priority of fighting it. After all, federal health agencies have spent billions to fight anthrax (which caused five deaths in 2001), smallpox (last U.S. death: 1949), and pandemic flu (yet to appear in the United States). And there is reason to think that search and destroy works, since health-care authorities abroad have kept rates of antibiotic-resistant bugs in their countries much lower than ours. In Dutch hospitals, the rate of MRSA is less than 1 percent. Canada's rate is 10 percent. And more than 100 studies have shown the effectiveness of search and destroy, including work released in the last month in the United States.

Unfortunately, the CDC, which release new guidelines Oct. 19, hasn't endorsed search and destroy:

Yet the CDC refuses to endorse search and destroy. It is sticking to the mantra that hospital workers should wash their hands more carefully and frequently, and that in most cases patients should be isolated only after symptoms of infection with MRSA appear. Routine surveillance to find patients who may not be symptomatic, but are still contagious, is rarely practiced, and not recommended in the CDC's new hospital infection-fighting guidelines, which were released last week after five years of deliberations. The guidelines do not include a routine recommendation for search and destroy.

The CDC refuses despite evidence to the contrary:

The Dutch approach is to test all high-risk patients before they are admitted. High risk, in practice, means diabetics, kidney-dialysis patients, and anyone who has been in a high-risk environment, such as a nursing home--or, from the point of view of the Dutch, the United States.

It's far more effective to isolate carriers, who may not yet be sick with the resistant microbes, than to wait until you have a confirmed infection, says Dr. Jan Kluytmans, a leading Dutch combatant in the resistance wars. Kluytmans' hospital in Breda, Netherlands, has had only one hospital-acquired MRSA infection since 2001, out of perhaps 40,000 patients. He estimates that the technique has prevented about 150 deaths. The University of Virginia Hospital in Charlottesville imposed the same system in 1980, and has maintained lower rates of MRSA than hospitals of comparable size. In late 2002, Rhode Island Hospital in Providence began search and destroy, and the MRSA infection rate at the hospital has dropped 43 percent, says chief epidemiologist Dr. Leonard Mermel, while it has continued to rise at most other hospitals in New England.

The primary concerns are economic:

With a few exceptions, American hospitals, for their part, have been leery of the short-term expense and staff burden posed by search and destroy. A quick nasal swab of an admitted patient may cost only $20, but the nursing staff has to carefully monitor isolated patients, and find room to house them. The hospitals' reluctance may be shortsighted, however: A recent study showed that the average hospital infection adds $20,000 to a patient's bill. [Mad Biologist: More recent work indicates that this is an underestimate. It's around $60,000] And while hospitals have traditionally passed on their costs to other payers, Medicare--which sets reimbursement standards--is starting to curtail payments to cover hospital errors, and may eventually stop paying to treat infections that could have been prevented.

The biggest push for search and destroy may come, sadly, from the threat of lawsuits.

One problem with antibiotic resistance, and hospital-acquired infections in general, is the externalization of the economic costs of resistance. Until recently, most of the incentives were based on government regulation, which was either lax or non-existant. This led to the failure to report roughly 90% of all infections. Until hospitals start paying for the costs of hospital-acquired infections--and thus the corresponding evolution of resistance due to these infections--the antibiotic resistance problem won't get any better.

Unfortunately, this is more difficult than it sounds because how "hospital-acquired" is technically defined makes a big difference. Currently, it is defined as an infection that occurs 48 hours after admission or up to three days after discharge. Given the pervasive underreporting, one wonders how many '47th hour' infections we're going to see. At least, we're slowly moving in the right direction.

Kinda.