Book Description

Methicillin-resistant Staphylococcus aureus (MRSA) emerged as a clinically relevant human pathogen more than five decades ago. The virulent bacterium was first detected in hospitals and other health care facilities where vulnerable hosts, frequent exposure to the selective pressure of intensive antimicrobial therapy, and the necessity for invasive procedures created a favorable environment for dissemination. MRSA emerged as an important cause of healthcare-associated infections, particularly central line-associated bloodstream infection, ventilator-associated pneumonia, and surgical site infection (SSI). Despite the adoption of infection-control measures, the incidence of MRSA infection at most U.S. hospitals steadily increased for many years, but it is now decreasing. While the decrease in the incidence of MRSA infection may be due to efforts to screen for MRSA carriage, it may also be due to secular trends (such as efforts to improve patient safety) and to confounders (such as efforts to improve the appropriate use of antibiotics and to decrease healthcare-associated infections in general, including catheter-associated bloodstream infection, ventilator-associated pneumonia, and SSI). A number of analyses suggest that MRSA infections are associated with increased mortality and cost of care when compared with those due to strains that are susceptible to methicillin. Even the availability of newer pharmaceutical agents with specific activity against MRSA has not ameliorated the challenge of caring for patients with MRSA. The widespread use of these agents has been limited, in part due to toxicity, cost, and uncertainty as to optimal indications. The management and control of MRSA have been further complicated by dramatic changes in the epidemiology of transmission and infection observed over the past two decades. Specifically, S. aureus strains resistant to methicillin, once exclusively linked to hospital care, have increasingly been detected among patients in the community who lack conventional risk factors for MRSA infection. Community-acquired MRSA has been linked to outbreaks of infection in hospitals and health care facilities. Conventional strategies for the control of MRSA have focused on the prevention of spread from patient to patient. The effectiveness of hand hygiene in preventing the spread of MRSA has been demonstrated in observational studies in which hand hygiene promotion campaigns were associated with subsequent reductions in the incidence of MRSA among hospitalized patients. While hand hygiene remains important in the effort to control MRSA transmission, the continued spread of the pathogen after its initial introduction in most facilities has prompted efforts to identify additional strategies. The use of contact isolation-including the donning of gowns and gloves when interacting with patients colonized or infected with MRSA and the assignment of such patients to single rooms or to a room with a group of affected patients-has been widely promoted and adopted. Such isolation precautions now are the centerpiece of most authoritative guidelines for MRSA control. Despite the broad consensus associated with the use of contact isolation for MRSA prevention, the specific evidence in support of this practice remains limited and indirect. The objective of this review was to synthesize comparative studies that examined the benefits or harms of screening for MRSA carriage in the inpatient or outpatient settings. The review examined MRSA-screening strategies applied to all hospitalized or ambulatory patients, as well as screening strategies applied to selected inpatient or outpatient populations, and compared them with no screening or with screening of selected patient populations. The review evaluated MRSA-screening strategies that included screening with or without isolation and with or without attempted eradication/decolonization.