New guidelines recommend antibiotic stewardship for preventing MRSA

MRSA under the microscope


A collection of experts from US medical organizations today released updated recommendations to help acute-care hospitals prevent one of the most common healthcare-associated infections (HAIs).

Among the changes in the updated guidelines, published today in Infection Control & Hospital Epidemiology (ICHE), is the elevation of antimicrobial stewardship to an "essential practice" for preventing infection with and transmission of methicillin-resistant Staphylococcus aureus (MRSA), a pathogen that causes roughly 10% of HAIs in US hospitals and is associated with significant morbidity and mortality.

The previous version of the guidelines, published in 2014, had listed antimicrobial stewardship as an unresolved issue.

The guidelines arrive in the wake of a COVID-19 pandemic-related rise in MRSA infections in US hospitals that reversed years of declines. MRSA bloodstream infections were one of several HAIs that increased during the pandemic as infection prevention and control staff and resources were diverted to COVID care. But prior to the pandemic, data from US hospitals showed that MRSA incidence declined by 18% from 2012 to 2017.

A senior author says that history, and the evidence that informs the new guidelines, indicates hospitals can be successful at preventing the spread MRSA.

"We can get back to the pre-2020 rates and then do even better," David Calfee, MD, ICHE editor and an infectious disease specialist at Weill Cornell Medicine, said in a press release.

Key practices for preventing MRSA spread

Other essential activities carried over from the previous guidelines include implementing a MRSA monitoring program, conducting a MRSA risk assessment, promoting US Centers for Disease Control and Prevention and World Health Organization recommendations for hand hygiene, ensuring proper cleaning and disinfection of equipment and the hospital environment, and educating patients and healthcare providers about MRSA.

MRSA is a common HAI, because some hospital patients, particularly those with severe underlying illness who have undergone invasive procedures, are colonized with the pathogen, and a substantial proportion of those patients go on to develop a MRSA infection. Those patients also shed MRSA into the hospital environment, and the healthcare workers who care for those patients can spread it other patients.

Basic infection prevention practices, such as hand hygiene and cleaning and disinfection of the healthcare environment and equipment, remain foundational for preventing MRSA.

As several studies have documented, ensuring that healthcare workers are washing their hands and cleaning hospital equipment properly has been associated with reduced transmission of the pathogen.

"Basic infection prevention practices, such as hand hygiene and cleaning and disinfection of the healthcare environment and equipment, remain foundational for preventing MRSA," Calfee said. "These fundamental practices help to prevent the spread of other pathogens as well."

Calfee is among the panel of experts involved in the collaborative effort, which was led by the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with contributions from other societies and organizations.

Rationale for stewardship

The guidelines note that while the quality of evidence for making antimicrobial stewardship programs an essential component of a MRSA prevention program is low, there is a theoretical rationale.

"Receipt of antibiotics without MRSA activity has been associated with significant increases in the intranasal burden of MRSA; thus, receipt of such antibiotics may increase the risk of infection in the colonized person and/or increase risk of transmission to others," the guidelines state.

Another change in the guidelines regards contact precautions, which involve the use of gloves and gowns when providing care for MRSA-colonized or MRSA-infected patients. While contact precautions are still deemed essential because they may help limit patient-to-patient spread, the guidelines acknowledge that some hospitals have chosen to modify or discontinue contact precautions, and they provide recommendations to help those hospitals monitor outcomes associated with those changes.

Other changes to the new guidelines include supporting data and specific recommendations for active surveillance testing for asymptomatic MRSA carriers and for MRSA decolonization strategies.


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