A model of success: The VA’s battle against MRSA

The growing problem of antibiotic resistance threatens the successful prevention and treatment of an increasing range of infections. This mounting public health concern has led some hospitals to implement antimicrobial stewardship programs and other infection control initiatives, some with impressive results.

According to a study published in the American Journal of Infection Control in January, an infection control program introduced in 2007 at more than 140 Veterans Affairs (VA) hospitals demonstrated a significant reduction in MRSA infection rates by 2015. The study found that the program, called the MRSA Prevention Initiative, led to a decrease in monthly hospital-acquired infection (HAI) MRSA rates by 87% in ICUs and by 80.1% in non-ICUs. Moreover, monthly infection rates dropped 80.9% in spinal cord injury units and 49.4% in long-term care facilities.

Infographic demonstrating reductions in monthly MRSA rates
Source: Healio.com

“MRSA was a problem across the country and in the VA as well,” Gary A. Roselle, MD, director of the National Infections Disease Service for the VA Central Office in Washington, D.C., told Infectious Disease News. “One thing the VA did, probably ahead of many other large institutions, was to make the decision from top management on down that this should be addressed in an aggressive and organized manner, with outcome measurements.”

An overall trend

Another key finding from the study on the VA MRSA Prevention Initiative was the decrease in the severity of MRSA infections over the study interval, according to Susan Casey Bleasdale, MD, FACP, assistant professor in the department of medicine, University of Illinois at Chicago.

“What they saw was a significant decline in the number of health care-associated infections, and a decline in the severity of infections, meaning invasive bacteremias associated with MRSA,” Bleasdale said in an interview. “You can have MRSA as part of your skin bacteria and can develop mild skin infections, or you can develop very severe infections where it’s in the bloodstream, [and] it can settle in your heart valve, it can cause stroke or other complications. They saw a significant decline in the number of invasive MRSA infections.”

Photo of Susan Bleasdale
Susan Casey Bleasdale

Bleasdale added that the improvements seen as part of the VA MRSA Prevention Initiative were also mirrored by findings in non-VA facilities. She cited a 2013 study conducted by the CDC that found a significant decrease in the burden of invasive MRSA infections across nine U.S. metropolitan hospitals between 2005 and 2011. The largest reductions were seen in HAIs.

“They extrapolated that to the U.S. population to show overall rates, and there was a significant decrease in the number of deaths,” Bleasdale said. “There was a reduction of about 9,000 deaths between 2005 and 2011, and a decrease of 30,000 severe infections from 2005 to 2011.”

Keys to success

According to Allison A. Kelly, MD, a staff physician with the National Infectious Disease Service who helps manage the National Antimicrobial Stewardship Taskforce and Stewardship Initiative, the VA’s strong guidance down the chain of command was an important factor in the success of the MRSA Prevention Initiative.

“The VA has a longstanding practice and policy of high-level central office guidance and resource development that disseminates down to the field, with the field implementing it,” Kelly told Infectious Disease News. “The MRSA program, which was the result of multidrug-resistant organism programs that expanded, is an excellent example of that.”

In addition to central guidance, successful local implementation was a crucial part of the program’s effectiveness, Roselle said.

“You have to have local implementation,” he said. “I think that’s important, because, in general, the work that’s going to have the greatest impact is the work that is closer to the patient care.”

Bleasdale said part of the success of the VA’s program, along with that of other facilities, is effective infection control measures, as well as an increased awareness of community-acquired MRSA and how best to treat it.

Reduction of HAIs, coupled with increased awareness of MRSA, has decreased the incidence of invasive MRSA, Bleasdale explained.

“In the past, it tended to be people who were in the hospitals who developed MRSA, but then we had this surge, in the early 2000s, of community-acquired MRSA,” she said. “People would develop mild abrasions on their skin, often during contact sports and other team sports, and would then have skin-to-skin contact, and MRSA would get into these small abrasions and cause skin infections.”

Ordinarily, Bleasdale said, skin infections are treated with a penicillin, but MRSA is resistant to that group of antibiotics. This resulted in several severe infections associated with community-acquired MRSA.

“We were trying to treat them with penicillin in the clinic, and they would get sicker and sicker, and then develop invasive infections,” she said. “I think that’s another part of how this got better — we started identifying these infections as MRSA earlier, and treating them sooner, and decreasing the severity of infection by not going to our penicillin antibiotic at first.”

Findings recently published in Infection Control and Hospital Epidemiology showed that the VA’s systemwide antimicrobial stewardship program reduced inpatient antibiotic use by 12% from 2010 to 2015.

Infographic demonstrating reductions in antibiotic use
Source: Healio.com

According to Bleasdale, there are three important mandates of antibiotic stewardship: to choose the best antibiotic for the infection, to use the narrowest spectrum of antibiotics, and to choose the appropriate duration of treatment.

“These three components reduce inappropriate antibiotic use, which could include giving antibiotics for a viral infection, or treating patients too long, particularly in the case of pneumonia,” she said.

Following the VA example

Bleasdale said that although some non-VA hospitals are already successful in controlling MRSA infections, there are still valuable lessons to learn from the VA program.

“The VA has a unified electronic medical record, [and] it has several initiatives that are applied throughout the nation,” she said. “You can see their multicenter studies through the VA, and you can take that information and see what has been effective.”

What has been effective, she suggested, has been the identification of MRSA, the isolation of patients with active infections, and antimicrobial stewardship.

Roselle had one piece of advice for hospitals seeking to reduce MRSA rates: do not give up.

“For a while, with MRSA, some hospitals became frustrated and believed they couldn’t have an impact,” he said. “That’s not true. You can influence outcomes. You can actually program insights that will change these sorts of infection rates.”

He added that hospitals do not need to follow the VA’s example to the letter: they only need to have a program in place and a mechanism for monitoring its outcomes.

“Other hospitals don’t have to do everything the VA did,” he said. “This just happened to work for us. There are other mechanisms and other methods. I think the big message is, if everybody works together and they buy in from top down, you can have good results. It can be done.” – by Jennifer Byrne

References:

Evans MA, et al. Am J Infect Contr. 2017;doi:10.1016/j.ajic.2016.08.010.

Jain R, et al. N Engl J Med. 2011;doi:10.1056/NEJMoa1007474.

Kelly AA, et al. Infect Control Hosp Epidemiol. 2017;doi:10.1017/ice.2016.328.

Dantes R, et al. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.10423.

Disclosures: Bleasdale, Kelly and Roselle report no relevant financial disclosures.

The growing problem of antibiotic resistance threatens the successful prevention and treatment of an increasing range of infections. This mounting public health concern has led some hospitals to implement antimicrobial stewardship programs and other infection control initiatives, some with impressive results.

According to a study published in the American Journal of Infection Control in January, an infection control program introduced in 2007 at more than 140 Veterans Affairs (VA) hospitals demonstrated a significant reduction in MRSA infection rates by 2015. The study found that the program, called the MRSA Prevention Initiative, led to a decrease in monthly hospital-acquired infection (HAI) MRSA rates by 87% in ICUs and by 80.1% in non-ICUs. Moreover, monthly infection rates dropped 80.9% in spinal cord injury units and 49.4% in long-term care facilities.

Infographic demonstrating reductions in monthly MRSA rates
Source: Healio.com

“MRSA was a problem across the country and in the VA as well,” Gary A. Roselle, MD, director of the National Infections Disease Service for the VA Central Office in Washington, D.C., told Infectious Disease News. “One thing the VA did, probably ahead of many other large institutions, was to make the decision from top management on down that this should be addressed in an aggressive and organized manner, with outcome measurements.”

An overall trend

Another key finding from the study on the VA MRSA Prevention Initiative was the decrease in the severity of MRSA infections over the study interval, according to Susan Casey Bleasdale, MD, FACP, assistant professor in the department of medicine, University of Illinois at Chicago.

“What they saw was a significant decline in the number of health care-associated infections, and a decline in the severity of infections, meaning invasive bacteremias associated with MRSA,” Bleasdale said in an interview. “You can have MRSA as part of your skin bacteria and can develop mild skin infections, or you can develop very severe infections where it’s in the bloodstream, [and] it can settle in your heart valve, it can cause stroke or other complications. They saw a significant decline in the number of invasive MRSA infections.”

Photo of Susan Bleasdale
Susan Casey Bleasdale

Bleasdale added that the improvements seen as part of the VA MRSA Prevention Initiative were also mirrored by findings in non-VA facilities. She cited a 2013 study conducted by the CDC that found a significant decrease in the burden of invasive MRSA infections across nine U.S. metropolitan hospitals between 2005 and 2011. The largest reductions were seen in HAIs.

“They extrapolated that to the U.S. population to show overall rates, and there was a significant decrease in the number of deaths,” Bleasdale said. “There was a reduction of about 9,000 deaths between 2005 and 2011, and a decrease of 30,000 severe infections from 2005 to 2011.”

PAGE BREAK

Keys to success

According to Allison A. Kelly, MD, a staff physician with the National Infectious Disease Service who helps manage the National Antimicrobial Stewardship Taskforce and Stewardship Initiative, the VA’s strong guidance down the chain of command was an important factor in the success of the MRSA Prevention Initiative.

“The VA has a longstanding practice and policy of high-level central office guidance and resource development that disseminates down to the field, with the field implementing it,” Kelly told Infectious Disease News. “The MRSA program, which was the result of multidrug-resistant organism programs that expanded, is an excellent example of that.”

In addition to central guidance, successful local implementation was a crucial part of the program’s effectiveness, Roselle said.

“You have to have local implementation,” he said. “I think that’s important, because, in general, the work that’s going to have the greatest impact is the work that is closer to the patient care.”

Bleasdale said part of the success of the VA’s program, along with that of other facilities, is effective infection control measures, as well as an increased awareness of community-acquired MRSA and how best to treat it.

Reduction of HAIs, coupled with increased awareness of MRSA, has decreased the incidence of invasive MRSA, Bleasdale explained.

“In the past, it tended to be people who were in the hospitals who developed MRSA, but then we had this surge, in the early 2000s, of community-acquired MRSA,” she said. “People would develop mild abrasions on their skin, often during contact sports and other team sports, and would then have skin-to-skin contact, and MRSA would get into these small abrasions and cause skin infections.”

Ordinarily, Bleasdale said, skin infections are treated with a penicillin, but MRSA is resistant to that group of antibiotics. This resulted in several severe infections associated with community-acquired MRSA.

“We were trying to treat them with penicillin in the clinic, and they would get sicker and sicker, and then develop invasive infections,” she said. “I think that’s another part of how this got better — we started identifying these infections as MRSA earlier, and treating them sooner, and decreasing the severity of infection by not going to our penicillin antibiotic at first.”

Findings recently published in Infection Control and Hospital Epidemiology showed that the VA’s systemwide antimicrobial stewardship program reduced inpatient antibiotic use by 12% from 2010 to 2015.

Infographic demonstrating reductions in antibiotic use
Source: Healio.com

According to Bleasdale, there are three important mandates of antibiotic stewardship: to choose the best antibiotic for the infection, to use the narrowest spectrum of antibiotics, and to choose the appropriate duration of treatment.

“These three components reduce inappropriate antibiotic use, which could include giving antibiotics for a viral infection, or treating patients too long, particularly in the case of pneumonia,” she said.

Following the VA example

Bleasdale said that although some non-VA hospitals are already successful in controlling MRSA infections, there are still valuable lessons to learn from the VA program.

PAGE BREAK

“The VA has a unified electronic medical record, [and] it has several initiatives that are applied throughout the nation,” she said. “You can see their multicenter studies through the VA, and you can take that information and see what has been effective.”

What has been effective, she suggested, has been the identification of MRSA, the isolation of patients with active infections, and antimicrobial stewardship.

Roselle had one piece of advice for hospitals seeking to reduce MRSA rates: do not give up.

“For a while, with MRSA, some hospitals became frustrated and believed they couldn’t have an impact,” he said. “That’s not true. You can influence outcomes. You can actually program insights that will change these sorts of infection rates.”

He added that hospitals do not need to follow the VA’s example to the letter: they only need to have a program in place and a mechanism for monitoring its outcomes.

“Other hospitals don’t have to do everything the VA did,” he said. “This just happened to work for us. There are other mechanisms and other methods. I think the big message is, if everybody works together and they buy in from top down, you can have good results. It can be done.” – by Jennifer Byrne

References:

Evans MA, et al. Am J Infect Contr. 2017;doi:10.1016/j.ajic.2016.08.010.

Jain R, et al. N Engl J Med. 2011;doi:10.1056/NEJMoa1007474.

Kelly AA, et al. Infect Control Hosp Epidemiol. 2017;doi:10.1017/ice.2016.328.

Dantes R, et al. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.10423.

Disclosures: Bleasdale, Kelly and Roselle report no relevant financial disclosures.