The following information is provided regarding this week's Seattle Times article on MRSA infections in hospitals.

Healthcare-associated infections, including MRSA, are a significant risk to hospitalized patients posing a major societal and financial burden; up to two million patients experience a healthcare-associated infection every year in the U.S., leading to approximately 88,000 deaths per year. Within the hospital, surgical site infections and three types of infections common in intensive care unit patients are particularly prevalent—central-line associated bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections. Together, these infections account for more than 80 percent of all healthcare-associated infections.

The recent Seattle Times series (Sunday, 16 November) article focuses attention on hospital-associated MRSA infections, one of the most important healthcare-associated infections. MRSA is one of a number of important multi-drug resistant organisms that cause serious healthcare-associated infections, but comprehensive infection control approaches must address all, not just one of, the culprits. For example, MRSA is thought to cause less than 10% of hospital-associated bloodstream infections. Leading causes of hospital-acquired bloodstream infections include coagulase-negative staphylococci, Staphylococcus aureus, including MRSA and methicillin-susceptible Staphylococcus aureus, enterococci, Candida species and gram-negative organisms such as Pseudomonas aeruginosa and Acinetobacter baumannii. More than 90% of coagulase-negative staphylococci and 60% of S. aureus isolates are resistant to methicillin, over 30% of enterococci and more than 10% of Candida organisms are resistant to important antimicrobial drug treatments and high levels of drug resistance also exist for multiple gram negative organisms causing serious infections. Thus, an approach to control of MRSA without a broader infection control program would fail with many other drug-resistant pathogens.

Healthcare facilities monitor multidrug-resistant organisms in a variety of ways because of the increasing incidence of these infections, the severity of infection caused by these organisms, changes in reporting requirements, and recommendations by the Healthcare Infection Control Practices Advisory Committee (HICPAC).

In response to increasing multi-drug resistant infections in hospitals, in 2008, Washington State Department of Health convened an Expert Panel on Evidence-Based Monitoring Strategies and Interventions for Antibiotic Resistant Organisms. The panel's recommendations included that hospitals should standardize the implementation of the Centers of Disease Control and Prevention/Healthcare Infection Control Practices Advisory Committee guideline, Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006 and routinely implement a collection of evidence-based processes known as performance bundles to prevent central line infections and promote best ventilator care to prevent occurrence and transmission of infections due to multidrug-resistant organisms.

Mandatory MRSA screening and isolation remain controversial among national experts and for that reason were not recommended. The debate about their value continues in part because of the limited reports of success so far, some reports of the failure of screening, the costs of screening and isolation, the unwanted side effects of patient isolation, the inability to find sufficient isolation rooms in some older hospitals with many 2-bed patient rooms, and because methicillin-susceptible S. aureus still constitutes an important infection control challenge in US hospitals.

Screening and isolation may have adverse consequences, including additional costs, reduced frequency of visits by attending physicians and nurses, anxiety and depression among isolated patients, and higher rates of bedsores and falls. In addition, screening tests are not perfect leading to the potential for false-positive tests in patents without MRSA, yet they would be subject to the adverse consequences of isolation. Patient populations who should be screened are not well defined and vary among published reports and the optimal timing and interval of screening tests are not well defined. More research is needed to determine the circumstances under which screening cultures are most beneficial, but the Expert Panel endorsed that screening should be considered at this time in some settings, especially if other control measures have been ineffective.

The Expert Panel did not recommend mandatory MRSA reporting however it did recommend that hospitals should conduct standardized surveillance to prevent transmission of multidrug-resistant organisms among high risk patients for that hospital. One important reason that mandatory reporting was not recommended is because of the current lack of standardized definitions and standardized surveillance methods for tracking MRSA in hospitals and therefore results of reporting would be difficult to compare and interpret. In addition, little is known about the effectiveness of public reporting for improving healthcare performance. A recent systematic review of the literature performed by the Healthcare Infection Control Practices Advisory Committee found the evidence for effectiveness of public reporting systems in improving healthcare performance to be inconclusive.

Prevention of healthcare-associated infections is at the heart of patient safety and healthcare facilities must strive for 100% adherence to recommended infection control practices. Public health authorities should continue to work with health care facilities to assure compliance with recommendations for implementation of standardized surveillance methods and prevention strategies for hospital-associated infections. Success will require administrative and scientific leadership and a significant financial and human resource commitment. Resources must be made available for infection prevention and control, including expert consultation, laboratory support, adherence monitoring, and data collection and analysis. Screening and reporting policies alone, especially if focused on only one infection, will not achieve the needed change in overall multidrug-resistant hospital associated infections.