The Decrease in Healthcare‐Associated Methicillin‐Resistant Staphylococcus aureus Infections and Savings From Glycopeptide Use
We evaluated changes in the rate of healthcare‐associated methicillin‐resistant Staphylococcus aureus (MRSA) infections and healthcare‐associated S. aureus infections after implementation of infection control precautions and the effect of this on glycopeptide use and expenditures for glycopeptides in a private medical center in Turkey in the years 2000‐2005. A striking decrease was obtained in the number of MRSA infections, and the expenditure for glycopeptide use also decreased.
Received March 21, 2006; accepted May 19, 2006; electronically published September 20, 2006.
Healthcare‐associated methicillin‐resistant Staphylococcus aureus (MRSA) infections are associated with high morbidity and mortality.1‐3 On the other hand, treatment of these infections is expensive because of prolonged length of stay and the need for extra testing and therapy. Therapy includes the use of expensive antibiotics, such as glycopeptides.2 Every hospital must do its best to prevent healthcare‐associated MRSA infections in order to decrease the morbidity, mortality, and cost associated with these infections.
Florence Nightingale Hospital is a 300‐bed, university‐affiliated private medical center in Istanbul, Turkey, where an infection control program was instituted in January 1998, and surveillance studies began in January 1999. There has also been a quality assurance program in place since June 2001. One of the most important goals of infection control and quality assurance at the hospital was to control healthcare‐associated S. aureus and MRSA infections. A series of preventive studies were undertaken with this purpose. The aim of this study was to evaluate the changes in the rate of healthcare‐associated MRSA infection after implementation of precautions and the effect of this on glycopeptide use and expenditures for glycopeptides.
Methods
At our hospital, all patients who develop healthcare‐associated infection have “Healthcare‐Associated Infection Follow‐up” forms, in addition to their routine hospital reports. All patients with healthcare‐associated S. aureus infections and healthcare‐associated MRSA infections between January 2000 and December 2005 were included in the study. Centers for Disease Control and Prevention definitions were used for diagnosis of healthcare‐associated S. aureus infections.4,5 Conventional methods were used for isolation and identification of staphylococci, and methicillin resistance was tested using oxacillin disks on plates containing Mueller‐Hinton agar with 4% NaCl.
The procedures used by the infection control program for preventing healthcare‐associated S. aureus and MRSA infections were as follows: (1) periodical education of the hospital staff about infection control and hospital hygiene and about hand hygiene (since February 1998), (2) surveillance for nasal S. aureus carriage among surgical staff and treatment of the carriers with intranasal antibiotic ointment (since January 2001), (3) use of intranasal antibiotic ointment 3 times per day for 3 days for all the patients undergoing elective surgery (since January 2001), (4) isolation of all patients admitted from other settings until an MRSA‐negative anterior nares culture was obtained (since September 2003), and (5) use of chlorhexidine baths for surgical patients the night before surgery (since January 2004).
Data on glycopeptide use rates and the price of each glycopeptide was obtained from the hospital’s pharmacy, and the price of each glycopeptide was converted to US dollars at the time of the study. The total expenditure for glycopeptides was calculated for each year by multiplying the price of each glycopeptide by the number of doses used and calculating the sum of the expenditures for 2 antibiotics, vancomycin and teicoplanin.
Changes in the number of healthcare‐associated MRSA infections and the expenditures for glycopeptides were determined in 3 two‐year periods: period I was 2000‐2001, period 2 was 2002‐2003, and period 3 was 2004‐2005. For both these values, decreases in percentages for period 2 were calculated as [(period 1 − period 2) / period 1] × 100; for period 3, the values were calculated as [(period 1 − period 3) / period 1] × 100.
Results
The decreases in the number of healthcare‐associated MRSA infections were 88% for periods 2 and 98% for period 3, compared with period 1. The decreases in glycopeptide use were 31% for period 2 and 59% for period 3, compared with period 1. Rates of healthcare‐associated S. aureus infection and rates of healthcare‐associated MRSA infection for 2000‐2005 are given in Table 1. Decreases in the number of healthcare‐associated MRSA infections and in glycopeptide expenditures in 2000‐2005 are given in Table 2.
Discussion
The decreases in the number healthcare‐associated MRSA infections relative to period 1 were 88% for period 2 and 98% for period 3. There were only 2 MRSA infections in the last 2 years of the study. Jacqua‐Stewart et al.6 also obtained reduced rates of colonization and infection with use of aggressive containment practices in a nursing home with a high MRSA infection rate, and Kotilainen et al.7 pointed out that it is possible to eradicate MRSA from a healthcare center ward and associated nursing home with methods similar to ours.
There was also a decrease in glycopeptide use and the associated expenditure. The decreases in glycopeptide use were 31% for period 2 and 59% for period 3, relative to period 1. In our study, the expenditure for glycopeptides included the total amount of glycopeptides used for the following reasons: (1) treatment of MRSA infection, (2) treatment of methicillin‐resistant coagulase‐negative staphylococcus infection, (3) prophylaxis for patients admitted from other settings and undergoing revision surgery, (4) de‐escalation therapy for patients with high fever, and (5) inappropriate use of glycopeptides by some consulting doctors from other settings.
As a result, we concluded that decreasing the rate of MRSA isolation in a healthcare setting is possible with education, screening for nasal carriage, treatment of carriers with antibiotic ointment, and use of isolation precautions. This not only decreases morbidity and mortality but also can reduce the expenditure for treatment of these infections, including the cost of glycopeptide use.
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