On 9/15/2009 Stephen Weber said:

Thanks again to everyone for participating and especially for your challenging questions. I hope you found this helpful. Please keep an eye out for upcoming sessions highlighting other elements from the MDRO Toolkit.

On 9/15/2009 Stephen Weber said:

Thanks Evan for your question about resistant gram negatives. One of the nice things about the toolkit is that we tried to focus on transmission control strategies that are effective across the entire spectrum of MDROs. What I would advise is to assess just how these bacteria fit into your hospital's MDRO and infection control risk assessment. Don't get too swayed by the fact that suddenly 80% of your Acinetobacter are now carbapenem resistant as opposed to "only" 50% of your S. aureus being MRSA. If there are many more S. aureus isolates than Acinetobacter at your place (which is usually the case), then MRSA remains your bigger problem. That said, if these bugs are still showing up as a major problem - bear in mind that basic infection prevention measures such as hand hygiene and close adherence to isolation precautions work against all MDRO. Another topic of concern might be antibiotic use and misuse - but that's a subject worthy of an entirely different session!

On 9/15/2009 Evan Carter said:

You've talked a lot about MRSA in this blog. What about measures for highly resistant gram negative bacteria, like ESBLs?

On 9/15/2009 Stephen Weber said:

Sharyl: I'm so glad to hear that you are collaborating with other hospitals across your city to maintain a consistent practice. Not only does this make the most sense from an epidemiological perspective, but also presents a unified front to clinicians who might have admitting priveleges to a number of institutions in your city. Based on the point I made earlier about persistent carriage - I really do believe in being very conservative about the removal of isolation precautions. Many docs, and others, will be resistant to this approach. However, the data are on our side. One approach to hardwire this practice is to try to geta policy through that prevents individual providers from writing orders to discontinue precautions. At many places, this keeps the isolation "flag" entirely in the control of infection control and allows for oversight to make certain best practices are followed.

On 9/15/2009 Stephen Weber said:

Thanks Sue. While some participants might argue that such a specific measure in a single state does not apply to them, beware! Similar measures have been proposed in a number of states, as I noted earlier. The final version of the Illinois law, as Sue suggests, would appear to allow for some flexibility in screening and surveillance. Therefore the "letter of the law" may not be too clear. That said, I would just stress that any decision in the face of such legislative mandate to perform only limited screening should really be carefully documented (including risk assessment and justification). In terms of who might be identified as high risk, it is hard to say. I would stick to identified risk factors in other settings (e.g. open wounds, recent antibiotics or hospital visit, etc).

On 9/15/2009 Karen Hilmy IP said:

Thanks for clarifiction about acute care hospitals.

On 9/15/2009 Sharyl Bergerud said:

That brings up a question of isolating any patients with a known history of MRSA or VRE. We currently track this and isolate but I'm getting varied compliance from physicians, especially those who have worked in other states who practice otherwise. In addition, I have others who are trying to "clear" their historical MRSA patients by culturing them while inpatient (on antibiotics). APIC and SHEA tend to leave the guidelines open to individual hospital policy and procedure at this point. Fortunately it's a city-wide practice as well as strongly suggested by our state hospital association, so we've stuck to it so far. Any advice?

On 9/15/2009 Sue Barnett said:

As you mentioned, Illinois now has a law regarding MRSA screening/surveillance in long term/residential facilities. I am IP for an inpatient psychiatric hospital, with 75 acute beds and 300+ forensic (cort-ordered, long term stay) patients. As a state operated facility, we must now address these new requirements. Our state ICC chair has recommended following the "letter of the law" which states that each facility will develop a plan for which admissions will be tested. As our population is essentially healthy, I have proposed testing only those patients who come in with respiratory symptoms, or with open wounds, for MRSA. What are your feelings/recommendations on this proposed action?

On 9/15/2009 Stephen Weber said:

Cathy: you bring up a very controversial issue. Thanks for the tough question! The truth is that carriage of MDROs like VRE and MRSA can be very prolonged. There's an old study (Sandford is the lead author) that suggests a median time of MRSA carriage of about 3 years! That siad - the risk posed by these patients is driven not only by the duration of carriage (which probably does decline slowly over time) but also the risk of transmission from that patient. Put another way, a patient recently discharged from the hospital who might have experienced a temporary decline in functional status and who therefore needs more direct assistance from staff is probably a greater risk than someone who returns fully independent (with no drains, dressings, etc). There are a number of protocols available to screen patients for continued carriage through the collection of periodic cultures. These methods are probably a lot less reliable for VRE than MRSA for a number of technical reasons. The key to any of these protocols is to make certain that follow up samples are not collected while the patient is still receiving the antibiotics with which the original infection was treated. In short - there's no quick answer to be obtained simply from looking at the calendar!

On 9/15/2009 Cathy said:

In our LTC and SNF if a resident comes to us with a recent history of MRSA or VRE or MDRO's we put them in a private room with precautions. With just a recent history how long do you feel that keeping them segregated is appropriate?

On 9/15/2009 Stephen Weber said:

Cheryl - I forgot to commenton the issue of physician support. This is the million dollar question on all of these issues, right?! In my experience, and that of the other authors, we hope that physicians are responsive to data and results. Are your docs aware of the current frequency of MDRO infections in your facility? Do they generally agree that MDRO infections are associated with worsened outcomes. Share the materials from the tool kit and show them the Burden Calculator. We've found that to be a good way to start getting them on board. Once you have their attention - I hope they will be asking you: "Well, what can we do about this?"

On 9/15/2009 Stephen Weber said:

Thanks for your question Cheryl. ASC (active surveillance cultures) have been shown to be an important tool in reducing the burden of MDRO (and specifically MRSA) in a number of settings. Just how broad the application of ASC needs to be (e.g. all patients, high risk, ICU) remains less clear. Susan Huang published a paper from Harvard that showed that ASC in the ICUs was very effective in reducing MRSA bloodstream infection rates. In contrast, Ari Robicsek and colleagues at Evanston published a report that highlighted a meaningful benefit only when ASC was applied to all hospital patients. The truth is that the jury is still out. What each of these seemingly conflicting studies does illustrate however is that it is absolutely essential to strengthen basic infection prevention practices before undertaking ASC. ASC is not a magic wand which will make MRSA vansih! Rather, the practice relies on good adherence to basic practices even after colonized patients are identified. In terms of guidelines, the CDC and others would agree that hospitals must make every effort to enhance basic practices first, but if MRSA rates remain unacceptably high, ASC should be pursued. I think this approach makes sesne. Once again - I will refer you to the Active Surveillance Checklist in the toolkit for more information. Thanks again!

On 9/15/2009 Cheryl Morrison said:

How important are ASCs for MDROs? Is it important to do them house-wide or just in critical care areas? What is the best way to obtain physician support for such a project?

On 9/15/2009 Stephen Weber said:

Thanks for your question Rieta. I can see that MRSA screenign remains a hot topic! I am not curreently aware of any jurisdictions in which nasal screening for MRSA has been mandated by law outside of the acute care setting. That said - a number of legislative bills have been proposed across the US that touch on this theme. Generally, local chapters of professional societies such as APIC can help keep tabs on what is going on in your area. While this toolkit does focus specifically on acute care hospitals, I do believe that a focus on careful risk and performance assessment are the most crucial first step in making a determination of the best intervention in any setting. The Risk Assessment Matric and Primer, which are included in the toolkit, could conceivably be adapted to other settings. In the toolkit, there is also an Active Surveillance Checklist that will also help walk leaders through the complex process of considering and deploying such a program. Good luck

On 9/15/2009 Rieta Merrell said:

In the Behavioral and Rehabilitation hospital settings, are there requirements to perform nasal swabbing for MRSA?

On 9/15/2009 Stephen Weber said:

Maggie - sorry I missed your earlier question about the CEO's role. Frankly - I believe that the engagement and active participation of senior leaders in MDRO control is essential. The toolkit is designed to help get these folks on board at your hospital. The MDRO Burden Calculator highlights the economic and clinical impact of MDRO, the MDRO Dashboard provides the means for communicating about the MDRO threat within your organization and the talking points really highlight key messages to be shared with key leaders. You show me a hospital where the CEO really "gets it" with respect to MDRO and I'll show you a place that is on the road to meaningful reductions in MDRO risk!

On 9/15/2009 Stephen Weber said:

Thansk for pointing that out, Karen. Remember that the toolkit is specifically targeted to practices in acute care hospitals. Therefore, not all of the questions will be directly applicable. While the authors and I believe that many fo the themes we developed in the toolkit could be applied to a degree in other settings, some of the specifics might get "lost in translation."

On 9/15/2009 Stephen Weber said:

Christina - great question. As you know, MDRO control in LTCF is particularly challenging given the relative lack of evidence-based practices. As I just suggested to Pamela - I would examine your facility's risk assessment for infection control before I undertook any screening practice. Practically speaking, in most institutions, the gap between current and optimal hand hygiene and other transmission control practices is a more suitable target than undertaking screening right away.

On 9/15/2009 Stephen Weber said:

Greetings. Thanks for signing in to today's session. I see we already have a couple of great questions - so let's get started. Pamela - your question about screening and decolonization is so timely as many hospitals are facing this question. In some states (like here in Illinois), screening for MRSA is actually the law for high risk patients. In all cases - the decision to screen should be undertaken in the context of your hospital's infection control risk assessment. In addition, before you decide to start screening, you really ought to make certain that other transmission control practices (hand hygiene and isolation precautions) are really optimized. After all - screening will only work if these other practices are being followed.

On 9/15/2009 Karen Hilmy IP said:

On the Chapter 4 - Competency Questions number 3 about the MDRO should don gowns and gloves.Does this distinguish between long term care facilities/ residential hospitals versus medical hospitals?

On 9/15/2009 Pamela Smith said:

Is it now then recommended that each new patient have a MRSA (nares) culture and antimicrobial "bath" upon admit? A hospital in our area is doing just that.

On 9/15/2009 Christina Darabos said:

What are some LTC facilities doing as a preventative measure? Aside from education or policies, are there any processes that are being implemented for screening, or isolation?

On 9/15/2009 Maggie Snow said:

What is the role of the CEO in regards to the spread of MDROs?