“We’re at the junction of crisis and success, and what we do over the next several years will hopefully determine which way we go.” – Dr. Edward Septimus, Hospital Corporation of America
We continue to see staph infections, specifically Methicillin-resistant Stephylococcus aureus (MRSA) infections, weave their way into national news. And the reason is an alarming one: MRSA infection is caused “by a type of staph bacteria that’s become resistant to many antibiotics used to treat ordinary staph infections,” as described by the Mayo Clinic.
Most recently, New York Giants tight end Daniel Fells contracted the antibiotic resistant condition MRSA and was in danger of losing his foot and required multiple surgeries to rid his body of the infection. Although the bacteria isn’t problematic most of the time, it can quickly become deadly. According to the CDC, in 2013 nearly 10,000 people died from MRSA infections in the United States.
During the panel “Combating Antibiotic-Resistant Bacteria (CARB): AHRQ’s Role and Activities in the White House-Mandated National Enterprise” at the 2015 Agency for Healthcare Research and Quality (AHRQ) Research Conference, co-hosted with AcademyHealth, Dr. Edward Septimus noted that we’re in the perfect storm, experiencing antibiotic resistant conditions at more alarming rates and seeing decreased investment. What’s more is that investments in antibiotics may no longer be enough. Whereas antibiotics were “miracle drugs” in the past, in this decade Septimus asks if we’re seeing the rise of the post-antibiotic area.
In September 2014, in response to President Obama’s request, the President’s Council of Advisors on Science and Technology (PCAST) released its Report to the President on Combating Antibiotic Resistance, in which the council makes recommendations on what steps the federal government could take to tackle this crisis. The recommendations included in the report were: ensure strong federal leadership; effective surveillance and response for antibiotic resistance; fundamental research; clinical trials with new antibiotics; increase economic incentives for developing urgently needed antibiotics; improve stewardship of existing antibiotics in healthcare; limit the use of antibiotics in animal agriculture; and ensure effective international coordination.
To make the best of these recommendations, research needs to be conducted so the federal government has a sense of what works best, for whom, under what circumstances, and at what cost. Enter health services research—and AHRQ.
One area where AHRQ is focusing its CARB efforts is in that of MRSA. These studies, funded by AHRQ, could profoundly change the way we deliver care:
The STOP SSIs (Study to Optimally Prevent Surgical Site Infections) Project
The STOP SSIs project, funded under an AHRQ ACTION I contract, is a collaboration between The Joint Commission, the University of Iowa, and the University of Maryland aimed at determining whether screening, decolonization (an attempt to remove S arureus or MRSA or both from an individual known to be ‘colonized’), and selective use of cefazolin and vancomycin can substantially reduce S. aureus (the number one pathogen associated with SSIs) SSI rates. Surgical site infections are the number one health care-associated infection (HAI) related to increased length of stay and higher health care costs, with estimates ranging from 30-50 percent, and S. aureus is the most common reason for readmission after surgery.
Prior to the STOP SSIs Project, the effectiveness of this approach—referred to by researchers as an evidence-based bundle—had not previously been compared to the effectiveness of the bundle’s standalone elements or to the effectiveness of no bundle. Focusing specifically on patients undergoing cardiac or orthopedic operations, researchers found that a bundle comprising of the screening, decolonization, and targeted prophylaxis was associated with a modest decrease in complex S aureus SSIs. Specifically, researchers found that, per 10,000 operations, 36 cases of complex S aureus occurred for the preintervention versus 21 for the intervention period. Results of this study were recently published in JAMA.
The REDUCE MRSA (Randomized Evaluation Decolonization vs. Universal Clearance to Eliminate Methicillin-Resistant Staphylococcus aureus) Trial
AHRQ’s REDUCE MRSA Trial, which was conducted in the largest inpatient health system in the United States, examined which method was most effective overall for eliminating the presence of MRSA in cultures in intensive care units (ICUs). Would the use of special soaps and nose ointments reduce bacteria on the body during periods of high risk for infection—i.e., decolonization—or would screening and isolating those who tested positive be more effective?
A three arm cluster-randomized trial of the prevention strategies revealed that universal decolonization was the most effective intervention to reduce MRSA infections; it led to a 37 percent reduction in MRSA clinical cultures and a 44 percent reduction in all-cause bloodstream infections, according to AHRQ. Furthermore, the study found that universal decolonization was highly cost effective. As reported in the implications of the REDUCE MRSA trial, “Compared with screening and isolation, universal decolonization was estimated to save $171,000 and prevent nine additional bloodstream infections for every 1,000 ICU admissions.”
The PROTECT Project
The final project discussed, AHRQ’s PROTECT Trial, focuses on health care-associated infections in nursing homes. The 3 million nursing home residents in the United States experience 2-3 million preventable HAIs each year, resulting in more than 150,000 readmissions and 380,000 deaths. To date, trials have focused on hospitals, despite the growing number of infections occurring outside the hospital. The purpose of this project was to determine how generalizable we can be outside of the ICU and, if so, whether those steps are feasible and practical.
In the PROTECT Project, supported by AHRQ, researchers will enroll 28 nursing homes to evaluate the ability of routine bathing with antiseptic soap and routine use of topical nasal antiseptic to prevent multi-drug resistant organisms and readmissions due to HAIs.
*The Agency for Healthcare Research and Quality has been negatively targeted (for elimination by the House and for a 35 percent funding reduction by the Senate) in fiscal year 2016 appropriations. The health services research it supports is critical to improving the health research enterprise. Learn more and help #SaveAHRQ by visiting the AcademyHealth website.