The new “superbug” known as MCR has medical authorities wondering how to prevent it from spreading. A new report in the journal Clinical Infectious Diseases reveals that an infection-control program can reduce transmission of the gut bacteria that can carry MCR by more than 40 percent. The remarkable thing: The program was designed to combat a different infectious threat.
Its intended target? MRSA, better known as drug-resistant staph. The program at the Veterans Administration Health Care System was created in 2007, at what may have been the height of concern over the presence of MRSA in the United States. That year, the Centers for Disease Control and Prevention estimated that MRSA caused 18,650 deaths and 94,360 serious infections in the U.S. each year. But how to prevent MRSA from spreading in hospitals was contentious for decades, with some institutions so discouraged that they said it wasn't even worth trying.
Enter the VA. In October 2007, the health care system mandated that all of its 127 acute-care hospitals do four things: Check all the patients being admitted to its hospital to see whether they carried MRSA (which can live quiescently in the nostrils); isolate patients who carried the bacterium and make sure that anyone who approached them wore gowns and gloves; improve hand washing (and hand sanitizer use) everywhere in hospitals; and change hospital operations so that infection prevention became a top priority, including hiring extra employees to enforce the MRSA program and gather data on it.
The proposal was bold, because it went further than most U.S. hospitals had even tried. And it worked. Within five years, the VA demonstrated that the program cut MRSA infections in intensive care units in its system by three-fourths, and MRSA infections elsewhere in its hospitals by two-thirds.
It was a major advance, the most comprehensive infection-prevention program in all U.S. health care, and its success changed the industry. But there was always a question: Had the program only affected rates of MRSA, or did it reduce the occurrence of other hospital infections too?
It was a reasonable question, because as dire as it is, MRSA is different from other hospital-infection bacteria such as E. coli and Klebsiella. It hangs out in the nose and on the skin, places that are relatively easy to swab, while the others reside in the gut, which is more invasive (or at least privacy-invading) to check. MRSA is a Gram-positive organism, which means it has a single-layer cell wall, more susceptible to antibiotics than the double-walled membranes possessed by the Gram-negative gut bugs. And because those membranes create extra protection, the gut bacteria are even more successful than MRSA at lingering on hospital surfaces such as bed railings and computer keyboards and doors.
The new research, published last week, answers that question with a yes. The analysis by Michihiko Goto, of the Iowa City VA, and 11 other VA physicians and researchers, shows that over the VA program’s almost ten years, serious hospital infections with Gram-negative bacteria fell by 43 percent.
Eli Perencevich, a professor of medicine at epidemiology at the University of Iowa Carver College of Medicine and the senior author on the study, who also heads a center at the Iowa VA, said success in beating back infections that the program didn’t even target comes from a few actions—which could be repeated by any health system.
The MRSA “bundle,” as it’s known, “has both vertical and horizontal components,” he said. “Vertical components target specific organisms, in this case MRSA. That is, everyone admitted was swabbed for MRSA, and isolated if they were positive.
“But the VA also created horizontal components, interventions that are effective against numerous pathogens,” he said. “In this initiative, there was an emphasis on hand hygiene, there were expanded educational activities at each VA and a focus on cultural transformation. They hired infection prevention staff, one person in each facility, to track surveillance and hand hygiene. You can imagine how those would be effective beyond just MRSA.”
By focusing on MRSA, in other words, the VA hospitals improved their overall infection control. And by doing that, they may have answered a second long-standing question: whether infection prevention makes a difference to hospitals’ bottom line.
There is no question that preventing infections is important in human terms, because it prevents patients’ suffering, keeps them from having to be in the hospital longer, and keeps trust in the health-care system from being dented. But medicine has struggled to make a case for infection prevention as a business action.
In fact, an analysis published earlier this year by the American Journal of Preventive Medicine found that, despite the VA initiative’s success in preventing so many MRSA infections, it did not pay for itself. From 2007-10, it found, the program cost the VA $207 million; the savings from from preventing MRSA infections were at most $75 million.
“So it was not cost-saving; it didn’t pay for itself,” said Richard E. Nelson, a health economist at the University of Utah who led the research. “But that doesn’t mean it wasn’t cost-effective, a good deal. It’s often the case in medicine that new initiatives are more expensive than what was being done before—but if they lead to better outcomes, for patients or for systems, then the increased cost may be worth the increased benefit.”
With the discovery that the MRSA Initiative prevented so many extra hospital infections, that finding may need to be reexamined.
“If we were to update our economic analysis to include these other pathogens, it would certainly make an even better case,” Nelson said. But, he added, the results show these programs are worth pursuing whether they strictly pay for themselves or not: “The bang for the buck is worth it.”