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Methicillin-resistant Staphylococcus aureus(MRSA) in rehabilitation and chronic-care-facilities: what is the best strategy?
© Minary-Dohen et al; licensee BioMed Central Ltd. 2003
Received: 12 May 2003
Accepted: 12 December 2003
Published: 12 December 2003
The risk associated with methicillin-resistant Staphylococcus aureus (MRSA) has been decreasing for several years in intensive care departments, but is now increasing in rehabilitation and chronic-care-facilities (R-CCF). The aim of this study was to use published data and our own experience to discuss the roles of screening for MRSA carriers, the type of isolation to be implemented and the efficiency of chemical decolonization.
Screening identifies over 90% of patients colonised with MRSA upon admission to R-CCF versus only 50% for intensive care units. Only totally dependent patients acquire MRSA. Thus, strict geographical isolation, as opposed to "social reinsertion", is clearly of no value. However, this should not lead to the abandoning of isolation, which remains essential during the administration of care. The use of chemicals to decolonize the nose and healthy skin appeared to be of some value and the application of this procedure could make technical isolation unnecessary in a non-negligible proportion of cases.
Given the increase in morbidity associated with MRSA observed in numerous hospitals, the emergence of a community-acquired disease associated with these strains and the evolution of glycopeptide-resistant strains, the voluntary application of a strategy combining screening, technical isolation and chemical decolonization in R-CCF appears to be an urgent matter of priority.
Methicillin-resistant Staphylococcus aureus (MRSA) strains were first identified in the early 1960's . They now have a worldwide distribution  and have evolved resistance to multiple antibiotics. The recent description of clinical strains highly resistant to glycopeptides following the acquisition of the vanA gene has increased fears that it will soon be impossible to treat patients infected with these epidemic strains . The prevalence of MRSA in France is among the highest in the European Union [4, 5], and a recent publication by a regional surveillance network showed that this prevalence continued to increase between 1996 and 2000 .
Recommendations of French CTIN for the control of MRSA
Early identification of patients colonized and/or infected with MRSA
Information of the status of the previously known MRSA positive patients at the time of hospital-to-hospital or ward-to-ward transfer
Detection of MRSA colonization and/or infection based on clinical samples
Detection of MRSA carriage based on screening samples (without precision on which sites should be cultured) at admission and during hospitalisation in high risk MRSA acute care facilities or in all facilities in case of outbreaks
Barrier isolation of MRSA positive patients
Technical isolation including
Compliance to hand disinfection,
Use of gloves and gowns for all contact with patients or their environment,
Use of dedicated medical equipments
Geographical isolation (individual rooms) or cohorting "which considerably facilitates the application of technical isolation"*
Decolonization with mupirocin associated with antiseptic daily body cleansing*
The recommendations published by the CTIN target, as a matter of priority, MRSA and Enterobacteria producing extended-spectrum β-lactamases, as these bacteria are highly pathogenic and commensal, favouring their clonal spread within hospitals and raising fears for their spread in the community. The CTIN suggests that patients colonised/infected with MRSA should be identified, that these patients should be placed in isolation and that complementary measures should be implemented, including screening for carriers upon admission and during hospitalisation and treating human reservoirs (see table 1). Several questions concerning the application of these measures in R-CCF remain unanswered, notably due to difficulties evaluating the effect of any given measure within a wider strategy. Given the lack of evidence to demonstrate the efficacy of some measures and a lack of means, the concerned establishments have implemented the recommendations of the CTIN only half-heartedly .
For several years, the Hygiene Department of Besançon University Hospital has placed all its means (computer facilities and biological platform) and competences at the disposal of a 120-bed chronic-care-centre (Tilleroyes Health Care Centre), with a view to controlling MRSA infections. As most of chronic-care-centers in France, the Tilleroyes Centre admitted more than 90% of elderly patients coming from acute care facilities. These patients are hospitalised approximately during 30 days and received mainly nursing cares and incidentally invasive medical cares. The aim of this article was to use the experience acquired and published data as a basis for considering the efficacy and feasibility of some of these measures, particularly those frequently contested by health professionals involved in the fight against nosocomial infections in R-CCF: screening, isolation and chemical decolonization.
The occurrence of MRSA in rehabilitation and long-term-care-facilities
In the study carried out by the Microbiology Surveillance Network of Northern France , the incidence of MRSA colonisation/infection in chronic-care-facilities was 0.69 per 1000 days of hospitalisation. This incidence increased significantly between 1996 and 2000, such that it was similar to the mean observed in all types of ward and in all hospitals considered together (0.84 per 1000 days). The frequency of methicillin resistance was considerably higher than that in other types of unit (61% versus 14.4 to 42.5%). In the Franche-Comté region of France, the incidence of MRSA in rehabilitation units was 0.55 per 1000 days in 2002, which is identical to the overall incidence in all types of ward, and the frequency of resistance was practically identical to that reported in northern France (62%). Despite these figures, the direct effect of MRSA infections in R-CCF appears to be limited, given the severity of the associated morbidity. In fact, two severe infections (one case of bacteraemia and one case of deep infection) were observed in the 26 colonised/infected patients (7.7%), whereas 20.7% of the colonised/infected patients in acute-care units had severe infections (35 infections, including 16 cases of bacteraemia, 11 deep infections and eight lung infections diagnosed from samples taken during invasive interventions, in a total of 169 colonised/infected patients). However, given that patients are continually transferred between R-CCF and acute-care facilities, it is reasonable to consider these units together with all other care units and to measure the effect of MRSA on a regional health care network rather than on the scale of a given ward or hospital. If this approach is used, the rare figures available show the amplification effect of R-CCF on MRSA propagation (11.6% of patients were carriers upon admission versus 18.7% upon discharge) . Several studies carried out in intensive care units have shown that the duration of hospitalisation is a risk factor for MRSA colonisation/infection [15, 16]. It therefore seems logical that hospitalisation in R-CCF may amplify the spread of MRSA. Furthermore, the high frequency of "openly" colonisations/infections like urinary infections or colonised wounds, favours the spread of strains both on the hands of staff and via the inert environment [17–19].
Role of screening
Efficiency of screening according to the type of department
Intensive careb N (%)
Patients positive on admission
Identified by CSc
Time to screening /CS +
6.7 +/- 7.3 days
Positive on discharge
Role of isolation
Incidence of acquisition of methicillin-resistant Staphylococcus aureus stratified according to Katz's index in a chronic-care centre.
Number of patients admitted
Number of acquisitionsa
Incidence of acquisition (%)
Role of chemical decolonization
Distribution of sites colonised by MRSA
Colonised on admission N (%)
Acquireda N (%)
Folds under breasts
R-CCF are at the centre of epidemics of MRSA colonisation, even if the consequences of these epidemics in terms of morbidity remain limited to them. The application of an effective prevention strategy to these departments and hospitals should considerably reduce the morbidity linked to MRSA in acute-care units. An effective strategy must be based on the identification of all reservoirs; it is therefore necessary to screen all patients systematically on admission to and discharge from these units and establishments. With this in mind, acute-care units should make their technical facilities available to these units. The isolation of patients identified as carriers, or colonised and/or infected individuals does not require the geographical isolation of these patients because the most common route of spread from patient to patient is via the hands of staff during care. Technical isolation creates extra work, which is not always compatible with the nursing time available. However, this extra work load can be limited by chemical decolonization, the efficacy of which is far from negligible. Given the increase in morbidity associated with MRSA observed in numerous hospitals, the emergence of a community-based disease linked to these strains and the emergence of glycopeptide-resistant strains, the application of a voluntary strategy including screening, isolation and decolonization in R-CCF appears to be an urgent matter of priority.
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