MRSA deep clean a waste? Not really.

The headline blared, PATIENTS STILL AT RISK FROM MRSA DESPITE 57 MILLION POUND DEEP CLEAN'. The entire premise, I thought, was so bizarre. The idea that a one-time cleaning of something would prevent the return of contamination. If this was true, my 5 year old son would be overjoyed. He could take a bath in June and be set for the entire summer.
MRSA infection is a complex problem that is not to be eradicated with a one shot effort. Simple solutions, those sometimes promoted by press and politicians, are part of the answer, but not the entire answer. Maybe that's because staph bugs don't read the newspaper or listen to political speeches. Otherwise they would know to completely leave the hospital and never return following the 'deep clean'.
The headline in question appeared in the UK's Independent, written by Brian Brady and Jane Merrick:

Thousands of patients will remain at risk from superbugs, despite a £57m "deep clean" of hundreds of hospitals, because a vital screening programme will not be put in place for at least a year.
One of the world's leading experts on hospital-acquired infections (HAIs) warned yesterday that every one of the hospitals cleaned under Gordon Brown's flagship health policy will be back to square one as soon as the cleaners finish, because no one is stopping bacteria such as MRSA and Clostridium difficile from coming into the buildings.
Professor Hugh Pennington of Aberdeen University said the deep-clean programme would be "an expensive waste of resources".

The thought that a one time deep cleaning would end Hospital acquired Infections is naive at best, dangerous at worst. Professor Pennington' s assertion that MRSA infections are not "...environmental..." depends on what your definition of environmental is.

"Professor Pennington said: "Politicians get hung up on cleaning, but the major issue isn't environmental; it is people bringing the bugs into hospitals. Once the bacteria hit the floor they die off. The natural home of MRSA is either in infected patients or up the noses of the rest of us, so that is what they should be attacking."

At VIGILAIR we stress that all infections are environmental. A good example of MRSA as an environmental pathogen
is found in an article published in the journal of the Hospital infection Society-- 'Ventilation grilles as a potential source of methicillin-resistant Staphylococcus aureus causing an outbreak in an orthopaedic ward at a district general hospital', (1998) 39: I 27-I 33).
This article showed how MRSA was being distributed in a hospital via the ventilation system. While it is true that most MRSA is introduced into the hospital by visitors, patients and staff, environmental controls are key in removing these pathogens from the environment. Pennington's statement that MRSA bacteria die when they hit the floor is contradicted by a large body of research. The November 2006 issue of Infection Control and Hospital Epidemiology contains a report on MRSA survival that is typical of this research:

"We examined the duration of survival of 2 strains of methicillin-resistant Staphylococcus aureus (MRSA) on 3 types of hospital fomites. MRSA survived for 11 days on a plastic patient chart, more than 12 days on a laminated tabletop, and 9 days on a cloth curtain."

Ignoring the care environment in the fight against MRSA is short sighted. The strategy that we recommend acknowledges that the environment plays a significant role in hospital acquired infection and that several tactics must be employed together to be successful.
We've been able to culture Staph from the cooling coils of hospital HVAC units. Psuedomonas, Staph and many other bacteria are taken from patient care areas, and then find an excellent breeding ground in the dark, cool and food rich home in hospital ventilation systems.
VIGILAIR technology removes the HVAC as a reservoir for pathogens by disinfecting the HVAC system. VIGILAIR UVGI deactivates bacteria, fungi and viruses on surfaces as well as in the air. Importantly, this protection is constant. Unlike one time cleanings the germicidal irradiation of cooling coils continues 24 hours a day, VIGILAIR technology is no silver bullet, either. It must be used in tandem with hand washing and 'deep cleaning'. The combination of these efforts is the best way to remove these pathogens. Any one of these tactics used in isolation will provide only a temporary relief, because hospital acquired infections are environmental by nature.

Study: MRSA Screening Fails to Lower Infection Rates

A new study published in the Journal of the American Medical Association says that universal MRSA screening upon admission to a hospital may not lead to fewer MRSA infections. The study compared two sets of surgery patients who received services at a Swiss hospital.

One group of more than 10,000 patients were screened for MRSA prior to surgery. If they tested positive for MRSA they were isolated and treated with disinfectant and antibiotics. The control group was of similar size and was not screened. Results from the study show no significant differences in the infection rates between the two groups.

From the Chicago Tribune:

"This is what we've been saying all long," said Kathy Warye, chief executive officer of the Association for Professionals in Infection Control and Epidemiology, a group that opposes efforts to mandate MRSA testing.

While screening patients can be a valuable, it's not a "magic wand" and it's not always the best way to deploy a medical institution's resources, said Dr. Stephen Weber, director of infection control at the University of Chicago Hospitals

Critics of the report's findings say the study may've overlooked some pre-existing MRSA reservoirs:

"Dr. Barry Farr, a MRSA expert, noted the Swiss hospital didn't screen patients on medical wards, who probably served as a reservoir of MRSA infections within the institution and skewed the study's results.

About one-third of surgery patients at the Swiss hospital had surgery before measures could be taken to control potential MRSA infections; that may have contributed to the findings, said Dr. Karen Kaul, chair of molecular pathology at Evanston Northwestern Healthcare."

Responses from both sides (pro and con) augment a central argument in VIGILAIR's infection control (IC) strategy.

• We believe that IC is dynamic and multifaceted
• There is no one strategy to eliminate infection
• There are many reservoirs of infection including patients, healthcare workers and the environment
• A prudent IC policy attacks pathogen reservoirs on several fronts simultaneously; bundling strategies works best

So, Now What?

MRSA screening has resulted in significant benefit for other facilities, notably Scandinavian hospitals that have virtually eliminated nosocomial MRSA infection after implementing 100% screening upon admission. This new study is not enough justification for a wholesale discrediting of MRSA screening. It is, however, more evidence that IC is more like a web than a chain. Breaking one link of transmission rarely does the trick.

Hand washing no panacea

I was delighted to hear the ABC song drifting from my bathroom last night.  It meant that my five year old son was following the instructions he learned in school to properly guage the amount of time he should wash his hands with soap and water.  Will he do this everytime? Probably not, but it is important to try.

The situation in my house is much like the situation in many healthcare facilities, according to an LA Tines article on the MRSA Watch blog site:

30 studies show hand washing neglect

Link: Beating the staph superbug - Los Angeles Times.

But, with a few exceptions, hospitals and public agencies have been slow to gear up against MRSA. More than 30 studies have shown, for example, that healthcare workers wash their hands about half as often as they're supposed to, even though washing before and after seeing each patient would drastically cut down on infection rates. Hospital surfaces and equipment aren't cleaned as often as they should be, and careless habits -- like touching potentially contaminated surfaces after hands have been washed but before touching the patient -- contribute to the spread. The first order of business should be to get a clear picture of MRSA. Where is it and how prevalent? An upcoming bill by state Sen. Elaine Alquist (D-Santa Clara) would make MRSA a reportable disease and require hospitals and nursing homes to report their infection rates. In Tennessee, which tracks MRSA, it quickly became the third most common reportable disease in the state, behind chlamydia and gonorrhea. A similar bill was vetoed in 2004 by Gov. Arnold Schwarzenegger, but the recent news from the CDC should make him rethink his position, despite the almost certain opposition of hospitals.

http://tahilla.typepad.com/mrsawatch/2008/01/30-studies-show.html

I bring this to your attention to demonstrate that infection control is dynamic.  There is no silver bullet.  Infection control requires multi-layers and some redundancies.  Our technology, VIGILAIR®, does not replace other sanitary efforts--it complements and enhances them.  Like hand washing, VIGILAIR® is not a cure all.  It is a prudent and effective way to reduce the airborne environmental pathogens within your facility.

More Evidence of MRSA's Airborne Spread

Epidemiologists are like medical detectives. They analyze an outbreak and then use their knowledge and tools to identify the outbreak source. Below is an excellent study from the Medical School in Kitakyushu, Japan. The study took place in a hospital area that housed 37 patients recovering from head and neck surgery. Three patients in single occupancy rooms became infected with MRSA after surgery.
Were all three patients colonized by the same strain of MRSA? If so, what was the source and how could patients in three separate rooms become infected with the same pathogen?
Researchers used air sampling machines and surface swabs to collect MRSA samples. Then the samples were analyzed using polymerase chain reaction and pulsed-field gel electrophoresis. The result?

"An epidemiological study demonstrated that clinical isolates of MRSA in our ward were of one origin and that the isolates from the air and from inanimate environments were identical to the MRSA strains that caused infection or colonization in the inpatients."

The conclusions of this study indicate that disinfecting the air circulated within their ward could help reduce colonization of patients (bold emphasis added by me).

"In this study, we confirmed that MRSA could be acquired by medical staff and patients through airborne transmission. The findings suggest the importance of protecting patients against cross-infectious agents existing in aerosols. Although measures for prevention and control of nosocomial infection with MRSA include handwashing with an antimicrobial agent; wearing a gown, gloves, and a mask; and removing MRSA from the nasal vestibule, few measures have been established to control airborne bacteria. Laminar unidirectional airflow, air ventilation, and air filtration could also be beneficial in hospital environments and should be considered. Further studies will be needed to assess the levels of MRSA contamination of air and to develop more effective means of controlling and removing airborne MRSA."

Once again we see that there is no silver bullet for infection control. Disease transmission is not all contact, nor is it all airborne, rather it is a dynamic combination of many things. In this hospital ward, airborne transmission took on increased importance because the patients in this care unit lack typical host defense mechanisms in their upper respiratory tracts.
VIGILAIR® systems are proven to reduce pathogen load within the air stream by destroying microorganisms with UVGI, and removing the microorganisms with filtration. You may download the research article in its entirety here.

Reference:
Teruo Shiomori, MD, PhD; Hiroshi Miyamoto, MD, PhD; Kazumi Makishima, MD, PhD. Significance of Airborne Transmission of Methicillin-Resistant Staphylococcus aureus in an Otolaryngology–Head and Neck Surgery Unit. Arch Otolaryngol Head Neck Surg. 2001;127:644-648

Hospitals Battle MRSA: Why Infection Control Arsenals Need Many Weapons

If you read UK newspapers you get the impression that MRSA is public health enemy #1. Fortunately the public’s focus on MRSA has helped to raise awareness and resources to reduce infections caused by this bacterium.

An excellent study of technology designed to eradicate MRSA is found in a recent issue of the Journal of Hospital Infection. Researchers assessed the short and long term effects of cleaning a hospital ward with Hydrogen Peroxide Vapor (HPV). Due to its oxidative properties, hydrogen peroxide is effective at eliminating many types of bacteria.

During the five month study, researchers measured MRSA contamination for the three months prior, and four weeks after an ICU was cleaned using HPV. Scientists used a machine like this one to create the vapor that was released inside the sealed, nine bed ICU. Previous studies have noted that HPV is considered a ‘big gun’ in disinfection, affording significant reduction of bacteria when combined with surface cleaning.

In the months prior to the HPV treatment, MRSA was isolated from 11.2% of sample sites. In the hours immediately following the HPV, no MRSA was isolated from the environment. The HPV did its job, end of story. Not quite.

The researchers wanted to look for MRSA after the HPV treatment, when real patients populated the ward. In less than 24 hours, the MRSA was back in the ICU:

“Twenty-four hours after the readmission of patients, MRSA was isolated from five environmental sites. All of the strains were indistinguishable from the strain with which the patient in bed space 8 was colonized, but the environmental contamination was not confined within that bed space.”

Despite the effectiveness of the ‘big guns’ (HPV), MRSA returned. In fact, detected MRSA surpassed the pre-HPV levels (11.2% v. 16.3%). Use of HPV is a great idea, but it cannot be the Infection Control Practitioner’s only weapon. Disinfection is an ongoing battle fought everyday, in every ward. Vigilance and multi-faceted approaches are the keys to long term success.

VIGILAIR® can be an important part of that strategy. Deployed within the Hospital’s air handlers, VIGILAIR® constantly disinfects the air through a combination of ultraviolet germicidal irradiation (UVGI) and high efficiency filtration. The technology is more than infection control, it is infection prevention.

As we always say, there is no panacea in the fight against MRSA, H5N1 and HAI. There needs to be a cross-discipline, evidence based strategy to identify, and eradicate all pathogen reservoirs within a hospital. With changes looming on the reimbursement horizon, this strategy will keep patients and hospitals healthy.

A white paper on airborne pathogens is available here.

Original Study:

K.J. Hardy, et al. Rapid recontamination with MRSA of the environment of an intensive care unit after decontamination with hydrogen peroxide vapour. Journal of Hospital Infection (2007) 66, 360-368

Image:

Bioquell

The Skinny on Airborne MRSA

The Skinny on Airborne MRSA

In our discussions with infection control professionals, MRSA is a frequent topic. It appears that there is a strongly held belief that MRSA cannot be transmitted via the air. For the doubters, I humbly submit:

1. “Staphylococcus aureus, often referred to simply as "staph," is a bacteria commonly found on the skin and in the nose of healthy people” -CDC.
2. “Normally, skin cells are replaced every 28 to 30 days”-Cleveland Clinic

If MRSA is frequently found on your skin, and you completely shed the top layer of your skin once-a-month, isn’t it reasonable that MRSA is hitching a ride on some of those millions of shed skin cells? You know, those skin cells that form cobwebs hanging from your ceiling?

Finally, If we doctors typically test for MRSA using nasal swabs, how did the MRSA get there? Could it be that people inhaled the MRSA through their noses? Air transmission may not be the largest contributor in the spread of MRSA, but it seems likely that it should be considered as one of the links in the chain of transmission.
(MRSA image-University of Texas)

UPDATE: For more information on MRSA's airborne spread, including a list of peer reviewed studies on the topic, please visit this posting from our blog.

MRSA blog vigilair