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Expanding the Universe of Methicillin-Resistant Staphylococcus aureus Prevention

Ebbing Lautenbach, MD, MPH, MSCE
[+] Article, Author, and Disclosure Information

From the University of Pennsylvania School of Medicine, Philadelphia, PA 19104-6021.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Ebbing Lautenbach, MD, MPH, MSCE, Division of Infectious Diseases, Department of Medicine, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, 825 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021; e-mail, ebbing@mail.med.upenn.edu.

Ann Intern Med. 2008;148(6):474-476. doi:10.7326/0003-4819-148-6-200803180-00009
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Staphylococcus aureus is one of the most common causes of infection in both the community and the health care setting. First described in 1961 (1), methicillin-resistant S. aureus (MRSA) has increased dramatically and now constitutes more than 50% of S. aureus isolates that cause infections in the hospital setting (24). Furthermore, MRSA infections are associated with poor clinical and economic outcomes (5).

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When Universal does not mean All
Posted on April 22, 2008
William R. Jarvis
Jason and Jarvis Associates and Emory University School of Medicine
Conflict of Interest: None Declared

To the editor,

We read with interest the study by Robicsek et al (1) and accompanying editorial (2). Congratulations to Robicsek et al for their successful intervention (70% MRSA infection reduction) using MRSA active detection and isolation (ADI). It is troubling that the editorialist failed to recognize this achievement. Instead of focusing on what should be done (use of MRSA Prevention Bundles), he offers excuses for why this hasn't/shouldn't occur. We believe the editorial requires comment. First, the editorialist states there is a "lack of rigorous scientific evidence" on how to limit MRSA. This is more applicable to a number of the Centers for Disease Control and Prevention (CDC) recommendations (e.g., outlawing false/long fingernails, maximum barrier precautions, etc.) with far less supporting evidence, yet never is. He discounts >150 quasi-experimental studies reporting MRSA control after MRSA Bundle (including ADI) implementation (3). Second, Lautenbach opines that several states' legislation "mandate uniform surveillance for MRSA", i.e., "one-size fits all". Perhaps the term "uniform" should be clarified. The Maryland bills and Illinois and Pennsylvania laws mandate active MRSA screening of facility-specific high-risk patients coupled with effective control measures (i.e., the SHEA Guideline approach [4]). MRSA high-risk patients exist at virtually every U.S. healthcare facility, so maybe this, like many CDC Guideline recommendations (Influenza prevention) should only come in one size. CDC lists groups for influenza immunization, without similar concerns voiced. Third, Lautenbach states that "screening for MRSA reduces MRSA infections---is not necessarily correct". We agree. MRSA screening alone will not reduce MRSA infections. Reductions require screening coupled with appropriate control measures. However, no study (quasi- experimental or randomized) has shown sustained 70% MRSA reductions without ADI inclusion.

Fourth, Lautenbach thinks it is "premature" to apply Robicsek's MRSA prevention bundle. Does he not believe that nearly 100,000 MRSA infections and 20,000 deaths annually require action? The MRSA Bundle works. We shouldn't be wasting time (and lives) debating the meritorious weight of each Bundle element (which has not been done with CVC-BSI, SSI or VAP Bundles). Fifth, Lautenbach states that "failure to act decisively"¦"¦.has resulted largely from the lack of rigorous scientific evidence". Au contraire, the failure of MRSA control results from hospitals choosing to continue to follow traditional infection control practices (e.g., isolating only culture-positive patients) despite a significant and growing body of evidence supporting a more aggressive approach. If prevention is primary, then implementing effective measures, like MRSA Bundles with ADI are, essential. Sincerely, William R. Jarvis, M.D. Carlene A. Muto, M.D., M.S. Jason and Jarvis Associates Division of Infectious Diseases Hilton Head Island, South Carolina 29928 University of Pittsburgh School of Medicine

3471 Fifth Street

1215 Kaufmann Building

Pittsburgh, PA 15213


1) Robicsek A, Beaumont JL, Paule SM, Hacek DM, Thomson RB, Kaul KL, MD, Peggy King P, and Peterson LR,. Universal surveillance for methicillin - resistant Staphylococcus aureus in 3 affiliated hospitals. Ann Intern Med. 2008;148:409-418.

2) Lautenbach E. Expanding the universe of methicillin-resistant Staphylococcus aureus prevention. Ann Intern Med. 2008;148: 474-476.

3) Farr BM. Doing the right thing (and figuring out what that is). Infect Control Hosp Epidemiol 2006;27:999-1003.

4) Muto CA, Jernigan JA, Ostrowsky BE, Richet HM, Jarvis WR, Boyce JM et al. SHEA guideline for preventing nosocomial transmission of multidrug- resistant strains of Staphylococcus aureus and Enterococcus. Infection Control & Hospital Epidemiology 24(5):362-386, 2003. http://www.shea- online.org/Assets/files/position_papers/SHEA_MRSA_VRE.pdf

Conflict of Interest:

None declared

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