Each issue of the CoramClick provides an in-depth focus on timely and practical solutions. In this issue of the Click, we are focusing on Anti-infectives. Back issues of the Click are available in the CoramClick archive for easy reference!

	MRSA, aka the "Superbug" Overuse of antibiotics has led to the development of stronger strains of bacteria resistant to the bactericidal effects of antibiotics — a prime example of this is Methicillin-resistant Staphylococcus aureus, or MRSA.	Vancomycin: The Treatment Strategy for MRSA Vancomycin is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant staphylococci, for patients who are allergic to penicillins, and for infections resistant to other antimicrobial drugs. Did You Know? Trivia, tips, and health-smart to-dos related to MRSA. Subscribe to the CoramClick Please include your email address, first and last name, and company name.
	Diagnosis Flagging: Supporting Evidence-based Guidelines in Site of Care Decisions for Hemodynamically Stable Patients The "perfect storm" has arisen, bringing government, payors, and hospitals together in a common goal to maximize bed utilization strategies, while continuing to optimize patient outcomes. With CMS guideline changes in 2008, providers stood at attention that acute care management was taking a turn.

MRSA, aka the "Superbug"

Methicillin resistant Staphylococcus aureus, MRSA, "Superbug" — these are all names for an increasingly prevalent resistant bacteria with significant implications for patients and the healthcare system.

Overuse of antibiotics over the years has led to the development of stronger strains of bacteria resistant to the bactericidal effects of antibiotics. Methicillin-resistant Staphylococcus aureus (MRSA) is one example of a strain of staph bacteria that is resistant primarily to penicillin and penicillin-related antibiotics and to several other antibiotics as well. MRSA is estimated to cause 94,000 invasive infections and 18,650 deaths a year in United States hospitals.

Staphylococcus aureus itself is one of the most commonly found bacterial pathogens. Staph. aureus is a common cause of skin and soft-tissue infections, most of which are minor and present as postules or boils and can be treated without antibiotics. However, staph bacteria can also cause serious infections such as catheter-related infections and endocarditis and can lead to sepsis. Staph. aureus is the most common pathogen cultured from nosocomial infections and the most commonly isolated organism from hospital-acquired pneumonias (approximately 18 percent), surgical site infection (approximately 20 percent), and nosocomial site infections overall (approximately 19 percent). Greater than 90 percent of coagulase-negative staphylococci and 60 percent of S. aureus isolates are resistant to methicillin. In the hospital, MRSA infections are associated with greater lengths of stay, higher mortality, and increased costs. The average cost of MRSA treatment has been reported to be $27,000 to $34,000 per case — typically double the cost of a non-resistant infection. (www.novationco.com/pressroom/releases/news_080506.asp. Published May 2008. Retrieved June 26, 2008.)

Staph. aureus is carried on the skin or in the nose in 20 to 30 percent of healthy people, but they are not necessarily infected. People who carry bacteria without evidence of infection are colonized. If an infection develops, it is typically caused by bacteria that colonize patients. The biggest risk for getting a MRSA infection is being colonized in the nose and, in fact, approximately 29 percent of persons who are MRSA colonized develop an MRSA infection within 18 months of detection of colonization. It is important to note that bacteria that colonize patients can be transmitted from one patient to another by the hands of healthcare workers.

Methicillin-resistant Staphylococcus aureus refers to types of staph. There are several strains that are resistant to antibiotics in the methicillin class. MRSA is often resistant to other antibiotics, as well with approximately 1 to 8 percent of people colonized with resistant staph.

Staph infections, including MRSA, typically develop in hospitals and healthcare facilities in patients with weakened immune systems. Patients at risk include those with significant co-morbidities, patients who are immunocompromised, or who have invasive devices such as central lines or urinary catheters.

Every additional day in the hospital increases the risk of exposure to, and contamination by, resistant organisms. A history of repeated and prior antibiotic exposure, and patients who were recently hospitalized or reside in a nursing home, are also at risk for exposure and the development of resistance.

Staph and MRSA can also cause illness in persons in the community. Community-acquired MRSA (CA-MRSA), historically uncommon, is now responsible for about 14 percent of all cases of MRSA, and 55 percent of all such infections treated in the emergency department. (www.medscape.com/viewarticle/583209 Wilde, JA, MRSA Infections in the Emergency Department. Published 12/29/08. Retrieved June 26, 2009.) Infections in the community typically present as skin infections that look like pimples or boils and occur in otherwise healthy, typically younger, people. Community-associated MRSA is genetically and often clinically distinct from typical healthcare-associated strains. CA-MRSA tends to be more virulent and more likely to cause death if inappropriately treated, but also tends to respond better to antibiotic treatment.

MRSA is most frequently transmitted via direct skin-to-skin contact or by contact with contaminated shared items or surfaces, such as towels, razors, used bandages, weight training benches, etc. In hospitals it is transmitted primarily from contact with infected or contaminated healthcare workers and can be found on hospital equipment. In the community, potential risk factors include exposure in locker rooms, on weight equipment, in daycare centers, schools, dormitories, military barracks, and correctional facilities, etc.

Surveillance

There is controversy as to the necessity and cost-effectiveness of screening patients for MRSA at the time of hospital admission. Increasingly, however, support for such surveillance is strengthening. In one study, a large university medical center evaluated the impact of surveillance on the rate of MRSA infections in their patient population. The rate of MRSA infection per 1,000 patient days averaged 0.5294 prior to the initiation of a surveillance program. When MRSA screening for all patients admitted to the ICU was implemented, the incidence dropped to 0.3924. When all patient admits were screened, the rate dropped even farther, to 0.1986 infections per 1,000 patient days — a 68 percent reduction. (Robison, A., Beaumont, JL, Paule, SM et al. (2008). Universal Surveillance for Methicillin-Resistant Staphylococcus aureus in 3 Affiliated Hospitals. Annals of Internal Medicine 148(6), 409-418.) Even when factoring in the costs of screening, universal surveillance proves to be cost-effective.

Treatment

Depending on the location of the infection and the site of acquisition (i.e., hospital or community), treatment may be with oral, nebulized, topical or IV antibiotics. For example, given that the nostrils are a common site of colonization or infection, nebulized or topical antibiotics are the treatment of choice, e.g. bacitracin or mupirocin ointment. Currently, vancomycin remains the drug of choice for treatment of serious MRSA infections from nosocomial and healthcare-associated cases. Combination therapy is sometimes needed. There are also newer drugs like linezolid and daptomycin that show promising results against MRSA.

Community-acquired MRSA treatment recommendations include clindamycin (Cleocin^®) or vancomycin in combination with a third generation cephalosporin. Trimethoprim-sulfamethoxazole (Bactrim^®, Septra^®) may also be prescribed.

Hospital Precautions

Recommended precautions to help prevent the spread of MRSA within a hospital include:

• Using contact precautions for MRSA-colonized or infected patients.
• Placing patients with MRSA colonization or infection under contact precautions to help reduce patient-to-patient spread within the hospital.
• Placing patients in a single or private room when available. A cohort* of patients with MRSA colonization or infection is acceptable when a single or private room is not available.
• Wearing a gown and gloves upon entry into the patient's room.
• Removing the gown and gloves before exiting the room.
• Hand hygiene upon entering and exiting the patient's room. Wearing gloves does not eliminate the need for hand hygiene.

Community Precautions

Preventive practices include:

• Cover any open sores with a bandage
• Practice good personal hygiene
• Wash your hands a number of times a day
• Shower after every gym workout
• Never share personal items such as towels, clothing, swim wear, combs, soap, shampoo, or shaving gear
• Know if the gym washes and dries towels in temperatures high enough to kill MRSA

Home Precautions

Similar precautions should be taken when the patient is home. As recommended by the CDC, patients, and anyone who comes in contact with the patient, should:

• Wash their hands with soap and water before and after direct contact with an infected individual.
• Use a cloth or linen towel ONCE when drying their hands.
• Use gowns and gloves when excessive body fluids are present.
• Change and wash linens regularly, particularly when soiled.
• Maintain the home environment and room of the person infected so that it is well cleaned routinely, especially when the area becomes soiled with body fluids.
• Always remember to notify healthcare workers/providers and other doctors when the patient has been diagnosed with an infection such as MRSA, VRE, or a multi-drug resistant organism.

*A cohort does not eliminate the need for compliance with hand-hygiene guidelines and other infection prevention measures.

Vancomycin: The Treatment Strategy for MRSA

Intravenous vancomycin is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant staphylococci, for patients who are allergic to penicillins, and for infections caused by vancomycin-susceptible organisms that are resistant to other antimicrobial drugs. Vancomycin is commonly given as monotherapy for MRSA, but combination with an aminoglycoside or rifampin, for example, may be necessary. Vancomycin is effective against MRSA only when an effective minimum inhibitory concentration (MIC) is present, so for certain patients and/or certain strains of MRSA, vancomycin may not be effective or may be required in higher doses.

The usual daily intravenous dose is 2g, divided either as 500mg every six hours or 1g every 12 hours. In order to reduce rate-related toxicities, each dose should be administered at no more than 10mg/min or over a period of 60 minutes, whichever is longer. However, infusion-related events may occur at any rate or concentration. Factors such as age, renal function, obesity, and hearing loss may also impact dosing.

Potential Adverse Effects

Infusion-related
During or soon after rapid infusion of vancomycin, patients may develop anaphylactoid reactions, including hypotension, wheezing, dyspnea, urticaria, or pruritus. Rapid infusion may also cause flushing of the upper body ("red neck") or pain and muscle spasm of the chest and back. These reactions typically resolve within 20 minutes but may last for several hours. Such events are infrequent if vancomycin is given by a slow infusion over 60 minutes.

Renal
While rare, renal failure has been reported, primarily in patients who were given concomitant aminoglycosides or who had pre-existing kidney dysfunction. Patients may present with elevated serum creatinine and/or blood urea nitrogen (BUN), at which time dose adjustments, including discontinuation, may be required. Renal dysfunction is often reversible upon discontinuation of vancomycin.

Ototoxicity
Hearing loss associated with vancomycin has been reported. Most of these patients had kidney dysfunction or a preexisting hearing loss or were receiving concomitant treatment with an ototoxic drug. Vertigo, dizziness, and tinnitus have been reported rarely.

Hematopoietic
Reversible neutropenia has been reported.

Other
Phlebitis, drug fever, nausea, chills, eosinophilia, rashes, vasculitis, diarrhea

Diagnosis Flagging: Supporting Evidence-based Guidelines in Site of Care Decisions for Hemodynamically Stable Patients

The "perfect storm" has arisen, bringing government, payors, and hospitals together in a common goal to maximize bed utilization strategies, while continuing to optimize patient outcomes. With CMS guideline changes in October of 2008, identifying no-pay events as well as highlighting incidents of hospital acquired infections, providers stood at attention that acute care management was taking a turn. Payors were quick to jump in the waters with CMS and began to identify their own no-pay lists, as well as renegotiate hospital payment strategies that put hospitals back at risk with DRG models. Hospitals themselves proactively looked at their acute care model strategy and identified a risk stratification process to identify certain populations for alternative sites of care, as well as stepping up to manage their own financial dollar bundles provided by both the government and third party customers.

So what do these strategies really impose to the acute care model? Some may argue that it forces a re-examination and compliance with already supported literature that states certain populations are better serviced at a lower level of acute care management. A lower level does not indicate a "lower standard," but rather a lower risk modifier for those that are appropriate for care outside of an acute institution. The care can be received in a skilled nursing institution, LTAC, physician infusion suite, ambulatory infusion suite, or home. We, as providers, are challenged with risk stratifying these key populations and looking at the most cost effective modality, to ensure the same or better outcomes for those we service.

Diagnosis flagging is a concept that looks at key populations, when risk stratified, that qualify for a lower level of acute care management, allowing for transition back into the community, and preferably home for continuation of treatment. These populations are chosen, based on evidence-based guidelines and flagged at point of entry within the medical facility. The point of entry can include: community physician practice, emergency room, observation unit, or direct admit status. Patients are reviewed for: hemodynamic stability, home environment, self-learning/teaching abilities, as well as caregiver support. First dosing often occurs at point of entry, with home options available for those flagged in the community. This model supports not only acute populations, but those with chronic conditions that present repeatedly with acute exacerbations.

The concept of proper diagnosis flagging invokes an earlier visualization model, compared to discharge flags that align with average length of stay models. The goal is proper identification and risk stratification, while optimizing outpatient outcomes and decreasing re-hospitalization events.

Did You Know?

• The number of MRSA fatalities in 2005 surpassed the number of fatalities from hurricane Katrina and AIDS combined and is substantially higher than fatalities at the peak of the U. S. polio epidemic. (Evans, RP (May, 2008). The silent epidemic: CA-MRSA and HA-MRSA Recommendations for prevention, identification, and treatment. AAOS Now May 2008 Issue http://www.aaos.org/news/aaosnow/may08/research1.asp . Retrieved June 27, 2009.)
  
  
• The most critical preventative factor for spreading MRSA infection is HAND WASHING
  
  
• If hands are visibly dirty or contaminated, healthcare workers should wash their hands with soap and water. If not visibly soiled, alcohol-based hand rubs can be used. (Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16. CDC slide.)

Reference

• Centers for Disease Control and Prevention. Environmental Management of Staph and MRSA in Community Settings. http://www.cdc.gov/ncidod/dhqp/ar_mrsa_Enviro_Manage.html. Published July 2008. Retrieved June 24, 2009.
  Rehm SJ. Staphylococcus aureus: the new adventure of a legendary pathogen. Cleve Clin J Med. 2008;75(3):177-180, 183-186, 190-192. PMID: 18383927.
• Klevens, RM, Morrison, MA, Nadle, J et al (2007). Invasive MRSA Infections in the United States. JAMA, 298(15):1763-1771 www.jama.com. ©2007 American Medical Association. All rights reserved. (Reprinted) JAMA, October 17, 2007—Vol 298, No. 15 1763. Downloaded from www.jama.com at CDC-Information Center, on October 18, 2007. Retrieved June 25, 2009.
• www.novationco.com/pressroom/releases/news_080506.asp. Published May 2008. Retrieved June 26, 2008.
  
• Wilde, JA, MRSA Infections in the Emergency Department. Published 12/29/08. Retrieved June 26, 2009). (www.medscape.com/viewarticle/583209).
  
• Supplement Article: SHEA/IDSA Practice Recommendation Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals Infect Control Hosp Epidemiology 2008;29:S62–S80.
  
• Evans, RP (May, 2008). The silent epidemic: CA-MRSA and HA-MRSARecommendations for prevention, identification, and treatment. AAOS Now. May 2008 Issue
  http://www.aaos.org/news/aaosnow/may08/research1.asp . Retrieved June 27, 2009.
  
• Robicsek, A., Beaumont, JL, Paule, SM et al. (2008). Universal Surveillance for Methicillin-Resistant Staphylococcus aureus in 3 Affiliated Hospitals. Annals of Internal Medicine 148(6), 409-418.

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