APIC MRSA Elimination Guideline

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Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital SettingsAntimicrobial StewardshipBest practice programs for the management of MRSA in the hospital setting are comprised mainlyof interventions that directly impact MRSA transmission. However, there is significant benefit frominterventions that have indirect or supplemental impact on MRSA prevention and control. An essentialsupplemental strategy that will affect long-term, sustainable MRSA management is antimicrobialstewardship.Antimicrobial stewardship may be defined as “the effective and responsible management of the useof antimicrobials in a given setting.” In the CDC’s Campaign to Prevent Antimicrobial Resistance,antimicrobial stewardship strategies are listed in steps five through 10 under the heading of “UseAntimicrobials Wisely.”Step 5. Practice antimicrobial controlEngage in local antimicrobial control effortsStep 6. Use local dataKnow your antibiogramKnow your patient populationStep 7. Treat infection, not contaminationUse proper antisepsis for blood and otherculturesCulture the blood, not the skin or catheter hubUse proper methods to obtain and process allculturesStep 8. Treat infection, not colonizationTreat pneumonia, not the tracheal aspirateTreat bacteremia, not the catheter tip or hubTreat urinary tract infection, not the indwellingcatheterStep 9. Know when to say “no” to vancoTreat infection, not contaminants or colonizationFever in a patient with an intravenous catheter isnot a routine indication for vancomycinStep 10. Stop antimicrobial treatment:When infection is curedWhen cultures are negative and infection isunlikelyWhen infection is not diagnosedGuideline Recommendations:The CDC/HICPAC “Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006”does not make specific recommendations regarding antimicrobial stewardship. The relative importance ofantimicrobial stewardship as a specific control measure for MRSA remains unclear. However, it does notethat judicious antimicrobial use is crucial to the management of MDRO in hospitals.The 2007 guideline from the Infectious Diseases Society of America (IDSA) and the Society forHealthcare Epidemiology of America (SHEA) recommends two core strategies for hospital antimicrobialstewardship programs:• Prospective audit of antimicrobial use with direct interaction and feedback to the prescribingphysician• Formulary restriction and preauthorization for immediate and significant reductions in response to anosocomial outbreak with monitors to assess and respond to unanticipated and unfavorable changesin resistance after implementing restrictions (B-III).50ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital SettingsThe core members of a comprehensive hospital antimicrobial management program are infectious diseasesphysicians, clinical pharmacists with infectious disease training, infection control professionals, hospitalepidemiologists, clinical microbiologists, and information system specialists.Additional strategies that will positively impact judicious antibiotic use include:• Education related to clinical treatment strategies and related hospital processes• Streamlining or de-escalating of empiric antibiotic therapy based on culture results• Evidence-based practice guidelines derived from local organism-specific resistance patterns• Antimicrobial order forms with automatic stops requiring physician justification for continuation• Computer-assisted programsThere is insufficient evidence to recommend the following:• Antibiotic cycling• Combination therapy to prevent resistanceRole of Susceptibility Testing in Antibiotic StewardshipReported susceptibility patterns for each clinical isolate is essential and should be readily assessableby physicians and pharmacists to assure that the “right bug” is getting the “right drug” throughout thetreatment regimen. The IDSA/SHEA guideline acknowledges that the clinical microbiology laboratoryplay a critical role in antimicrobial stewardship by providing patient-specific culture and susceptibilitydata by assisting infection control efforts in the surveillance of resistant organisms and in the molecularepidemiologic investigation of outbreaks.Susceptibility testing results should be compiled into antibiograms for MRSA and for other significantpathogens. Antibiograms include local and up-to-date susceptibility/resistance information and are usedto guide treatment decisions regarding appropriate empiric choices of antibiotics. Infection prevention andcontrol professionals must support and facilitate the process of antibiogram development with the hospitallaboratory and pharmacy teams.An Antibiotic Stewardship Success StoryFishman, N. “Antimicrobial Stewardship” in Am J Infect Control. 2006 Jun;34(5 Suppl 1):S55-63.Comprehensive control: The Hospital of the University of Pennsylvania (HUP) program as a paradigm.Excerpted: “When the HUP program was used to prescribe antimicrobials, antibiotic use wasmore appropriate and there was an increased cure rate and a decreased failure rate. There wasalso a trend toward decreased emergence of resistance, although the sample size and duration offollow-up in this study was too short to draw any significant conclusions.The HUP program was also associated with significant economic advantages for the institution comparedwith usual practice. Annual savings (600 interventions per month) amounted to $302,400 for antibioticASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY 51
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APIC MRSA Elimination Guideline

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