Running Header: HOSPITAL ACQUIRED MRSA

Hospital Acquired Methicillin Resistant Staphylococcus Aureus: A Review of the Literature

Katie Cooleen
Northeastern University
November 15, 2016

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Annotated Bibliography
Avery, T.R., Elkins, K.R., Huang, S.S., Hudson, L.O., Ke, W., Lipsitch, M., . . . Spratt, B.G.
(April 24, 2012). Patient Sharing and Population Genetic Structure of Methicillin
Resistant Staphylococcus Aureus. Proceedings of the National Academy of Sciences of the
United States of America, Vol. 109, No. 17, pp. 6763-6768. http://www.jstor.org/stable/41588603
This article discusses the transmission process of methicillin resistant Staphylococcus aureus (MRSA), in
the hospital setting. To evaluate this process, research was done to evaluate the proportion of shared
patients between hospitals and their correlation with genetic similarity in MRSA strains in those hospitals.
30 of 32 hospitals in Orange County, California were used to collect data for this study. This particular
place was chosen because it is a large county that has relatively low population flow from the outside. The
study found that patient sharing did predict the level of similarity in the genetic variation of the MRSA
strain, therefore, patient sharing does result in the spread of MRSA. The writer of this source seems
credible because the study was done by the Harvard School of Public Health, which is a very well known
and prestigious school that has a reputation for excellent and accurate work. The study was very
developed and used statistical and scientific tests to reach the conclusions. This source is helpful to my
project because it discusses the direct transmission of a common hospital acquired infection. A limitation
might be that it solely focuses on MRSA, which limits the use of the information.
Bakullari, A., Eckenrode, S., Eldridge, N., Galusha, D., Metersky, M. L, Pandolfi, M. M., . . . Wang,
Y. (October 2014). The Association between Age, Sex, and Hospital-Acquired Infection
Rates: Results from the 2009-2011 National Medicare Patient Safety Monitoring System.
Infection Control and Hospital Epidemiology, Vol. 35, No. S3, pp. S3-S9.
http://www.jstor.org/stable/10.1086/677831
This article helps to define the relationships between age, sex, and hospital-acquired infection (HAI). This
study focuses on national rates in hospitalized patients using data from the Medicare Patient Safety
Monitoring System. The study uses randomly selected medical records of patients that were hospitalized
for acute cardiovascular disease, pneumonia, or major surgery between January 1, 2009, and December
31, 2011. 85,461 patients were used in the study, and they were broken up into groups, where their age,
sex, rate of occurrence of HAI for those who were at risk, and rate of patients with at least one HAI were
taken into account. The study found that all groups except for younger female surgical patients had higher
rates of catheter-associated urinary tract infections (CAUTI). However, there was no overall evidence of
significant differences in the rate of HAIs in most age groups. The study did find that men have a higher
rate of overall HAI than women. This source is credible because it is using sources that come from many
different credible schools, such as Yale, Harvard, and Connecticut School of medicine. The way the
researchers collected their data was also credible because they used a large sample size with a wide range
of ages and different medical problems. This article would be helpful for my research because it discusses
a few different types of infections, and the prevalence in different patient populations.
Avery, T. R., Hayden, M. K, Huang, S. S., Perlin, J. B., Platt, R., Ray, G. T., Septimus, E. (October
2014). Cost Savings of Universal Decolonization to Prevent Intensive Care Unit Infection:

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Implications of the Reduce MRSA Trial. Infection Control and Hospital Epidemiology, Vol.
35, No. S3, pp. S23-S31. http://www.jstor.org/stable/10.1086/677819
This article discusses the estimates and the impact of healthcare costs in regards to using alternative
strategies for reducing blood stream infection in intensive care units. It focuses on MRSA, specifically
screening using nares screening and isolation, targeted decolonization, and universal decolonization. The
researchers of this article created a model to estimate the health care costs of doing these preventative
measures, such as targeted decolonization and universal decolonization strategies compared to nares
screening and isolation. The results showed that universal decolonization was the most effective strategy,
and it estimated that it was both lower in intervention cost, as well as lower in total ICU cost than the
screening and isolation or the targeted decolonization. This is a credible source because it references
many legitimate sources, such as previous studies, national statistics, and government costs. This source is
credible because the research was performed in an accurate, unbiased way. The trial was a randomized
trial that compared the three variables. It took information from 43 different hospitals, and 74 ICUs. I
think this would be helpful to my research because this is a different way to look at hospital acquired
infections. I think the cost of HAI is an important topic to discuss when talking about HAI. A limitation
of this article could be that it only focuses on MRSA, and only focuses on the intensive care setting.
Fakih, M. G., Krein, S. L., Meddings, J., Olmsted, R. N., Rogers, M. A., Saint, S. (September 27,
2016). Reducing unnecessary urinary catheter use and other strategies to prevent
catheter-associated urinary tract infection: an integrative review. BMJ Quality and Safety Journal.
http://qualitysafety.bmj.com/content/early/2013/09/27/bmjqs-2012-001774.full.pdf+html
This article discusses catheter-associated urinary tract infections (CAUTI). It discusses the cost, how
common they are, and the prevention by reducing urinary catheter use. This looked at 30 studies that were
done regarding this topic, and found that the removal of catheters reduced the rate of infection by 53%.
This article discussed other ways to further prevent CAUTI, including reminders and stop orders. This
article compares previous studies, which is good, because they are looking at 30 different studies that
were executed, which gives the study more input. However, it is difficult to figure out the credibility of 30
other studies, so this makes it slightly less credible. However, if the other studies are credible, than this
source provides a nice summary and analysis of the information regarding CAUTI. I think this could be
useful to me, however, the limitation is that it only discusses one kind of HAI.
Bakullari, A., Eckenrode, S., Eldridge, N., Galusha, D., Metersky, M. L, Pandolfi, M. M., . . . Wang,
Y. (October 2014). Racial and Ethnic Disparities in Healthcare-Associated Infections in the
United States, 2009-2011. Infection Control and Hospital Epidemiology, Vol. 35, No. S3.
http://www.jstor.org.ezproxy.neu.edu/stable/pdf/10.1086/677827.pdf
This article discusses the racial and ethnic disparities in HAI in the United States, with the goal being to
see if these disparities exist. The data was collected from the Medicare Patient Safety Monitoring System
(MPSMS). This data was taken of discharges from hospitals of adult patients who were treated for acute
cardiovascular disease, pneumonia, or major surgery from January 1, 2009 until December 31, 2011. 70,
019 patients were included in the study sample, and they were broken into six racial and ethnic groups.

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The conclusions found that out of these patients, Asian and Hispanic patients had significantly higher
rates of HAIs than white non-hispanic patients. This article seems credible because the study was done
using a large sample size, and data was taken from a reliable source, the MPSMS. I think this would be a
good article to use because this information is a good indicator for the prevalent populations that are most
affected by HAI.

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Introduction
Hospital acquired infections (HAI) are any kind of infection that occurs in the hospital,
and is not acquired before the beginning of medical care. Methicillin resistant Staphylococcus
aureus, or MRSA, is a type of HAI. It is an infection that results from a type of Staphylococcus
bacteria that is resistant to many antibiotics that are used to treat regular Staphylococcus
infections. A few common presentations of MRSA infections include central line-associated
bloodstream infections (CLABSI), urinary tract infections, ventilator-associated pneumonia
(VAP), or surgical site infections (Calfee et al., 2014). MRSA can present in the skin, soft tissue,
bloodstream, or other parts of the body. MRSA infection is associated with longer hospital stays,
higher hospital costs, and increased morbidity and mortality (Calfee et al., 2014). If this infection
spreads into the bloodstream, it can cause septicemia, abscesses, meningitis, or pneumonia,
which can all be life threatening.
There are many different variables that affect hospital acquired infections. Some of these
variables include the frequency that invasive devices are used, how long they are used for, how
well the procedure to place them was performed, and the care of the devices once they are placed
(Bakullari, A., et al. 2014a). There are a wide range of invasive devices, but some common ones
include central lines, foley catheters, or ventilation devices. This literature review will look at the
most recent research on hospital acquired MRSA, with the focus on patient population, economic
impact, and prevention.

Methodology

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Many of the sources used in this review were found through the Journal Storage Database
(JSTOR) database, which was accessed through the Northeastern Library website. By searching
for hospital acquired infections I found two sources about general studies of the prevalence of
certain hospital acquired infections. After this initial search was completed, a new search was
executed using the search term MRSA in JSTOR, and many different sources were found. All
articles that were used were considered timely, and were all published within the last five years.
Besides the two articles discussed above, six other sources were found using the JSTOR
database.
Another resource that I utilized was information that Beth Israel Deaconess Medical
Center sent out to employees about a new protocol for MRSA prevention. This information was
sent in the form of research articles. This is relevant to my research, and the material fits well
into the themes of the review, with a differing viewpoint.
There are a few limitations to the research that was found. One limitation is that the
sources discuss studies done from all over the world. This gives a wider range of variables,
especially regarding medical practice and policies in different countries. This allows the research
to discuss the broader impact of MRSA, but is not be beneficial to draw specific conclusions for
one specific country. Another limitation is that the sources used a wide range of study
techniques. This is beneficial because it provides differing viewpoints, but could also cause
different outcomes. Some of the sources collected data from other sources to draw conclusions,
which may also be limiting depending on the interpretation of data. Another limitation is that
there are some articles used in the review that have the same author, or were taken from the same
journal. This could create a bias in the findings found in the literature.

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Results
Patient Population of MRSA
There are a few studies that were observed that discussed the types of patients that most
often present with MRSA, and one regarding the sharing of a specific strain of MRSA between
populations. One study researched patient sharing and the population genetic structure of
methicillin resistant Staphylococcus aureus. Avery et al. (2012), performed a research study that
focused on whether the pattern of genetics in strains of MRSA was related in different hospitals
in Orange County, California. This particular place was chosen because there is not a lot of
population flow and there are many people that live in this area. 30 hospitals were used in the
study. The heterogeneity between the MRSA populations in different hospitals was assessed to
see if there was any overlap in genetics. In the conclusion of the study, it was found that the
extent of patient sharing does predict the extent of genetic similarities in the MRSA. The study
found that the more patients the hospital shared, which indicates patients going to different
hospitals for care, the more genetically similar their MRSA strain was (Avery et al, 2012). The
study also found that pairs of hospitals that had greater patient sharing showed greater
significance in similarities, which shows correlation (Avery et al, 2012).
There were two different studies that looked at different patient demographics and which
were most associated with hospital acquired infection. Both of these sources dealt with data from
the Medicare Patient Safety Monitoring System. One article discussed age and gender, and the
other discussed ethnic disparities. There are also patient factors such as age and gender that are
thought to influence the prevalence of HAI. According to Bakullari et al. (2014a), it was
hypothesized that elderly patients are more at risk to develop a HAI based on their decreased

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immune system due to age. However, this study found that this assumption was incorrect, and
concluded that there is not a significant difference in the development of HAI based on age.
However, the study that was conducted did find a difference in infection rate between men and
women, with men having a higher rate of HAI overall. The other study that used data from the
Medicare Patient Safety Monitoring system looked at racial and ethnic disparities in HAI.
Bakullari et al. (2014b), analyzed data from 79,019 patients. Through this analysis, it was
concluded that Asian and Hispanic patients had significantly higher rates of HAI compared to
white non-hispanic patients.
Economic Impact of MRSA
The cost of MRSA is an important aspect to look at when discussing the topic. Hospital
acquired infection causes both individual and hospital costs. One study analyzed the cost of
different strategies that are used to prevent MRSA infection in the intensive care unit setting.
Avery et al. (2014), performed the study looking at three different strategies for reduction of
infection. The three strategies included nares screening and isolation, targeted decolonization,
and universal decolonization. The nares screening and isolation includes testing the nares for
MRSA and using contact precautions for any of the positive MRSA carriers. The targeted
decolonization includes a universal nares screenings, contact precautions for carriers, and
decolonizing carriers with daily chlorhexidine baths and mupirocin treatment. The universal
decolonization does not include screening at admission, but contact precautions are used if the
patient has had a history of MRSA, and daily chlorhexidine baths and mupirocin are given to all
patients. The researchers of this article created a model to estimate the health care costs of doing
these preventative measures, such as targeted decolonization and universal decolonization

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strategies compared to nares screening and isolation, which was previously the standard.
Effectiveness was measured using data from the Reduce MRSA trial, which is a randomized trial
of the three studies, and cost estimates were taken from different published sources. The results
showed that universal decolonization was the most effective strategy, and it estimated that it was
both lower in intervention cost, as well as lower in total ICU cost than the screening and isolation
or the targeted decolonization. Universal decolonization was estimated to have the lowest mean
intervention cost, and was estimated to save $155 per admission. The study estimates that
universal decolonization would save approximately $171,000 annually.
Another source that analyzes the cost of treatment deals with the economic impact of
redundant antimicrobial therapy in hospitals in the United States. Shultz et al. (2014), conducted
a study that explored the incidence and economic impact of potentially redundant antimicrobial
therapy. This study was a retrospective analysis of inpatient data that was taken from 398 US
hospitals. The data was taken from patients who were discharged between January 2008 and
December 2011. The study defines potentially redundant antimicrobial therapy as patients that
were receiving overlapping antibiotic spectrums for two or more consecutive days. This study
found that during this span of a few years, the cost of redundant treatment was about $9.9
million. The potential savings in drug costs by reducing the 17 most common redundant
antimicrobial combinations exceeded $12.9 million for the hospitals in the study. If this data was
used in all hospitals across the United States, the potential savings for this time span would be
about $163 million, which is about 2% of total expenses for hospitals in the United States in the
year of 2012.
Prevention of MRSA

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There are many strategies that have been published regarding the prevention of the spread
of MRSA. One common strategy that is often discussed is the use of contact precautions. Calfee
et al. (2014), recommends using contact precautions for MRSA-colonized and MRSA-infected
patients. This source also recommends that contact precautions should be used if a patient has
ever had a history of MRSA, because it is suggested that patients may be carriers for a prolonged
amount of time, with a median duration of 8.5 months. However, there are newer studies that
have emerged recently that show differing thoughts. Edmond et al. (2015) did a before and after
study of discontinuing contact precautions for MRSA for colonized and infected patients. This
was done in a 865 bed teaching hospital. The results concluded that there were no changes in the
rates of MRSA for device-associated infections, no changes in the rates of catheter-associated
urinary tract infections, no changes in central-line-associated bloodstream infections, and no
changes in the rates of ventilator associated pneumonia. This study has conclusions that are
much different than what many other sources have reported for contact precaution guidelines.
Another article discusses universal glove and gown wearing for all patients in an ICU
setting and its impact on decreasing the acquisition of MRSA. Harris et al. (2013), conducted a
cluster-randomized trial that took place in 20 medical and surgical intensive care units in 20
hospitals in an 8 month span in 2012. This particular study further discusses the idea of the
importance of contact precautions in preventing the spread of MRSA. This study found that
using contact precautions on every patient did not show a reduction in MRSA acquisition. This
further supports the idea that contact precautions may not be as significant in the prevention of
MRSA as other sources believe.

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Another strategy that is discussed when preventing the spread of MRSA is environmental
decontamination. Calfee et al. (2014) discusses how objects in the room can become
contaminated, such as the surface of tables, bedrails, furniture, sinks, and floors. Therefore, this
source suggests ensuring cleaning and disinfection of equipment and the environment before a
new patient uses the space. This concept is further supported by Simor et al. (2013), where a
study was conducted in 176 Canadian hospitals to look at the associations between prevalence,
institutional characteristics, and infection control policies. This study was done by having each
hospital participate in a weekly prevalence survey, where patients that were colonized or infected
with MRSA were identified. This was compared with each facilitys infection control policy.
The study concluded that a lower prevalence of MRSA was associated with facilities that
routinely used enhanced environmental cleaning, and facilities that routinely used private rooms
for patients that tested positive for MRSA.
Another strategy that is discussed in terms of prevention of MRSA is daily topical
chlorhexidine gluconate (CHG) baths. Septimus et al. (2014), discussed the results of 4
randomized cluster trials that evaluated the effectiveness of CHG baths for patients in intensive
care units. This study showed that the daily CHG bathing technique greatly decreased the risk of
developing bloodstream infections. Simor et al. (2013), further supports this strategy. This source
looks at european studies, and concludes that routine daily use of CHG bathing for patients with
MRSA was related to a lower MRSA infection rate.
There are also ways for categorizing prevention measures against MRSA.
Septimus et al. (2014), discusses both vertical and horizontal approaches to prevent HAI.
Vertical approaches aim to reduce colonization, infection, and transmission, mostly through

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active surveillance testing (AST). After these things are accomplished, measures that aim to
prevent transmission of the HAI are implemented. Horizontal approach aims to reduce the risk
infection by implementation of standardized practices that do not depend on patient-specific
conditions. Examples of these standardized practices include hand hygiene, minimizing
unnecessary use of invasive devices, and improving environmental cleaning. Some conclusions
that were drawn from this particular article were that both types of strategies were effective in
some way, as long as they were implemented effectively.

Comments
The research shows that MRSA is a very relevant and important topic that needs to be
addressed in the healthcare field. However, more research must be done to come to concrete
conclusions regarding many of the areas of MRSA research. Currently, many of the studies lack
consistency. There are many studies that are done based off of data that was from the past. More
research needs to be done in a manner of conducting a full study with specific independent
variables and how they affect dependent variables, such as MRSA prevention. It is often difficult
to come up with a study that only deals with the variables that the researcher wants to look at. In
a hospital setting, it is impossible to create a completely controlled environment, therefore it is
often difficult to tell which variable is affecting the outcome.One example that demonstrates the
lack of consistency in findings is the use of contact precautions in the prevention of MRSA.
Some literature states that it should be used if anyone has a history of MRSA, colonization of
MRSA, or an infection of MRSA. However, there is other research that says the impact of the

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use of contact precautions is not significant, and some hospitals are going as far as discontinuing
this strategy. These kinds of discrepancies must be solved with further research.
Many of the articles that were found to review MRSA were studies that were done in
intensive care units. This may be because it is a more controlled environment than other types of
units. However, this does not allow for a full scope of information regarding MRSA. Also, many
of the studies are based on information from all over the world, without full explanation of how
different healthcare policies might affect the results of the research. This is another aspect of the
literature that must be addressed to come up with solid conclusions. While there is overlap in
some of the conclusions of the literature, there needs to be more consistency. Overall, the
literature shows that there is a lot of information regarding MRSA, however, more research
needs to be conducted to better understand all aspects of this topic.

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References
Avery, T.R., Elkins, K.R., Huang, S.S., Hudson, L.O., Ke, W., Lipsitch, M., . . . Spratt, B.G.
(April 24, 2012). Patient Sharing and Population Genetic Structure of Methicillin
Resistant Staphylococcus Aureus. Proceedings of the National Academy of Sciences of the
United States of America, Vol. 109, No. 17, pp. 6763-6768. http://www.jstor.org/stable/41588603
Avery, T. R., Hayden, M. K, Huang, S. S., Perlin, J. B., Platt, R., Ray, G. T., Septimus, E. (October
2014). Cost Savings of Universal Decolonization to Prevent Intensive Care Unit Infection:
Implications of the Reduce MRSA Trial. Infection Control and Hospital Epidemiology, Vol.
35, No. S3, pp. S23-S31. http://www.jstor.org/stable/10.1086/677819
Bakullari, A., Eckenrode, S., Eldridge, N., Galusha, D., Metersky, M. L, Pandolfi, M. M., . . . Wang,
Y. (October 2014a). The Association between Age, Sex, and Hospital-Acquired Infection
Rates: Results from the 2009-2011 National Medicare Patient Safety Monitoring System.
Infection Control and Hospital Epidemiology, Vol. 35, No. S3, pp. S3-S9.
http://www.jstor.org/stable/10.1086/677831
Bakullari, A., Eckenrode, S., Eldridge, N., Galusha, D., Metersky, M. L, Pandolfi, M. M., . . . Wang,
Y. (October 2014b). Racial and Ethnic Disparities in Healthcare-Associated Infections in the
United States, 2009-2011. Infection Control and Hospital Epidemiology, Vol. 35, No. S3.
http://www.jstor.org.ezproxy.neu.edu/stable/pdf/10.1086/677827.pdf
Calfee, D. P., Salgado, C. D., Milstone, A. M., Harris, A. D., Kuhar, D. T., Moody, J., . . . Yokoe, D. S.
(2014, July). Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission
and Infection in Acute Care Hospitals: 2014 Update. Infection Control & Hospital
Epidemiology, 35(07), 772-796.
http://www.jstor.org.ezproxy.neu.edu/stable/pdf/10.1086/676534.pdf
Edmond, M. B., Masroor, N., Stevens, M. P., Ober, J., & Bearman, G. (2015). The Impact of
Discontinuing Contact Precautions for VRE and MRSA on Device-Associated Infections.
Infection Control & Hospital Epidemiology, 36(08), 978-980. doi:10.1017/ice.2015.99
Harris, A. D., Pineles, L., Belton, B., Johnson, K., Shardell, M., Loeb, M., . . . Morgan, D. J. (2013,
October 16). Universal Glove and Gown Use and Acquisition of Antibiotic-Resistant Bacteria
in the ICU A Randomized Trial. The Journal of the American Medical Association, 310(15),
1571-1580.
https://portal.bidmc.org/~/media/Files/BIDMCToday/2016/April/ContactPrecautions/MedLit1.as
hx
Schultz, L., Lowe, T. J., Srinivasan, A., Neilson, D., & Pugliese, G. (2014). Economic Impact of
Redundant Antimicrobial Therapy in US Hospitals. Infection Control and Hospital
Epidemiology, 35(10), 1229-1235.

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http://www.jstor.org.ezproxy.neu.edu/stable/pdf/10.1086/678066.pdf
Septimus, E., Weinstein, R. A., Perl, T. M., Goldmann, D. A., & Yokoe, D. S. (2014, July).
Approaches for Preventing Healthcare-Associated Infections: Go Long or Go Wide?
Infection Control & Hospital Epidemiology, 35(07), 797-801.
http://www.jstor.org.ezproxy.neu.edu/stable/pdf/10.1086/676535.pdf
Simor, A. E., Williams, V., McGeer, A., Raboud, J., Larios, O., Weiss, K., . . . Gravel, D. (2013, July).
Prevalence of Colonization and Infection with Methicillin-Resistant Staphylococcus Aureus
and Vancomycin-Resistant Enterococcus and of Clostridium difficile Infection in Canadian
Hospitals. Retrieved from http://www.jstor.org/stable/10.1086/670998