I guess everything changes when it happens to you! Editorial Reflections on World MRSA Day.

Editorial By Rodney E. Rohde, PhD

Abstract:

On any given day, approximately 1 in 25 inpatients in U.S. acute care hospitals has at least one healthcare–associated infection (HAI), adding up to about 722,000 infections in 2011. Pneumonia and surgical-site infection are the most common infection types, and Clostridium difficile is the most common pathogen. Practically, what this means is that over 200 patients will die the day you read this article and every day after that until the global community is able to address this healthcare crisis. If you do the simple math, you will realize that about 4% of hospitalized patients developed one or more HAIs due to the care received in the hospital, resulting in approximately 75,000 deaths. Imagine a jet airliner going down every day in this country and the American public accepting it without much notice. In reality, that is what is happening with HAIs. More Americans die every year from MRSA than from HIV/AIDS and H1N1 combined.

Main Article:

When I answered the phone at home one evening in late December 2007 and heard the voice of a worried woman, the genesis of an idea for my future research path began to take shape. She was concerned about her husband, she said. The retired couple from Utah had traveled over the holidays and the husband, a cancer patient, developed sores on his torso. They went to the emergency room, where a doctor diagnosed a staph infection and prescribed antibiotics. No laboratory tests were done. The man’s condition worsened, so when the couple returned home he went to his family doctor. After an examination and some laboratory tests, the doctor determined that the man had MRSA — methicillin-resistant Staphylococcus aureus — an infection that cannot be treated with most typical antibiotics.

MRSA became one of my primary areas of expertise after I became an assistant professor in Texas State’s Clinical Laboratory Science Program within the College of Health Professions back in 2002. I have since conducted numerous prevalence and incidence studies on MRSA in a variety of environments, including  prisons, dormitories, recreation centers, physical therapy educational settings, and most recently in homes,¹ as well as on nursing students and animals. In a sense, I am the classic clinical microbiologist and research scientist interested in documenting and discovering information about this dangerous microbe. However, it wasn’t until I started work on my PhD in 2006 that I revisited that “genesis of an idea” while receiving numerous “cold calls” and emails from concerned individuals who had been diagnosed with MRSA or had loved ones dealing with this deadly infection.

I remember it like yesterday – such a vivid reminder of the confusion, concern, and plight of these individuals dealing with such a difficult healthcare problem. The wife of the patient from Utah had some basic knowledge about MRSA from newspapers and other media coverage and she was very concerned about what had happened to her husband at the emergency room given his immunocompromised state because of the cancer. She just wanted to know why this had happened and whether she or anyone else they had been in contact with should be concerned about transmission.

it is very important to have a culture done

I spent more than an hour on the phone explaining to her the difference between “regular Staph” and MRSA. I told her that it is very important to have a culture done so that a proper diagnosis and identification of MRSA can be made².  I also let her know that if the infection worsens, the patient might have to be admitted to a hospital and given strong antibiotics intravenously. I emphasized that it is always important to ask for a culture and antibiotic susceptibility test if her husband were to get another infection.

The man improved after being correctly diagnosed by his family physician. He received a combination of two powerful drugs and eventually recovered from the infection. To this day, that phone call remains a pivotal moment in my career. I realized that I needed to begin the process of understanding this disease from the perspective of those who had experienced it. I needed to begin delving deeper into the learning experiences of people who had lived through a MRSA infection in order to improve the practical management and outcomes of this disease. Simply put, I was becoming a more hybrid, translational researcher and it has become one of my primary passions.

“…Sometimes you don’t even know
which questions to ask….”

Often acquired in healthcare facilities or during healthcare procedures, the extremely high incidence of MRSA infections and the dangerously low levels of literacy regarding antibiotic resistance in the general public are on a collision course³. Traditional medical approaches to infection control and the conventional attitude healthcare practitioners adopt toward public education are no longer adequate to avoid this collision. In many cases, the patient simply does not know what to even ask of their healthcare providers. I documented this time and again through patient interviews. We must all learn to take an active role to be an advocate for patients who do not understand what antibiotic resistance means to their health – whether it’s in the healthcare facility or at home in the community. MRSA and other resistant organisms are not only in healthcare. Community facilities and locations can be major reservoirs of resistant organisms like MRSA. Recently, I and colleagues completed a study that documented prevalence rates of Staphylococcus aureus (15%) and MRSA (2%) in a physical therapy multi-use educational room.⁴  The lines have blurred between healthcare and community-associated MRSA. Education, for both healthcare providers and the general public, has become critical. Health literacy regarding antibiotic resistance, HAIs such as MRSA, and one’s responsibility in this perfect storm must be a priority for global public health.

For several decades now, the high incidence of HAI and the dangerously low levels of literacy regarding antibiotic resistance in the general public have been on a collision course. The “Perfect Storm” has arrived and is painfully evident in the numbers of illnesses and deaths due to HAI. Moreover, the general public seems to be more worried about headline diseases such as Ebola and Zika than the one right under their noses (or their hospital bed). While global outbreaks such as Zika are worthy of our most heroic public health efforts, in reality more United States citizens will die this year and every year from HAI – a preventable infection!^5,6

Progress is being made per CDC’s National and State Healthcare-associated Infection Progress Report such as these reported findings:

• A 46 percent decrease in central line associated blood stream infection (CLABSI) between 2008 and 2013.^7-9
• A 19 percent decrease in surgical site infections (SSIs) related to the 10 select procedures tracked in the report between 2008 and 2013.^7-9
• A six percent increase in catheter associated urinary tract infections (CAUTI) between 2009 and 2013; although initial data from 2014 seem to indicate that these infections have started to decrease.^7-9
• An eight percent decrease in hospital-onset MRSA bacteremia between 2011 and 2013.^7-9
• A 10 percent decrease in hospital-onset difficile infections between 2011 and 2013.¹⁰

The ultimate goal, however, is zero preventable HAIs. It will take a multi-modal approach on multiple fronts of the battlefield.^10-11 We are still experiencing thousands of needless deaths each year. It’s time for all of us – global healthcare professionals of all walks of life, private and public government agencies, professional organizations, and the general public – to join hands and confront this war head on! If we do not, the consequences will be tragic and potentially unwind all of the past public health advances that our parents, grandparents and great-grandparents enjoyed.

We must all strive to do better

On this day – World MRSA Day – this editorial is aimed to inform laboratory professionals, business thought leaders, medical/health educators, healthcare professionals, healthcare facilities experts, EVS professionals, government agencies, professional organizations, philanthropists, and the clinical diagnostics field at large about MRSA awareness. We must all strive to do better regarding past, current and future paradigms for HAI detection, management and national and state strategies for reduction of these deadly infections.

Finally, medical laboratory professionals play an integral role in the healthcare system by providing diagnostic services that not only directly impact therapeutic management of patients, but also by offering their expertise in interpretation of the results in the mounting numbers and types of HAI identification.  Further, medical laboratory professionals must inform physicians and others in the sometimes difficult and cloudy interpretation of antibiotic susceptibility assays and menus of tests available to physicians. In that light we should all have a basic grasp of the basis and rationale for interpreting HAI testing, and generally appreciate the downstream effects of reporting a result. Lastly, educators must become leaders in preparing clinically competent laboratory professionals, and other healthcare professionals, by providing them with opportunities to expand their training and understanding of antibiotic-resistant microorganisms in general, and HAI in particular.

We can and must be better. If not, we all fail. We fail ourselves. We fail each other. And, we especially fail those patients who need our voice and advocacy – even those who don’t know what questions to ask!

References:

1. Felkner M, Rohde R, Valle-Rivera AM, Baldwin T, Newsome LP. Methicillin-Resistant Staphylococcus aureus Nasal Carriage Rate in Texas County Jail Inmates. J. Corr HealthCare. 2007. 13(4), 289-295.
2. Rohde, RE. Two Laboratory Tests you Must Demand: Advice from MRSA Survivors and a Scientist, InfectionControl.tips 2016. 1(1-4) https://infectioncontrol.tips/2016/01/11/2labtests-mrsa/
3. Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of healthcare–associated infections. N Engl J Med 2014; 370:1198-1208.
4. Rohde, R.E. Denham, R., & Brannon, A. Methicillin Resistant Staphylococcus aureus: Nasal Carriage Rate and Characterization in a Texas University Setting. Clinical Laboratory Science, 2009. 22(3): 176-184.
5. Klevens RM, Morrian MA, Nadle J. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA 2007; 298:1, 763-771.
6. Bancroft EA. Editorial: Antimicrobial resistance — It’s not just for hospitals. JAMA 2007; 298:1, 803-804
7. Rohde RE. A Secret Weapon for Preventing HAI: A scientist’s message to hospitals trying to rid themselves of healthcare-associated infections. Elsevier Connect, July 15, 2014. Available from http://www.elsevier.com/connect/a-secret-weapon-for-preventing-HAI Accessed 9/2/2016.
8. Rohde RE. Healthcare Facilities Today – published written interview, Scholar bringing EVS role in infection prevention to the forefront. Q2, April 2015: pp. 11-13. Available from http://www.healthcarefacilitiestoday.com/posts/Scholar-bringing-ES-role-in-infection-prevention-to-the-forefront–9115 Accessed 9/2/2016.
9. Rohde, RE, Felkner M, Regan J, et al. Healthcare-Associated Infections (HAI): The Perfect Storm has Arrived! R.E. Rohde – Invited Focus Series. Clin Lab Sci Winter 2016;29(1):28-31.
10. Dhagat PV, Gibbs KA, & Rohde RE. Prevalence of Staphylococcus, including Methicillin Resistant Staphylococcus aureus (MRSA), in a Physical Therapy Educational Facility. Journal of Allied Health 12/2015; 44(4):215-218.
11. Centers for Disease Control and Prevention. (2012) Healthcare-associated Infections (HAI) Progress Report. Available from http://www.cdc.gov/hai/progress-report/index.html Accessed 9/2/2016.