MRSA Literary Sources Critique - Research Paper Example

? Hospital care facilities are constantly searching for ways to minimize the spreading of diseases between patients while they are being treated. A search was conducted to find literature that reported findings from studies on in-patient diseases and their contraction rates between patients. This review contained literature based on a particular disease, MRSA which was described below. Literature that contained certain types of patients were excluded from this study for consistency purposes. This included studies that involved patients from an area other than ICU, surgical patients, and pediatric patients. Studies where there was no MRSA screening were also excluded because these studies did not offer the information needed to address the major goal of this review. In addition, studies where MRSA infection was not confirmed by microbiologic techniques were excluded because this review was designed to study only patients that were confirmed to carry the infection after both screening and microbiologic techniques. Based on the findings from the cases in the literature, the broad problem was that too many patients are transmitting Methicillin resistant Staph aureus in ICU. Specifically, the literature aimed to provide evidence for the question, “Would the high transmission rate decrease if screening in adult patients was conducted upon admittance to the ICU unit as opposed to not screening?” This problem is important to pursue because it affected patient outcomes including the length of stay and complications from other illnesses. This problem also had a potential impact on the quality of treatment due to overcrowding and understaffing. The costs were also affected since the hospital was forced to use more money for testing, medicine, and housing patients. Finally, the access to needed medications was limited, and ordering caused further delays. For the purposes of this study, the patients in each case study were limited to adults who were admitted to the ICU section. Children were not included in any of the studies regarding MRSA, and patients in other sections of the facility were also excluded. The following review placed eleven case studies into discussion, focusing on the interventions, comparisons, and outcomes of the studies. Each study included a report on the interventions used for that study, with interesting results from each case study. Clancy, Grepler, Wilson, Douglas, Johnson, and Price (2006), used swab samples which were obtained upon admission to ICUs and weekly thereafter patients who tested positive from nasal or clinical specimens were placed in contact isolation, even after readmission DNA fragments were analyzed for similarity of banding PFGE patterns. Dalla Valle, Pasca, De Vitis, Marzani, Emmi, and Marone (2009), also gathered swab samples, although they obtained the samples upon admission and twice-weekly thereafter. Patients who screened positive received isolation and/or antibiotic or colonization therapy. Honda, Krauss, Coopersmith, Kollef, Richmond, Fraser, and Warren (2010), conducted nasal screening, and had the patients who screened positive had contact precautions implemented with no antibiotic or colonization therapy. Clancy and Dalla Valle would have probably described Honda’s practice as irresponsible since antibiotics were not administered and patients were not relocated to a secluded area. This made the study ineffective, because there was no way to prevent the spread of MRSA between patients in the ICU. Other case studies that used the swab method included Lucet, Paoletti, Lolom, Paugam-Burtz, Trouillet, Timsit, Deblangy, Andremont, and Regnier (2005) used nasal swabs to obtain within 24 hours at admission and weekly thereafter. Although once a week was a consistent testing window, the case study probably would have generated far stronger results if testing had been conducted at lease twice a week. Contact precautions were implemented in MRSA positive patients. Another method used to determine MRSA was the standard culture method. Cunningham, Jenks, Northwood, Wallis, Ferguson, and Hunt (2007), used standard culture method during a six month period in 2005 and PCR tests for the following six month period ending in 2006. MRSA positive patients received nasal mupirocin three times per day and topical triclosan for five days. However, positive patients should also have been isolated from other patients to prevent further spreading of MRSA. Additional testing should also have been conducted throughout the treatment period to monitor the patients’ progress. Huang, Yokoe, Hinrichsen, Spurchise, Datta, Miroshnik, and Platt (2006), conducted MRSA screening by culture methods and engaged in contact precautions for culture positive patients (generally notified after 48 hours). However, like the Cunningham case, the patients should have continued screening at least twice weekly to ensure monitor progress in the treatment. Patel, Weinheimer, Waites, and Baddley (2008), placed contact isolation on patients with MRSA positive specimens. Another case study gave evidence that additional steps reduced the spreading of MRSA between patients in ICU. Thompson, Workman, & Strutt (2008), reduced acquisition rate of MRSA by following events: implementing new ICU, addition of another wing of two bed rooms and following general infection control procedures throughout the facility. Platt, Takvorian, Septimus, Hickok, Moody, Perlin, Jernigan, Kleinman, and Huang (2010) screened ICU admitted patients for cultures, using contact precautions if patients were found positive with MRSA followed by isolating the patients if they tested MRSA positive, and decolonization of all patients who were not tested. However, better results would have been achieved if all patients entering ICU had been screened upon admission, with consisted biweekly screening of MRSA positive patients during treatment. In the MRSA screening and treatment process, Wang, Lauderdale, Lee, (2010) used two phases. Phase I included contact isolation only if clinical cultures were positive. In Phase II, all admitted patients were screened for MRSA colonization Patients who tested positive by surveillance were put on contact isolation. Kurup, Chlebicka, Tan, Chen, Oon, Ling, Ling, and Hong (2010), screened patients using in-house PCR method. Patients who tested positive had strict contact isolation and had whole body washes with Prontoderm solution for 5 days. In the interventions made in all the case studies, a trend arose with one particular issue in most of the studies. The studies showed that there was a lack of additional screening during treatment once the patients were diagnosed with MRSA. This issue is arguably an important one because the staff needed to monitor the progress of the patients once treatment began to determine the most effective treatment methods. Clancy, et al. (2006), compared pre-intervention period, on screening (From July 1999 through March 2003) to the post-intervention screening (April 1, 2003, through June 30, 2004). Huang, et al. (2006), compared pre- intervention period, of screening January 1996 to August 2003) to the post-intervention screening (Oct 2003 to December 2004). This was helpful in showing whether the changes implemented throughout the case study were effective than before the study was conducted. However, these studies did not study the effects of trying alternative testing methods or alternative treatment methods, both of which may have reduced the number or MRSA positive patients and the length of treatment and recovery. The strengths of the Clancy, et al. (2006), was that it used PFGE typing to analyze samples (great sensitivity) and included an assessment of exposure/outcome blinded. However, the study had a selection bias with no comparison of patient characteristics between the pre and post periods. A contamination bias was also present where MICU Turn around time (TAT) = 48-hour delay from swabbing until microbiologic diagnosis may have caused nosocomial transmission until these patients were isolated (reason for insignificant decline). The facility was physically changed on post period and may have presented confounding variables to alter results. Finally, there was no indication on TAT for results from microbiology to contact isolation and may have been largely different for each patient. Dalla Valle, et al. (2009), compared a new PCR method to the previous period where traditional culture testing methods were used to test patients to determine if outcomes were improved. However, this study did not compare the effects of different treatment methods or compare results pre and post test. Cunningham, et al. (2007), simultaneously compared/ran culture and PCR methods from same samples to determine if outcomes were improved, but this study also failed to address alternative treatment methods and did not note pre and post test differences. In the case study by Dalla Valle, et al. (2009), the strengths included a large sample and assessment of exposure/outcome blinded. On the other hand, the case study had contaminated bias, and this observational study was a retrospective and could not take into account possible confounding variables such as changes in later MRSA epidemiology or management. Also, the authors did not describe the collection method of specimens. The study illustrates that if screening does decrease transmission rates, then a much quicker TAT from PCR methods would have positive effect in the reduction of MRSA transmission in the ICUs. Cunningham, et al. (2007), compared both methods simultaneously and also ensured the assessment of exposure/outcome blinded. However, the small sample, limited population, no power of analysis to determine the sample size needed to uncover a specific size difference between groups. Also, the authors do not mention what type of antibiotic therapy to consider claims on infection rate vs. colonization rate. The p value was not calculated, and patients who were admitted and left the ICU within 24 hours were not screened. This study showed an agreement of 91.8% between screening methods and with Cunningham‘s, et al. (2007), above study it can be suggested that we should use the PCR method since it decreases TAT and is comparable to the gold standard of the culture methods. Honda, et al. (2010), compared the likelihood of staph aureus infection with patients that were either colonized or not colonized with MRSA or colonized with MSSA. Kurup, et al. (2010), took the study a step further and compared colonized patients to non-colonized patients in terms of ICU length of stay and amount of antibiotics given. Although this study could have been even stronger if it had included pre study data comparing colonized patients to non-colonized patients. Patel, et al. (2008), discovered an MRSA colonization effect on clinical outcomes including but not limited to mortality within three months after ICU admission. However, this study did not give additional data about the mortality rates of patients who were non-colonized. This would have given the staff a better indicator of how colonization affected treatment and recovery. Lucet, et al. (2005), compared acquisition of MRSA prior and after the implemented use of alcohol based hand rub solution. However, they did not compare this treatment method to other treatment methods. Patel, et al. (2008), utilized three interventions to reduce acquisition rate for MRSA. However, the study did not include data regarding comparisons between treatments. Platt, et al. (2010), evaluated three interventions using trials that were randomized in an attempt decrease MRSA infections. This study did not offer comparisons on different testing methods and did not continue to test patients during the treatment period. Wang, et al. (2010), compared phase I with no isolation of positive MRSA carriers (unless clinical samples were positive) and Phase II with isolation of patients who tested positive with MRSA upon close observation. However, the study did not contain various testing methods and did not offer pre study data. Clancy, et al. (2006), reported a decrease in both nosocomial SICU infections and MICU infections, although the SICU infections decreased at a much faster rate than the MICU infections. following results. SICU P Read More