Critique on Methicillin-resistant - Co-colonization - Essay Example

Critique on Methicillin-resistant co-colonization. Approximate word count: 1180. At the outset the claim that this particular study as per their knowledge is the first to assess independent risk factors in a co-colonization scenario. Hence a lenient approach is being adopted in this critique for the simple reason that only once we have more data/publications the world over in the same area of research, can there be a concrete establishment of the actual prevalence, risk factors and clinical outcomes of patients who are co-colonized by vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). One or two studies cannot be a reliable indicator. Despite this, we present here our critique on the research article "Methicillin resistant co-colonization" by Jon P. Furuno et al. The authors have identified a genuine problem that occurs as nosocomial infections world-wide. Although adequate, some elaboration on the extent of the VRE and MRSA individual infections world-wide in Introduction and discussion would have achieved a better impact in the minds of the reader. Such an elaboration becomes essential taking into consideration that these kinds of publications are read not only by clinicians but also by researchers worldwide working in non-medical areas, as well. In the aims of the study, patient-to-patient transmission, one of the major routes of nosocomial infections, was not included. This becomes vital taking into observation that some of the patients included in the study were transferred from another hospital to University of Maryland Medical Center (UMMC) [see table 1] and from UMMC to other hospitals and elsewhere. Without including this particular parameter, the authors suggest limiting of patient-to-patient transmission as a remedial measure. In the laboratory methods, a reference to the mentioned method of culturing is missing. If the method adopted is novel, the same should have been mentioned at appropriate places. Additionally, they do not indicate how Vancomycin resistant Staphylococcus aureus (VRSA) and Vancomycin intermediate Staphylococcus aureus (VISA) were identified. If not included in the present study the same should be mentioned, as the way introduction and discussion were presented, the reader gets a false impression that the researchers were also looking for VRSA and VISA. Statistical analysis might not be accurate or might be biased as the subsequent positive clinical cultures do not tally with the original clinical cultures [initial cultures were from anterior nares and peri-rectal cultures while the subsequent positives were from blood, Cerebrospinal fluid (CSF) or urine]. Reason for this was not properly explained. Hence although this study addresses one major problem worldwide, the findings and recommendations need more credence. Whereas it has been clearly mentioned in the article and in table 1 that certain numbers of patients were from other hospitals, what requires clarification is that whether those patients acquired the infection in the first hospital or at UMMC. If this has not been established by the authors, the same should have been mentioned. Presentation of more details with regard to such patients becomes essential in these kinds of studies. Needless to say, the authors make no attempt to elucidate the impact of previous infections in co-colonized patients given the observation (see table 1) that more than 75% of the co-colonized patients were previously infected with either MRSA or VRE. In this scenario, the authors try to speculate that prior infection with VRE, MRSA or both might have contributed to the decision of the patients being admitted to MICU, and might have also had previous admissions and exposures A significant proportion of the patients were put on Vancomycin prior to culture. The authors need to clarify whether this had any significant influence on the quality of results generated with specific reference to the bacterial cultures, in the present study. This becomes vital given the observations that antimicrobial drugs prior to admission seem to have an influence on co-colonization, VRE colonization and MRSA colonization (see table 2). The same can be extrapolated to antimicrobials given during the hospital stay. When a vast majority of co-colonized patients have either cardiac disease (30.8%; table 1) or diabetes mellitus (21.5%), it is interesting to note that neither of these two have had a specific influence on the final outcome, in general, and co-colonization, in particular (c.f., table 2). The authors also mention that the mean length of the hospital stay (SD) is not significant between those co-colonized and those not co-colonized. Because MRSA and VRE are nosocomial infections, duration of stay becomes a vital assessment parameter, which the authors try to downplay. The same, can be extended to one of the major outcomes of co-colonization of VRE and MRSA that of Death [see table 3]. At least they should have specified how many of the patients, without co-colonization, who died have infection with either MRSA or VRE alone. Taken together, these two findings defeat the entire purpose and novelty of the study/research. Furthermore, such findings add more credibility to the popular anonymous quote 'what is clinically significant might not be statistically and vice versa'. Put simply, too much undue attention to statistics has been given by the authors. In a study of this type, presumed to be the first of its kind, less attention to statistics and more to clinical aspects will elicit interest in this direction by other researchers worldwide. What arouses curiosity is the failure of the authors to establish the species of VRE, given the fact that in their previous study, done a decade ago, they could (reference # 29). In addition to this, the authors suggest that VRE and MRSA could not be detected on admission by clinical cultures. Although understandable, they could have utilized the latest state-of-the-art methods viz., PCR, ELISA, etc., that would have divulged the vital information within an hour; based on which admission can be directed to the appropriate sections/units/wards. Additionally, such a testing would have provided insights as to whether there was a patient-to-patient transmission, which is vital, particularly in nosocomial infections. Furthermore, the authors also mention that many of the patients were discharged to other hospitals and elsewhere. Were they abetting the spread of the infection A note on the infection status of patients discharged, would have added more clarity to the article. In an attempt to project their study as a first, the authors blatantly try to overlook/downplay a number of other studies which the authors themselves cite (references: 14, 15, 27, etc.). By not correlating this study with the earlier ones properly, perhaps the authors may be failing in their attempt to correctly link/identify the actual risk factors associated with co-colonization. Probably such a failure to correlate earlier studies with their own, made the authors rely heavily on statistics, which again is improperly carried. Furthermore, the authors mention that earlier studies relied on clinical samples, pray on what did the subsequent positive cultures, in the present study, relied on: non-clinical samples Maybe the authors should have defined what a 'clinical culture' is. Overall going through the contents of the research article one gets an impression that the authors were trying to conduct a post-mortem of a nosocomial epidemic that occurred during the mentioned period of the study. Consequently, the findings presented should be taken with a pinch of salt. Read More