Study Purpose:

To evaluate the effectiveness of implementing the new methicillin-resistant Staphylococcus aureus (MRSA) control measures in a tertiary care unit in Japan

Intervention Characteristics/Basic Study Process:

The study was conducted in Japan, where the rate of MRSA was the second highest in the Asia-Pacific region—69.5%—in 2002. Although Japan was following infection control practices, the rate was not going down because its survey for the incidence of MRSA was not standardized. In 2003, according to the Society for Healthcare Epidemiology of America (SHEA), Japan started to strictly follow the evidence-based infection control guidelines, which included wearing gowns, masks, and gloves, in addition to implementing contact isolation in a separate room and conducting nasal swab cultures for colonization before discontinuing isolation. Two basic metrics also have been included to conduct surveys on the basis of SHEA and the Infection Control Practices Advisory Committee. To conduct this study, the authors have reviewed patients' data from January 2003–December 2010.

Sample Characteristics:

• N = 1,000
• AGE: No specific age noted
• MALES, FEMALES: Not noted
• KEY DISEASE CHARACTERISTICS: MRSA

Setting:

• SITE: Single site           
• SETTING TYPE: Inpatient           
• LOCATION: Tertiary care center in Japan

Phase of Care and Clinical Applications:

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Elder care

Study Design:

• Quasi-experimental cohort study conducted to evaluate the changes of MRSA incidence and MRSA bloodstream infection (BSI) incidence after implementation of the infection control practices in the tertiary care center

Measurement Instruments/Methods:

•  SAS (version 9.2)

Results:

The study showed a significant reduction in MRSA infection or colonization and MRSA BSI (p < .0001) after strongly implementing the new infection control practices in the tertiary setting.

Conclusions:

This was the first study conducted at a tertiary level in Japan. It was based on the evidence based-practice showing a significant reduction in MRSA spread and MRSA infection burden, which was proved after strictly following the new practices of MRSA control, including isolating the patient. Through this study, the authors also standardized in discontinuing the isolation of MRSA patients based on SHEA and the Infection Control Practices Advisory Committee.

Limitations:

• Measurement/methods not well described
• Measurement validity/reliability questionable
• Other limitations/explanation: This study implemented multifaceted interventions, and defining the relative effect of each intervention is impossible. The test used is only able to detect the outcomes and cannot detect changes in trends.

Nursing Implications:

Nurses play an important role in implementing infection control practices, as nurses are the one who come into contact with patients first. Nurses can follow these guidelines and also advise other healthcare workers to do the same.

Study Purpose:

There is an emerging problem of growing multi-drug resistant gram-negative rods (MDR-GNRs), and rapid and sensitive detection is difficult. There is no consensus regarding the list of drug-resistant bacteria to target for infection control and infection control policies for multi-drug resistant gram-negative organisms (DR-GNRs) often lack strong evidence to identify the minimum interventions needed to reduce their transmission. The authors were trying to determine if horizontal transmission can be prevented by detecting and appropriately controlling targeted drug-resistant bacilli before they acquire resistance.

Intervention Characteristics/Basic Study Process:

In January 2005, a prevention policy against MDR-GNR infection was implemented. After isolating strains that met the defined criteria, contact precautions were implemented. Active interventions, including approval for specific antibiotics prior to use and regulating the prescription of certain antimicrobials, were not applied. The preintervention period (January 1, 2003 to December 31, 2004) was compared to intervention period (January 1, 2005 to December 31, 2010).

Sample Characteristics:

• N = 1,287,296 total inpatient days
• OTHER KEY SAMPLE CHARACTERISTICS: No exclusion criteria; active sampling from asymptomatic patients was not conducted; data included dates of detection, types of culture samples, inpatient or outpatient status, names of the detected strains, and results of susceptibility testing; inpatient days of care were defined as the sum of each daily inpatient census for the month

Setting:

• SITE: Single site    
• SETTING TYPE: Multiple settings    
• LOCATION: Shizuoka Cancer Center, Nagakute, Aichi, Japan

Phase of Care and Clinical Applications:

• PHASE OF CARE: Multiple phases of care

Study Design:

Retrospective study (pre- and postintervention) based on the examination of a bacterial testing database

Measurement Instruments/Methods:

MDR-GNRs were defined as gram-negative bacilli that were insensitive to at least three of the specified classes of antimicrobials, metallo-beta-lactamase-producing bacilli, and extended spectrum beta-lactamase (ESBL)-producing bacilli. Strains of MDR-GNRs were isolated at least 48 hours after admission, and only newly detected stains were included and excluded cases in which the same strain was later detected in the same patients. Each species was included if multiple strains were isolated from the same patients.

Results:

The overall incidence density rate of all multi-drug resistant nonfermenting gram-negative bacilli over the eight-year study period (2003–2010) was 0.31 per 10,000 patient days. Rates did not increase significantly between the preintervention period (0.15 per 10,000 days) and the intervention period (0.35 per 10,000 days). The overall incidence rate of MDR enterobacteriaceae infections was 0.49 per 10,000 days. However, the preintervention period was 0.19 per 10,000 days, and the intervention was 0.56 per 10,000 days, representing a statistically significant decrease.

Conclusions:

The study increased the detection of enterobacteriaceae bacteria with an increase in ESBL-producing organisms, but no significant change in detection rate of MDR non-glucose-fermenting bacilli was found. Contact precautions were implemented to limit the emergence of MDR-gram negative bacilli, but the efficacy of these policies was deemed uncertain.

Limitations:

• Retrospective study
• No active surveillance of asymptomatic patients
• Incidence measurements based solely on clinical cultures and may be insufficiently sensitive because asymptomatic patients may have been missed

Nursing Implications:

MDR-GNRs are an emerging worldwide problem. Nurses have a significant responsibility to ensure proper precautions are taken as quickly as possible when these organisms are detected. Nurses should ensure that the patient is properly educated, but more importantly, should implement contact precautions and ensure that other healthcare providers are following these precautions.