The Assistance Publique-Hopitaux de Paris (AP-HP) achieved and maintained its improvements through an intensive 15-year program of surveillance, barrier precautions, and hand hygiene.
In the March 22nd Archives of Internal Medicine, lead author Dr. Vincent Jarlier from Groupe Hospitalier Pitie-Salpetriere, Paris and colleagues note that while MRSA accounted for 15% of S. aureus strains in French hospitals in the 1970s, by the early 1990s it was accounting for approximately 35%.
In 1993, AP-HP launched its long-term program for controlling MRSA. Program guidelines included decreasing cross-contamination by using single-bed rooms, improving hand hygiene, conducting active surveillance in high-risk patients, and quickly notifying staff of cases. An alcohol-based hand rub solution was particularly useful, the researchers said.
AP-HP oversees 23 acute care hospitals and 15 rehabilitation and long-term care hospitals. In its acute care hospitals, the incidence of MRSA cases per 1000 hospital days fell from 1.16 in 1996 to 0.57 in 2007, a relative change of 51% (p < 0.001). Over the same period, the proportion of MRSA among S. aureus strains fell from 39.4% to 21.6% (relative change 45%, p < 0.001). Both measures had their strongest impact in intensive care units and surgical wards.
In 2001, AP-HP began to promote the use of alcohol-based hand-rub solutions in place of hand washing. In acute care hospitals, use of the alcohol solution climbed steadily from 2 L per 1000 hospital days in 2000 to 26 L in 2007.
The MRSA rate declined more sharply after institution of the alcohol-rub campaign in these hospitals (-4.7% per year vs -2% per year prior to 2001).
In rehabilitation and long-term care hospitals, use of the alcohol solution never climbed above 10 L per 1000 hospital days. MRSA incidence actually rose between 1996 and 2001, from 0.49 to 0.94 per 1000 hospital days. It finally started to fall in 2001, and was 0.54 by 2007. The proportion of MRSA among S. aureus remained high throughout the survey, ranging between 54% and 73%, according to the authors.
Dr. Jarlier and colleagues note that because of the study’s observational design and lack of control group, they can say their program was associated with a MRSA reduction but not that it caused it -- although the “clear and sustained decline in MRSA rates” supports that theory.
Concluding, they write, “A sustained reduction of MRSA burden can be obtained at the scale of a large hospital institution with high endemic MRSA rates, providing that an intensive program is maintained for a long period.”
Arch Intern Med 2010;170:552-559.