Brittany's Policy Paper

Policy Proposal on rapid MRSA detection

MRSA (methicillin-resistant staphylococcus aureus) is an infection that can be acquired from either short or long-term hospital stay or working in the hospital (1). The disease is highly contagious, and can easily transfer from an infected patient to other patients, or even a hospice worker. If not detected early, it may continue through the entire hospital (1). The disease stems from S. aureus bacteria. Two prevalent diseases caused by this bacterium are MSSA (methicillin-susceptible S. aureus), and MRSA. These diseases are very closely related, but as their names suggest, they differ by MSSA’s susceptibility to the antibiotic methicillin, so it’s easily treated (5). MRSA, the more important and serious infection caused by S. aureus, is resistant to the antibiotic methicillin. This makes it very hard to treat, as some of the more reliable antibiotics are in the same family as methicillin. To test patients for MRSA, lab tests are run on a sample collected from a patient’s nostril, rectum, axilla, or an external wound. The indication that the disease is MRSA, versus MSSA, is the presence of the gene mecA. Until recently, detection of the mecA gene would be a 72 hour wait (4).
While waiting for results that the mecA gene is or is not present, there are many issues that must be addressed. First, the patient must be placed in isolation for precautions (1). Not only increasing cost for the patient, but also for the hospital that has to provide all necessary safety measures (3). Then a medication must be prescribed to begin treatment on the infection. While the doctor would typically use popular antibiotics like penicillin or methicillin, there is a chance that the infection is resistant, so a different approach should be used (1). An antibiotic that could be prescribed is vancomycin, but it is very expensive (1). While Vancomycin is FDA approved, many doctors still use caution when prescribing it because there are some toxic side effects (3). Vancomycin is not as active on MSSA as it is on MRSA, so if the results indicate there is no mecA gene in the culture, the patient would be taking an unnecessary antibiotic. Overuse of vancomycin could lead to more antibiotic resistance.
Recently, there have been remarkable gains in the experiments needed to detect the mecA gene present in MRSA. A new test called IDI-MRSA assay has significantly increased the turn around time for MRSA detection (2). What once took labs 72 hours to detect, now only takes 3 hours to detect (2). While some labs have been able to use the new testing procedure, others are still using the traditional technique. A quicker diagnosis of the infection is critical, though. The new testing keeps costs down for patients and hospitals, and gives doctors prompt feedback for what antibiotic should be prescribed to contain the infection and further keep from the increase in antibiotic resistance. This policy recommends all hospitals within the American Hospital Association to use the new testing for MRSA detection.
POLICY
A. All AHA members conducting MRSA testing should have the ability to use IDI-MRSA assay by April 1, 2009. This ability includes, but is not limited to, the IDI-MRSA testing kits, the Smart Cycler, and proper education of technicians and doctors in contact with the testing.
B. Funding the upgrade will be at the hospital’s expense.
C. The IDI-MRSA assay should be used in all tests for the detection of MRSA within the healthcare facility. Each test must use samples from both nostrils of the patient.

This policy is for the benefit of all individuals in the health system, including both patients and workers. The ability to rapidly detect MRSA will help confine the infection, keep patient hospital-stay low, and help doctors prescribe the necessary and appropriate antibiotics, which in turn keeps from antibiotic resistance from increasing.
When taking samples from the patient, it’s not usual to take a sample from both nostrils, usually only one side is used. While some may find this unnecessary, it has recently been shown that in almost 60% of patients treated for MRSA, the pathogen is found in only one of the two nostrils (5). Therefore, to ensure the sample is correctly collected it is to be taken from both nostrils. Many may question our decision to only recommend the new policy, rather then require hospitals to use the new tests for MRSA detection. We acknowledge that in most situations which provide a policy for affiliates to follow, enforcement is needed to make sure there is compliance. The American Hospital Association is a prestige organization which our members take pride in being a part of. Therefore, we trust our members will take the initiative to follow given recommendations. This enables such hospitals to claim their respect and duty to the American Hospital Association, creating a more reliable and honorable reputation for them.
The importance of detecting MRSA is significant given how highly contagious the disease is. Along with the importance of detecting the disease, comes the importance of effectively and properly treating MRSA, as is the case with any disease. We feel that our new policy will speed up the process of detecting the disease, which leads to a quicker solution to treating the disease with the most appropriate antibiotics. Too often, popular antibiotics are being misused and overprescribed, leading to the critical issue of antibiotic resistance- the ultimate source of MRSA.

References:
1) Desjardins, M., Guibord, C., Lalonde, B., Toye, B., Ramotar, K. “Evaluation of the IDI-MRSA Assay for Detection
of Methicillin-Resistant Staphylococcus aureus from Nasal and Rectal Specimens Pooled in a Selective Broth.” Journal of Clinical Microbiology. v44. April 2006: 1219-1223. Accessed 30 Sept 2008.
<http://jcm.asm.org>
2) Fong, I., Kolia., M. “MRSA in the 21st Century.” Emerging Infectious Disease. v9. 2003: 99-
154. Accessed 30 Sept 2008. <http://www.cdc.gov>
3) Hardy, K., Szczepura, A., Davies, R., Bradbury, A., Stallard, N. “ A Study of the Efficacy and Cost-Effectiveness of
MRSA Screening and Monitoring on Surgical Wards using a new, rapid molecule test (EMMS).” BMS Health Services Research. v7. Oct 2007: 160. Accessed 30 Sept 2008. <http://www.pubmedcentral.nih.gov>
4) Loulie, L., Goodfellow, J., Mathieu, P., Glatt, A., Louie, M., Simor, A.E. “ Rapid Detection of Methicillin-Resistant
Staphylococci from Blood Culture Bottles by Using a Multiplex PCR Assay.” Journal of Clinical
Microbiology. v40. Aug 2002: 2786-2790. Accessed 30 Sept 2008. <http://jcm.asm.org>
5) Lowy, F. “Antimicrobial resistance: the example of Staphylococcus aureus.” The Journal of Clinical Investigation. May 2003. Accessed 5 Oct 2008. <http://www.jci.org>

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