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MRSA prevention: Treat the entire ICU

July 2013

Published in the July 2013 issue of Today’s Hospitalist

MRSA prevention: Treat the entire ICU

FORGET TARGETED MRSA SCREENING: Researchers report a dramatic reduction in the number of positive cultures and bloodstream infections by treating all patients in the ICU as if they have MRSA.

A study published in the June 13 New England Journal of Medicine tested three strategies among more than 74,000 patients in 74 community-hospital ICUs between 2009 and 2011. Researchers achieved a 44% reduction in bloodstream infections and positive cultures by giving all ICU patients twice-daily nasal mupiricin and daily chlorhexidine baths. In the other two groups, patients who were found to be colonized after screening were isolated or treated with mupiricin.

An accompanying editorial noted that the findings should change practice. It also called for states to stop mandating targeted screening because the practice has proven to be ineffective. The editorial noted, however, that mupiricin resistance could become a problem with wider use.

COPD: Study backs only five days of steroids

WHILE INTERNATIONAL GUIDELINES recommend treating patients with acute COPD exacerbations with glucocorticoids for between seven and 14 days, a randomized noninferiority study has reached another conclusion. In the study, researchers found that patients treated for only five days had the same outcomes as those receiving conventional treatment with much less steroid exposure.

Swiss researchers publishing online in the Journal of the American Medical Association randomized more than 300 patients presenting with an acute COPD exacerbation to an ED in one of five teaching hospitals. Of those patients, 92% were admitted.

Patients were treated with 40 mg of prednisone per day for either five or 14 days. The authors found similar reexacerbation rates in both groups. Among those taking short-term steroids, 37.2% had a reexacerbation within 180 days compared to 38.4% of those taking conventional therapy. However, those receiving short-term therapy had a median time to reexacerbation of 43.5 days compared to 29 days for patients receiving conventional steroid therapy.

Rethink pneumonia readmission penalty?

CRITICS WHO CHARGE that the excess-readmission penalty put in place by the Centers for Medicare and Medicaid Services is too broad have new ammunition with a study published online by Clinical Infectious Diseases.

Researchers retrospectively identified more than 770 patients with nonnosocomial pneumonia admitted to one hospital in 2010 who survived to discharge. The authors tracked many factors for those patients including illness severity, comorbidities, and whether patients had health care-acquired pneumonia (HCAP) or community-acquired pneumonia (CAP).

The study found that 24.4% of HCAP patients went on to be readmitted vs. only 4.1% of CAP patients. Researchers also found that HCAP patients were 7.5 times more likely than those with CAP to bounce back after discharge.

Factors related to readmissions for HCAP patients included being admitted from long-term care, prior antibiotic use and prior hospitalization. The study noted that all of those factors are beyond the direct control of the index hospital.

As a result, researchers concluded that using one rule to regulate payment without taking HCAP criteria into account is “inappropriate.”