MRSA nasal carriage patterns and the subsequent risk of conversion between patterns, infection, and death

Abstract

Background: Patterns of methicillin-resistant S. aureus (MRSA) nasal carriage over time and across the continuum of care settings are poorly characterized. Knowledge of prevalence rates and outcomes associated with MRSA nasal carriage patterns could help direct infection prevention strategies. The VA integrated health-care system and active surveillance program provides an opportunity to delineate nasal carriage patterns and associated outcomes of death, infection, and conversion in carriage.

Methods/findings: We conducted a retrospective cohort study including all patients admitted to 5 acute care VA hospitals between 2008-2010 who had nasal MRSA PCR testing within 48 hours of admission and repeat testing within 30 days. The PCR results were used to define a baseline nasal carriage pattern of never, intermittently, or always colonized at 30 days from admission. Follow-up was up to two years and included acute, long-term, and outpatient care visits. Among 18,038 patients, 91.1%, 4.4%, and 4.6% were never, intermittently, or always colonized at the 30-day baseline. Compared to non-colonized patients, those who were persistently colonized had an increased risk of death (HR 2.58; 95% CI 2.18;3.05) and MRSA infection (HR 10.89; 95% CI 8.6;13.7). Being in the non-colonized group at 30 days had a predictive value of 87% for being non-colonized at 1 year. Conversion to MRSA colonized at 6 months occurred in 11.8% of initially non-colonized patients. Age >70 years, long-term care, antibiotic exposure, and diabetes identified >95% of converters.

Conclusions: The vast majority of patients are not nasally colonized with MRSA at 30 days from acute hospital admission. Conversion from non-carriage is infrequent and can be risk-stratified. A positive carriage pattern is strongly associated with infection and death. Active surveillance programs in the year following carriage pattern designation could be tailored to focus on non-colonized patients who are at high risk for conversion, reducing universal screening burden.

Figure 1. Flow Diagram.

Derivation of the study cohort.

Figure 2. Proposed Algorithm for Reducing Screening.

Number of nasal MRSA screens avoided by application of the initial carriage pattern and clinical criteria identifying patients at low risk for conversion.

Figure 3. Outcomes by Carriage Pattern.

The time to (a) death, (b) MRSA infection, and (c) MSSA infection in patients who had a non-colonized, intermittently colonized, or always colonized nasal carriage pattern at 30 days. The risk of death and of MRSA infection, adjusted for age, number of screening tests in the follow-up period, number of acute care and long term care admissions, total acute care and long term care hospital days, diabetes, renal disease, HIV infection, decubitus ulcer, eczema, and antibiotic exposure, was significantly higher among patients with a colonized compared to non-colonized nasal carriage pattern.