Importance of Multifaceted Approaches in Infection Control: A Practical Experience from an Outbreak Investigation

Abstract

Background: This study presents the results of a multidisciplinary, nosocomial MRSA outbreak investigation in an 8-bed medical intensive care unit (ICU). The identification of seven MRSA positive patients in the beginning of 2014 led to the closure of the ward for several weeks. A multidisciplinary, retrospective investigation was initiated in order to identify the reason and the source for the outbreak, describe MRSA transmission in the department and identify limitations in infection control.

Methods: The investigation comprised an epidemiological description of MRSA cases from 2012 to 2014 and a characterization of MRSA isolates, including phage-, spa- and PFGE-typing. Additionally, MRSA screening was performed from the hospital staff and the environment. To identify the reason for the outbreak, work-related, psychological and behavioral factors were investigated by impartial audits and staff interviews.

Results: Thirty-one MRSA cases were registered during the study period, and 36 isolates were investigated. Molecular typing determined the outbreak strain (phage type 54/812, PFGE type A4, spa type t003) and identified the probable index case. Nasal carriage in one employee and a high environmental contamination with the outbreak strain was documented. Important gaps in nursing procedures and general management were identified. Elevated stress levels and communication problems preceded the outbreak. Compliance with hand hygiene and isolation procedures was evaluated as appropriate.

Conclusion: This study demonstrates the complexity of controlling hospital-associated infections. The combined use of different typing methods is beneficial for outbreak investigations. Psychological, behavioral and other work-related factors have an important impact on the spread of nosocomial pathogens. These factors should be addressed and integrated in routine infection control practice.

Fig 1

Epidemiological curve (a) and hospitalisation history (b) of MRSA positive patients in the affected department, 2012–2014. Place of hospitalisation is indicated: green = ICU; blue = SW; beige = other department.

Fig 2

Epidemiological curve according to spa type (a), PFGE type (b) and phage type (c). Numbers in boxes refer to individual cases as listed in Table 2. Arrows indicate the probable index case.

Fig 3. Analysis of work related factors, management and nursing procedures by impartial audits performed by specialized infection control nurses (audit form: S1 File).

Fig 4. Investigation of work-related and psychological factors by nurse interviews (questionnaire: S2 File).