Reducing transmission of methicillin-resistant Staphylococcus aureus in a surgical ward of a resource-limited hospital in Indonesia: an intervention study

Abstract

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is endemic in healthcare settings in Indonesia.

Aim: To evaluate the effect of a bundle of preventive measures on the transmission and acquisition of MRSA in a surgical ward of a resource-limited hospital in Indonesia.

Methods: The study consisted of a pre-intervention (7 months), intervention (2 months), and post-intervention phase (5 months) and included screening for MRSA among eligible patients, healthcare workers (HCWs), and the hospital environment. In the intervention phase, a bundle of preventive actions was introduced, comprising: a hand hygiene educational program, cohorting of MRSA-positive patients, decolonization therapy for all MRSA-positive patients and HCWs, and cleaning and disinfection of the ward's innate environment. Hand hygiene compliance was assessed throughout the study period. The primary outcome was the acquisition rate of MRSA among patients per 1,000 patient-days at risk. Clonality of MRSA isolates was determined by Raman spectroscopy and multilocus sequence typing.

Findings: In total, 1,120 patients were included. Hand hygiene compliance rate rose from 15% pre-intervention to 65% post-intervention (P<0.001). The MRSA acquisition decreased from 9/1,000 patient-days at risk pre-intervention to 3/1,000 patient-days at risk post-intervention, but this difference did not reach statistical significance (P=0.08). Raman type 9 which belonged to ST239 was the single dominant MRSA clone.

Conclusion: The introduction of a bundle of preventive measures may reduce MRSA transmission and acquisition among surgery patients in a resource-limited hospital in Indonesia, but additional efforts are needed.

Keywords: Asia; Indonesia; Infection control; Panton-Valentine leukocidin; Patient isolation; Staphylococcus aureus.

Figure 1

Flow chart of patients included in the analysis.

Figure 2

Cohorting procedure for MRSA-positive patients in the study ward. MRSA, methicillin-resistant Staphylococcus aureus. Zone A contained more beds than presented in the picture.

Figure 3

Methicillin-resistant Staphylococcus aureus acquisitions among patients versus hand hygiene compliance rate among healthcare workers. The solid horizontal line represents the average of acquisition rate, the grey area represents the 95% confidence interval around that mean. The dashed horizontal line represents the average of hand hygiene compliance. PI=pre-intervention phase; I= intervention phase; PoI=post-intervention phase.

Figure 4

Trend of hand hygiene compliance during the study period. PI, pre-intervention phase; I, intervention phase; PoI, post-intervention phase.

Figure 5

Raman spectra of methicillin-resistant Staphylococcus aureus isolates.The correlation matrix displayed is used to analyse the relatedness between isolates. Red clusters show isolates that are indistinguishable based on the cut-off value. The grey areas indicate isolates that are not related based on the similarity threshold. Yellow areas to orange areas gradually show the potentially related isolates. RT9 includes 39 MRSA isolates from patients (pre-intervention: 15 isolates and post-intervention: 24 isolates) and one MRSA isolate from the environment in the post-intervention phase. RT11 contains 15 MRSA isolates from patients (pre-intervention: 2 isolates, intervention: 3 isolates, post-intervention: 10 isolates). RT8 consists of 10 PVL-positive MRSA isolates from patients in the postimplementation phase.

Figure 6

Endemicity profile of large clusters of MRSA assigned to RT9, RT11, and RT8. Month 1–7=pre-intervention phase; month 8–9=implementation of intervention phase; month 10–14=post-intervention phase. MRSA, methicillin-resistant Staphylococcus aureus; RT, Raman type.