Fighting HAIs: A Q&A with Carlene A. Muto, MD

ICT spoke with Carlene A. Muto, MD, medical director of the Department of Hospital Epidemiology and Infection Control at the University of Pittsburgh Medical Center, about her views on healthcare-acquired infections (HAIs) and multidrug-resistant organisms (MDROs). Muto has been a member of the University of Pittsburgh Infectious Diseases Epidemiology Research Unit since 1999. She is board certified in internal medicine and infectious disease. She chairs the Antibiotic Resistance Task Force of the Society for Healthcare Epidemiology of America (SHEA) and is co-chair of the Clostridium difficile Outbreak Committee. Muto’s research interests include the epidemiology of MRSA and vancomycin-resistant enterococci and identifying ways to halt the nosocomial transmission of resistant organisms.

Q:What are you seeing in terms of MDRO prevalence?

A:There are no dashboards or national numbers for comparison but we have been following our hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA) infections since the beginning of time. We can tell where the numbers are increasing and which units are at higher risk, so based on our own historic data, we set out to determine where we would focus our efforts initially. We looked through all of our intensive care units (ICUs) and all of our patient-care areas for the locations that had the highest rate of hospital-acquired MRSA infections. Our interventions are based on our MRSA bundle, which consists primarily of active surveillance testing of the nares for MRSA, followed by contract droplet precautions, and diligence to hand hygiene and education. Once we were able to better identify the silent reservoir—those who are just colonized—and make sure the interventions and precautions were put into place, we saw fewer infections. Transmission of organisms was decreased; we were no longer passing the organism as readily. Before we identified the silent reservoir, we didn’t know people had the pathogen, so inadvertent transmission occurred. We experienced great success in our medical ICU, which is where we started
our efforts. After the first three years, we achieved an 85 percent reduction in our HA-MRSA rates.

If you can get people to simply try the interventions and actually look for colonized individuals, infection prevention efforts are self-propelling because healthcare professionals then realize there is this significant reservoir they would have otherwise not detected and they could have inadvertently passed this organism to others. So what you have to do is get healthcare professionals to bite, and once they start the methodology, it drives itself. The outcomes and reduction of infection rates are amazing; even our physicians who direct and work in the ICUs wouldn’t have it any other way because their patients are being spared adverse outcomes that otherwise we could continue to see. We then rolled out our intervention from our medical ICU to our cardiothoracic ICU and since that time we have rolled out to all of our ICUs in our health system as well as non-ICU areas that were considered high risk.

Q:Are you encouraged by the numerous recent initiatives from the private and public sector to help address and fight infections caused by MDROs?

A:I am very encouraged by what I am seeing. Some of the players at the table are late-comers but that’s OK because at least they are at the table now. Many of our infection-prevention interventions have been in place since 2000 and so the outcomes are not new to us, but we are happy to see that there are more facilities now at the table. That means anecdotal evidence and evidence derived from studies can be more formally supported, and that can only encourage even more facilities to become better engaged in the fight against MDROs.

Q:Do you think hospitals are doing what it takes to address MDROs?

A:It’s impossible to know because they are not measured or reported to any department of health, with a few exceptions. Our department of health in Allegheny County has made it a requirement that all MRSA cases must be reported. Because there are no comparisons nationally there are no ways through which you can report the process measures that are in place. What I can say is that over the last five years, there has been a lot more prevention awareness and activity occurring nationally. Is it enough? Absolutely not. What I think has happened is visionaries got on board and saw that if evidence-based practices could work in one or two facilities, it could work in theirs. Some states like Pennsylvania have actually required MRSA testing, which has added another whole body of work. There are three other states that require MRSA testing by law. So that’s pushing everyone still somewhere in the middle on mandatory MRSA testing. Some may be thinking it’s a good idea, others may say maybe it’s not, and still others are not sure.

Once it is required by law, especially if the law requires something that is scientifically supported, you’ll get more people to do it—especially to avoid the penalties of non-compliance. So, we are getting there because more people are realizing the benefits of prevention strategies, but I’m not sure all of the paths to a singular destination are the same. I don’t care how you get to the finish line as long as you get there.

Q:What is your recommendation for how to boost compliance with evidence-based practices to fight infections?

A:Facilities will have no idea of what their compliance is unless they ask that it be measured. So make certain that your process measures are being done; after all, if you are not actually doing the processes that you think you are, you are not going to see the full benefit of your interventions. At our facility we measure compliance with interventions such as culturing, isolation, and hand hygiene regularly—we use dashboards containing all of these compliance measures. All hospitals need to do something like this because they will think they are doing fine, but when they actually look at their measures closely, they might not be fine. Measurement is the only way you can figure out what’s broken and what to fix. That’s how bundles got to be so successful—you measure the processes as well as the outcomes. You can see what needs to be addressed. Once you have the measures and you’re perfect, your outcomes will follow. What you do about the challenge of noncompliance is the other side of the issue. That’s not something an infection control professional can fix, that’s something that can only be fixed by your healthcare system, and your whole chain of leaders—both medical leaders and hospital administrators. You must achieve buy-in so that the support leverage is there. That’s how you change a culture. Just measuring it and never being better than 50 percent isn’t enough. You must insist that you achieve near perfection, or else it won’t happen.

We’re big on the multi-disciplinary approach. I am very happy to hear that the full responsibility of infection control has clearly extended itself outside of this department. Now, with all of the initiatives underway, people are becoming self-appointed infection watchdogs and are engaged in the war against infections. We could never accomplish these sorts of things if they were based on the traditional infection control department, as you now need every hospital department to embrace the initiatives and be perceived as the change agent. Even if healthcare professionals are not the ones actually performing the evidence-based practices, they must make it clear to the people they oversee that this is something they believe in and they support.