We know we should do it, but we often don't wash our hands. While for you and me it may merely mean succumbing to a cold, for health care workers, it can mean spreading bacteria to a patient. And not just any old bacterium, but a multi drug resistant organism, MDRO, that has the potential to cause difficult-to-treat infections.
Adults in intensive care units (ICUs) are routinely screened for MDROs upon admission to the unit, but this precautionary practice is not extended to the pediatric care unit (PICU). Children are checked for the bacteria some time during their stay - but not at the outset - making undetected MDROs possible. A group of physicians at Hopkins Hospital implemented the screening system used in the ICU in the PICU.
"We know that the percent of antibiotic resistant bacteria are increasing in the pediatric intensive care unit (PICU), but there is not a lot of data characterizing the problem with MDRO infections in the PICU," Aaron Milstone, a pediatric infectious disease specialist and the first author on the study, said in an e-mail interview.
Milstone's study tracked two MDROs: methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). "Our main goal was to determine whether cultures sent during clinical care reflect the burden of MRSA and VRE in the PICU," Milstone said.
A patient can be colonized with MDRO and not show symptoms. However, an asymptomatic person can spread the bacteria to someone who could become infected.
"We focused our study mainly on colonization. [By] screening cultures [we can] identify colonized patients who can serve unknowingly as a reservoir and spread infection to other people. If a patient has VRE and their nurse or doctor is unaware, if good handwashing is not practiced, then dirty hands can carry VRE to the next patient. The next patient can become colonized and is at risk of an infection due to VRE," Milstone said.
If a patient is known to have an MDRO, approaches like isolation are implemented to impede transmission to others. "Identifying colonized patients and isolating them is one strategy to prevent transmission and reduce infections. This has never been studied in children," Milstone said.
The study found that screening children for MRSA and VRE upon entry to the PICU led to discovery of a much higher prevalence of these bacteria than previously known. Without screening, MRSA levels were underestimated by 52 percent and VRE levels were underestimated by 79 percent.
"We did show that screening patients increased the number of days patients harboring MRSA or VRE were appropriately isolated. Isolation can reduce transmission, but also may have negative consequences," Milstone said.
The study did not report a statistically significant difference in MDRO infections during the intervention compared to the period before the screening was implemented.
Undeterred, Milstone pointed out that that's not what he and his colleagues were after.
"The number of infections we have in our unit is very low. It would be nearly impossible to show a significant reduction in the number of infections in such a short period of time. But remember, hypothetically, decreasing the number of infections from two to one may not be statistically significant, but it can make a real difference in the care of that one child," Milstone said.
Milstone and his team are continuing their research. "We are leading a multi-center clinical trial to determine whether bathing children in the PICU daily with an antiseptic can reduce transmission of MRSA and VRE and reduce infections, we are determining the number of patients colonized with MRSA or VRE at the time of admission to the PICU, we are looking at the risk of infection in patients colonized with MRSA or VRE, and we are monitoring MDRO transmission and infection rates over time."
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