BMJ  2004;329:533 (4 September), doi:10.1136/bmj.329.7465.533

Paper

Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA): systematic review of the literature

B S Cooper, postdoctoral research fellow1, S P Stone, senior lecturer2, C C Kibbler, postdoctoral research fellow1, B D Cookson, director3, J A Roberts, professor in economics of infectious disease4, G F Medley, reader, ecology and epidemiology5, G Duckworth, director6, R Lai, assistant librarian7, S Ebrahim, professor in epidemiology of ageing8

1 University Department Medical Microbiology, Royal Free Campus, Royal Free and University College Medical School, University London, London NW3 2PF], 2 Academic Department Geriatric Medicine, Royal Free Campus, Royal Free and University College Medical School, 3 Laboratory of Healthcare Associated Infection, Central Public Health, Laboratory, Health Protection Agency, London NW9 5HT, 4 Collaborative Centre for Economics of Infectious Disease, Department Public Health and Policy, London School of Hygiene and Tropical Medicine, University London WC1E 7HT, 5 Department of Biological Sciences, University of Warwick, Coventry CV4 7AL UK, 6 Division of Healthcare Associated Infection and Antimicrobial Resistance, Health Protection Agency, Communicable Disease Surveillance Centre, London NW9 5EQ, 7 University Library, Royal Free Campus, Royal Free and University College Medical School, 8 Department of Social Medicine, Bristol University Medical School, University of Bristol BS8 2PR

Correspondence to: S P Stone s.stone{at}rfc.ucl.ac.uk

Abstract

Objective To evaluate the evidence for the effectiveness of isolation measures in reducing the incidence of methicillin resistant Staphylococcus aureus (MRSA) colonisation and infection in hospital inpatients.

Design Systematic review of published articles.

Data sources Medline, Embase, CINAHL, Cochrane Library, System for Information on Grey Literature in Europe (SIGLE), and citation lists (1966-2000).

Review methods Articles reporting MRSA related outcomes and describing an isolation policy were selected. No quality restrictions were imposed on studies using isolation wards or nurse cohorting. Other studies were included if they were prospective or employed planned comparisons of retrospective data.

Results 46 studies were accepted; 18 used isolation wards, nine used nurse cohorting, and 19 used other isolation policies. Most were interrupted time series, with few planned formal prospective studies. All but one reported multiple interventions. Consideration of potential confounders, measures to prevent bias, and appropriate statistical analysis were mostly lacking. No conclusions could be drawn in a third of studies. Most others provided evidence consistent with a reduction of MRSA acquisition. Six long interrupted time series provided the strongest evidence. Four of these provided evidence that intensive control measures including patient isolation were effective in controlling MRSA. In two others, isolation wards failed to prevent endemic MRSA.

Conclusion Major methodological weaknesses and inadequate reporting in published research mean that many plausible alternative explanations for reductions in MRSA acquisition associated with interventions cannot be excluded. No well designed studies exist that allow the role of isolation measures alone to be assessed. None the less, there is evidence that concerted efforts that include isolation can reduce MRSA even in endemic settings. Current isolation measures recommended in national guidelines should continue to be applied until further research establishes otherwise.

Introduction

The incidence of hospital acquired methicillin resistant Staphylococcus aureus (MRSA) continues to rise globally.1-4 Attempts to control this spread have relied principally on three measures: hand hygiene among healthcare workers, restriction of antibiotics, and the detection and isolation of infected or colonised patients. We consider the detection and isolation of infected or colonised patients, which is central to most national guidelines.5-8

Isolation measures for patients are intended to interrupt transmission of MRSA. The most intensive forms of isolating patients are isolation wards (designated for the treatment of known or suspected carriers of MRSA) and nurse cohorting (the physical segregation of MRSA patients in one part of a ward, with nursing by designated staff who care exclusively for these patients). Other isolation measures include the use of single bedded rooms, cohorts of patients on general wards (without designated nursing staff), and barrier precautions (use of aprons or gowns, gloves, and, in some cases, masks by healthcare workers as the only physical barrier to transmission).

Such control measures may place substantial burdens on hospital resources, and the value of their continued use has been questioned9 but the effectiveness of isolation measures in reducing transmission and controlling MRSA has not been assessed systematically. Much of the research is of a quasi-experimental nature8 10 and the associated threats to validity need to be considered.11 12 We therefore undertook a systematic review of the evidence for the effectiveness of isolation measures in the management of MRSA in hospitals.

Method

Search strategy
We developed a search strategy that covers the main subject areas of the review (MRSA, screening, and isolation of patients and control of infection). We searched the following databases, with no language restrictions: Medline 1966-December 2000, Embase 1980-December 2000, CINAHL 1982-May 2000, System for Information on Grey Literature in Europe (SIGLE) 1980-May 2000, and the Cochrane Library to December 2000. We also hand searched key journals.

Study selection
Articles were obtained if abstracts abstracts mentioned endemic or epidemic MRSA and an attempt at control in hospital. As the number of studies was far greater than anticipated, we revised the original protocol (which had imposed no quality restrictions). We imposed the minimal requirement that accepted studies should include a component of prospective data collection. If they were entirely retrospective comparisons should have been planned and not prompted by part of the outcome data. No such restrictions were imposed for studies using the most intensive forms of isolation (isolation wards and nurse cohorting) as these have the greatest implications for the allocation of resources and organisation of services. We rejected studies not mentioning an isolation policy or without relevant MRSA related outcomes.

Data extraction
We divided each study into phases, where appropriate, defined by major changes in isolation or other infection control measure. Data extraction included documentation of potential threats to validity, measures taken to avoid, record, or adjust for these and an assessment of the appropriateness of any statistical analysis undertaken.

Data synthesis
Two reviewers independently evaluated the strength of evidence in each study by examining the study design, quality of data, and presence of plausible alternative explanations of outcomes. They characterised the evidence on a case by case basis as "none," "weak," "of intermediate strength," or "stronger." We considered formal meta-analysis inappropriate because of heterogeneity in outcome measures and patient populations. Full details of the search strategy, study selection, and data extraction are available in a technical report.13

Results

The search selected 4382 abstracts. Appraisal of abstracts selected 254 papers. The final review included 46 studies (table 1).14-60


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  		Table 1 Characteristics of the 46 accepted studies

 

Study design
We found no randomised controlled trials and only four prospective planned comparison studies with predefined study phases.19 37 49 60 Most designs were interrupted time series—that is, time series of outcome measures recorded before and after one or more interventions.

Review of the 36 studies allowing comparisons between isolation policies indicated that in 27 the comparisons being made were dependent on knowledge of the outcome data. Short retrospective studies with successful outcomes were particularly vulnerable to this problem. This, and the predominance of unplanned retrospective reports, shows that reporting bias is likely to be important.

Threats to internal validity of evidence
In the absence of cluster randomised trials, all comparative studies were vulnerable to selection bias, yet recording and adjustment of potential confounders was minimal (table 2). In two studies we considered changes in case mix to represent a plausible explanation for changes in the incidence of MRSA.40 43


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  		Table 2 Selection, performance, detection and attrition bias

 

Table 2 details other important biases, the studies that were vulnerable to them (the majority) and the measures some took to avoid them (the minority).

Trends, regression to the mean, seasonal effects and changes in MRSA strain
Of 30 studies with two or more phases and pre-intervention time series, clear underlying trends in MRSA levels were apparent in 13. In all cases the trend was for increasing MRSA levels before major interventions.

Trends in the number of patients colonised on admission may also complicate interpretation of outcomes. Although 18 studies assessed whether patients were colonised on admission, we could only assess trends in five.29 30 37 45 47 In two studies these trends provided a plausible explanation for changes in outcome measures.29 43

Regression to the mean effects were considered likely when unusually high MRSA incidence data prompted the intervention and when these data were included in the study. We considered this threat to provide a plausible explanation of outcomes in seven studies.15 19 20 21 44 45 55

Inspection showed that seasonal effects may have been important in two20 55 of 14 studies with time series of 18 months or more. In the 21 studies with shorter time series it was not possible to disentangle seasonal from intervention effects. Although studies often gave no details of MRSA strain typing, we considered the documented introduction of a new strain to plausibly explain control failure.29

Statistical validity
Of the 38 interrupted time series, 24 reported results of statistical analysis. In all but one study35 patient outcomes were assumed by authors to be independent. Such assumptions are inappropriate when transmission from patient to patient occurs and would increase the likelihood of a false positive outcome. In one study we considered the independence assumption to be justified as outcomes at hospital level from distinct hospitals were used.27

Evidence for control of MRSA
In 45 of the 46 studies multiple simultaneous control measures were apparent. It was not possible to assess the relative contribution of individual measures.

In 14 studies it was impossible to draw any conclusions about the effect of interventions. Most of the remaining 32 reported evidence consistent with reduction in MRSA transmission but in 18 of these the evidence was considered weak, especially in small and successfully controlled outbreaks managed by isolation wards or nurse cohorting.14 16 36 47 48 50 52 53 58 None the less, it remains possible that immediate deployment of such measures may be successful.

The strongest evidence came from six longer time series, with detailed information on interventions and fewer plausible alternative explanations for the outcome (table 3, figure). In four studies major outbreaks were controlled or MRSA numbers substantially reduced over prolonged periods.22 23 25 32 33 The main isolation measures were single room in two studies,23 32 33 nurse cohorting in one,22 and isolation ward in one.25 Another isolation ward study reported failure to control the spread of MRSA,28 and another reported control by an isolation ward for many years followed by eventual failure.29


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  		Table 3 Studies providing stronger evidence

 


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  		Outcome of studies considered to present the strongest evidence Interrupted time series for A: Coello et al22 B: Cosseron Zerbib et al23 C: Duckworth et al25 D: Faoagli et al28 E: Farrington et al29 F: Harbath et al.32 33 Table 3 gives explanatory text. Asterisks indicate phases with most intensive isolation policies. In D and E isolation policies in both phases were similar (isolation wards), but in the second phase the capacities of the isolation wards were exceeded in both cases, and the overflow was cohorted or isolated in single rooms

 

We considered eight other studies to present "intermediate" evidence of reduction of MRSA by measures that included an isolation ward,43 51 nurse cohorting,15 19 or other interventions.27 35 37 One showed the failure of an isolation ward to control MRSA.24

Discussion

Our primary conclusion is that major methodological weaknesses and inadequate reporting in research into the effectiveness of isolation measures mean that many plausible alternative explanations for reductions in MRSA cannot be excluded. We have produced guidelines to facilitate the planning and publication of better quality studies.13

The secondary conclusion is that, despite the limitations of existing research we found evidence that concerted interventions that include isolation measures can reduce MRSA transmission substantially, even in settings with endemic MRSA. We found no evidence to show that current isolation measures recommended in many countries5-8 are ineffective at reducing transmission from isolated patients: the only two studies that directly measured this reported large reduction in the transmission rate per source.27 35 None the less, we found reports of control failure despite the employment of intensive isolation measures including isolation wards.28 29 These studies indicate a need to investigate precisely how such isolation measures should be used. We address this question further elsewhere, using mathematical models to explore the effectiveness and cost effectiveness of isolation wards under different assumptions.13 61

Strengths of the study
In contrast with narrative reviews,3 10 62 63 64-66 where study selection may be biased, our systematic comprehensive search strategy, data extraction and documentation of component threats to validity provided a rigorous evaluation of the shortcomings of existing research. In particular, no studies tell us anything about the relative effectiveness or cost effectiveness of individual measures in different clinical situations. These would be fertile areas for further research.

Nevertheless, a lack of evidence of an effect associated with specific measures should not be mistaken for evidence of lack of effect. Having considered the evidence we believe isolation measures recommended in national guidelines should continue until further research establishes otherwise.

The six studies19 20 22 25 26 29 30 we considered to present the strongest evidence for assessing the effect of isolation, although they often failed to consider potentially important confounders, provide testable hypotheses that could be assessed in future studies.


What is already known on this topic

National guidelines in many countries recommend patient isolation to control the spread of MRSA

Traditional narrative reviews differ as to its effectiveness

Most of the research is of a quasi-experimental nature, and no review has systematically assessed the threats to valid inference associated with such studies

What this study adds

The shortcomings of existing research are rigorously evaluated through a systematic comprehensive search strategy, data extraction, and documentation of component threats to validity

Major methodological weaknesses and inadequate reporting in many studies mean that plausible alternative explanations for reductions in MRSA cannot be excluded

There is evidence that interventions that include isolation can achieve major reductions in MRSA, even when endemic, but there are no well designed studies that allowed the role of isolation measures alone to be assessed

Studies considered to provide stronger evidence or evidence of intermediate strength provide testable hypotheses for future well planned studies

Guidelines have been produced to facilitate such research (www.hta.nhsweb.nhs.uk)


Priority for research
MRSA is associated with substantial morbidity and mortality.8 67 The emergence of glycopeptide resistant Staphylococcus aureus strains,68 which further reduce therapeutic options, makes the implementation of well designed interventional studies to inform the choice of control measures a research priority.

{elps.f1}This is an abridged version, the long version is on bmj.com

The study was funded for two years by the Health Technology Assessment Board of the NHS R&D HTA Programme.

Competing interests: None declared.

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(Accepted 14 June 2004)


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Rapid Responses:

Read all Rapid Responses

Getting hold of the full MRSA report
Phillip P Simons
bmj.com, 3 Sep 2004 [Full text]
Isn't it time to change our approach to the management of methicillin resistant staphylococcus aureus (MRSA) ?
michael a james
bmj.com, 9 Sep 2004 [Full text]
Weak evidence on effectiveness of isolation measures on control of MRSA
Savvas Papagrigoriadis
bmj.com, 27 Sep 2004 [Full text]
CONTACTS BETWEEN ICU PATIENTS AND NON-UNIT EMPLOYEES DURING AN MRSA OUTBREAK
Jaap E. Tulleken, et al.
bmj.com, 1 Dec 2004 [Full text]
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