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

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

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.

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