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Screening, isolation, and decolonisation strategies in the control of meticillin resistant Staphylococcus aureus in intensive care units: cost effectiveness evaluation

BMJ 2011; 343 doi: (Published 06 October 2011) Cite this as: BMJ 2011;343:d5694
  1. Julie V Robotham, mathematical modeller1,
  2. Nicholas Graves, professor of health economics2,
  3. Barry D Cookson, director3,
  4. Adrian G Barnett, associate professor2,
  5. Jennie A Wilson, deputy director4,
  6. Jonathan D Edgeworth, consultant microbiologist and honorary senior lecturer56,
  7. Rahul Batra, infection research fellow6,
  8. Brian H Cuthbertson, chief7,
  9. Ben S Cooper, senior research fellow89
  1. 1Modelling and Economics, Health Protection Agency, London NW9 5EQ, UK
  2. 2Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
  3. 3Laboratory of Healthcare Associated Infection, Health Protection Agency, London, UK
  4. 4Infection Prevention and Control, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
  5. 5Department of Infectious Diseases, King’s College London School of Medicine, Guy’s Hospital, London, UK
  6. 6Directorate of Infection, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
  7. 7Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
  8. 8Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
  9. 9Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
  1. Correspondence to: J V Robotham julie.robotham{at}
  • Accepted 9 August 2011


Objective To assess the cost effectiveness of screening, isolation, and decolonisation strategies in the control of meticillin resistant Staphylococcus aureus (MRSA) in intensive care units.

Design Economic evaluation based on a dynamic transmission model.

Setting England and Wales.

Population Theoretical population of patients on an intensive care unit.

Main outcome measures Infections, deaths, costs, quality adjusted life years (QALYs), incremental cost effectiveness ratios for alternative strategies, and net monetary benefits.

Results All decolonisation strategies improved health outcomes and reduced costs. Although universal decolonisation (regardless of MRSA status) was the most cost effective in the short term, strategies using screening to target MRSA carriers may be preferred owing to the reduced risk of selecting for resistance. Among such targeted strategies, universal admission and weekly screening with polymerase chain reaction coupled with decolonisation using nasal mupirocin was the most cost effective. This finding was robust to the size of intensive care units, prevalence of MRSA on admission, proportion of patients classified as high risk, and precise value of willingness to pay for health benefits. All strategies using isolation but not decolonisation improved health outcomes but costs were increased. When the prevalence of MRSA on admission to the intensive care unit was 5% and the willingness to pay per QALY gained was between £20 000 (€23 000; $32 000) and £30 000, the best such strategy was to isolate only those patients at high risk of carrying MRSA (either pre-emptively or after identification by admission and weekly screening for MRSA using chromogenic agar). Universal admission and weekly screening using polymerase chain reaction based detection of MRSA coupled with isolation was unlikely to be cost effective unless prevalence was high (10% of patients colonised with MRSA on admission).

Conclusions MRSA control strategies that use decolonisation are likely to be cost saving in an intensive care unit setting provided resistance is lacking, and combining universal screening using polymerase chain reaction with decolonisation is likely to represent good value for money if untargeted decolonisation is considered unacceptable. In intensive care units where decolonisation is not implemented, evidence is insufficient to support universal screening for MRSA outside high prevalence settings.


  • We thank John W Edmunds and Albert Jan van Hoek for useful discussions on the economic evaluation.

  • Contributors: BSC, NG, BDC, and JAW designed the study. JVR and BSC wrote the code, carried out the model parameterisation, computer simulations, and analysis, with economic input from NG and statistical input from AGB. RB, JDE, and BHC provided individual level intensive care unit data, and survival and quality of life data, as well as advice on analysis. JVR drafted and revised the manuscript with input from BSC, NG, AGB, BDC, JAW, JDE, RB, and BHC. All authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. JVR, NG, and BSC act as the guarantors.

  • Funding: This work was funded by a grant from the Department of Health Policy Research Programme (PR-IP-0807-0410026). The views expressed are not necessarily those of the department. The authors’ work was independent of the funders, who had no role in the study design, analysis of data, writing of the manuscript, or decision to submit for publication. We acknowledge support from the Mastering Hospital Antimicrobial Resistance in Europe consortium. BSC acknowledges support from the Oak Foundation. The Mahidol Oxford Research Unit is supported by the Wellcome Trust.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: Details of the computer code for the model are available from the corresponding author at Julie.Robotham{at}

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