Effectiveness of Interventions to Prevent MRSA Infection in Hospital Settings

This systematic review evaluates the effectiveness of interventions to prevent MRSA infection among patients admitted in hospital settings. It includes a comparative analysis of various preventive interventions and their efficacy.

CHAPTER-2
Effectiveness of interventions to prevent MRSA infection among
patients admitted in hospital settings-A systematic review
2.1. INTRODUCTION
MRSA or Methicillin-resistant Staphylococcus aureus, belongs to the family of Staphylococcus
bacteria which is resistant to a number of antibiotics and results in healthcare associated
infections (HAI) across hospitals and clinical environments engaging in invasive treatments (De
la Gandara et al. 2016). Infections of MRSA are caused due to invasive procedures such as
surgical interventions, joint replacement and placements of tubing intravenously. Such MRSA
infections are primarily known as health-care associated MRSA (HA-MRSA), can be prevented
with adherence to specific healthcare interventions (Steinmetz et al. 2015). A systematic review
is a commonly used method of research for the purpose ofcollecting and synthesizing essential
data after comprehensive screening of a wide variety of publications, trials and scientific
research.The following systematic reviewaims to evaluate upon these preventive interventions
and present a comparative analysis considering the effectiveness of each.The systematic review
comprised of a range of studies engaging in randomized controlled trials or pre and post
interventions to assess the efficacies of various preventive interventions for MRSA.
2.2. BACKGROUND
The World Health Organization (2019) denotes that surgical procedures are the reason for almost
90% of MRSA. If left untreated sepsis associated with MRSA contributes to almost 30 to 50% of
mortality incidences in hospitals. Further, the Center for Disease Dynamics, Economics & Policy

(2019), estimated the prevalence rate of MRSA in Ireland to be 40%. In the absence of timely
administration of treatment and preventive interventions, MRSA leads extremely debilitating and
damaging health implications, especially associated with the skin, such as boils, blisters, skin
peeling and infections at the root of the hair follicles. Infections caused due to MRSA bacterial
strains are associated with symptoms such as painful and swelling reddish bumps in the skin,
which upon lack of treatment and management, results in increased transmission of infection and
the development of infected skin areas which are warm when touched, filled with pus or other
fluids and may be accompanied by fever in the patent (Haysom et al. 2018).
A prolonged absence of treatment can aggravate and MRSA infection which results in chronic
symptoms where the infection transmits to the bones, blood, surrounding organs and tissues
further progressing to multiple organ failure, sepsis and death. For the timely prevention and
management of infections associated with MRSA, multiple interventions are considered to be
effective. Some examples of interventions which have been evidenced to be advantageous in the
prevention of MRSA include personal hand hygiene, using disinfectants and antibiotics for
patient management, administration of contact precautions like glove usage and screening and
isolation of patients (Brown et al. 2016).
For the prevention of high rates of prevalence associated with transmission of MRSA infections,
hospitals and clinical organizations are implementing strategies and programs for prevention and
timely management of the same (Matsumoto 2016). Some of these include, adoption of
comprehensive and standardized hand hygiene protocols, adherence to precautionary practices
associated with patient contact such as usage of gloves and gowns (Paiva et al.2017).
A number of strategies which may also be considered as beneficial for prevention of MRSA
include conductance of disinfection and sanitation of medical equipment, dissemination of

educational frameworks targeting MRSA awareness in the workforce and implementation of
alert and assessment programs outlining preventive screening of patients (Bassetti et al.2016).
Despite the wide range of available preventive programs, there is a lack of scientific evidence on
the comparative effectiveness of each, which forms the primary rationale, objectives and
questions for this systematic review.
Hence, the aim of this thesis is to provide a comparative review of the multiple interventions
effective for the prevention of MRSA incidence as well as present a critical evaluation regarding
the effectiveness of each of the infection prevention interventions which will be selected across a
target population of adult patients admitted in hospital settings.The following systematic review
also provided assistance to screen and acquire comprehensive information on the range of
interventions administered in hospital settings for the prevention of infections associated with
MRSA. The following systematic review was also helpful in the identification of essential
limitations across the various identified interventions for MRSA prevention, further resulting in
the evaluation of possible improvements and recommendations for enhanced MRSA infection
prevention across hospital settings.
2.2.1 AIM
The aim of this review is to describe the effectiveness of interventions targeted at the prevention
of MRSA infections among patients in hospital settings.
2.2 METHODS
A systematic review was used as the chosen methodology for this thesis for the purpose of
evaluating and critically appraising existing literature on preventive programs available in
hospitals to eradicate MRSA infection occurrence. A systematic review was used for the

collection and synthesis of essential data components after an extensive exploration of a broad
range of published research (Shamsheeret al. 2015). A systematic review was chosen as the
preferred research methodology since it allowed convenient research screening and acquisition
of a wide range of credible, significant and valid information, which in this case, includes
multiple MRSA preventive interventions.
Systematic review was also chosen as the preferred methodology due to its ability to aid in
identification of strategies underlying practical application of MRSA preventive interventions,
identification of research limitations paving the way for further research and reduced possibilities
of bias during drawing of conclusions due to its incorporation of a broad variety of research
studies and findings (Moher et al. 2015).
For the analysis of the acquired data, narrative synthesis was used which comprised of grouping
of acquired data based on themes with the usage of common key words and terms. Narrative
synthesis was chosen as the preferred mode of data analysis since it allows easy identification
and summarization of key findings in a situation of broad research questions and outcomes
which in this case, proved to be beneficial in the identification of important themes and findings
from a wide range of MRSA infection prevention strategies (Cruzes et al. 2015).
2.3.2 INCLUSION CRITERIA
The articles relevant to the study and to be used for systematic review were selected based on the
following PICOS question:
What is the effectiveness of intervention programs targeted at prevention of MRSA infections
occurring among patients in hospital settings?
• P: Population: Adults Patients admitted in Hospitals

• I: Interventions: All MRSA infection prevention intervention programs
• C: Comparison: Pre and post intervention with same group
• O: Outcome: Reduction of MRSA infections in Hospitals
• S: Setting: Hospital settings
2.3.3 EXCLUSION CRITERIA
Articles which contained studies not relevant to the keywords or the PICOS questions were
excluded from the study. Such articles were excluded either because they focused only upon
hospital acquired infections other than MRSA or dealt with non-adult populations such as
paediatrics or neonates. Additionally, articles which assessed MRSA prevention across non-
hospital settings such as residential settings and community settings.
2.3.4 INFORMATION SOURCES AND SEARCH STRATEGY
For conducting a search strategy and selection of articles relevant to the research question,
databases such as CINAHL, MEDLINE, ERIC and Academic Search Complete were searched.
For the purpose of conducting the database search, the following search terms were used due to
their relevance to the research question:: prevent * OR avoid* OR control OR reduc*OR
decreas*AND interven* OR program* OR therap*OR treat* AND MRSA OR “methicillin
resistant staphylococcus aureus”AND Hospital* OR “Acute care setting*” OR “Acute care*”
OR “Acute setting*” OR “Clinical setting*” OR “In patient” OR Inpatient OR Ward* OR Unit*.
To further enhance the search process, the search terms were combined using Boolean operators
coupled with setting of limiters like: selecting English as the language of preference as well as
selecting humans as the preferred subject of studies (Machiet al. 2016). Limiters are required to

ensure that articles which are relevant to the research are selected considering and those that are
irrelevant are excluded from the screening process altogether. It was ensured that articles
published within 2009-2019 were included for this study (Majid et al. 2017).
2.3.5 STUDY SELECTION
The citations were screened based on their relevance to the chosen timeframe, research PICOS
question and the selected keywords. For appropriate screening and selection, the researcher
ensured inclusion of articles which are peer reviewed since a research reviewed and evaluated by
more than one researcher is associated with reduced possibilities of bias. Articles which were
excluded were those irrelevant to the chosen timeframe, or used interventions not adhering to
MRSA infections, hospital settings or adult populations.Clinical studies which evaluated the
comparative differences between incidences of MRSA prior to and after administration of
MRSA preventive interventions were included whereas publications which are primarily opinion
articles and editorials not engaging in pre and post intervention comparative analysis will be
excluded. Further, publications of international organizations have been considered to discuss the
existing prevalence of MRSA but not as a part of a systematic review. After completing the
search, duplicates of all the articles were removed by exporting to a reference manager software
such as Endnote. To further ensure selection of articles for the systematic review, Covidence
software was used after removing all the duplicates of the articles. Screening of all articles was
performed by another reviewer. Additional screening of articles for their title, abstract and full
text versions was performed by additional two reviewers. Conflicts in opinion were resolved
after discussion and arriving at a consensus(Jahan et al. 2016).
2.3.6 DATA EXTRACTION

For the purpose of extracting data, a data extraction table was used – a credible and relevant
method which aids in retrieval of major essential components of chosen research articles and
compilation of the same into concise, convenient and organized information. The data extraction
tables included information of the chosen studies based on the details of the authors, settings of
the study, the research designs used, the outcomes and findings, the interventions utilized as well
a brief outline on results of quality assessments. An additional data extraction table was also
added which focused upon summarizing the findings of each study in alignment with the
identified research questions (Hira et al.2015).
2.3.7 QUALITY APPRAISAL
The assessment of quality and validity of the research papers selected for the systematic review,
tools and checklists of critical appraisal developed by the Joanna Brigg’s Institute (JBI) were
used. Such tools and checklists developed by JBI have worldwide acceptability and usage due to
their ability to assess the validity of results and findings presented in studies, by using a range of
easy-to-understand yet critical set of checklists, questionnaires and as well as supportive
information for guiding researchers. The trustworthiness, validity and conclusiveness of the
results across studies using a wide range of research designs, are possible to be covered by the
checklists developed by JBI. These include cross sectional studies, cohort studies, randomized
controlled trials, case control studies, systematic reviews and quasi experimental studies. JBI
quality appraisal checklists assess the scientific validity of studies with the aid of multiple choice
options across 9 to 13 questions, like ‘yes’, ‘no’ and ‘unclear’, on grounds of validity and
reliability of outcomes, cause-effect relationships, confounding variables, presence of
concealment, exposure interventions, adherence to randomization and blinding.

For evaluating the methodological quality of the studies to be included in the systematic review,
the JBI checklists which were used primarily were those associated with quality assessment of
cohort studies, case control studies, randomized controlled studies, quasi-experimental studies
and analytical cross sectional studies - since these were the research designs used prevalently in
the screened articles. Studies which scored positive in most of the questions were included in the
study resulting in a total of 15 articles of moderate to high quality to be used in the systematic
review. Studies which were scored poorly and were excluded, primarily due to usage of
unreliable or invalid outcome and exposure measurements or due to poor research design.
Overall, two reviewers performed the critical appraisal, and after arriving at a consensus, labelled
a total of 15 studies as ‘include’ in the final verdict mentioned in the JBI checklist for addition in
the systematic review. Of two randomised controlled trials included in this study, most of the
studies presented positive answers across the total 13 questions, with however, negative
responses observed in terms of follow up, blinding and allocation concealment. A total of 4
analytical cross sectional studies were assessed using these checklists where most papers met 9
of the prescribed criteria, with negative responses observed in case of evaluation of confounding
factors. Only one case control study was appraised which scored a ‘yes’ for 8 out of 10 questions
and ‘no’ in terms of measurement and time period of exposure administration. A total of 3 cohort
studies were critically appraised, where most score 8 to 9 questions correctly across a total of 11
questions with negative responses observed in case of lack of adequately addressing follow up.
The remaining 5 studies were critically appraised using checklists for quasi experimental studies
where most studies scored a ‘yes’ in 6 to 7 of the total of 9 questions and a ‘no’ scored in terms
of lack of control group and absence of adequate follow up measurements (Joanna Brigg’s
Institute 2019).

2.3.8 SYNTHESIS OF RESULTS
The data obtained from the studies were synthesized considering a narrative approach and hence,
summarized into 4 major themes of preventive interventions, mainly, organizational
interventions, contact precautions, environmental disinfection and screening and isolation.
2.3.9 SEARCH PROCESS AND RESULTS
As evident from the PRISMA diagram (see Figure 1), the initial results yielded a total of 490
studies, which was reduced to 280 articles after removing articles which are duplicate. Studies
which had titles and abstracts irrelevant to the research question and keywords were excluded
which ultimately yielded 30 articles for final screening. The final 15 articles for the systematic
review were selected after excluding studies which did not include adult patients (n = 3), were
conducted across non-hospital environments (n = 4) and those which did not discuss MRSA
intervention as a preventive measure (n = 8).