Methicillin-Resistant Staphylococcus aureus in Nursing Homes: Putting the Problem in Perspective

Abstract

Strains of methicillin-resistant Staphylococcus aureus (MRSA) are presently endemic in many university, community-teaching, and Veterans' Affairs (VA) medical centers, particularly in the eastern half of the United States. Because elderly patients often are transferred between affected hospitals and extendedcare facilities, many nursing homes are being asked to care for patients with MRSA. In parts of the country where MRSA is prevalent, nursing homes have felt compelled to implement special infection control measures for MRSA similar to those used in hospitals. Some facilities have adopted very restrictive policies, which have caused colonized or infected residents to be excluded from many activities that are important for their health and wellbeing. In addition, more than a few nursing homes have refused to accept patients colonized with MRSA, resulting in prolonged hospital stays while patients await nursing home placement. Why have nursing homes decided to exclude patients with MRSA but willingly accept patients with methicillin-susceptible strains of S aureus or with multi-drug resistant, gram-negative rods? Perhaps such policies have emerged in part because MRSA strains are mistakenly assumed to be more virulent. Alternatively, nursing home personnel may assume that the special MRSA precautions implemented in some hospitals also must be used in nursing homes, even though the two environments (and patient populations) are different in many respects. Mu h of the problem stems from our lack of knowledge r garding the epidemiology of MRSA in nursing homes. To date, very few reports have described investigations of MRSA in nursing homes or other extended-care facilities.1-10 The most thorough studies of MRSA in extended-care facilities have en conduc ed in VA-affiliated long-term care units.7-10 Unfortunately, the results of studies performed at VA-affiliated facilities may not be applicable to most nursing home residents. The VA-affiliated facilities at which careful studies have been conducted are located at or ne r VA medical centers where MRSA is highly endemic. I a dition, the VA medical centers often have house staff and care almost exclusively for men. In contrast, in most of the 15,900 certified nursing homes in the United States, there are no house staff, and more than 70% of the residents are women, a majority of whom are more than 80 years old. Because the residents in the two types of facilities differ substantially, further studies are needed to determine patterns of MRSA infection in free-standing, nonfederal nursing homes. This issue of Infection Control and Hospital Epidemiology includes an article that adds to the small amount of information available regarding MRSA in co munity nursing homes. The article by Hsu11 describes periodic point prevalence culture surveys of re dents in a 150-bed community nursing home located in an area where MRSA is endemic in nearby hospitals. All consenting residents had periodic nasal