title: Sustained meticillin-resistant Staphylococcus aureus control in a hyper-endemic tertiary acute care hospital with infrastructure challenges in Singapore.
abstract: BACKGROUND
  Meticillin-resistant Staphylococcus aureus (MRSA) has been entrenched in Singapore hospitals since the 1980s, with an excess of 600 non-duplicate cases of infections (120 bacteraemia episodes) each year in our 995-bed university hospital. Approximately 5% of our hospital beds are used as isolation facilities.
  
  
  OBJECTIVE
  To study the impact of an MRSA control bundle that was implemented via gradual geographic extension across hospital wards.
  
  
  METHODS
  The bundle included active surveillance on admission and transfer/discharge to identify ward-based acquisition of MRSA, isolation and cohorting of MRSA-infected patients, enhanced hand hygiene initiatives, and publicly displayed feedback of MRSA acquisition and hand hygiene compliance rates. Implementation was between October 2006 and June 2010 in order to provide lead-time for the incremental development of infrastructural capacity, and to develop an ethic of infection prevention among staff. Results were analysed via interrupted time-series analysis.
  
  
  RESULTS
  MRSA infections fell midway through the implementation, with MRSA bacteraemia declining from 0.26 [95% confidence interval (CI): 0.18-0.34] cases per 1000 inpatient-days in the first quarter of 2004 to 0.11 (95% CI: 0.07-0.19) cases per 1000 inpatient-days in the first quarter of 2012. MRSA acquisition rates fell a year after the programme had been fully implemented, whereas hand hygiene compliance rose significantly from 47% (95% CI: 44-49) in the first quarter of 2009 to 69% (95% CI: 68-71) in the first quarter of 2012.
  
  
  CONCLUSIONS
  Successful staged implementation of an MRSA bundle in a hyper-endemic setting is sustainable and represents a model that may be adapted for similar settings.
authors.affiliation: Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Infection Control Team, National University Health System, Singapore. Electronic address: mdcfda@nus.edu.sg.
authors.forename: D
authors.initials: D
authors.lastname: Fisher
authors.forename: P A
authors.initials: PA
authors.lastname: Tambyah
authors.forename: R T P
authors.initials: RT
authors.lastname: Lin
authors.forename: R
authors.initials: R
authors.lastname: Jureen
authors.forename: A R
authors.initials: AR
authors.lastname: Cook
authors.forename: A
authors.initials: A
authors.lastname: Lim
authors.forename: B
authors.initials: B
authors.lastname: Ong
authors.forename: M
authors.initials: M
authors.lastname: Balm
authors.forename: T M
authors.initials: TM
authors.lastname: Ng
authors.forename: L Y
authors.initials: LY
authors.lastname: Hsu
mesh_terms: D001291:Attitude of Health Personnel; D063373:Hand Hygiene / Q000379:methods*; D006801:Humans; D017053:Infection Control / Q000379:methods*; D055624:Methicillin-Resistant Staphylococcus aureus / Q000302:isolation & purification*; D015995:Prevalence; D011446:Prospective Studies; D012846:Singapore / Q000453:epidemiology; D013203:Staphylococcal Infections / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control*; D062606:Tertiary Care Centers
keywords: Active surveillance; Cohorting; Hand hygiene; Infection control; Meticillin-resistant Staphylococcus aureus; Time-series analysis