In 2008, the Society for Healthcare Epidemiology of America and Infectious Diseases Society of America—partnering with the American Hospital Association, Association for Professionals in Infection Control and Epidemiology, and the Joint Commission—published the “Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals,” a collection of recommendations focused on common hospital-acquired infections. With new research emerging and the need for up-to-date information, the organizations recently released an update to the compendium. As part of the compendium, updated recommendations were made on the prevention of MRSA infection and transmission.

Getting to the Basics

Published in Infection Control and Hospital Epidemi-ology, the recently updated compendium recommendations provide a roadmap for prioritizing and implementing strategies to help prevent MRSA infection and transmission. These strategies are broken down into basic practices (Table 1) and special practices. “Based on evidence, expert opinion, and experience, the basic practices are recommended for all hospitals, regardless of the burden of MRSA,” explains lead author David P. Calfee, MD, MS. “These are good, basic infection control practices. Many would be useful in preventing a wide variety of healthcare-associated infections (HAIs) and preventing transmission of various pathogens, including MRSA.”


When considering MRSA control practices, conducting a risk assessment is important. This should include an analysis of infection rates, the basic practices that have and have not been implemented already, and whether implemented practices are adhered to consistently, according to Dr. Calfee. “Writing a policy and making sure it’s actually being followed are two different things,” he adds. “A good understanding of the epidemiology of MRSA within your facility is really the first step.” He notes that all providers should be cognizant of their accountability to prevent HAIs like MRSA (Table 2).

Considering Special Practices

Special practices should be considered if the basic practices have been implemented with good adherence to each intervention but there is still evidence of MRSA transmission, infection, or both, according to Dr. Calfee. “Special practices are additional strategies to implement if MRSA hasn’t been adequately controlled with basic practices,” he says. The basic practices remain virtually unchanged from the 2008 version of the compendium recommendations, but the special practices section has been expanded to include interventions based on recent study findings that largely relate to universal decolonization.

“Studies show that performing daily chlorhexidine bathing to all ICU patients, regardless of their MRSA status, may reduce MRSA transmission and infection,” Dr. Calfee says. “Special practices also include various ways to use classic MRSA decolonization therapy—usually a combination of chlorhexidine plus intranasal mupirocin. Historically, MRSA decolonization therapy has been used only when patients are known to have MRSA. However, a recent, large study showed that a universal approach to using this therapy may be useful.” The recommendations discuss these and other approaches to help providers make informed decisions that are best for their institution.

Implementing Practices

The compendium recommendations encourage the “4E” approach—engage, educate, execute, and evaluate—to implementation. The guideline includes specific recommendations on how to implement the 4E approach and provides references to other tools, education materials, checklists, and more. “Take active surveillance testing for MRSA, for example,” says Dr. Calfee. “There’s a lot of information on the various types of testing, how to respond to different results, and what to do when waiting for results. This document walks providers through the steps that should be considered if they’re thinking about implementing one of these approaches. The guidelines also give the pros and cons of each.”

Existing Needs

More research is needed on the potential risk of developing resistance to agents used in universal MRSA decolonization. With more widespread use, this may impact future opportunities to prevent HAIs. “We need to clarify the long-term effects of some of the antiseptic- and antibiotic-related approaches to MRSA,” Dr. Calfee says. “Also, many believe that antimicrobial stewardship could be effective in helping control the spread of multi-resistant organisms in general. However, we lack data on exactly how effective antimicrobial stewardship is on MRSA infection and transmission.”

Until new data emerge, Dr. Calfee encourages providers to use the updated compendium recommendations to structure their approach to assessing and addressing MRSA infection and transmission within their institution. He stresses the importance of making an individual institutional risk assessment because issues are often different from hospital to hospital and because the resources that hospitals have to battle MRSA are not unlimited.


Calfee DP, Salgado CD, Milstone AM, et al. Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35:772-796. Available at:

Calfee DP, Salgado CD, Classen D, et al. Strategies to prevent transmission of methicillin-resistant Staphylococcus aureus in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(suppl):S62-S80.

Sievert DM, Ricks P, Edwards JR, et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009–2010. Infect Control Hosp Epidemiol. 2013;34:1-14.

Hidron AI, Edwards JR, Patel J, et al. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007. Infect Control Hosp Epidemiol. 2008;29:996-1011.

Dantes R, Mu Y, Belflower R, et al. National burden of invasive methicillin-resistant Staphylococcus aureus infections, United States, 2011. JAMA Intern Med. 2013;173:1970-1978.