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        Systematic review of isolation policies in the hospital management of methicillinresistant Staphylococcus aureus: A review of the literature with epidemiological and economic modeling
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        Systematic review of isolation policies in the hospital management of methicillinresistant Staphylococcus aureus: A review of the literature with epidemiological and economic modeling
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        Systematic review of isolation policies in the hospital management of methicillinresistant Staphylococcus aureus: A review of the literature with epidemiological and economic modeling
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Abstract

Objectives: This study reviewed the evidence for the effectiveness of different isolation policies and screening practices in reducing the incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in hospital inpatients in an effort to develop transmission models to study the effectiveness and cost-effectiveness of isolation policies in controlling MRSA.

Objectives: This study reviewed the evidence for the effectiveness of different isolation policies and screening practices in reducing the incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in hospital inpatients in an effort to develop transmission models to study the effectiveness and cost-effectiveness of isolation policies in controlling MRSA.

Data sources: Sources included MEDLINE, EMBASE, CINAHL, The Cochrane Library, and SIGLE (1966–2000), as well as handsearching key journals. No language restrictions were used.

Review methods: Key data were extracted from articles reporting MRSA-related outcomes and describing an isolation policy in a hospital with epidemic or endemic MRSA. No quality restrictions were imposed on studies using isolation wards (IW) or nurse cohorting (NC). Other studies were included if they were prospective or used planned comparisons of retrospective data. Stochastic and deterministic models investigated long-term transmission dynamics, studying the effect of a fixed capacity IW, producing economic evaluations using local cost data.

Results: A total of forty-six studies were accepted: eighteen IWs, nine NC, nineteen other isolation policies. Most were interrupted time series, with few planned formal prospective studies. All but one reported multiple interventions. Consideration of potential confounders, measures to prevent bias, and appropriate statistical analysis were mostly lacking. No conclusions could be drawn in a third of the studies. Most others provided evidence consistent with reduction of MRSA acquisition. Six long interrupted time series provided the strongest evidence. Four of these studies provided evidence that intensive control measures that included patient isolation were effective in controlling MRSA. In two others, IW use failed to prevent endemic MRSA. There was no robust economic evaluation. Models showed that improving the detection rate or ensuring adequate isolation capacity reduced endemic levels, with substantial savings achievable.

Conclusions: Major methodological weaknesses and inadequate reporting in published research mean that many plausible alternative explanations for reductions in MRSA acquisition associated with interventions cannot be excluded. No well-designed studies allow the role of isolation measures alone to be assessed. Nonetheless, there is evidence that concerted efforts that include isolation can reduce MRSA even when endemic. Little evidence was found to suggest that current isolation measures recommended in the United Kingdom are ineffective, and these practices should continue to be applied until further research establishes otherwise. The studies with the strongest evidence, together with the results of the modeling, provide testable hypotheses for future research. Guidelines to facilitate design of future research are produced.