Figure 1.
A compartment model of the transmission dynamics of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and
hospital-acquired MRSA (HA-MRSA) in a 400-bed hospital. The arrows and parameter values correspond to entry and exit from the 5 compartments.
The number of hospital admissions per day is L, with the fractions of patients admitted with CA-MRSA colonization, CA-MRSA infection, HA-MRSAcolonization, and HA-MRSA infection expressed as l , l , l , and l , respectively. The transition rates between compartments or exit rates from
compartments are expressed as follows: g , g , and g are exit rates of susceptible patients, patients colonized with CA-MRSA, and patients colonized
with HA-MRSA, respectively (with the mean length of stay defined as 1/g , 1/g , and 1/g
H , respectively); the colonization rates of susceptible patients
to the CA-MRSA colonization compartment are (1-h)bCC/N and (1-h)bIC/N and to the HA-MRSA colonization compartment are (1-h)bCH/N and(1-h)b /
N where h is the compliance with hand washing hygiene (with h p 0 corresponding to 0% compliance and h p 1 corresponding to 100%
compliance), b , b , b , and b are the rates of colonization transmission to patients from health care workers contaminated by patients with CA-
MRSA colonization, CA-MRSA infection, HA-MRSA colonization, and HA-MRSA infection, respectively, and N is the total number of patients in thehospital. The rates of infection of patients with CA-MRSA colonization and patients with HA-MRSA colonization are f and f , respectively. The cure
rates of patients with CA-MRSA infection and HA-MRSA infection are t and t , respectively, and the death rates of these patients are d and dH,
respectively. The rates of decolonization of patients with CA-MRSA colonization and HA-MRSA colonization are a
and a , respectively.
We hypothesized that CA-MRSA will replace the traditional
HA-MRSA strain in the health care setting over time, and we
The deterministic differential equa-
sought to identify the epidemiological factors that would result
tions model describes the transmission dynamics of CA-MRSA
in the dominance of CA-MRSA strains and the competitive
within a 400-bed tertiary care hospital with ∼25,000 admissions
exclusion of HA-MRSA strains. A deterministic mathematical
per year. Individuals within the hospital are in 5 mutually ex-
model was developed to quantify the temporal patterns of CA-
clusive states: susceptible (S), colonized with either CA-MRSA
MRSA spread into the hospital setting. Using this model, we
(CC) or HA-MRSA (CH), or infected with either CA-MRSA
quantified the consequences of the expanding community res-
(IC) or HA-MRSA (IH). Individuals enter the hospital in one
ervoir and the increased documentation of more-severe infec-
of these states and exit via death or hospital discharge. Steady
tions caused by CA-MRSA in the dissemination of this new
states of MRSA colonization or infection are achieved over time.
strain into the hospital. The model was also extended to de-
Within the hospital, susceptible individuals can become colo-
termine the optimal strategy or combination of strategies that
nized with either CA-MRSA or HA-MRSA and can subse-
would prevent the in-hospital cross-transmission of CA-MRSA.
quently become infected with the respective MRSA strain.
CA-MRSA in Hospitals • CID 2009:48 (1 February) • 275
Table. 1.
Estimates and values for the transmission dynamics of community-acquired
methicillin-resistant Staphylococcus aureus (CA-MRSA) and hospital-acquired MRSA
(HA-MRSA).
Total no. of patients
No. of admissions per day
Patients colonized with CA-MRSA
Patients colonized with HA-MRSA
Patients infected with CA-MRSA
Patients infected with HA-MRSA
Length of stay, by patient group
Susceptible patients
Patients colonized with CA-MRSA
Patients colonized with HA-MRSA
Patients infected with CA-MRSA
Patients infected with HA-MRSA
Hand hygiene compliance efficacy, %
Transmission rate per susceptible patienta
Patients colonized with CA-MRSA
per patient colonized with CA-MRSA/N
Patients colonized with HA-MRSA per
patient colonized with HA-MRSA/N
Patients colonized with CA-MRSA per
patient infected with CA-MRSA/N
Patients colonized with HA-MRSA per
patient infected with HA-MRSA/N
Rate of infection per colonized patient per
day of length of stay, %
Death rate per infected patient per day of
length of stay, %
Infection cure rate per infected patient per
day of length of stay, %
Decolonization rate per colonized patient
per day of length of stay, %
BI, data obtained from the Beth Israel Deaconess Medical Center.
a Transmission of MRSA from a colonized or infected patient to a susceptible patient with an as-
sumption that hand hygiene compliance is 0%.
Transmission of MRSA between individuals occurs through
placed on contact precautions, thereby reducing their trans-
contact with health care workers. To simplify the model, co-
mission risk, compared with that for the unidentified reservoir
colonization with CA-MRSA and HA-MRSA and environmen-
of asymptomatically colonized patients. The model compart-
tal contamination were not included. Control strategies for
ments are illustrated schematically in figure 1. Steady states of
preventing the spread of MRSA include improving compliance
MRSA colonization or infection are achieved over time. Math-
with hand hygiene and placing individuals who are infected
ematical equations are provided in a separate publication [17].
with MRSA on contact precautions [16]. Patients who are in-
A deterministic model was used to better present the basic
fected with either HA-MRSA or CA-MRSA are assumed to be
reproduction number and to consider the long-term behavior
276 • CID 2009:48 (1 February) • D'Agata et al.
Figure 2.
Numerical simulation using baseline parameter values and showing the proportion of hospitalized patients colonized or infected with
community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and hospital-acquired MRSA (HA-MRSA) over time. The patient subpop-ulations converge to endemic steady states. CC, patients colonized with CA-MRSA; CH, patients colonized with HA-MRSA; IC, patients infected withCA-MRSA; IH, patients infected with HA-MRSA; t, time.
of the models in these large patient populations. Patients were
nization and subsequent transmission [22, 23]. The ratios of
therefore aggregated into compartments and were considered
the transmission parameters for patients colonized or infected
to be homogenous. Using stochastic, individual-based models
with CA-MRSA and HA-MRSA (bCC/b
would allow for patient heterogeneity; however, the increase in
therefore set at ∼4:3. A simulation was also performed to de-
behavioral detail provides data that are more difficult to in-
termine the transmission dynamics of CA-MRSA if there were
terpret and apply, compared with data provided by determin-
no differences in growth rate between CA-MRSA and HA-
istic models [18].
MRSA and, therefore, an equal risk of transmission.
Parameter estimates are obtained
from the Beth Israel Deaconess Medical Center's computerized
database system, which provides patient and infection-controldata. Values were also extrapolated from population-based sur-
Transmission dynamics of CA-MRSA in the hospital.
veillance or multicenter studies of the USA300 and other strains
Simulations of the baseline model demonstrate that CA-MRSA
(table 1). The length of stay (LOS) of patients colonized with
becomes endemic in the hospital over time. At baseline, the
CA-MRSA was assumed to equal the LOS of susceptible pa-
endemic prevalence of HA-MRSA is higher that the prevalence
tients, because patients colonized with CA-MRSA are predom-
of CA-MRSA, reflecting a greater admission rate and longer
inantly healthy individuals whose colonization status would not
LOS among patients who harbor HA-MRSA, compared with
affect their LOS. Patients who are colonized with HA-MRSA,
patients who harbor CA-MRSA (figure 2). Increasing the influx
however, are a group of patients with multiple comorbidities
into the hospital of patients who are colonized or infected with
and with longer LOS.
CA-MRSA, however, leads to a rapid reversal of dominance,
Unique differences in the biology of CA-MRSA, compared
with CA-MRSA strains surpassing the endemic prevalence of
with HA-MRSA, are incorporated into the transmission pa-
HA-MRSA (figure 3). The prevalence of CA-MRSA will further
rameter (b). In vitro studies have demonstrated that the growth
increase, given the feedback loop dynamics between the com-
rate of CA-MRSA is ∼1.33 times faster than the growth rate
munity and the hospital, whereby an increase in the influx of
of HA-MRSA [22]. The decreased doubling time can provide
patients harboring CA-MRSA and a subsequent decrease in the
CA-MRSA strains an advantage toward more-successful colo-
prevalence of HA-MRSA in the hospital will lead to an overall
CA-MRSA in Hospitals • CID 2009:48 (1 February) • 277
Figure 3.
Effect of an increased influx of patients colonized with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and
the feedback loop that creates a decrease in the influx of patients colonized with hospital-acquired MRSA (HA-MRSA). The percentage of admissionsthat are of patients colonized with HA-MRSA are held constant at 3%, 5%, and a baseline value of 7% as the percentage of admissions that areof patients colonized with CA-MRSA increases from 0% to 15%.
decrease in the number of patients with HA-MRSA exiting and
patients infected with CA-MRSA increases the prevalence of
subsequently reentering the hospital. Figure 3 illustrates this
CA-MRSA (figure 5). This increase is more marked if the LOS
among colonized individuals increases, and it reflects the larger
To determine whether the increase in the prevalence of CA-
reservoir of colonized individuals, compared with infected in-
MRSA was attributable only to the greater value for the trans-
dividuals. Increasing the influx of patients who are colonized
mission parameter of CA-MRSA, based on the decreased dou-
with CA-MRSA into the hospital, combined with an increased
bling time, a simulation was performed with the transmission
LOS of patients who are either colonized or infected with CA-
parameter of CA-MRSA equal to the transmission parameter
MRSA, leads to even greater numbers of patients colonized
of HA-MRSA. This simulation shows findings similar to those
with CA-MRSA over time (figure 5).
of the baseline model (figure 3); the prevalence of CA-MRSA
The competitive exclu-
continues to increase over time and surpasses the prevalence
sion of HA-MRSA by CA-MRSA is demonstrated using the
of HA-MRSA, but this requires that a greater number of pa-
basic reproductive number (R ). R quantifies the mean number
tients who harbor CA-MRSA enter the hospital (figure 4).
of secondary cases of MRSA colonization generated by 1 col-
Patients who harbor MRSA act as reservoirs for these path-
onized individual. If R !
1, the strain becomes extinct. Baseline
ogens and provide a constant source of transmission. Increasing
R values for colonized CA-MRSA and HA-MRSA are
the LOS of these individuals will, therefore, increase exposure
0.692 respectively. In this case, with no influx
to CA-MRSA among susceptible individuals. The baseline
of colonized or infected patients, both strains are eliminated.
model assumed that the mean LOS among patients infected
In general, the strain with the higher R value becomes endemic
with CA-MRSA was 10 days. This value reflects the predom-
and drives the other strain to extinction, provided that its R0
inance of skin and soft-tissue infections caused by the com-
value is 11. Numerical simulations demonstrate that compet-
munity strain. CA-MRSA is also implicated in more-severe in-
itive exclusion of HA-MRSA occurs when the LOS of patients
fections, which are reported with increasing frequency. These
who are either colonized or infected with CA-MRSA increases,
infections are associated with longer LOS and, therefore, result
R 0 exceeding the critical value of 1. The interpre-
in greater exposure to the reservoirs of CA-MRSA [9–11]. The
tation of the epidemic reproductive rates for HA-MRSA and
numerical simulations demonstrate that prolonging the LOS of
CA-MRSA assumes that there are no admissions of colonized
278 • CID 2009:48 (1 February) • D'Agata et al.
Figure 4.
Effect of an increased influx of patients colonized with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and
the feedback loop that creates a decrease in the influx of patients colonized with hospital-acquired MRSA (HA-MRSA) when the transmission risk ofCA-MRSA is equal to that of HA-MRSA (b p b p
or infected individuals with either strain. Ongoing admission
bials, or combinations of such strategies) to 0% (to reflect the
of either colonized or infected individuals guarantees that the
inevitable emergence of resistance to the antimicrobial agents)
epidemic is never eliminated. The level of endemicity is com-
[28]. We also simulated the effect of these interventions and
mensurate with admission rates and parameters in the model,
of combinations of these interventions as the rate of entry of
as described by the formulas for the steady states.
patients with CA-MRSA increased.
The effects of 3 standard control strategies
Simulations demonstrate that all 3 interventions are effective
were evaluated: (1) compliance with hand hygiene, (2) screen-
in decreasing the spread of CA-MRSA. The magnitude of their
ing for MRSA colonization, and (3) decolonization of colonized
effect, however, differs substantially, depending on the level of
individuals (figure 6). Screening results in the identification of
compliance or efficacy of each strategy. Decolonization of pa-
previously unrecognized, asymptomatically colonized individ-
tients known to be colonized with CA-MRSA is the most ef-
uals, who are subsequently placed on contact precautions.
fective strategy and would result in the lowest percentage of
Screening is therefore assumed to reduce the transmission risk
total patients colonized with CA-MRSA. The greater efficacy
of colonized individuals to the transmission risk of infected
of decolonization, compared with that of hand hygiene or
individuals, who are already on contact precautions (b
screening, reflects the first-order effect of decolonization, which
would directly eliminate the reservoir of MRSA. The other 2
The identification of the unrecognized
reservoirs with screening requires action, including not only
strategies, hand hygiene and screening, have a second-order
the timely placement of newly identified colonized individuals
effect, because they decrease MRSA transmission but do not
on contact precautions, but also compliance with these pre-
eliminate the source. The impact of reduced efficacy of decol-
cautions. Sensitivity analyses were performed to evaluate the
onization with the emergence of resistance to the decolonizing
"finding is not enough" concept of screening [26]. Decoloni-
antimicrobial was also simulated [28].
zation of colonized individuals was simulated by adding the
Compliance with hand hygiene had the greatest return of
movement of colonized individuals into the susceptible com-
benefits, with a decrease in compliance resulting in marked
partment. The efficacy of decolonization with topical agents
increases in the percentage of patients who were colonized with
was set at 66% [27]. The parameter varied from 100% (to reflect
CA-MRSA; conversely, improved compliance dramatically de-
potentially more-efficient decolonization strategies, such as
creased the percentage of colonized patients. In contrast with
whole-body antimicrobial washes, use of systemic antimicro-
the other 2 interventions, there was no diminishing return as
CA-MRSA in Hospitals • CID 2009:48 (1 February) • 279
Figure 5.
The effect of increased admissions of patients colonized with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA)
and the effect of an increased length of stay (LOS) among patients colonized with CA-MRSA (A) and patients infected with CA-MRSA (B) on thepercentage of patients colonized with CA-MRSA.
hand hygiene approached 100%, compared with improving the
efit if hand hygiene compliance was 190%. Conversely, if there
effectiveness of screening and decolonization toward 100%. The
was poor compliance with hand hygiene, effective screening
simulations also showed that, once compliance with hand hy-
strategies reduced the overall spread of CA-MRSA substantially
giene surpassed 80%, it became a more effective strategy than
(figure 7). Combining screening and decolonization strategies
while maintaining a baseline hand hygiene compliance of 60%
The efficacy of these interventions as the influx of CA-MRSA
had a small additional benefit, even when the efficacy of these
into the hospital increased was also evaluated. The simulations
interventions was maximized (figure 7).
showed that the relationship between the efficacies of the 3interventions remained comparable, regardless of the rate of
entry of patients colonized with CA-MRSA. The magnitude ofeffect however, increased with all 3 interventions as more in-
The rapid emergence and spread of CA-MRSA in the com-
dividuals with CA-MRSA entered the hospital.
munity has become a major public health threat. Our model
Combination of interventions.
Combinations of 2 inter-
strongly suggests that CA-MRSA will become the dominant
ventions and their impact on the spread of CA-MRSA were
MRSA strain in hospitals, with competitive exclusion or near
evaluated. These simulations further verified the importance of
exclusion of the traditional HA-MRSA strain. Several hospitals
including improved hand hygiene compliance with other in-
have already documented the predominance of CA-MRSA over
terventions and showed that, when compliance with hand hy-
HA-MRSA strains as a cause of hospital-acquired infections,
giene was maximized, the additional benefit of effective screen-
which provides preliminary validation of our model [11, 13,
ing or decolonization interventions was small. Screening
interventions, for example, had minimal or no additional ben-
Our model focused predominantly on the epidemiological
280 • CID 2009:48 (1 February) • D'Agata et al.
Figure 6.
Comparison of the percentage of patients colonized with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) at
steady state for 3 interventions (hand hygiene, screening, and decolonization). In the models shown, patients colonized with CA-MRSA account for3% of admissions per day (baseline; A), 6% per day (B), 10% per day (C), and 20% per day (D).
factors contributing to the reversal of dominance between HA-
catastrophic outbreak [31]. Another mathematical model that
MRSA and CA-MRSA strains in hospitals. Simulations dem-
described the population dynamics of antimicrobial-resistant
onstrate that the expanding community reservoir of CA-MRSA
bacteria among the community, hospitals, and long-term care
will lead to a greater influx of CA-MRSA strains in hospitals,
facilities also demonstrated the important role of both the com-
with a rapid increase in the endemic hospital prevalence of CA-
munity reservoir and the LOS in the spread of antimicrobial-
MRSA. The model strongly suggests that even small increases
resistant organisms [32].
in the number of patients entering the hospital with CA-MRSA
The replacement of the traditional HA-MRSA strain with
will contribute substantially to the in-hospital dissemination of
CA-MRSA strains, as shown in our model, is further supported
CA-MRSA. The second factor that strongly contributes to the
by unique bacterial characteristics of CA-MRSA that may pro-
replacement of HA-MRSA by CA-MRSA is the expanding in-
vide these strains with a competitive advantage over HA-MRSA.
hospital reservoir of CA-MRSA. Recent surveillance studies
CA-MRSA carries a smaller version of the staphylococcal cas-
have documented that CA-MRSA strains are increasingly im-
sette chromosomes mec (type IV SCCmec), which confers meth-
plicated in severe hospital-acquired infections, including blood
icillin resistance, compared with larger cassettes carried by HA-
stream and surgical site infections [11, 13, 15]. The morbidity
MRSA (type 1-III SCCmec) [23]. CA-MRSA also tend to carry
and mortality associated with these nosocomial infections imply
fewer antimicrobial resistance genes, compared with HA-MRSA
that the reservoir of patients who harbor CA-MRSA in the
[23]. The fitness cost of antibiotic resistance may, therefore, be
hospital will expand, because both the number of CA-MRSA–
minimized by the carriage of smaller or fewer genes, thereby
infected patients and their LOS will increase. A recent model
providing CA-MRSA with a competitive advantage over HA-
of CA-MRSA transmission in a correctional facility also dem-
MRSA strains. The more rapid growth rate among CA-MRSA
onstrated that prolonged incarceration time would lead to a
strains, compared with that among HA-MRSA strains, would
CA-MRSA in Hospitals • CID 2009:48 (1 February) • 281
Figure 7.
Comparison of the percentage of patients colonized with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) at
steady state for hand hygiene compliance, screening, and decolonization interventions. A, Hand hygiene compliance increases from 0% to 100% andthe efficacy of decolonization increases from 0% to 25%, 50%, 75% and 100%. B, Hand hygiene compliance increases from 0% to 100% and theefficacy of the screening intervention increases from 0% to 25%, 50%, 75%, and 100%. C, The efficacy of the decolonization strategy increases from0% to 100% and the efficacy of the screening strategy increases from 0% to 25%, 50%, 75%, and 100%.
further increase this advantage by potentially out-competing
have also incorporated the transmission dynamics between
HA-MRSA strains and increasing the likelihood of colonization
health care workers and patients, and the models have included
[22, 23]. Our model included the decreased doubling time of
parameters that reflect the staffing ratio, the probability of
CA-MRSA in the transmission parameter but avoided the in-
health care worker contamination, and the rate of contact be-
clusion of greater biological fitness, because studies that directly
tween health care workers and patients [35–37]. In this model,
compare the fitness between these 2 strains have not been per-
it was assumed that health care workers would contribute to
formed to date. Our model simulations also showed that, even
the spread of HA-MRSA and CA-MRSA equally; therefore, sep-
if an assumption is made that there is no difference in growth
arate compartments for health care workers were not included.
rate between CA-MRSA and HA-MRSA and, therefore, that
The baseline parameters for our model were obtained from
the transmission risks are equal, the prevalence of CA-MRSA
population-based surveillance and multicenter studies that de-
will still increase and surpass that of HA-MRSA over time.
fined CA-MRSA predominantly on the basis of the absence of
Our model was extended to evaluate the efficacy of 3 control
risk factors for health care exposure. Recent data suggest that
strategies aimed at limiting the spread of CA-MRSA strains.
a substantial proportion of patients with health care exposure
Decolonization was the most effective strategy. This interven-
harbor CA-MRSA at admission to the hospital [38]. Thus, our
tion eliminated the reservoir of CA-MRSA, whereas the other
baseline values may underestimate the extent of CA-MRSA
2 interventions only decreased the cross-transmission of CA-
burden in the hospital. Last, to simplify our model, cocolon-
MRSA between patients. Although the decolonization strategy
ization with CA-MRSA, HA-MRSA, or methicillin-susceptible
was the most effective, clarifications to this conclusion are war-
S. aureus and colonization with multiple MRSA strains were
ranted. First, CA-MRSA may preferentially colonize sites other
not addressed and may lead to different results.
than the nares, and therefore skin-to-skin or skin-to-fomite
Our model strongly suggests that CA-MRSA will quickly
transmission may play a greater role in the spread of CA-MRSA
replace the traditional HA-MRSA strain in hospitals. The ex-
than in the spread of HA-MRSA [29]. More-aggressive and
panding community reservoir of CA-MRSA, coupled with the
costlier decolonization strategies, in addition to nasal decolo-
greater growth rate and potentially greater biological fitness of
nization (which is used predominantly for HA-MRSA), may
this strain, support the conclusions of our model. The con-
therefore be indicated. Second, the emergence of resistance to
sequences of this reversal in dominance raise great concern,
the decolonizing agent, in addition to the high recolonization
because the reported serious infections caused by CA-MRSA
rates, need to be considered, because this strategy may provide
strains will now occur among hospitalized patients, who are a
only temporary benefit [28]. Improving compliance with hand
more debilitated and older patient population. Effective controlis possible, but it necessitates compliance, especially with hand
hygiene was a very effective strategy and had the greatest return
of benefits, with rapid decreases in the endemic prevalence ascompliance increased and, conversely, rapid increases as com-
pliance decreased. Improving compliance with this simple, in-expensive, and effective practice continues to be at the forefront
The joint Division of Mathematical Sciences/Na-
tional Institute of General Medicine Sciences Initiative through the National
of infection-control strategies. Interestingly, simulations that
Institutes of Health (R01GM083607 to E.M.C.D., G.F.W., and S.R.) and
combined hand hygiene compliance and screening showed that
the National Science Foundation (to M.A.H. and S.R.).
the efficacy of a screening strategy is dependent on the level of
Potential conflicts of interest.
R.C.M. has been a consultant for Pfizer,
Cubist, and Targanta. All other authors: no conflicts.
hand hygiene compliance. In fact, when compliance with handhygiene was maximized, screening had no additional benefit in
decreasing the endemic prevalence of CA-MRSA. When com-pliance was poor, however, screening was effective. These data
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Case: 1:14-cv-06913 Document #: 48 Filed: 04/15/16 Page 1 of 6 PageID #:237 IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS HEIDBREDER BUILDING GROUP, LLC, on behalf of plaintiff and the class members defined herein, Magistrate Judge Cole ASSOCIATION OF THE WALL AND and JOHN DOES 1-10, PETITION FOR ATTORNEY'S FEES
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