Management and care of MRSA Decolonization treatment, psychosocial health, and cross-sector collaboration

Methicillin-resistant Staphylococcus aureus (MRSA) causes morbidity and mortality worldwide. To prevent the spread of MRSA, most European countries have implemented a strategy that includes case finding, contact precautions during hospitalization, and the decolonization treatment of MRSA carriers. A downside of this strategy is stigmatization, poor mental health, and reduced quality of care among MRSA carriers. Information about MRSA, decolonization treatment, and MRSA follow-up swabs is mainly provided by practice staff in the Region of Southern Denmark. It might be a challenge to acquire and maintain MRSA competencies in general practice, due to low MRSA prevalence and guideline complexity. In the Region of Southern Denmark, the effect of decolonization treatment has not been studied and internationally it is not known whether there is a socio-economic inequality in the effect of decolonization treatment. Psychosocial consequences and illness perception between infected and carriers have been sparsely examined and further, we do not know if these consequences are long-lasting. In addition, there is very little research into how MRSA care programs are organized. This PhD thesis consists of one published paper and two manuscripts. The published paper (Paper I) and the two manuscripts (Paper II and Paper I) are based on three studies conducted from 2020 to 2022 in the Region of Southern Denmark using three different study populations.

The primary objective of Paper I was to examine whether socioeconomic factors were associated with successful decolonization treatments. The study was a cohort study featuring data from Danish national registers and a regional MRSA database. We included 2,536 individuals who initiated MRSA decolonization treatment between 2007 and 2018. Each person had a follow-up of 2 years. We found that adherence to follow-up swabs was 66% 1 month and 30% 6 months after decolonization treatment. The success rate of decolonization treatment was 36%. Early retirement, being more educated, and living in municipalities
with a high population density were associated with a higher success rate of MRSA clearance.

In Paper II, the objective was to investigate stigmatization, mental health, and illness perception among patients with either MRSA infection or MRSA carriage 1 month after the MRSA diagnosis and to investigate the association between stigmatization, mental health, and illness perception at 6 and 12 months compared to 1 month after MRSA diagnosis. We used a longitudinal cohort design based on data from the questionnaires. We included 135 individuals with MRSA and each individual had a follow-up of 1 year. Participants included were literate in Danish, over 17 years of age, and residents in the Region of Southern Denmark. In total, 11% of the participants perceived a clear stigma, 19% had been abandoned by healthcare services, and 24% had a poor mental health state. Carriers and infected individuals perceived the same level of poor mental health and stigmatization. However, being infected was associated with higher levels of symptoms and perceived consequences. We found no changes in stigmatization or mental health state within the first year of diagnosis. However, an increased timeline for continued MRSA positivity and a more threatening view of the control of treatment was found.

The objective of Paper III was to develop a framework for cross-sector videoconferencing and to pilot test this framework in MRSA consultations in clinical practice. In the cross-sector videoconference, an infection control nurse participated in the MRSA consultation. A participatory design-inspired study was conducted to ensure systematic user involvement. To develop the framework for the cross-sector videoconference, we conducted a workshop for stakeholders who were familiar with MRSA care programs. Subsequently, this framework was pilot tested in clinical practice. In the pilot test, we included eight patients diagnosed with MRSA who planned to initiate decolonization treatment and the participating patients practice staff. The result was a structured framework whose main focus was to solve real-time patient needs and plan the MRSA care program. The pilot test showed that MRSA care is complex and that it benefits from cross-sectional collaboration. The relationship during the cross-sector videoconference was characterized by mutual respect and shared knowledge, and the communication was characterized as problem-solving and accurate. Few among the practice staff perceived the shared consultation as time consuming and asked for a clearer description of roles and responsibilities. The main barrier identified by a few of the patients was the wish for face-to-face consultations with the infection control nurse, but contrary to practice staff, the patients found the cross-sector videoconference time efficient.

The overall conclusion is that adherence to follow-up swabs and the success rate of MRSA decolonization treatment were suboptimal. A higher success rate of MRSA decolonization was associated with being able to retire early, having a higher education, and living in more densely populated areas. Furthermore, MRSA-infected individuals perceived MRSA as more threatening than MRSA carriers; however, infected individuals and carriers perceived the same levels of poor mental health and stigmatization, which did not decrease over time. Finally, both practice staff and patients experienced a few disadvantages with the
cross-sector videoconferencing intervention; however, the majority found the model useful when a physical meeting was not possible. Future research should aim to discover ways to increase the efficiency of MRSA clearance and minimize psychosocial downsides and socioeconomic and geographical inequalities.