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EDITORIALS: Alex van Belkum and Henri Verbrugh 40 years of methicillin resistant Staphylococcus aureus BMJ 2001; 323: 644-645 [Full text]

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40 Years of MRSA: The England and Wales Experience

Georgia Duckworth   (13 October 2001)

40 Years of MRSA: The England and Wales Experience 13 October 2001
Georgia Duckworth, Head, Division of Healthcare-Associated Infection and Antimicrobial Resistance Public Health Laboratory Service / Communicable Disease Surveillance Centre Send response to journal: Re: 40 Years of MRSA: The England and Wales Experience	Editor - Van Belkum and Verbrugh’s editorial 1 on methicillin- resistant Staphylococcus aureus (MRSA) focussed on the Dutch experience. However, England had the dubious honour of first detecting methicillin resistance in Staphylococcus aureus 2 and despite the apparent disappearance of these strains in the UK in the 1970s, their descendants are causing significant problems now. The first epidemic strain, EMRSA-1, appeared to be indistinguishable to that reported from eastern Australian hospitals, and caused many hospital outbreaks in the Thames regions with spread beyond. This was superseded by EMRSA-15 and 16, the prevalent strains in England in the 1990s. Control in the early days was along “Search and Destroy” lines, but difficulties controlling MRSA in an unsupportive working, political and financial environment led to growing exhaustion in Infection Control Teams and the notion that spread was inevitable. There was considerable debate in the UK 3 as to whether we should ‘live’ with MRSA, using an universal precautions approach. A risk assessment approach, especially protecting high risk areas such as cardiothoracic and orthopaedic wards, was generally favoured 4. MRSA accounted for 3984 reported bacteraemias with methicillin susceptibility information in 2000, compared to 66 in 1991 in England and Wales: 42% of Staphylococcus aureus bacteraemias in 2000, compared to 2% in 1991. The rise has been across all regions and is superimposed on a steady incidence rate of methicillin-susceptible Staphylococcus aureus. These are much worse figures than those in the Netherlands, where infection control teams are able to maintain control largely based on the “Search and Destroy” approach. The limited published evidence indicates that community MRSA in England still largely reflects spread from hospitals, unlike the situation described elsewhere. The leader referred to controlling antibiotic use. This is undoubtedly good practice, but the evidence for impact on controlling MRSA is weak. The many confounding factors in the complex hospital environment make it difficult to evaluate the relationship between antibiotic use and the burden of MRSA 5. As outbreaks are predominantly of one strain, cross -infection probably accounts for the far greater attributable fraction of disease than antibiotic use. The emergence of a new, more resistant strain, EMRSA-17, in England and the description of glycopeptide resistance in Scotland further reduce therapeutic options and highlight the need to raise the profile and resources for infection control. The political climate in England is changing, with a growing focus on controlling healthcare-associated infections and antimicrobial resistance. This has culminated in the establishment of a compulsory surveillance system for Staphylococcus aureus bacteraemias by the Department of Health 6. The Minister of Health gave an undertaking that MRSA rates according to hospital activity will be published by named Acute NHS Trusts in 2001. This will clearly focus Chief Executives’ minds on infection control in their Trusts. No competing interests. Georgia Duckworth, Head, Division of Healthcare-associated Infection and Antimicrobial Resistance, Public Health Laboratory Service / Communicable Disease Surveillance Centre, 61 Colindale Avenue, London NW9 5EQ. gduckworth@phls.org.uk Barry Cookson, Director, Laboratory of Hospital Infection, Public Health Laboratory Service / Central Public Health Laboratory, 61 Colindale Avenue, London NW9 5EQ. Andrew Pearson, Head, Nosocomial Infection Surveillance Unit, Public Health Laboratory Service / Central Public Health Laboratory, 61 Colindale Avenue, London NW9 5EQ. Natasha Crowcroft, Consultant Epidemiologist, Immunisation Division, Public Health Laboratory Service / Communicable Disease Surveillance Centre, 61 Colindale Avenue, London NW9 5EQ. 1. Van Belkum A, Verbrugh H. 40 years of methicillin-resistant Staphylococcus aureus. Br Med J 2001; 323: 644-645. 2. Jevons MP. Celbenin-resistant staphylococci. Br Med J 1961; i:124- 5 3. Cookson B. Is it time to stop searching for MRSA? Br Med J 1997; 31: 664-666. 4. Working Party Report. Revised guidelines for the control of methicillin-resistant Staphylococcus aureus infection in hospitals. J Hosp Infect 1998; 39: 253-290. 5. Crowcroft NS, Ronveaux O, Monnet DL, Mertens R. Methicillin- resistant Staphylococcus aureus and antimicrobial use in Belgian Hospitals. Infect Control Hosp Epidemiol 1999;20: 31-36. 6. Department of Health. Surveillance of healthcare associated infections. CMO’s Update 2001; 30: 6.