Rapid Responses to:

PAPERS: N S Crowcroft and M Catchpole Mortality from methicillin resistant Staphylococcus aureus in England and Wales: analysis of death certificates BMJ 2002; 325: 1390-1391 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Death certificates are an unreliable source of data

Anne K Liggett, Ben Swift   (14 December 2002)

Death by disease or treatment

Janice E Lessard   (15 December 2002)

MSRA: of little or no clinical consequence?

Richard G Fiddian-Green   (15 December 2002)

MRSA more virulent than MSSA ?

G.N. Malavige   (17 December 2002)

Deaths from MRSA

Robert C Spencer, 0   (17 December 2002)

Rising mortality from methicillin resistant Staphylococcus aureus – is this the tip of the iceberg ?

Kanna K Gnanalingham   (29 December 2002)

Welsh Surveillance Data demonstrates an MRSA plateau

Anthony J Howard, Mari Morgan and David N Looker   (16 January 2003)

Mortality rate for MRSA and Staphylococcus aureus infection may be the same.

Christopher D Settle   (29 January 2003)

MRSA: Increased Ascertainment has made a significant contribution

Rosemary A. McCann, Jennifer M. Hill   (29 January 2003)

Death certificates are an unreliable source of data 14 December 2002
Anne K Liggett, SHO Histopathology Level 3 Sandringham Building, Leicester Royal Infirmary, Leicester. LE1 5WW, Ben Swift Send response to journal: Re: Death certificates are an unreliable source of data	The apparent increasing prevalence of MRSA infection and its consequences are very much in the public eye; accuracy in the analysis of such issues is therefore of paramount importance, given not only the inevitable clinical complexities of treating such patients but also the frequent media attention associated with such infections. In assessing the impact of MRSA on mortality, Crowcroft and Catchpole (1) use death certificates as their primary information source. Death certificates have repeatedly been shown to contain incomplete and inaccurate information (2-4). In one study (2), only 55% of certificates were completed to an acceptable minimum standard. Other published data has shown that there is a substantial discrepancy between the diagnosis given on the death certificate and findings at autopsy (3). The true prevalence of MRSA related mortality might therefore vary widely from that reported on death certificates. Conclusions drawn from the analysis of death certificate data cannot be considered accurate without further correlation of the data with the clinical notes and other supportive information, such as microbiological diagnosis. For deaths attributed to infective causes, many certificates are issued without reference to the causative organism (4); one paper showed that only 10.9% of certificates issued with septicaemia as the cause of death provided information as to the causative organism (2). Crowcroft and Catchpole use the ICD-9 codings for Staphylococcus aureus as an initial search tool; this method may have excluded many deaths certified as being due to septicaemia not qualified by an organism, thereby underestimating the true prevalence of Staphylococcus related death. Admittedly, no ICD-10 code exists specifically for MRSA, an issue that requires resolving. Within our region (Trent) the codes A49.0 and B95.6 are used for both Methicillin Resistant and usual type Staphylococcal septicaemia. Also the code for “carrier of unspecified infection” (Z22.3) is used frequently to code such individuals. The Australian Modified ICD-10 has gone someway in resolving this issue by creating a new diagnosis code for their Third Edition, being “Multidrug Resistant Staphylococcus aureus”, with its code Z06.1. We would also concur with the authors for the need for a specific code within the United Kingdom, not only for mortality data but also morbidity statistics. Conversely, an overestimate of the contribution of MRSA infection to the patient’s death may have resulted since the authors included in their figures cases in which MRSA was mentioned on any line of the death certificate. Swift and West (2) showed that the second part of the certificate (any condition contributing to, but not directly causing, the death) tended to be used as a “catch-all” category, with certifying doctors including any coexistent condition whether it related to the death or not, leading to a potential over reporting of MRSA as contributory to death. Asymptomatic carriers of the organism may have been included. Apart from the issues relating to death certification, the results may be at least partly explained by the increased awareness of MRSA over the last decade. The authors assert that “increased reporting is unlikely to explain the increase” (1) but provide no reasoning for this statement; it could be argued that through increasingly publicised infection control policies within hospitals and greater public awareness of MRSA, fewer cases of MRSA infection go undiagnosed than may have been the case ten years ago. Antibiotic resistant infection and its associated mortality is an important issue; it is also one that grabs headlines. Methods used in the assessment of the topic need to be rigorous and based in data more reliable than that provided by death certificates. This does, of course, again raise the question of why death certification practice is so flawed. 1. Crowcroft N S, Catchpole M. Mortality from Methicillin Resistant Staphylococcus Aureus in England and Wales: analysis of death certificates. BMJ 2002; 325: 1390-91. 2. Swift B, West K. Death certification: an audit of practice entering the 21st century. J Clin Pathol 2002; 55: 275-79 3. Singleton J D, Cottrell B J. Analysis of the sensitivity of death certificates in 440 hospital deaths: a comparison with necropsy findings. J Clin Pathol 2002; 55: 499-502 4. James D S, Bull A D. Information on death certificates: cause for concern? J Clin Pathol 1996; 49: 213-16 Competing interests:   None declared
Death by disease or treatment 15 December 2002
Janice E Lessard, Lecturer Department of Geriatric Medicine University of Toronto Send response to journal: Re: Death by disease or treatment	The past practice of isolating patients with severe neutropenia arising from cancer chemotherapy was abandoned when studies revealed that isolation did not prevent the spread of hospital infections to these immunologically suppressed patients. In fact, isolation protocols increased the mortality rate even in this predominantly younger population. It was hypothesized that the significant bother of donning gloves and gowns deterred hospital staff from entering the patient's isolation room, thereby depriving the patient of effective communication with staff as well as limiting professional observation and physical examination. This begs the question as to what extent death was caused by MRSA per se as opposed to the intervention of the isolation treatment. Isolation protocols not only include encumbrances upon professional staff from physically accessing the patient, but more importantly severely inhibits the patient from leaving their hospital bedroom, limiting both their physical activity and appetite. Out of sheer boredom the patient spends most of the 24 hour day horizontal in the bed. The ravages of excessive bedrest have been noted since the days of Dr. John Asher, BMJ 1946. Not the least of these consequents are hypostatic pneumonia, hypocalcemia, osteopenia, fecal impaction, bed sores, and depression. Few studies have been done regarding the effectiveness of hospital isolation techniques in preventing the spread of antibiotic resistant organisms and none are convincing. In contradistinction, those elderly who survive hospitalization with MRSA are frequently discharged to a nursing home in a weakened, deteriorated state where they do improve. Fortunately, most nursing homes do not isolate these people and yet spread by these carriers to other nursing home Residents, who by definition are chronically ill or disabled, seems to be low. As pointed out by Drs. Crowcroft and Catchpole, 86% of those who die were elderly. Isolation increases their 'invisibility'. This is a double whammy for the elderly who tolerate physical inactivity the least well and at the same time, are the most likely to have their signs and symptoms not recognized by physicians. Perhaps in hospitals the well being of older people takes a back seat to the threat of illness and death to younger people, hindering the investigation of the benefits and adverse effects from the intervention of isolation? Competing interests:   None declared
MSRA: of little or no clinical consequence? 15 December 2002
Richard G Fiddian-Green, None None Send response to journal: Re: MSRA: of little or no clinical consequence?	It is reported that “The number of infections caused by methicillin resistant Staphylococcus aureus (MRSA) is increasing every year in England and Wales” and that “infections due to MRSA seem to be an increasing cause of mortality in England and Wales”(1). This conclusion does not fit with the facts. In most studies performed selective decontamination of the gut prevents nosocomial infections but does not improve outcome, but a meta- analysis did suggest that outcome have been improved some 10% (2). Thus most nosocomial infections appear to originate from the gut and have an equivocal effect upon outcome. These infections appear to be the product of translocating gut organisms and/or from a lowering of resistance to other invading organisms induced by the translocation of endotoxin and is associated release of cytokines (3,4). It would appear, however that it is the development of gut mucosal ischaemia and disruption of the “gut mucosal barrier” rather than the development of nosocomial infections per se that is the primary determinant of adverse outcomes (5). Indeed gut mucosal ischameia would appear to precede the development of nosocomial infections (6). Furthermore preventing gut mucosal ischaemia with perioperative plasma volume expansion during cardiovascular surgery prevents the development of complications including nosocomial infections (7). Whilst intravenous lines may become infected with MSRA these infections invariably resolve spontaneously after the lines have been removed and are rarely of any significant clinical consequence. Do MSRA infections have an adverse effect upon outcome when they develop in patients who have not had an antecedent episode of gut mucosal ischaemia? This possibility has not been examined. Does methicillin reduce mortality in patients whose Staphylococcus aureus infections are not resistant to methicillin? In my review of the literature on PubMed I was not able to find any evidence to suggest that it might. It would seem, therefore, that MSRA infections might be of little or no clinical consequence. 1. Crowcroft and Catchpole. Mortality from methicillin resistant Staphylococcus aureus in England and Wales: analysis of death certificates. BMJ (14 December 2002) 2. Ramsay G, van Saene RH. Selective gut decontamination in intensive care and surgical practice: where are we? World J Surg. 1998 Feb;22(2):164 -70. Review 3. Fiddian-Green RG, Gantz NM. Transient episodes of sigmoid ischemia and their relation to infection from intestinal organisms after abdominal aortic operations. Crit Care Med. 1987 Sep;15(9):835-9. 4. Soong CV, Blair PH, Halliday MI, McCaigue MD, Campbell GR, Hood JM, Rowlands BJ, Barros D'Sa AA. Endotoxaemia, the generation of the cytokines and their relationship to intramucosal acidosis of the sigmoid colon in elective abdominal aortic aneurysm repair. Eur J Vasc Surg. 1993 Sep;7(5):534-9. 5. Soong CV, Halliday MI, Hood JM, Rowlands BJ, Barros D'Sa AA. The use of tonometry to predict mortality in patients undergoing abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 1998 Jan;15(1):24-8. 6. Fiddian-Green RG, Baker S. Nosocomial pneumonia in the critically ill: product of aspiration or translocation? Crit Care Med. 1991 Jun;19(6):763- 9. 7. Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg. 1995 Apr;130(4):423-9. Competing interests:   None declared
MRSA more virulent than MSSA ? 17 December 2002
G.N. Malavige, Lecturer in Microbiology University of Sri Jayawardanapure, Nugegoda, Sri Lanka. Send response to journal: Re: MRSA more virulent than MSSA ?	Methicillin resistant staphylococci (MRSA) is a important pathogen in hospital aquired infections. Nosocomial infection due to MRSA is related to the length if stay in the hospital or ICU. MRSA infection appears to occur in patients with reduced susceptibility to infection such as patiets with chronic medical illnesses and elderly patients. Those, who have impaired neutrophil function (patients with diabetes, chronic liver disease or prolong corticosteroid therapy) are particulary susceptible to infection with MRSA. Risk factors for community acquired MRSA are diabetes, serious underlying illness, recent antibiotic therapy and previous hospitalisation. Therefore, it is evident that those who suffer from MRSA infections are already debilitated and immunosuppressed and are more likey to have a higher morbidity and mortality than immunocompetent patients. Studies have shown that hospital aquired MRSA is not more virulent than Methicillin sensitive S. aureus (MSSA). There was no difference found in animal lethality, production of enzymes and the production of toxins for invasiveness, among MRSA and MSSA. However, some studies show that community aquired MRSA may be more virulent. Therefore, studies should be done to determine whether MRSA is virulent or not by comparing MRSA infections in immunocompetent and immunosuppresed individuals. References: 1 Haddadin AS, Fappiano S A, Lipsett P A. Methicillin resistant staphylococci (MRSA) in the intensive care unit. Postgrad Med J 2002; 78: 385-392 2 Staphylococcus Aureus MRSA. Infectious disease epidemiology section office of public Health, Lousiana Dept of Health and hospitals. www.oph.dhh.state.la.us Competing interests:   None declared
Deaths from MRSA 17 December 2002
Robert C Spencer, Chairman Hospital Infection Society Bristol Royal Infirmary, Marlborough Street Bristol BS2 8HW, 0 Send response to journal: Re: Deaths from MRSA	There seems to be little doubt that MRSA deaths increased from 93-98. Increased reporting (due to increased awareness) may account for some but not all the increase. However where staphylococcal infection is the final underlying cause of death, it is worth noting that the percentages have not changed: 34.3% in 1993 and 34.3% in 1998 whilst the burden of MRSA within these figures has increased (as seen in bacteraemia data). In hospitals today: 1.There are more invasive procedures (Intensive care etc) 2.More antibiotic use 3.Increased bed occupancy/overcrowding 4.Low staffing levels (there is a substantial amount in the scientific literature that now links this to nosocomial infections). Surveillance is important but is not in itself the answer. Improved quality of buildings (more side rooms), better staffing ratios, more rational prescribing and more beds in hospitals so occupancy rates can get to the governments goal of 92.7% are all essential if we want things to improve. The Society believes handwashing is still important and infection control, including MRSA control, is the personal responsibility of every member of staff in the NHS. Control of MRSA has been a major priority for the Hospital Infection Society since its inception as evidenced by the fact that it has been the subject of FOUR sets of guidelines by the HIS in conjunction with other professional groups since 1985, and that recently a working party has been re-convened to assess both MRSA and VRSA. We are absolutely delighted that other national agencies have at long last realised the importance of MRSA and its impact on healthcare and moreover we hope they will support this Society in its efforts to have this recognised by the appropriate allocation of resources at local and national level. Competing interests:   None declared
Rising mortality from methicillin resistant Staphylococcus aureus – is this the tip of the iceberg ? 29 December 2002
Kanna K Gnanalingham, SpR Neurosurgery West London Centre for Neurosciences, Charring Cross Hospital, Fulham Palace Road, London, UK Send response to journal: Re: Rising mortality from methicillin resistant Staphylococcus aureus – is this the tip of the iceberg ?	Editor – The study by Crowcroft and Catchpole further highlights the importance of methicillin resistant Staphylococcus aureus (MRSA) as a significant cause of morbidity and mortality in England and Wales.1 Despite the limitations of using data from death certificates, these authors demonstrated an increase in the percentage of death certificates mentioning MRSA from 7.5% in 1993 to 25% in 1998. 1 However, this increase may represent only the tip of an iceberg. Asymptomatic colonisation with MRSA is recognised to be more common than infections with MRSA in hospital as well as community based studies. 2-4 Moreover, colonisation with MRSA may not be an entirely benign process, and it may be a risk factor for hospital acquired infection. 5,6 Once colonised with MRSA, up to 25% of patients subsequently develop staphylococcal infections. 2-4 In neurosurgery for example the annual prevalence of MRSA isolates has increased from 16 cases in 1993 (1.9% of admissions to the unit) to 60 cases in 1999 (6.7% of admissions). 4 Overall, 28% of patients with MRSA (ie 56 out of 203 patients) were infected with MRSA and of these only 3 patients (1.5%) died due to overwhelming sepsis with MRSA. 4 Thus, colonisation appears to precede infection with MRSA and a only small proportion of these patients die as a result of MRSA related infections. Therefore the increase in the deaths related to MRSA reported by Crowcroft and Catchpole may represent the tip of the iceberg as regards the total MRSA reservoir and this is important to note in terms of surveillance of MRSA. 1 Furthermore, it is generally recognised that a policy of screening and treatment of MRSA carriers and infected patients is important for the effective control of MRSA, although this view is not universal. 5,6 Screening and control measures for MRSA colonisation reduce the number of MRSA infections and MRSA bacteraemia and are cost effective. 5-7. A small rise is deaths related to MRSA may also represent a much larger rise in MRSA colonisation and infections. This is likely to have considerable clinical and economic implications. 5 References: 1. Crowcroft NS, Catchpole M. Mortality from methicillin resistant Staphylococcus aureus in England and Wales: analysis of death certificates. BMJ 2002;325:1390-1391. 2. Pujol M, Pena C, Pallares R, Ariza J, Ayats J, Dominguez MA, Gudiol F. Nosocomial staphylococcus aureus bacteraemia among nasal carriers of methicillin-resistant and methicillin susceptible strains. Am J Med 1996;100:509-516. 3. Muder RR, Brennen C, Wagener MM, Vickers RM, Rihs JD, Hancock GA, Yee YC, Miller JM, Yu VL: Methicillin-resistant staphylococcal colonization and infection in a long-term care facility. Annals of Internal Medicine. 1991;114:107-12. 4. Gnanalingham KK, Elsaghier A, Kibbler C, Shieff C. The impact of Methicillin resistant Staphylococcus Aureus (MRSA) in a Neurosurgical unit: A growing problem Journal of Neurosurgery 2003;98:8-13. 5. Cookson B. Is it time to stop searching for MRSA?: Screening is still important BMJ 1997;314:664-665. 6. Van Belkum A, Verbrugh H. 40 years of methicillin resistant staphylococcus aureus: MRSA is here to stay – but it can be controlled. BMJ 2001;323:644-645. 7. Habarth S, Martin Y, Rohner P, Henry N, Auckenthaler R, Pittet D. Effect of delayed infection control measures on a hospital outbreak of methicillin-resistant staphylococcus aureus. J Hosp Infection 2000;46:43- 49. Competing interests:   None declared
Welsh Surveillance Data demonstrates an MRSA plateau 16 January 2003
Anthony J Howard, Director, PHLS in Wales Dept of Medical Microbiology and Public Health Laboratory, University of Wales, CF14 4XW, Mari Morgan and David N Looker Send response to journal: Re: Welsh Surveillance Data demonstrates an MRSA plateau	Crowcroft and Catchpole (1) conclude from a study of death certificates that infections due to MRSA are an increasing cause of mortality in England and Wales. That this was likely to have been the case in Wales over the period of their study, 1993-1998, is supported by surveillance data which demonstrates a large rise in bacteraemias caused by Staphylococcus aureus between 1991 and 1997 (see figure). This can largely be attributed to increasing occurrence of MRSA as a cause of these infections from 1993 although a smaller rise in methicillin sensitive S aureus bacteraemias was also recorded. The degree to which this increase in staphylococcal bacteraemias has affected outcomes in relation to the underlying clinical conditions is, however, unknown, and for the reasons pointed out by Liggett cannot be accurately inferred from data derived from death certificates. What the Welsh surveillance data does not support is the statement that the number of infections caused by MRSA is continuing to increase every year in England and Wales and the supposition that mortality is also continuing to rise. The number of bacteraemias in Wales has changed little since 1997 and laboratory reports relating to overall numbers of isolates from infected and colonised patients reached a plateau in 2000 after a relatively small rise between 1998 and 2000 (5650 to 6031 reports). Presumably the steady state that has been achieved reflects the interaction of the innate transmissibility and virulence of the S aureus clones circulating; our ability to prevent transmission and infection; and the selective pressure exerted by antibiotic usage. If we are to shift this steady state, and reduce the overall burden of disease caused by S aureus we will need to introduce on a wide scale new initiatives that deal more effectively with the latter two issues. 1. Crowcroft and Catchpole. Mortality from methicillin resistant Staphylococcus aureus in England and Wales: analysis of death certificates. BMJ (14 December 2002)   Competing interests:   None declared
Mortality rate for MRSA and Staphylococcus aureus infection may be the same. 29 January 2003
Christopher D Settle, consultant microbiologist Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP. Send response to journal: Re: Mortality rate for MRSA and Staphylococcus aureus infection may be the same.	Dear sir, The authors note that the number of deaths where staphylococcal infection was the final underlying cause increased over the period 1993- 1998. They also found that the number of death certificates mentioning methicillin resistant Staphylococcus aureus (MRSA) had risen over this period. In addition, amongst certificates indicating a staphylococcal final cause of death, the percentage mentioning MRSA rose sharply from 8% in 1993 to 44% in 1998. It is unsurprising that the number of certificates mentioning MRSA and the percentage of deaths from staphylococcal infection where MRSA is also mentioned on the certificate have risen. This can be accounted for by the general rise in colonisation rate of the population with MRSA. If one were to assume that in all cases where the final cause of death was staphylococcal and MRSA was mentioned in the certificate, that death was due to MRSA, then between 1993 and 1998 the percentage of staphylococcal deaths due to MRSA would appear to have risen from 8% to 44%. When MRSA is mentioned in a certificate, it is not possible to be sure whether this was the final cause of death, even in those cases where staphylococcal infection was listed as the final cause, because there is no ICD-9 or ICD- 10 code for MRSA infection. The authors acknowledge this and highlight it as a limitation of the study. The assertions regarding deaths due to MRSA must therefore be treated with caution. Whilst the number of certificates mentioning staphylococcal infection rose by 250% between 1993 and 1998, the number of cases where staphylococcal infection was the final cause of death rose by exactly the same amount. If, between 1993 and 1998, overall MRSA infection rates rose from 7.5% to 25% (8% to 44% amongst those where the final underlying cause of death was staphylococcal) and such infections had a greater mortality rate, then the percentage of certificates with staphylococcal infection as the final cause of death could be expected to increase rather than stay the same. Consequently, one might infer that MRSA, whilst more prevalent than before due to increased colonisation rates, is no more virulent than Staph. aureus. If this is the case then emphasising the fact that numbers of MRSA infections are on the increase may give rise to public concern without justification. This is particularly likely given the spin with which some of the UK media prepare such stories. The authors do not analyse the fact that the proportion of certificates listing the final underlying cause of death as staphylococcal remained the same over the period studied. The number of staphylococcal deaths increased, but the percentage, or death rate, remained the same. The conclusion that ‘This study confirms the fact that the rise in MRSA infections seen over the past decade is leading to an increase in deaths’ is likely to be misinterpreted as an indication that MRSA infection has a higher mortality rate, which is a conclusion that cannot be drawn from this paper. Although a larger number of people are apparently dying from MRSA infections than used to previously, it is quite possible that these individuals would previously have died from Staph. aureus. In simple terms, a proportion of those patients who would have been colonised with Staph. aureus in the past are now colonised instead with MRSA. Despite this, the percentage of patients colonised with Staph. aureus or MRSA whose final underlying cause of death was staphylococcal appears unchanged over time. Perhaps the major concern should be why the number of certificates mentioning staphylococcal infection and the total number of people dying due to staphylococcal infection appear to be increasing rather than which specific type of Staph. aureus is to blame. At present, there is great media and public interest in nosocomial infections and particularly those caused by MRSA. In the current climate, there is also a fair degree of stigma associated with acquisition of the organism. In reporting the results of research on infections caused by MRSA, it is therefore important to be cognisant of the fact that the public is sensitive to reporting of such matters, whilst the press appear happy to exaggerate the severity of the problem. Competing interests:   None declared
MRSA: Increased Ascertainment has made a significant contribution 29 January 2003
Rosemary A. McCann, Consultant in Communicable Disease Control Greater Manchester Health Protection Unit, M30 0NJ, Jennifer M. Hill Send response to journal: Re: MRSA: Increased Ascertainment has made a significant contribution	Drs Crowcroft and Catchpole conclude that increased reporting is unlikely to explain the increased mortality from infections due to MRSA during the five-year period of their study (1). We consider that increased ascertainment, as opposed to reporting, probably makes a significant contribution to the observed increase. Between 1993 and 1998, there was increased national interest in hospital acquired infection and antibiotic resistance, the publication of guidelines for NHS Trusts and nursing and care homes on the control of MRSA (2,3) and the establishment of the Nosocomial Infection National Surveillance Service (4). During this time, many Trusts adopted aggressive screening policies for identification of MRSA carriers and used markers on the cover of patients’ records to identify carriers on re-admission. We believe that all of these initiatives served to increase doctor and nurse awareness of MRSA and thus make it more likely that MRSA would appear on a death certificate. We experienced difficulty in interpreting the data in this article. The second row of the printed table gives the number of deaths in which staphylococcal infection was given as the underlying cause of death (216 in 1993 and 546 in 1998). In the text, the authors state that in these certificates, the proportion mentioning MRSA increased from 8% (13/156) in 1993 to 44% (114/258) in 1998. We were unable to determine the source of the denominators in these latter statistics and expected an explanation of why they differ from the figures presented in Row 2 of the table. We appreciate that all relevant data cannot be presented in a short report but contend that this is crucial to the key findings. Finally, we agree with the recommendation for further improvement in surveillance of healthcare associated infection. We would suggest that two additional data fields are added to any future analysis: place of death and history of invasive procedure. We suspect that MRSA is more likely to be mentioned on certificates for deaths occurring in hospitals and residential homes than in those, which occur at home. In our experience, an increasing proportion of elderly patients in Nursing Homes are colonised with MRSA. The status of those who receive domiciliary care is less likely to be determined. REFERENCES: 1. Crowcroft NS, Catchpole M. Mortality from Methicillin Resistant Staphylococcal Aureus in England and Wales: Analysis of death certificates BMJ 2002; 325: 1390-1 2. Guidelines on the control of Methicillin Resistant Staphylococcus Aureus in the Community: Report of a combined Working Party of the British Society for Antimicobial Chemotherapy and the Hospital Infection Society, prepared by G. Duckworth & R. Heathcock. Journal of Hospital Infection (1995) 31; 1-12 3. Revised Guidelines for the control of Methicillin Resistant Staphylococcus Aureus infection in hospitals: Report of a combined Working Party of the British Society for Antimicobial Chemotherapy, the Hospital Infection Society and the Infection Control Nurse Association. Journal of Hospital Infection (1998) 39; 253-290 4. NINSS Partnership. Surveillance of hospital-acquired bacteraemia in English Hospitals 1997-2001. Public Health Laboratory Service Competing interests:   None declared