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Authors' reply
- Natasha S Crowcroft, Theresa L. Lamagni, Cleo Rooney, Mike Catchpole, Georgia Duckworth (5 March 2003)
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Caring for a loved one with MRSA
- Winifred Beaumont (21 May 2003)
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Natasha S Crowcroft, consultant epidemiologist Immunisation Division CDSC, 61 Colindale Avenue London NW9 5EQ UK, Theresa L. Lamagni, Cleo Rooney, Mike Catchpole, Georgia Duckworth
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Mortality from Methicillin Resistant Staphylococcus aureus in England and Wales Mortality data from routine death certification can never be as accurate as research data collected for the specific purpose of measuring the contribution of a particular disease such as methicillin resistant Staphylococcus aureus (MRSA) infection to death (1). We had to use the text from the death certificates to identify MRSA because there are no specific ICD codes for it. This is one of the reasons that no one has previously carried out an analysis of MRSA deaths using the medical certificate of cause of death. However, the WHO Update Reference Committee for ICD-10 has agreed a set of optional additional codes for use from 1996 to identify resistance to antibiotics in infectious diseases (2). MRSA may be only one of a large number of medical conditions preceding the death. It is up to the certifying doctor to decide which conditions contributed to the death. The infection may not be mentioned at all on the certificate, or the certifier may omit reference to antibiotic resistance. Thus, death certificates may under-estimate deaths from many infections including MRSA. In 1998, just over 2800 cases of MRSA bacteraemia were reported to the Public Health Laboratory Service (PHLS), a far greater number than the 114 deaths from staphylococcal infection which indicated MRSA on the death certificate. Consequently, deaths from MRSA infection identified in this study (3) may well represent the tip of the iceberg of deaths and severe infections (4). The study does not purport to have obtained a robust estimate of total mortality due to MRSA, but rather to examine the trend of MRSA deaths as determined through death certification. McCann and Hill feel that the increasing trend is attributable at least in part to increased ascertainment (5). We do not believe this to be the case for two main reasons. Firstly, the increase was greatest amongst those deaths for which staphylococcal infection was the underlying cause of death, not just a contributing cause. The increase in deaths due to staphylococcal infection (underlying cause) seen in the period under study was in fact entirely accounted for by an increase in MRSA (Figure 1). Figure 1. Deaths with a staphylococcal infection final underlying
cause, with and without mention of MRSA (England & Wales)
Secondly, the rise parallels the increase in MRSA seen in reports of Staphylococcus aureus bacteraemia, with a correlation coefficient of 0.93 (Figure 2). Figure 2. Percentage of deaths due to staphylococcal infection with
mention of MRSA and percentage of staphylococcal bacteraemia reported to
PHLS as MRSA 1992-1998 (England & Wales)
Bacteraemia reports are one of the most robust sources of surveillance data in England. These show a dramatic rise in MRSA over the 1990s (Figure 3). Figure 3. Staphylococcus aureus bacteraemia reported to the PHLS,
with methicillin susceptibility (England & Wales)
This rise does not appear to indicate MRSA replacing MSSA, but additional to MSSA, as seen for death certificates. Furthermore, we do not believe that the rising contribution of MRSA in death certificates and to bacteraemias reflects earlier under-diagnosis of infection, as methods for culturing S. aureus have not changed significantly over the period and this is not a difficult micro-organism to identify. It is therefore difficult to dismiss these deaths as being of no clinical consequence (6). McCann and Hill had difficulty interpreting the data in the article and rightly suspected that this might be because the paper was condensed into a short report (5). The denominators for the table includes the cases which met the data definitions as given in the methods. For the figures in the text the cases were excluded which included the code 08.4, ‘gastro-intestinal infections with other specified bacteria’. We expected this code to yield substantial numbers of staphylococcal infections but on visual inspection many of the death certificates included text for another health care associated infection, Clostridium Difficile. Only deaths with a mention of staphylococci were included in the figures in the text. In shortening the paper to meet BMJ requirements, this fact was omitted from the methods. Janice Lessard raises an important issue of the impact of isolation on survival (7). In the UK National Health Service isolation may not account for as great an impact on the elderly as elsewhere because isolation facilities are relatively limited. In particular, facilities for care of the elderly are not usually high risk areas for the serious sequelae of MRSA infection and isolation in side rooms is therefore infrequent (8). A separate point is made about the value of isolation in controlling MRSA. A recent systematic review of the evidence for the effectiveness of different isolation policies and screening practices in reducing MRSA incidence in in-patients showed that robust studies were few, but there was limited evidence that isolation policies were consistent with lower levels of MRSA (9). Furthermore, transmission models developed as part of this review showed that having an isolation ward delayed the rate at which the prevalence increased and reduced the ultimate endemic level of MRSA. Settle raises a point about the virulence of MRSA compared to MSSA (10). It is not disputed that MRSA can be virulent. The outcome of MRSA infections is at least similar to that of MSSA infections when mortality is corrected for underlying disease, and may even be worse (7). However, it must be remembered that MRSA, like MSSA, are heterogeneous, although a small number of MRSA clones predominate in England and Wales. Although there is seemingly good news from Wales on the abatement of previously escalating MRSA (11), this does not appear to be the case in England (Figure 3). The overall picture for both England and Wales remains a sorry one, with some of the highest levels of methicillin resistance in Staphylococcus aureus bacteraemia in Europe (12). Infection control needs to be a higher priority at every level of the health service; we support wholeheartedly the call by the Hospital Infection Society for appropriate allocation of resources to infection control (13). Crowcroft NS a Lamagni, TL a Rooney C b Catchpole M a Duckworth G a a Communicable Disease Surveillance Centre, 61 Colindale Avenue
London NW9 5EQ
References 1. Liggett AK, Swift B. Death certificates are an unreliable source of data. bmj.com, 13 Dec 2002 2. World Health Organization. Update Reference Committee Paper WHO/GPE/CAS/C/02.59. www.aihw.gov.au/international/who_hoc/hoc_02_papers/ accessed 27th February 2003 3. Crowcroft N S, Catchpole M. Mortality from Methicillin Resistant Staphylococcus aureus in England and Wales: analysis of death certificates. BMJ 2002; 325: 1390-91. 4. Gnanalingham KK. Rising mortality from methicillin resistant Staphylococcus aureus – is this the tip of the iceberg? bmj.com, 28 Dec 2002 5. McCann RA, Hill JM. MRSA: Increased ascertainment has made a significant contribution. Bmj.com 29 January 2003 6. Fiddian-Green RG. MRSA: of little or no clinical consequence? bmj.com, 14 Dec 2002 7. Lessard JE. Is death by disease or treatment? BMJ 2003;326:501 8. Working Party Report. Revised guidelines for the control of methicillin -resistant Staphylococcus aureus infection in hospitals. Journal of Hospital Infection 1998; 39:253-290. 9. Duckworth, G. Personal communication 10. Settle CD. Mortality rate for MRSA and Staphylococcus aureus infection may be the same. bmj.com 29th January 2003 11. Howard AJ, Morgan M. Welsh surveillance data show plateau. BMJ 2003;326:501 12. EARSS (European Antimicrobial Resistance Surveillance System). Annual Report EARSS – 2001. Bilthoven, The Netherlands, 2002. Available at http://www.earss.rivm.nl/ . 13. Spencer RC. Deaths from MRSA. bmj.com, 17 Dec 2002 Competing interests: None declared |
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Winifred Beaumont, full time carer retired
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My husband was in a NHS hospital for 6 months 1999/2000--visiting each day I was afraid that the very bad standards of cleanliness and hygiene would result in his suffering an infection on top of heart disease and a stroke, quite enough for him to bear. More by luck than proper standards he did not become infected. Since then I have nursed him at home, during this time he has developed pressure sores and leg ulcers, the District Nurses attend twice a week. Now, in spite of being in his own home he has MRSA. That brings me to the point of my letter. Just before I was told he has MRSA I watched a TV programme, audience based, on the subject of infections contracted in hospital, the results of which appear to be sometimes more serious than the reason for admission in the first place. Quite a high proportion of the audience had very sad experiences to relate--and the mood was one of anger about lack of even quite primitive rules of hygiene. For instance the importance of hand washing, a neglected art now. In the audience were two consultants--one a gynaecologist and one dealing with plastic and reconstructive surgery. The latter seemed very pleased to announce that out of ten people in hospital only one would get MRSA or a similarly contracted infection, he thought this excellent. The gynaecologist quite confidently stated that he would not wash his hands between patients if examining outer skin, but only if carrying out a more intimate process. I was amazed at both and so were the people there who had lost relatives due to negligence. Much anger resulted but the consultants seemed amused. This complacence seems widespread in medical/nursing circles. In leaflets I have obtained it is stated that 30% of people may have MRSA, the fact that these leaflets quote figures for mostly hospital patients lead me to believe that the spread into the general public is being ignored. It is creeping up I believe to much higher figures. Patients, with open wounds, sent home with this infection, are being treated by District Nurses going from patient to patient, without really stringent regulations of hygiene being enforced. Now my husband has this to bear I have the extra worry of it all. I have dreaded him having to go into hospital but now the thing I was worried about has been brought into my home, possibly by cross infection? Although I wasn't told to notify the various people that attend to him chiropodists etc, I did ring to warn them. That too was greeted with "Oh don't worry 20% of people have it" Is it now on a level with the common cold? Or even higher? Are we moving toward a situation where almost everyone has picked it up, and that can be the norm? Or is anyone trying to prevent this? I could write a book about what I observed during those six months in an NHS hospital and what I have experienced since. The attitude of the two consultants on the programme fills me with dread. I'm sure if more widely known the population would share this fear. Competing interests: None declared |
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