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Rapid Responses: Rapid Responses published:
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Controlling methicillin resistant Staphylococcus aureus
- Alan W Fowler (24 November 2003)
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Ideal content for National electronic Library of Infection (NeLI)
- Jane Mani-Saada (24 November 2003)
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MRSA: it can be controlled
- Andrew N Bamji (24 November 2003)
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Controlling methicillin resistant Staphylococcus aureus in Cystic Fibrosis.
- Filippo Festini, Silvana Ballarin, Carmen Loganes and Teresa Codamo (30 November 2003)
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Prevention is better than cure
- Feroz Dinah (3 December 2003)
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Staphylococcus aureus infection not MRSA colonisation should be the focus of our efforts
- John Paul, Marc Cubbon, Sally Curtis, Janice Bates (4 December 2003)
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MRSA- answers are here.
- Eugene Sherry, Dr Max Reynolds, Dr PH Warnke, Dr S Sivananthan (9 December 2003)
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MRSA Education: Regional Perioperative Guidelines for Surgical Specialities
- Nadim Aslam (12 December 2003)
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Epidemiology of MRSA - frightening facts or dangerous fiction?
- Peter Wilson, Vanya Gant, John Holton, Stephen Morris-Jones, Geoffrey Ridgway, Geoff Scott, Nandini Shetty, Mike Wren, Alimuddin Zumla (17 February 2004)
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Methicillin Resistant Staphylococcus Aureus
- Peter M. Bretland (10 March 2005)
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Alan W Fowler, Retired Consultant Orthopaedic Surgeon Home
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Controlling methicillin resistant Staphylococcus aureus Editor – In 1887 Lister reported in the Lancet and British Medical Journal that “during the last nine months not a single instance of pyaemia, hospital gangrene or erysipelas has occurred”. Lister attributed this to his antiseptic regimen based on the liberal use of 1 in 20 carbolic acid during surgery and carbolized gauze dressings afterwards. These results were obtained in spite of the fact that, in order to show his confidence in antisepsis, he continued wearing dirty operating clothes and refused to wear gloves. How is it that 136 years later we are unable to match Lister’s achievements in spite of having much less toxic antiseptics? The answer must be that we are trusting too much in asepsis and antibiotics. Lister insisted that asepsis in an imperfect world was not to be trusted. This is still true today. Organisms will always be with us and no amount of asepsis will eliminate them. They float in the air, they lurk beneath the surgeon’s gloves, they drop down from a stray wisp of hair and they escape through the side of the mask. Local antibiotics should not be confused with antisepsis. Spraying antibiotics into the wound before closure does not kill all organisms and creates problems with resistance which renders the proper use of antibiotics ineffective. In 1965 my letter to the BMJ entitled Neo-Listerism (1) advocated a return to Listerian principles and suggested the following regimen: 1.Wounds are thoroughly washed out with I / 2000 solution of chlorhexidine before closure 2.All instruments which have been handled are immersed in the same solution 3.All suture materials and implants are steeped in the same solution before insertion 4.Hand bowls for rinsing contain 1 /10,000 chlorhexidine 5.Gauze dressings are wrung out in 1 / 2000 chlorhexidine. Thirty eight years on, antisepsis is still regarded as out-dated and Lister is mainly remembered as an eccentric who invented the carbolic spray, although he gave this up in his later years. Why do we not admit that asepsis is losing the war and we need to change our strategy? Alan W. Fowler (1) Fowler AW. BMJ 1965; i: 252 Competing interests: None declared |
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Jane Mani-Saada, Research Assistant NeLI City University, London, EC1V 0HB
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A link to this editorial has been added to the NeLI (http://www.neli.org.uk) a Specialist Library of the National electronic Library for Health providing healthcare professional with access to the best available resources in infectious and communicable disease. We would welcome and encourage experts in the field to alert us to similar resources. Competing interests: None declared |
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Andrew N Bamji, Consultant (rheumatology/rehabilitation Queen Mary's Hospital, Sidcup, kent DA14 6LT UK
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We have managed to kepp MRSA out of our rehabilitation unit by a combination of pre-screening, rigorous hygiene and vigorous treatment. Any patients referred from the acute hospital wards require two clear sets of swabs - and if we find (for they are all swabbed on arrival) that they are MRSA positive then they are isolated and treated until clear. Thus we would agree with Fowler's Rapid Response observations, but I would go further. It is, of course, not only MRSA that is a problem; clostridium difficile is also rampant.It is no use wringing hands and saying the situation is out of control. We have been put under pressure to relax our criteria because they delay transfers, and because (and this is implied) our standards are perhaps too high to be realised in the mainstream. Such a defeatist attitude is wearing, but we can understand it when nurses are so short in numbers on acute wards. But doctors are offenders, too, and the principles of Semmelweiss and Lister need to be reintroduced to undergraduate and postgraduate curricula. Indeed many of today's doctors in training do not even seem to have heard of Semmelweiss, and all too frequently do not cleanse their hands between patients. It is certainly bad that our current acute hospital infection rates are so high - particularly when compared to experience in World War 1 in facial injury patients here, when antisepsis (using hypochlorite rather than chlorhexidine) kept serious infection to a minimum. And, of course, there were no antibiotics. Competing interests: None declared |
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Filippo Festini, Cystic Fibrosis Nurse Specialist Italian Cystic Fibrosis Nurses Group, c/o C F Centre, Meyer Hospital, 50135 Florence, Italy, Silvana Ballarin, Carmen Loganes and Teresa Codamo
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Editor, Duckworth in her paper (1) underlines the importance of infection control policies for methicillin resistant Staphylococcus aureus (SA) in health care environments. SA is often the first pathogen which colonizes the respiratory tract of patients with Cystic Fibrosis (CF). Studies have suggested an increased susceptibility of CF patients to colonization by SA (2). Before the introduction of a widespread use of antibiotics, SA was the main cause of morbidity and mortality in infants with CF (3). Today is well known that SA may contribute to the abnormal chronic inflammatory response of CF patients' airways. However, the clinical impact of SA in CF patients can be managed quite well with antibiotic therapy but the onset of methicillin-resistance makes the treatment more difficult, less effective and more expensive. In the USA, 18.8% of SA found in airways cultures from CF patients were methicillin resistant (4) Several studies indicate that the presence of methicillin resistant SA (MRSA) in CF patients' airways may worsen clinical conditions: it increases the frequency of antibiotic therapy courses in CF children (5) and worsens pulmonary function (6). The transmission of MRSA between patients with CF has been documented both in Hospital environments (7) and out of health care settings (8) Recently, published Guidelines on infection control in CF recommend the adoption of proper isolation measures to CF patients with MRSA in their respiratory cultures (9) The Italian CF Nurse Specialist Group has carried out recently a study on infection control measures adopted in 21 Italian CF Centres, which follow 3363 CF patients (88.9% of Italian CF population). The survey evidenced that 4.9% of CF patients has MRSA. Fourteen CF Centres have adopted policies of segregation for patients with MRSA in their respiratory tract, that is, they maintain these patients separated from others patients with specific measures. in particular providing clinics in different days and in different rooms. The statistical analysis has shown that among the patients followed by Centres in which segregation is not applied to patients with MRSA, the prevalence of MRSA is higher (67/1080, 6.2%) than among those who are followed in Centres in which a segregation policy is carried out (98/2283 patients, 4.2%) (Odds Ratio 0.68, CI95% 0.49-0.95, Chi-square test p=0.016). The Italian experience suggests that measures of segregation are effective in containing the prevalence of MRSA among CF patients. References 1. Duckworth G.Controlling methicillin resistant Staphylococcus aureus. BMJ 2003;327:1177-1178. 2. Goerke C, Kraning K, Stern M, Doring G, Botzenhart K,Wolz C. Molecular epidemiology of community-acquired Staphylococcus aureus in families with and without cystic fibrosis patients. J Infect Dis 2000;181:984-9. 3. Anderson DH. Therapy and prognosis of fibrocystic disease of the pancreas. Pediatrics 1949;3:406-17. 4. Burns JL, Emerson J, Stapp JR, et al. Microbiology of sputum from patients at cystic fibrosis centers in the United States. Clin Infect Dis 1998;27:158-63. 5. Miall LS, McGinley NT, Brownlee KG, Conway SP. Methicillin resistant Staphylococcus aureus (MRSA) infection in cystic fibrosis. Arch Dis Child 2001;84:160-2. 6. Thomas SR, Gyi KM, Gaya H, Hodson ME. Methicillin-resistant Staphylococcus aureus: impact at a national cystic fibrosis centre. J Hosp Infect 1998;40:203-9. 7. Givney R, Vickery A, Holliday A, Pegler M, Benn R. Methicillinresistant Staphylococcus aureus in a cystic fibrosis unit. J Hosp Infect 1997;35:27- 36. 8. Schlichting C, Branger C, Fournier JM, et al. Typing of Staphylococcus aureus by pulsed-field gel electrophoresis, zymotyping, capsular typing, and phage typing: resolution of clonal relationships.J Clin Microbiol 1993;31:227-32. 9. Saiman L, Siegel J. Infection control recommendations for patients with cystic fibrosis: Microbiology, important pathogens, and infection control practices to prevent patient-to-patient transmission. American Journal of Infection Control 2003; 31: S1-S62 Competing interests: None declared |
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Feroz Dinah, Spr Trauma & Orthopaedics St Helier Hospital, Carshalton, Surrey SM5 1AA
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Dear Editor, Dr. Duckworth has rightly drawn concern to the escalating problem of MRSA infection in UK hospitals[1]. She mentions hand washing as the foundation of robust infection control, and I would like to summarise the results of an audit of handwashing and MRSA infection in a Plastic surgical unit (In press). This was a prospective blinded observational study of hand washing practices of healthcare workers (HCWs) over 100 patient contact episodes. The results were fed back to the healthcare workers, and the study was repeated 6 months later. Although there was no significant difference in compliance rates with hand washing between the two studies – 40-45% compliance before patient contact, and 80-85% after patient contact – there was a significant reduction in nosocomial MRSA infection rates between the 12-month periods before and after the first study, from 1.9% to 0.9% (p<0.04, 95%CI of difference: 0.1 to 1.95%). Analysis of pharmacological expenditure for the ward showed a four-fold increase in alcohol gel use, and 40% decrease in Teicoplanin use. In real terms, every £1 spent on alcohol gel resulted in a £9 saving on Teicoplanin expenditure. When the pilot was extended to general medical, surgical and orthopaedic wards, every extra pound spent on alcohol gel was equivalent to a £20 saving on Teicoplanin use. Alcohol gel has been shown to kill over 99.9% of transient organisms like MRSA[2, 3], and is a modern equivalent of the Chlorina liquida used by Semmelweiss before examining women in labour to reduce mortality from hospital-acquired infections[4]. MRSA is a costly problem, and we need to ensure we use the most cost-effective measures to prevent and control it. 1. Duckworth G. Controlling methicillin resistant Staphylococcus aureus. BMJ 2003; 327: 1177-8. 2. Reybrouck G. Handwashing and hand disinfection. J Hosp Infect 1986; 8(1): 5–23. 3. Ehrenkranz NJ, Alfonso BC. Failure of Bland Soap Handwash to Prevent Transfer of Patient Bacteria to Urethral Catheters. Infection Control Hosp Epidemiol 1991; 12(11): 654 – 662. 4. Rotter ML, 150 years of Hand Disinfection – Semmelweis’s Heritage. Hyg Med. 22 Jahrgang 1997 – Heft 6 pp 332 – 339. Competing interests: None declared |
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John Paul, Consultant Microbiologist Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, Marc Cubbon, Sally Curtis, Janice Bates
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The recent editorial on methicillin-resistant Staphylococcus aureus (MRSA) [BMJ 2003; 327: 1177-1178] exemplifies how we have made a single resistance gene (mecA) the focus of all our efforts at the expense of losing sight of the whole species (Staphylococcus aureus). One thing that is clear is that invasive Staphylococcus aureus disease of any kind is bad. Although some studies associate MRSA infection with poorer clinical outcome, other studies show methicillin-susceptible strains to be equally virulent. Staphylococcus aureus commonly colonises humans, behaving as a harmless commensal. In hospitals, invasive procedures such as surgery or vascular catheterisation may lead to bacteraemia [Hiramatsu K, Nasu M 2002 Nippon Rinsho. 2002 Nov;60(11):2107-11] but rates of infection can be minimised by adherence to good practice. For example, MALIK, A et al. [2002 42nd Interscience conference on antimicrobial agents and chemotherapy. Abstract K-663] reported low rates of line-related sepsis in a hospital where dedicated teams were responsible for line care. If we could redirect our efforts to effect universally good practice, would we need to be so worried about a single resistance determinant? By emphasising the importance of colonisation with a resistant organism infection control policies may cause us to neglect the factors that actually lead to infection. Disturbingly, the concluding lines of the editorial [BMJ 2003; 327: 1177-1178] suggest that policy makers may be willing to revisit strategies of “search and destroy” (i.e. mass screening of patients, isolation of those found to be colonised). The UK is now a high prevalance country for MRSA. Two decades ago SPICER, W.J. [Journal of hospital infection 1984 5 (supplement A) 45-49] described the failure of “search and destroy” methods in a high-prevalance situation in Australia. It seems wildly optimistic to suppose that we could emulate the low MRSA rates of a country like the Netherlands (incidence <0.5%) by a simple change in policy. Even with low incidence, maintaining a “search and destroy” policy cost a Dutch hospital 2,265 lost hospitalisation days, 48 ward closures and 78,000 additional microbiological cultures over ten years [Eur J Clin Microbiol Infect Dis. 2002 Nov;21(11):782-6]. One of the elements of a “search and destroy” strategy is screening. In the UK, reliance on MRSA screening varies between hospitals. We obtained information on annual numbers of MRSA screening swabs and total bacteriology workloads from eight NHS Trusts. MRSA swabs accounted for between 2 percent and 24 percent of bacteriology workload. For the same eight Trusts, MRSA bacteraemia rates varied from about 0.1 to 0.4 bacteraemias/1000 bed days but there was no significant correlation between high levels of screening and low rates of bacteraemia. This strongly suggests that we cannot rely on screening alone to control MRSA. Mass screening would need to be supported by a costly expansion in isolation facilities. We wish to appear pragmatic and thoughtful about infection control rather than cynical and encourage the MRSA Working Party to do likewise. We believe we should focus our attention on promoting universally good practice to minimise infection rates caused by all organisms. Competing interests: None declared |
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Eugene Sherry, Sen.Lect.,Univ. Sydney Sydney, NSW 2750, Dr Max Reynolds, Dr PH Warnke, Dr S Sivananthan
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Dear Dr Duckwoprth and Colleagues Do not despair about MRSA. The knowledge and technology exists to clear all hospitals of this infection. Much of it comes from industry but it seems doctors don't read widely (enough). See www.nicrosol.com.au Also see papers referenced below. Our group has clear answers to the problem of MRSA, TB, SARS and Candida. We are happy to work with you. Best wishes
References: Sherry E, Warnke PH, Boeck H. Percutaneous treatment of chronic MRSA osteomyelitis with a novel plant- derived antiseptic. BMC Surg. 2001;1(1):1. Epub 2001 May 16. Sherry E, Boeck H, Warnke PH Topical application of a new formulation of eucalyptus oil phytochemical clears methicillin-resistant Staphylococcus aureus infection. Am J Infect Control. 2001 Oct;29(5):346. No abstract available. Sherry E, Warnke PH. Alternative for MRSA and Tuberculosis (TB): Eucalyptus and Tea-Tree Oils as New Topical Antibacterials AAOS, Dallas.Feb 2002 Sherry E , Warnke PH, Boeck H. Sherry E, Sivananthan S, Warnke PH, Eslick G. Topical phytochemicals used to salvage the gangrenous lower limbs of type 1 diabetic patients. Diabetes Res Clin Pract. 2003 Oct;62(1):65-6. No abstract available. Competing interests: Co-author of papers cited |
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Nadim Aslam, Specialist Registrar Nuffield Orthopaedic Centre, Headington, Oxford. OX3 7NP
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Dear Editor Dr Duckworth has correctly pointed out the other important issues such as lack of isolation facilities, staffing levels and bed occupancy rates which affect our ability to control MRSA infection [1,2,3].MRSA colonization or infection is of particular importance in patients undergoing operations involving implant materials such as in orthopaedic surgery [4,5]. My specialist registrar training has shown considerable variation in MRSA perioperative policy implementation between regional hospitals, despite national guidelines [6]. This led me to carry out a regional audit of the perioperative management of orthopaedic patients in order to assess the level of clinician awareness and the uniformity of current guidelines between hospitals [in press]. A postal questionnaire was designed asking for information on various aspects of perioperative management of MRSA patients was sent to key personnel in each hospital. 78% of respondents knew there was a preadmission screening policy. 15% were unaware of any MRSA policy. There was considerable variation in theatre protocol and antibiotic regimes used. Only 48% of hospitals had an MRSA free zone for orthopaedic patients. This study emphasised the need for both a uniform set of guidelines within a training region as well as the need for greater awareness of the importance of MRSA control. Current differences in perioperative protocol may lead to confusion in the management of patients when clinicians, especially surgical trainees, move between hospitals in a region. In considering a set of guidelines, there are a number of specific problems that need to be addressed. Firstly, there is often a lack of awareness of pre-operative screening policies and hospital guidelines amongst surgical staff. Secondly, there can be the use of inappropriate peri-operative antibiotics in MRSA positive patients. MRSA infection of a prosthesis as a result of ineffectual antibiotics is both a disaster for the patient and an area of potential litigation. Lastly, there needs to be an emphasis on the role of theatres in allowing appropriate segregation of patients at induction, operation and recovery. Although key personnel such as microbiologists and infection control nurses play an essential role in MRSA control, it is felt that a set of guidelines should be primarily aimed at the operating surgical team, who have continuity of patient care and therefore overall responsibility for MRSA control. Once a uniform set of guidelines has been set in place, with an emphasis on informing orthopaedic surgical specialists, a re-audit of the process will be undertaken to see whether this results in both greater awareness and increased compliance. References: 1.Duckworth G. Controlling methicillin resistant Staphylococcus aureus. BMJ 2003; 327: 1177-8. 2.Shanson DC, Johnstone D, Midgley J. Control of a hospital outbreak of methicillin resistant Staphylococcus aureus infections: value of an isolation unit. J Hosp Infect 1985; 6: 285-292. 3.Selkon JB, Stokes ER, Ingram HR. The role of an isolation unit in the control of hospital infection with methicillin resistant Staphylococci. J Hosp Infect 1980; 1: 41-46. 4.Cafferkey MT, Hone R, Keane CT. Sources and outcome for methicillin resistant Staphylococcus aureus bacteraemia. J Hosp Infect 1988; 11:136-143. 5.Romero-Vivas J, Rubio M, Fernandez C, Picazzo JJ. Mortality associated with nosocomial bacteraemia due to methicillin-resistant Staphylococcus aureus. Clin Infect Dis 1995; 21: 1417-1423. 6.Duckworth G, Cookson B, Humphreys H, Heathcock R. Revised methicillin resistant Staphylococcus aureus infection control guidelines for hospitals. Report of a combined working party of the British Society for Antimicrobial Chemotherapy, the Hospital Infection Society and the Infection Control Nurses Society.1998. Competing interests: None declared |
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Peter Wilson, Consultant Microbiologist University College Hospitals London, London WC1E 6DB, Vanya Gant, John Holton, Stephen Morris-Jones, Geoffrey Ridgway, Geoff Scott, Nandini Shetty, Mike Wren, Alimuddin Zumla
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Editor - Duckworth’s editorial highlights the health threats posed by methicillin resistant Staphylococcus aureus (MRSA).1 Recent reports in the local and national press have claimed high rates of MRSA colonisation of inanimate surfaces in public areas of NHS and private health facilities.2- 4 These findings are interesting as until now Staphylococcus aureus has not been observed to persist in the environment, and MRSA transmission has been considered to be primarily through indirect close person to person contact. The finding is important as infection control strategies are directed at reducing transmission opportunities via hands; the discovery of new reservoirs of MRSA would have profound implications for patient safety and infection control practice. We conducted an experiment comparing our standard MRSA isolation technique (as recommended by the British Society of Antimicrobial Chemotherapy) with the media used by the microbiologist cited in the press reports (2 standard selective media kindly supplied by Dimanco, Henlow UK). Without prior notification, environmental swabs were taken from similar communal patient areas as described in the articles (e.g. lift buttons, door handles), and processed to determine the presence of MRSA. There had been no change in cleaning schedules. Full results have been reported elsewhere.5 We could not detect MRSA from 20 specimens tested by each method, although both techniques did isolate methicillin resistant coagulase negative staphylococci – universal skin commensals not associated with transmitted infections. Even with use of selective media MRSA cannot be distinguished on morphological features alone, and further confirmatory tests are required. Possibly these tests were not performed or inappropriately applied in the newspaper study. Health care associated infection is a public health concern. Whilst we applaud research that highlights infection control issues likely to lead to improvements, we are deeply concerned that prominence given to statements based on unpublished and unreviewed bacteriological studies, incomplete or inaccurate reporting will cause damage to public education, professional trust and resource allocation. We suggest that an independent study be undertaken by the Health Protection Agency to confirm or refute the published observations. 1. Duckworth G. Controlling methicillin resistant Staphylococcus aureus. BMJ 2003;327:1177-8. 2. Bradbury, A. Killer hospital bugs spread. Evening Standard 2003, Sep 26. 3. Bradbury, A. & Smith, R. Shock at levels of hospital superbug. Evening Standard 2003, Dec 23. 4. Superbug 'timebomb' puts UK at risk. The Western mail 2003, Sep 18 2003. 5. Manning, N., Wilson, P. & Ridgway, G. (2004). Isolation of MRSA from communal areas in a teaching hospital. Journal of Hospital Infection in press. Competing interests: None declared |
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Peter M. Bretland, consultant radiologist (retired) retired; home:3 Bramalea Close, North Hill, Highgate. London N6 4QD
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In spiteof the considerable publicity that this unpleasant organism has recently received two aspects appear to have been neglected.
1.It is well known that the commonest placein which all staphylococci are carried in humans is the nose.
2.The use of masks (other than in theatre) when undertaking dressings or other sterile procedures seems to have virtually disappeared from medical and nursing practice (although it seems to have persisted in dentistry).
Could I suggest that measures to deal with these two things could do a lot to help infection control.
Competing interests: None declared |
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