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EDITORIALS: Andreas Voss Preventing the spread of MRSA BMJ 2004; 329: 521 [Full text]

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MRSA - an epidemiological problem.

Nicholas Akerman   (10 September 2004)

Preventing the Spread of MRSA

Barry. A. Dale   (12 September 2004)

Consider hospital curtains as a reservoir of infection

A Richardson   (7 January 2005)

Eliminating the MRSA problem.

Richard G Fiddian-Green   (7 January 2005)

MRSA - an epidemiological problem. 10 September 2004
Nicholas Akerman, Research Registrar St. James' University Hospital, Leeds, LS9 7TF Send response to journal: Re: MRSA - an epidemiological problem.	I can not help feeling that the attitude towards MRSA in this country is very much a case of ‘shutting the gate after the horse has bolted’. It is interesting to read the article by Voss [1] that in Scandinavia and the Netherlands, where the prevalence of MRSA is low, they advocate a screening and decolonisation policy for healthcare workers. My own experience of working outside the United Kingdom (Australia) was that you are unable to work with patients without being screened and cleared. Having worked in England in medicine for over 12 years I have never once been screened. Surely we should at least be adopting this policy to help combat the problem. Patients themselves must shoulder some of the blame in bringing MRSA into our hospitals. It would be a mammoth task to screen the entire hospital population, but a staggered approach would be a start. Screening elective surgical patients prior to admission could be the first step. Then perhaps general practice attenders. I appreciate that in the short term there is a financial implication (how much and by whom?) to be consider in screening and decolonising MRSA from the general population. In the long term, in stopping MRSA being brought in at the front door, so reducing lengthy hospital stays, expensive drug treatment and potential litigation it will be more cost effective. 1) Voss A. Preventing the spread of MRSA. BMJ 2004; 329: 521. Competing interests: None declared
Preventing the Spread of MRSA 12 September 2004
Barry. A. Dale, Consultant Bacteriologist / Infection Control Doctor Dumfries & Galloway Royal Infirmary, Dumfries, DG1 4AP Send response to journal: Re: Preventing the Spread of MRSA	Few would challenge Professor Voss's assertion that " the control of MRSA is and will continue to be of the utmost importance to the infection control community". Yet this very assertion contains hidden within it one of the greatest challenges to be faced by the infection control community in the UK today, for until the control of MRSA "is of the utmost importance" to all frontline NHS staff attempts at control are doomed to failure. The installation of this simple truth in the minds of clinical staff is of the highest priority. The all to prevalent perception that MRSA control is the responsiblity and sole provenance of infection control professionals is outdated and if perpetuated will prove detrimental to achieving control of MRSA in NHS hospitals. Competing interests: None declared
Consider hospital curtains as a reservoir of infection 7 January 2005
A Richardson, Retired Medical Microbiologist Colletts Close, Corfe Castle, Dorset, BH20 5HG Send response to journal: Re: Consider hospital curtains as a reservoir of infection	I am concerned that hospital curtains may be a reservoir of infection, including the MRSA bacteria. Curtains are swished around a patient before a wound is inspected or dressed. It would be of interest to do a microbiological survey up and down the country of hospital curtains. Perhaps if they were found to be a hazard, the curtains could be impregnated with an antibacterial substance. Regular cleaning of curtains is important. Perhaps disposable paper curtains may be helpful. Competing interests: None declared
Eliminating the MRSA problem. 7 January 2005
Richard G Fiddian-Green, FRCS, FACS Sanders, Temple Gdns, Moor Park. Send response to journal: Re: Eliminating the MRSA problem.	MRSA is an uncommon but serious problem for those surgeons who insert prostheses, notably heart valves. The reality is that, with the possible exception of a heart valve, once a prosthesis has become infected it usually needs to be removed to resolve the problem be the organism MRSA or not. Prevention is, therefore, of far greater importance than treatment and any accompanying need for isolation. Prophylactic antibiotics are effective in preventing infections after elective surgery but concerns about the development of MRSA has dictated restricting the use of vancomycin to those having cardiac surgery and especially valvular surgery (1). To the best of my knowledge the effects of prophylactic antibiotics have never been standardised for transient periopererative episodes of intramucosal acidosis that may occur in as many as 50% of patients having cardiac surgery(2). These episodes can set the stage for the development of infections from gut organisms (3), the principle cause of nosocomial infections after elective surgery(4). There are simple and effective means of preventing most of these episodes (5) but in the absence of the routine monitoring of intramucosal pH these means may loose their benefical effects because of ineffective application and outcome from all causes revert to the levels present before monitoring(6). If an intramucosal acidosis were to be prevented from developing perioperatively, or limited to less than an hour or possibly even two and the prophylactic administration of vancomycin restricted to these periods, might the need for selective decontamination, MRSA infections and the contraversial need for isolating patients be avoided? 1. Movahed MR, Kasravi B, Bryan CS. Prophylactic use of vancomycin in adult cardiology and cardiac surgery. J Cardiovasc Pharmacol Ther. 2004 Mar;9(1):13-20. 2. Fiddian-Green RG. Gut mucosal ischemia during cardiac surgery. Semin Thorac Cardiovasc Surg. 1990 Oct;2(4):389-99. 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. van Saene HK, Petros AJ, Ramsay G, Baxby D. All great truths are iconoclastic: selective decontamination of the digestive tract moves from heresy to level 1 truth. Intensive Care Med. 2003 May;29(5):677-90. 5. 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. 6. Moira McKendry, Helen McGloin, Debbie Saberi, Libby Caudwell, Anthony R Brady, and Mervyn Singer Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery BMJ, Jul 2004; 329: 258. Competing interests: Patents issued in my name