Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Getting hold of the full MRSA report
- Phillip P Simons (3 September 2004)
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Isn't it time to change our approach to the management of methicillin resistant staphylococcus aureus (MRSA) ?
- michael a james (9 September 2004)
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Weak evidence on effectiveness of isolation measures on control of MRSA
- Savvas Papagrigoriadis (27 September 2004)
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CONTACTS BETWEEN ICU PATIENTS AND NON-UNIT EMPLOYEES DURING AN MRSA OUTBREAK
- Jaap E. Tulleken, Rob Spanjersberg, Jack J.M. Ligtenberg, Tjip S. van der Werf, Lieuwe S. Hofstra and Jan G. Zijlstra (1 December 2004)
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Phillip P Simons, Communications Manager National Coordinating Centre for Health Technology Assessment
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An electronic file (pdf format) of the full text of this publication in the Health Technology Assessment monograph series is available at the URL below, along with an abstract, an executive summary and instructions for ordering the printed version. http://www.ncchta.org/project.asp?PjtId=1108 Competing interests: None declared |
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michael a james, consultant cardiologist taunton & somerset hospital, musgrove park, taunton, somerset. TA1 5DA
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I am puzzled as to why the human race seems incapable of learning lessons from history and disappointed that the medical profession, despite its declared obsession with "evidence based practice", is no different. We have the perfect example from history of how to deal with organisms that are capable of rapidly acquiring multiple resistances, in the form of tuberculosis. This organism was extremely sensitive to antibiotic therapy but almost defied treatment because of its ability to rapidly acquire resistance, and not just to one antibiotic. With simple logic that seems to defie the modern world it was correctly argued that the organism was unlikely to be able to acquire resistance to several antibiotics simultaneously and multiple antibiotic treatment regimens were born. With the resultant near eradication of a former pandemic. (the particular problems of treating TB which require prolonged courses of treatment have of course resulted in a failure to completely eradicate the infection which is now making a comeback, but that should not negate the remarkable achievements of the multiple antibiotic regimens - indeed it makes their success all the more remarkable and would suggest that for infections which will only require short courses this approach to treatment should be all the more effective.) However, instead of learning from this important lesson we seem to be doggedly reassured that we must use fewer and fewer antibiotics to resolve this problem, but it just is not working is it? To make matters worse, instead of applying some logical thought to the problem, we are exhorted to join into an ever increasing frenzy of hand washing which is bordering on hysteria. This is entirely non evidenced based and defies logic. Hand washing alone can never remove all infection from the hands (that's why we use sterile gloves isn't it), whilst a controlled trial on alcohol gel found it to be ineffective.[1] This is of course hardly surprising, bottles of chlorhexidine antiseptic have been demonstrated to be capable of harbouring dangerous bacteria, goodness knows what could be grown from a bottle of stagnant gel that vaguely resembles a culture medium. Besides, we never expected antiseptics to be capable of sterilising things, that is why we sterilize equipment by heat or radiation. Why the obsession with hand washing? there are far more likely culprits to target - stethoscopes, blood pressure cuffs and even just our clothes to name but a few; and how about trying cleaning the floors, furniture or the curtains round the beds now and again, but then we're far too busy saving money to worry about that. Whilst it is clearly likely that any measure designed to increase people's awareness of simple hygiene measures will have SOME impact on cross-infection it equally clearly is not the cause of the problem. Where does this approach end? to take it to its logical conclusion we will turn all wards into sterile theatre suites and we will scrub and change gowns at every bedside. No doubt this would have some further impact but we all know it will not solve the problem, while we keep admitting patients (and perhaps staff) who are carrying the problem around with them to these sterile areas. It is far more logical and more likely to be effective to think about the causes and sources of infection and target them. We have recently been provided with evidence that screening patients admitted to an orthopaedic unit and excluding patients with MRSA can eradicate infection in that unit.[2] How about some more screening and targetted treatment and we probably need to include staff in this process - if we are excreting MRSA from our nose or perineum it really does not matter how many times we wash our hands! Cooper et al have at least started to look in the right direction, but I entirely agree with your editorial comment, lack of evidence can not be taken as evidence of lack of benefit, especially when there were so many weaknesses in the studies evaluated. Besides, 4 out of the 6 best studies showed that isolation measures did work. Finally I come back to TB. We are facing a foe which we know is clever enough to develop resistance to our antibiotics, rapidly and not just to methicillin. Where is the logic in sending our antibiotics into this battle one at a time? It seems like surrounding your enemy with an army 3 times their size but sending your soldiers in to storm their positions one at a time! Yours faithfully M A James MD, FRCP References 1 Kramer A, Rudolph P, Kampf G, Pittet D. Limited efficacy of alcohol based gels. Lancet 2002;359:1489-90 2 Biant LC, Teare EL, Williams WW, Tuite JD. Eradication of MRSA by "ring fencing" of elective orthopaedic beds. BMJ 2004;329:149-51 Competing interests: None declared |
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Savvas Papagrigoriadis, Consultant Surgeon King's College Hospital
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Sir, The systematic review by BS Cooper et al reveals such weakness of research on isolation measures for control of MRSA that one wonders whether a lot of efforts and resources are invested on policies without sufficient evidence. It is amazing that only 4 studies out of 46 (less than 10%) found isolation measures to be effective. Some questions arise: Could the level of general cleanliness of the hospital be more important than isolation of infected patients? Are MRSA epidemics mainly the result of the fact that we nowadays treat increasingly more ill patients with decreased defenses? After all, how exactly do you "isolate" an organism who lives in the patient's own throat? Yours Faithfully
Competing interests: None declared |
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Jaap E. Tulleken, internist-intensivist Intensive & Respiratory Care Unit (ICB), University Hospital Groningen, The Netherlands, Rob Spanjersberg, Jack J.M. Ligtenberg, Tjip S. van der Werf, Lieuwe S. Hofstra and Jan G. Zijlstra
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Sir, we read with interest the study of Cooper et al. The authors carefully evaluated the evidence for the effectiveness of measures in reducing the incidence of MRSA colonisation and infection in hospital inpatients. They demonstrated that no well-designed studies exist that allow the role of a single isolation measure to be assessed. In contrast, no evidence is provided that current preventive practices are ineffective. We therefore agree with the authors key point that we should continue with the concerting measures including isolation of infected and colonized patients, barrier precautions (gowns, gloves and masks) and restriction of antibiotics to reduce MRSA. Although living in a country that has a low prevalence of MRSA we were recently confronted with an outbreak in our university hospital. To prevent further spread of MRSA, in addition to general precautious measures we introduced strict visiting rules for health care workers at our ICU : 1) only if necessary for patient treatment, it was allowed to enter the ICU, 2) before entering the ICU visitors should wash hands with alcohol-based hand rub, wear gloves, gown and mask and put their name on a form. In the beginning of December 2003 4 patients became positive on a surgical ward and four patients on the surgical ICU (one of the four adult ICU’s). The surgical ward and ICU were closed for new patients and meanwhile, all new surgical ICU dependant patients, were admitted to our medical ICU and to the neurological ICU. Suspected and known MRSA patients were cohorted on the surgical ward and ICU with staff that cared exclusively for these patients. The capacity of our unit was extended from 12 to 14 beds during weekdays. Our bed occupancy was >95% and all hospital employees agreed to adhere to the protocol. In the outbreak period of 4 months 14000 cultures of MRSA were done from 600 patients and 2000 employees. 28 positive patients were found on different wards. The paediatric ICU was closed for several days because of a MRSA culture positive patient. A colonized health care worker was found to be the transmission factor. Furthermore, 16 members of staff on different wards, 3 laboratory workers, 1 technician and 5 others including family of health care workers were found to be MRSA positive. No positive cultures for MRSA were found at our ICU. During one month there were about 1020 consulting visits. The number of median (range) visits of physicians during weekdays 16(7-31) differed statistically significant from weekend days 6(5-13) p< 0.001. Physical therapist visits 8(6-11) vs. 1(1-6) p < 0.0001. No changes were found in the number of visiting radiology personnel, ward nurses for patient transport and material related visits. Our observations made clear that despite restrictive visiting rules a great number of non-unit employees visit our ICU. Most strikingly, however, is the fact that, while the patient population did not really change, a substantial decrease in the number of visits of physicians and physical therapists was seen during weekends. This gives reasons for doubt about the need for visits during weekdays. Knowing that health care workers are major vectors in the spread of MRSA the value of restriction of their ICU visits should be assessed in future planned intervention trials. Even in teaching hospitals. 1. Cooper BS, Stone SP, Kibbler CC, Cookson BD, Roberts JA, Medley GF et al. Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA): systemic review of the literature. BMJ 2004;329:533-9 Competing interests: None declared |
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