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Preventing infections caused by intravascular devices reduces MRSA bacteraemia rates
- Mark Melzer, Lindsey Bain (Infection Control Doctor) and Yasmin J Drabu (Medical Director and DIPC) (1 May 2008)
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Rapid MRSA tests do not prevent acquisition of MRSA during hospital stay.
- Ed J. Kuijper (6 May 2008)
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Mark Melzer, Consultant Microbiologist Department of Microbiology, Queen's Hospital, Barking, Havering and Redbridge Trust, Romford, Essex, Lindsey Bain (Infection Control Doctor) and Yasmin J Drabu (Medical Director and DIPC)
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Dear Sir, We read with interest Jeyaratnam et al’s paper (1) that demonstrated rapid MRSA screening by PCR, compared to culture techniques, had no effect on MRSA acquisition and bacteraemia rates on four medical and six surgical wards at St Thomas’ Hospital. At King George Hospital, Barking, Havering and Redbridge (BHR) Trust, we have demonstrated through bacteraemia surveillance (June 2003 – December 2006) that 19/118 (16.1%) of hospital- acquired MRSA bacteraemic episodes, occurring on medical and surgical wards, were secondary to infected peripheral cannulae insertion sites. In June 2007, the trust implemented a programme aimed at reducing these infections. This followed guidance in the ‘Saving Lives’ programme(2). Skin decontamination devices (Chlorprep Single Swab Applicator) and ‘Venflon packs’ were supplied to all wards. Inside ‘Venflon packs’ labels for date of insertion and removal for peripheral cannulae were provided together with Tegaderm to replace tape and gauze dressings. Junior doctors and nurses were trained to use these packs and, in particular, how to label and insert cannulae in an aseptic manner. From June 2007 to March 2008, total episodes of MRSA bacteraemia trust wide fell from 56 to 32 (42.9%), compared to the preceding 10 months. Over this 20-month period, policies on the selective screening of high-risk patients (critical care, neonates, elective orthopaedic surgery, frequent hospital re-attenders and patients from care homes) have remained unchanged. Recently, we screened all patients on six medical and surgical wards and demonstrated that MRSA is as prevalent within our trust (median prevalence rate 11.5%, range 7-23%), as St Thomas’ (median value 6.1%, range 2.7-19.7%). Based on Jeyaratam et al’s finding and our own experience locally, we believe the government target of universal MRSA screening of elective inpatients, costing our trust £97 000/annum, is unlikely to impact significantly on MRSA bacteraemia rates. By March 2011, the government aims to MRSA screen all hospital inpatients which would cost us an additional £837 000/annum. This amount would be five times more expensive if PCR assays were introduced. In contrast, enhanced bacteraemia surveillance and targeted interventions aimed at reducing infection at sites that cause MRSA bacteraemia is likely to be money well invested. Universal screening appears to be wasteful and we believe the government’s strategy to reduce MRSA infections through universal screening requires a fundamental rethink. Reference: (1) Jeyaratnam D, Whitty CJM, Phillips K, Liu D, Orezzi C, Ajoku U, French GL. Impact of rapid screening tests on acquisition of meticillin resistant Staphylococcus aurueus: cluster randomised crossover trial. BMJ 2008;336: 927-30. (2) Saving Lives: reducing infection, delivering clean and safe care. Peripheral intravenous cannula care bundle. www.clean-safe-care.nhs.uk Competing interests: None declared |
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Ed J. Kuijper, Medical Microbiologist Dept. Medical Microbiology, Leiden University Medical Centre, PO BOX 9600, 2300 RC Leiden
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Rapid MRSA tests do not prevent acquisition of MRSA during hospital stay. We have read with great interest the article of Jeyaratnam et al. The authors concluded from this well designed study that a rapid test as compared with a conventional culture for the detection of MRSA at admission did not reduce the rate of MRSA acquisition, MRSA transmission and infection rates during hospitalization (1). A positive, but expected finding was that the rapid test reduced the number of inappropriate pre- emptive isolation days when compared to conventional cultures and, subsequently, had an impact on the bed usage. The fact that an MRSA outbreak occurred in both study arms during the study period clearly demonstrates that acquisition of MRSA can not be prevented by rapid MRSA detection only, but is also dependent on proper pre-emptive isolation (only 30% of positive MRSA patients were pre-emptive isolated in this study), on appropriate infection control measures (only 41.7% handwashing compliance in this study), on the recognition of MRSA colonized personnel as source of MRSA spreading (not investigated in this study) and on the effectiveness of side-rooms and cohorting in a designated ward area. Succesfull combating of MRSA in an MRSA endemic settings starts in the hospital by the rigorous application of general good infection control practice to prevent nosocomial transmissison. This is of more importance than the use of rapid tests with a good negative predictive value (99.4%) but unacceptable low positive predictive value (55.1%). (1). Jeyaratnam D, Whitty CJM, Phillips K, Liu D, Orezzi C, Ajoku U, French GL. Impact of rapid screening tests on acquisition of meticillin resistant Staphylococcus aurueus: cluster randomised crossover trial. BMJ 2008;336: 927-30. Competing interests: None declared |
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