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An important area that has not received attention is the potential
risk for spread of antimicrobial resistance associated with the
international transfer of patients.
The problems of antimicrobial resistance and nosocomial infections
occur worldwide. The spread of resistance across international boarders
may manifest itself as a specific outbreak or as the clonal spread of a
resistant organism or resistance element (e.g. mobile b-lactamases). There
are many examples in the literature of the importation of a patient
colonised with a resistant organism leading to a localised outbreak. For
example a patient from Spain was transferred to a Burns Unit in Norway
leading to an outbreak of infection caused by a multi-resistant
Acinetobacter infection that resulted in the death of one of the four
patients affected. 1
Clonal spread of organisms is exemplified by methicillin resistant
Staphylococcus aureus (MRSA). International transmission of MRSA clones
associated with transfer of colonised patients has been reported in Europe
between the Netherlands and Belgium 2 and it is likely that increased
movement of patients between the UK and mainland Europe will facilitate
the spread of resistance in both directions. MRSA is a major problem in UK
hospitals causing, on average, 0.17 bacteraemias/1000 bed days. 3 Using
data from the European Antimicrobial Resistance Surveillance System
(EARSS) 4 a comparison with other European countries can be made. In 2001
44.4% of invasive isolates of S. aureus in the UK were MRSA. The
equivalent figures for other countries are France 33.4%, Germany 17.5%,
Belgium 21.6% and Netherlands 0.5%. Thus MRSA seems to be more of a
problem in the UK than some other countries and those with low rates such
as the Netherlands, may be concerned that the admission of UK patients may
lead to an influx of MRSA and its associated problems. However the
situation is more complicated in that different clones of MRSA have
different susceptibility to antimicrobials. The 2 major clones circulating
in the UK, EMRSA-15 and EMRSA-16, remain susceptible to agents such as
minocycline, trimethoprim,rifampicin and fusidic acid and occasionally
gentamicin. However there are clones such as the Iberian clone and the
Brazilian clone that are prevalent (and spreading) in Southern Europe
which are resistant to many more agents. 5 Thus the UK may be a net
exporter of MRSA but may acquire more resistant clones from Europe.
Clonal spread of resistance elements is exemplified by extended-
spectrum b-lactamases (ESBLs) which are b-lactamases that confer
resistance to third generation cephalosporins such as cefotaxime and
ceftazidime and have been associated with outbreaks. 6 They are found in
Enterobacteriaceae such as E. coli and Klebsiella spp. and are
transferable between strains and species. The prevalence in France of 32%
of Klebsiella spp. from intensive care units is significantly higher than
that in the UK and international spread of a French ESBL (TEM-24) has been
reported in Spain. 7
Although it is proposed that patients will only be receiving routine
elective surgery abroad, their follow-up will presumably be in the UK and
patients who have complications are likely to be repatriated to a UK
hospital. Thus there is a concern that they will facilitate the spread of
resistant organisms to and from mainland Europe.
In the UK the control of nosocomial infection has become a priority
following publication of the National Audit Office report in 2000. 8
Measures have been introduced through the Controls Assurance Standard for
Infection Control to ensure good practice in all Trusts. Antimicrobial
resistance has also been an area of concern and the Department of Health
currently has a campaign to tackle this by education of the public and
medical profession to reduce inappropriate antibiotic use.
If patients are to be sent abroad, we need to ensure that the
institutions to which they are sent have an appropriate infection control
framework in place. We also need to be aware of the resistance patterns of
pathogens in the institutions involved in order to inform the choice of
empiric therapy for post-operative infections in returning patients.
Finally consideration should be given to whether patients should be
screened for carriage of resistant organisms either before transfer or on
return to the UK.
References
1. Onarheim H, Hojvik T, Harthug S, Digranes A, Mylvaganam H, Vindenes HA.
Outbreak of multiresistant Acinetobacter baumannii infection. Tidsskr Nor
Laegeforen 2000: 120(9); 1028-33.
2. Deplano A, Witte W, van Leeuwen WJ, Brun Y, Struelens MJ. Clonal
dissemination of epidemic methicillin-resistant Staphylococcus aureus in
Belgium and neighboring countries. Clin Microbiol Infect 2000: 6(5); 239-
45.
3. Anonymous. The first year of the Department of Health’s mandatory MRSA
bacteraemia surveillance scheme in acute NHS Trusts in England: April 2001
– March 2002. CDR Weekly 2002: 12(25); 1-17
5. Oliveira D, Santos-Sanchez L, Mato R, Tamayo M, Ribeiro G, Costa D, de
Lancastre H. Virtually all methicillin-resistant Staphylococcus aureus
(MRSA) infections in the largest Portuguese teaching hospital are caused
by two internationally spread multiresistant strains: the 'Iberian' and
the 'Brazilian' clones of MRSA. Clin Microbiol Infect 1998; 4(7); 373-384.
6. Hobson RP, MacKenzie FM, Gould IM. An outbreak of multiply-resistant
Klebsiella pneumoniae in the Grampian region of Scotland. J Hosp Infect
1996: 33(4); 249-62.
7. Canton R, Oliver A, Coque TM, Varela-Mdel C, Perez-Diaz JC, Baquero F.
Epidemiology of extended-spectrum beta-lactamase-producing Enterobacter
isolates in a Spanish hospital during a 12-year period. J Clin Microbiol
2002: 40(4); 1237-43.
There is often a very wide gap between what people say they plan to
do, or are prepared to do, and their actual behaviour so the Mori findings
need interpreting with caution.
Patients frequently protest when services move very modest distances.
Travelling to Brighton from Central London for medical treatment might
seem a reasonable thing to do in principle but be a much more daunting
propostion when considered in the light of ill health and the rail system.
Competing interests:
No competing interests
11 July 2002
Ann Turner
research wrker
AAW PCT, 1 The Causeway, Goring on Sea, Worthin BN12 6BT
The infection risks of exporting patients
An important area that has not received attention is the potential
risk for spread of antimicrobial resistance associated with the
international transfer of patients.
The problems of antimicrobial resistance and nosocomial infections
occur worldwide. The spread of resistance across international boarders
may manifest itself as a specific outbreak or as the clonal spread of a
resistant organism or resistance element (e.g. mobile b-lactamases). There
are many examples in the literature of the importation of a patient
colonised with a resistant organism leading to a localised outbreak. For
example a patient from Spain was transferred to a Burns Unit in Norway
leading to an outbreak of infection caused by a multi-resistant
Acinetobacter infection that resulted in the death of one of the four
patients affected. 1
Clonal spread of organisms is exemplified by methicillin resistant
Staphylococcus aureus (MRSA). International transmission of MRSA clones
associated with transfer of colonised patients has been reported in Europe
between the Netherlands and Belgium 2 and it is likely that increased
movement of patients between the UK and mainland Europe will facilitate
the spread of resistance in both directions. MRSA is a major problem in UK
hospitals causing, on average, 0.17 bacteraemias/1000 bed days. 3 Using
data from the European Antimicrobial Resistance Surveillance System
(EARSS) 4 a comparison with other European countries can be made. In 2001
44.4% of invasive isolates of S. aureus in the UK were MRSA. The
equivalent figures for other countries are France 33.4%, Germany 17.5%,
Belgium 21.6% and Netherlands 0.5%. Thus MRSA seems to be more of a
problem in the UK than some other countries and those with low rates such
as the Netherlands, may be concerned that the admission of UK patients may
lead to an influx of MRSA and its associated problems. However the
situation is more complicated in that different clones of MRSA have
different susceptibility to antimicrobials. The 2 major clones circulating
in the UK, EMRSA-15 and EMRSA-16, remain susceptible to agents such as
minocycline, trimethoprim,rifampicin and fusidic acid and occasionally
gentamicin. However there are clones such as the Iberian clone and the
Brazilian clone that are prevalent (and spreading) in Southern Europe
which are resistant to many more agents. 5 Thus the UK may be a net
exporter of MRSA but may acquire more resistant clones from Europe.
Clonal spread of resistance elements is exemplified by extended-
spectrum b-lactamases (ESBLs) which are b-lactamases that confer
resistance to third generation cephalosporins such as cefotaxime and
ceftazidime and have been associated with outbreaks. 6 They are found in
Enterobacteriaceae such as E. coli and Klebsiella spp. and are
transferable between strains and species. The prevalence in France of 32%
of Klebsiella spp. from intensive care units is significantly higher than
that in the UK and international spread of a French ESBL (TEM-24) has been
reported in Spain. 7
Although it is proposed that patients will only be receiving routine
elective surgery abroad, their follow-up will presumably be in the UK and
patients who have complications are likely to be repatriated to a UK
hospital. Thus there is a concern that they will facilitate the spread of
resistant organisms to and from mainland Europe.
In the UK the control of nosocomial infection has become a priority
following publication of the National Audit Office report in 2000. 8
Measures have been introduced through the Controls Assurance Standard for
Infection Control to ensure good practice in all Trusts. Antimicrobial
resistance has also been an area of concern and the Department of Health
currently has a campaign to tackle this by education of the public and
medical profession to reduce inappropriate antibiotic use.
If patients are to be sent abroad, we need to ensure that the
institutions to which they are sent have an appropriate infection control
framework in place. We also need to be aware of the resistance patterns of
pathogens in the institutions involved in order to inform the choice of
empiric therapy for post-operative infections in returning patients.
Finally consideration should be given to whether patients should be
screened for carriage of resistant organisms either before transfer or on
return to the UK.
References
1. Onarheim H, Hojvik T, Harthug S, Digranes A, Mylvaganam H, Vindenes HA.
Outbreak of multiresistant Acinetobacter baumannii infection. Tidsskr Nor
Laegeforen 2000: 120(9); 1028-33.
2. Deplano A, Witte W, van Leeuwen WJ, Brun Y, Struelens MJ. Clonal
dissemination of epidemic methicillin-resistant Staphylococcus aureus in
Belgium and neighboring countries. Clin Microbiol Infect 2000: 6(5); 239-
45.
3. Anonymous. The first year of the Department of Health’s mandatory MRSA
bacteraemia surveillance scheme in acute NHS Trusts in England: April 2001
– March 2002. CDR Weekly 2002: 12(25); 1-17
4. European Antimicrobial Resistance Surveillance System (EARSS) Database
at: http://www.earss.rivm.nl/PAGINA/interwebsite/home_earss.html
5. Oliveira D, Santos-Sanchez L, Mato R, Tamayo M, Ribeiro G, Costa D, de
Lancastre H. Virtually all methicillin-resistant Staphylococcus aureus
(MRSA) infections in the largest Portuguese teaching hospital are caused
by two internationally spread multiresistant strains: the 'Iberian' and
the 'Brazilian' clones of MRSA. Clin Microbiol Infect 1998; 4(7); 373-384.
6. Hobson RP, MacKenzie FM, Gould IM. An outbreak of multiply-resistant
Klebsiella pneumoniae in the Grampian region of Scotland. J Hosp Infect
1996: 33(4); 249-62.
7. Canton R, Oliver A, Coque TM, Varela-Mdel C, Perez-Diaz JC, Baquero F.
Epidemiology of extended-spectrum beta-lactamase-producing Enterobacter
isolates in a Spanish hospital during a 12-year period. J Clin Microbiol
2002: 40(4); 1237-43.
8. Comptroller and Auditor General. The Management and Control of Hospital
Acquired Infection in Acute NHS Trusts in England. HC 230 1999/2000.
http://www.nao.gov.uk/publications/nao_reports/9900230.pdf
Competing interests: No competing interests