Controlling methicillin resistant Staphylococcus aureus
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7425.1177 (Published 20 November 2003) Cite this as: BMJ 2003;327:1177
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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statements based on unpublished and unreviewed bacteriological studies,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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Eugene Sherry MD FRACS
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
Competing interests: No competing interests
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 xmlns:nov2111="urn:x-prefix:nov2111" by="by" a="a" simple="simple" change="change" in="in" policy.="policy." even="even" with="with" low="low" incidence="incidence" maintaining="maintaining" search="search" and="and" destroy="destroy" policy="policy" cost="cost" dutch="dutch" hospital="hospital" _2265="_2265" lost="lost" hospitalisation="hospitalisation" days="days" _48="_48" ward="ward" closures="closures" _78000="_78000" additional="additional" microbiological="microbiological" cultures="cultures" over="over" ten="ten" years="years" eur="eur" j="j" clin="clin" microbiol="microbiol" infect="infect" dis.="dis." _2002="_2002" nov2111:_782-6.="nov2111:_782-6." p="p"/>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
Competing interests: No competing interests
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 xmlns:difference="urn:x-prefix:difference" _95ci="_95ci" of="of" difference:_="difference:_" _0.1="_0.1" to="to" _1.95.="_1.95." analysis="analysis" pharmacological="pharmacological" expenditure="expenditure" for="for" the="the" ward="ward" showed="showed" a="a" four-fold="four-fold" increase="increase" in="in" alcohol="alcohol" gel="gel" use="use" and="and" _40="_40" decrease="decrease" teicoplanin="teicoplanin" use.="use." real="real" terms="terms" every="every" _1="_1" spent="spent" on="on" resulted="resulted" _9="_9" saving="saving" expenditure.="expenditure." when="when" pilot="pilot" was="was" extended="extended" general="general" medical="medical" surgical="surgical" orthopaedic="orthopaedic" wards="wards" extra="extra" pound="pound" equivalent="equivalent" _20="_20" p="p"/> 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
Competing interests: No competing interests
EDITOR,
As Duckworth stated1 MRSA rates have soared in the last decade2, but
the way we use our hospitals has changed as well. The number of single
isolation rooms are usually very limited in English hospitals which run at
>95% bed occupancy at the best of times. The MRSA carriers have to
compete for those precious single-rooms with patients with viral gastro-
enteritis, Clostridium-difficile associated diarrhoea and those colonised
or infected with multi-resistant organisms like Acinetobacter baumanni, an
increasing problem in the South-East, and which, unlike MRSA at present,
can be untreatable. In this hospital, half of all patients with MRSA have
brought it into hospital with them. If we adopted a search and destroy
approach to MRSA, our Infection Control Team would do virtually nothing
else. We have come to the view that the pedestal that MRSA has been put
upon in this country is counterproductive. Recent media coverage, mostly
of the alarmist genre, only reinforce the perception that as far as
hospital-acquired infection goes, only MRSA really matters. Why?
We would rather be spending our time teaching people that the real
issue is hospital-acquired infection (HAI) no matter what the causative
agent. Halting the spread of HAI and minimising the risk to patients is
about people and what they do, not individual micro-organisms. MSSA is no
less virulent than MRSA and MSSA still causes more bacteraemias nationally
than MRSA does2, so why is it perceived to be of lesser importance?
Surely all hospital-acquired S. aureus bacteraemia matters and we would
better spend our time tackling the commoner causes of it? Intravascular-
line associated S. aureus bacteraemia rates would be a more meaningful
performance indicator than the current MRSA improvement score, which
currently doesn’t even distinguish between hospital and non-hospital
acquired cases.3
An American speaker at a conference I attended last year commented:
“You Brits think Infection Control is MRSA!” He implied that over the pond
the British MRSA obsession is something of a joke. I’ve no idea how
representative that view was of course, but it was an interesting
observation. As an Infection Control Officer in a general hospital in
South-East England, I found Georgia Duckworth’s article on MRSA1 only
reinforced my growing conviction that we English are losing the plot as
far as Infection Control is concerned. Maybe that’s why we have such a
problem with it.
1Duckworth, G
Controlling methicillin-resistant Staphylococcus aureus
BMJ:2003;327, 1177-8
2 Health Protection Agency
Staphylococcus aureus bacteraemia laboratory reports and methicillin
susceptibility: England and Wales, 1992 – 2002
http://www.hpa.org.uk/infections/topics_az/staphylo/lab_data_staphyl.htm
3Commision for health Improvement. Methicillin resistant
staphylococcus aureus (MRSA) improvement score. London CHI 2003.
www.ratings.chi.nhs.uk/Trust/Indicator
Competing interests:
None declared
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Methicillin Resistant Staphylococcus Aureus
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
Competing interests: No competing interests