Should we screen low risk patients for meticillin resistant Staphylococcus aureus?
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4035 (Published 08 October 2009) Cite this as: BMJ 2009;339:b4035
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We support the call by Michael Millar (1) for further work on the
ethics on screening for MRSA (and indeed other healthcare associated
infections (HAIs)). However, a number of the points he offers in arguing
against widespread MRSA screening require further examination.
There are many gaps in our knowledge around the effectiveness and
practicability of MRSA screening. In Scotland we have been carrying out an
extensive piloting process since August 2008 – the NHS Scotland MRSA
Screening Pathfinder Programme – in three Health Board areas. This
programme aims to test the assumptions and estimates within our 2007
Health Technology Assessment modelling on the effectiveness and cost-
effectiveness of various screening strategies (2). The interim report of
the Pathfinder Programme (3) noted in passing that compliance with pre-
existing targeted local screening programmes was found to be ‘variable’ –
which is probably a widespread issue. There is no firm evidence presented
within the current UK guidance (4) to support targeted screening as a best
option, and the initial Scottish HTA modelling (2) specifically found
targeted screening to be neither effective nor cost-effective as an
intervention.
The concept of ‘high risk’ for MRSA screening is complex – this may
refer to the patient’s intrinsic status, to the ward or specialty housing
a patient, or to the procedures being undertaken. Our experience with the
Pathfinder Project was that rapid and repeated patient movement between
wards made it impossible to apply a ‘high risk only’ strategy for
decolonisation at ward or specialty level. Millar acknowledges that
colonised patients are at higher risk of self-infection – even ‘low risk’
patients often have invasive procedures or indwelling devices.
The adverse consequences cited by Millar for universal screening are
principally those arising from social isolation in single rooms, deferred
treatment, and patient acceptability or consent. Given the increasing move
toward delivering hospital care in single rooms across the UK, there is a
wider issue for the NHS to address in terms of how we deliver good patient
care in single rooms, taking into account the opportunities and challenges
this strategic direction affords. A survey of patients in a single-room-
only Scottish hospital for example showed a 93% preference for single
rooms on their next admission (5). The Pathfinder Project interim report
(3) showed a 0.03% patient refusal rate when offered screening, and only
0.05% of patients had their treatment deferred.
It is a frequent and specific feature of HAIs that there are issues
of both personal health benefit and reducing risk to others in controlling
prevalence in hospitals. We agree that more information is needed to
underpin rational policy developments; we expect that the final report of
the Pathfinder Programme (due at the end of this year) and the ensuing
revision of the HTA modelling assumptions and key variables will
facilitate both the decision making processes for national policy in
Scotland and for the formulation of a practical and pragmatic ethical
framework.
References
1. M. Millar. Should we screen low risk patients for meticillin
resistant Staphylococcus aureus? BMJ 2009 339: b4035-b4035
2. The clinical and cost effectiveness of screening for MRSA. NHS
Quality Improvement Scotland Health Technology Assessment Report 9:
October 2007
http://www.nhshealthquality.org/nhsqis/controller?p_service=Content.show...
3. NHS Scotland MRSA Screening Pathfinder Programme: interim report
March 2009 http://www.documents.hps.scot.nhs.uk/hai/mrsa-screening/mrsa-
screening-interim-summary.pdf
4. Coia JE, Duckworth GJ, Edwards DI, Farrington M, Fry C, et al.
Guidelines for the control and prevention of methicillin-resistant
Staphylococcus aureus (MRSA) in healthcare facilities. J Hosp Infect
2006;63(suppl 1):S1-44.
5. Single Room Provision Steering Group Report. Scottish Government,
October 2008 http://www.scotland.gov.uk/Resource/Doc/253500/0075129.pdf
Competing interests:
J Reilly and P Christie have strategic roles in the NHS Scotland MRSA Screening Pathfinder Programme.
Competing interests: No competing interests
MRSA screening: A wasteful department of health driven exercise or enhancing quality of care for patients
We support in principle the comprehensive arguments made by Michael
Millar (1). We wish to share with the readers a slightly different
approach to MRSA screening and HCAI management. Blackpool Victoria
Hospital, a large district hospital in northwest England introduced in
2008 rapid [PCR based] MRSA screening for all emergency admissions
[medical & surgical], critical care [ITU, cardiac ITU, surgical high
care and high dependency units] offered from microbiology laboratory
between 8am - midnight [based on hospital admission peaks with average
turn-around-time of 5-hrs].
The key objectives for this screening strategy were: Use of rapid MRSA
results for clinical decision making; optimising antibiotics; optimising
use of limited single rooms; targeting MRSA bio-burden reducing protocol
to carriers; enhancing clinical quality of care; providing rapid
reassurance to patients of their optimal management and reducing HCAI.
Some of the key features of a comprehensive HCAI strategy were - team
working between chief executive & executive directors, infection
control team and clinical teams [doctors & nurses]; raising awareness
in public and staff using 'ban-the-bug' - campaign with banners &
posters across the hospital; executive directors lead mandatory infection
prevention road shows; hand hygiene and ANTT campaigns, MRSA PCR screening
service, etc. The key results were: 78% reduction in MRSA bacteraemia, 45%
reduction in C. difficile infections; 25% reduction in ESBL infections;
31% reduction in glycopeptide usage (2).
We observed that the conventional 'risk-based' approach to screening had
an extremely low level of correlation with MRSA carriage and this approach
leads to poor compliance for screening from already busy front line nurses
and junior doctors. Rapidly available MRSA results can compliment clinical
decision making, permit rapid optimisation of patient management and
actually prevent harm [reduce avoidable infections, morbidity &
mortality] to the patient. The key to a successful HCAI strategy is to
have trust management, infection control team and clinical teams actively
on board and the strategy carefully planned to address local HCAI problems
of the trust rather than be target driven (3).
References
1. M. Millar. Should we screen low risk patients for meticillin resistant
Staphylococcus aureus? BMJ 2009 339: b4035-b4035
2.A. Guleri, R. Palmer, C. Danson, N. Harper, et al. Exploring the fourth-
dimension: the clinico-economic impact of a distinct model of MRSA
screening by PCR in United Kingdom. Poster P-1890. 19th European
Conference of Clinical Microbiology and Infectious Diseases, Helsinki. May
2009.
3.Health and social care act 2008
Competing interests:
None declared
Competing interests: No competing interests