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Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA): systematic review of the literature

BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7465.533 (Published 02 September 2004) Cite this as: BMJ 2004;329:533

Rapid Response:

Isn't it time to change our approach to the management of methicillin resistant staphylococcus aureus (MRSA) ?

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

Competing interests: No competing interests

09 September 2004
michael a james
consultant cardiologist
taunton & somerset hospital, musgrove park, taunton, somerset. TA1 5DA