Tackling the spread of MRSA
By Sir Richard Thompson, President, Royal College of Physicians
With the notable exceptions of the Scandinavian countries and the Netherlands, meticillin-resistant staphylococcus aureus (MRSA) has become endemic in healthcare organisations across Europe and many other parts of the world. The impact of this situation on the delivery of healthcare is now significant, both in terms of human morbidity and mortality and financial costs.
There are no simple answers to its control. Factors involved in the introduction and spread of MRSA within a healthcare organisation include the following:
* The selective advantage MRSA enjoys in healthcare settings, where antibiotics are used heavily and sometimes inappropriately.
* Many patients carrying MRSA go unrecognised; unless active surveillance to detect them is employed on admission to hospital they may then cross infect other vulnerable patients.
* Transfer of patients with MRSA between hospitals, and between wards and departments, is a major cause of dissemination.
* Healthcare workers can contribute to the spread of MRSA when appropriate infection control measures are not followed, or sometimes because they are themselves MRSA carriers.
* The clinical environment can become contaminated with MRSA and act as a source for acquisition by patients and staff.
* The inevitable delay between the laboratory receipt of a specimen and the identification of a new patient with MRSA allows time for cross-infection to occur.
The general perception that hospital environments are often not clean is rightly of major concern, not just to the public at large but also to infection control specialists. It is entirely possible that visual dirt represents a reservoir of potential pathogens, including MRSA, and therefore basic cleaning could have an impact on the rate of MRSA as well as other healthcare-associated infections. But this is unproven. However, apart from any infection risk from a dirty environment, patients expect a clean uncluttered hospital, criticise hospitals they consider dirty, and associate them with a general lack of care.
Recognition of the complexity of the subject led the Department of Health (England) in 2005 to publish this country’s first multi-pronged strategy on the subject; the Action on Health Care Associated Infections in England and shortly thereafter the Code of Practice for the Prevention and Control of Healthcare Associated Infections’, otherwise known as the ‘Hygiene Code’. Compliance with this code has been a legal requirement for NHS Trusts since 2006, as well as (since 2009) one of the necessary conditions for successfully registering with the Care Quality Commission as an approved healthcare provider.
The medical profession has also sought to establish key principles for the management of MRSA in hospitals. The 2006 report by the Royal College of Physicians of Edinburgh and the Royal College of Physicians and Surgeons of Glasgow is still a valuable resource for those trying to introduce high quality infection control, while the Royal College of Physicians of London last year published its ‘Top 10 Tips for effective antibiotic prescribing’.
The principles advocated by the former were derived from an extensive review of the literature in the light of accepted good practice, the increasing experience of the value of targeted screening, and in some cases, common sense. Their conclusion was that successful programmes have largely been based on early identification of the MRSA reservoir and prompt implementation of contact precautions. However, unless adequate resources, both human and environmental, are in place, any such attempts to control healthcare associated infections are bound to fail, and worse, could add meaningless extra burdens on to the shoulders of already hard-pressed clinical, infection control and laboratory staff.
To have an impact, there must be adequate numbers of trained staff who meticulously observe best infection control practices – overseen by a medical infection prevention and control director – in clean wards equipped with adequate numbers of single rooms, a plentiful and accessible supply of wash hand basins and hand disinfectants. The possible emergence on a large scale of ‘community’ MRSAs which are more virulent than current ‘hospital’ strains justifies this more proactive approach.
However, on a positive note, the widespread application of procedures, especially hand washing and disinfection have led to a welcome reduction in the number of new cases of MRSA. Further research is now needed into how MRSA spreads by means other than dirty hands.