In the past decade or so the number of MRSA infections in the United States has increased significantly. A report in 2007 by the Centre for Disease Control and Prevention (CDC), estimated that the number of MRSA infections treated in hospitals doubles nationwide, from approximately 127,000 in 1999 to 278,000 in 2005, while at the same time deaths increased from11, 000 to more than 17,000.
Another study led by the CDC and published in the October 17, 2007 issue of the Journal of the American Medical Association estimated that MRSA would have been responsible for 94,360 serious infections and associated with 18,650 hospital stay related deaths in the United States in 2005. These figures suggest that MRSA infections are responsible for more deaths in the US each year than AIDS.
The UK office for national statistics reported 1,629 MRSA related deaths in England and Wales during 2005, indicating a MRSA mortality rate, half the rate of that in the United States for 2005, even though the figures from the British sources were explained to be high because of improved levels of reporting, possibly brought about because of the continued high public profile of the disease during the time of 2005 United Kingdom general election. (www.statistics.gov.uk)
So with all the above in mind, what measures do healthcare professionals put in place to tackle MRSA?
There are several steps that can be undertaken to minimise the spread of MRSA.
Hospital staff should wash their hands before and after having physical contact with patients using soap or rapidly acting antibacterial alcohol solutions.
Patients colonised with MRSA should be kept away from other patients in separate rooms either alone or with other patients with MRSA.
Access to such rooms should be restricted to essential staff.
Hospitals staff should wear disposable gloves and aprons prior to coming into contract with a MRSA patient. (Shnayerson, M & Plotkin, M, J 2003)
MRSA can survive on inanimate objects or surfaces such as linen, sinks and floors and even mops used for cleaning. For this reason areas where MRSA patients are nursed should be thoroughly cleaned using disinfectant. ()
The document ‘Wining Ways by the Department of Health in 2003 was a driving force in reinforcing the importance of hand hygiene. More recently ‘A Matrons charter: An action Plan For Cleaner Hospitals also by the Department of Health in 2004 begins to recognise the importance of patient involvement in monitoring and reporting of standards of cleanliness. These recent government documents promote the empowerment of patients through patient information and are in line with the clinical governance strategy of engaging patients in partnership to improve care.
This concept was originally founded in the NHS plan (DoH 2000) which encouraged the empowerment of patients. The concept of empowering patients by giving them greater involvement of management of their care is a relatively new concept. (Duncanson & Pearson 2005) although it is accepted that giving patients information about their condition empowers them and distributes decision making powers between patient and nurse. (Henderson 2003)
The NHS launched the ‘clean your hands campaign’, the drive for this was research undertaken by Pittet et all 2004 and Roo et all 2002, which links the spread of MRSA to poor hand washing practices amongst healthcare professionals. ()
Nurses wore badges and posters were put up saying ‘it’s ok to ask’ but the question needs to be raised even with the campaign would patients feel comfortable asking staff to wash their hands?
A research paper printed in the British Journal of Nursing in 2007 entitled ‘Patients feelings about hand washing, MRSA status and patient information’ asked this very question.
The research showed that there was a consensus of opinion among many respondents that it would be seen as a betrayal of trust between patient and nurse if they asked this question, some respondents had made the comment they might be seen as trouble makers if they asked health care staff to wash their hands.
There was a clear indication from the data collected that access to information on MRSA was lacking for patients and a huge 72% of people indicated they would not feel comfortable asking staff to wash their hands.
Research undertaken in other studies supported the findings from this research that patients would feel more confident about asking staff and staff would feel more comfortable being asked to wash their hands if there was a cultural change in the attitude to make such practice routine in hospitals.
To that end the profile surrounding should be maintained constantly. Undoubtedly, the current drive involve patients in shaping the future of health care through the foundation trusts and patients asociatations for example should be continued so that something as critical and fundamental as hand hygiene become beyond the need to question.
What else is being done? Well the government has instructed doctors to cut back anti biotic prescribing, ministers are trying to improve overall standards of hygiene, perhaps by reintroducing the concept of Ward Matrons with responsibility for Ward cleanliness.
Will an old school type matron be able to tackle these problems as matron of yesteryear no longer exist, people now have different principles and ways of living, working and some may say that this is not a manner that can be taught, so will it just end up being another type of cleaner?
Previously the public health laboratory service statistics on MRSA were collected voluntarily so the totals were obviously conservative, but in 2001 the reporting of al SA & MRSA infections became mandatory. ()
A BBC journalist reported in 2002 that whilst hospital patient numbers have increased in the last 20 years, cleaning operatives have halved. In 1984 there were more than 100,000 cleaners working in the NHS today there are under 55,000, is this due to a lack of finance?
At the present rate, the outlay for the running of the NHS by the year 2010, it will cost upwards of £500,000,000 each day, so what will happen about infection control then? ()
Are these cuts in cleaners causing an increase in infection? Even though many of us carry the MRSA bacteria without any knowledge of it or it affecting us, it is much easier for people who are already unwell to be affected by the bacteria.
Without effective and consistent cleaning regimes the bacteria can easily be passed from one person to another and further afield. So the NHS continue to make cuts more people are being kept in small spaces increasing infection and as reported in the Western Mail in October 2006, on the whole NHS hospital to not quarantine patients with MRSA as they do not have the space to do so, again increasing the risk of a MRSA patient passing the infection onto another patient who does not have it.
The present regime of asking everyone to wash their hands will go some way to preventing infection, however, a BBC news report saw that 50% of staff ignored this; this adds to the lax hygiene issue in hospitals. ()
Some countries such as The Netherlands and Finland have been successful in their efforts of controlling MRSA.
The Dutch have adopted a policy known as ‘Search and Destroy’.
"We definitely have community-acquired MRSA in the Netherlands, but rigorous screening in hospitalized patients reduces spread and prevents cross-fertilization of community-acquired strains with nosocomial MRSA," said principal investigator Christina M. Vandenbroucke-Grauls, MD, PhD, during her presentation at the 46th Interscience Conference on Antimicrobial Agents and Chemotherapy.
"At this point about 8% to 10% of MRSA cases in our hospitals are community-acquired." Dr. Vandenbroucke-Grauls, an infection control specialist at the Vrije University Medical Centre in Amsterdam, Netherlands, added that MRSA constitutes less than 1% of all hospital-acquired S aureus strains in the Netherlands. Community-acquired MRSA is defined as such if the patients' symptoms of infection began within 48 hours of being hospitalized and the patient has had no evidence of exposure to nosocomial MRSA.
The country began a rigorous program in 2002, dubbed "search and destroy," after having seen a slow increase in MRSA that started 20 years ago. The infection control policies that were introduced in Dutch hospitals to contain MRSA consist of the following measures:
- isolating and screening high-risk patient groups,
- screening low-risk groups,
- strict isolation of carriers, and
- Treatment of people carrying MRSA.
(www.medscape.com/viewarticle/545366)
Compared to the mechanisms in place for the UK, they are more stringent and effective. The search and destroy policy has prevented a huge outbreak of MRSA in the Netherlands, they have done this by sticking to their policy, they do not have the same problems that we have in the UK such as lack of space to put patients they do not cross contaminate their patients. They have a programme in place to monitor and act on the MRSA infection, the latest action is to screen pig farmers as after recent research they have identified that 27% of pig farmers had the infection. (www.medscape.com/viewarticle/545366) This robust screening and prevention has a proven track record and should be implemented across the globe to combat MRSA.
The department of health reported an increase of 8% in overall SA bloodstream infections from 17933 in 2001/2002 to 19311 in 2003/2004 of these around 40% are MRSA, making the UK’s rate among the worst in the UK. ()
In addition to the physical effect of MRSA the potentially serious psychological effects of enforced isolation after a prolonged MRSA infection on patients who may already be depressed as a result of illness or separation from their families are often overlooked. In one study carried out at the National Spinal Injuries Centre at Stoke Mandeville Hospital, Buckinghamshire, 16 MRSA-positive patients with spinal cord injuries aged between 18 and 65 and their matched controls completed a series of questionnaires to measure aspects of the psychological impact on them. The measures used were functional independence, depression, anxiety, and the affective states of anger, vigour, fatigue and confusion. The MRSA-positive patients scored higher in all measures and the score for depression was the highest. ()
We must also consider the stigma of having MRSA, recent surveys conducted showed that people visiting the hospital would be wary of coming into contact with a patient with MRSA for fear of contracting the illness themselves; they also identified that not knowing enough about the illness made them think the worst. (Duncan,C & Dealy, C 2006)
So what is likely to happen in the future?
Doctors are very worried about what the future holds for MRSA. The number of reports of MRSA infections rises by the year and more recent evidence suggests that deaths due to MRSA are increasing at a similar rate.
Already the spectre of a bug resistant to all antibiotics is approaching, although new antibiotics are being developed all the time, pessimistic experts believe it is only a matter of time at current rates until virtually every weapon in the pharmaceutical arsenal is nullified.
Nihilists suggest that there could come a point at which bacteria retake the upper hand and doctors as in previous centuries have no answer to some bacterial infections. (Klein, E, Smith,D,L & Laxminarayan, R 2007)
Bibliography
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Klein, E, Smith,D,L & Laxminarayan, R (2007) Hospitalizations and Deaths caused By Methicillin-Resistant Staphylococcus aureus, United States, 1999-2005 – Emerging Infectious Diseases
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Klevens et al (2007) Invasive Methicillin- Resistant Staphylococcus aureus Infections in the United States, JAMA
- Centres for Disease Control and Prevention
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Duncanson, V & Pearson, L, V. (2005) A Study of the Factors Affecting the Likelihood of Patients Participating in a Campaign to Improve Staff Hygiene: British Journal of Nursing: 6 (4) 26-30
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Henderson, S (2003) Power Imbalance Between Nurses & Patients- A Potential Inhibitor of Partnership In Care – Journal of Clinical Nursing 12 (5) 501-508
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Duncan,C & Dealy, C (2006) Patients Feelings about hand washing, MRSA status and Patient Information: British Journal Of Nursing 16 (1) 56-62
- Hernan, M, D & Chang, R (2006) MRSA and Staphylococcal Infections: Lulu.com: Birmingham
- Hausler, T (2007) Viruses Vs Super bugs: A solution to the Antibiotic Solution: Macmillan: London
- Shnayerson, M & Plotkin, M, J (2003) The Killers Within: The Deadly Rise of Drug-Resistant Bacteria: Backbay Books: Sussex
