Dispelling the myths around MRSA

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Dispelling the myths around MRSA

• Brian I. Duerden
• Inspector of Microbiology
• Infection Control
• Department of Health

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What is MRSA?

• Methicillin Resistant Staphylococcus aureus
• S. aureus discovered 1880s
• Infected surgical wounds
• S. aureus causes INFECTIONS
• Wounds (accidental and surgical)
• boils, abscesses
• blood stream infections (bacteraemia)
  endocarditis
• pneumonia (ICU - ventilators post-influenza)
• CARRIAGE COLONISATION is normal

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The family Staphylococcus

• Normal habitat skin
• S. epidermidis
• Everyone normal commensal flora
• Harmless (except very susceptible patients)
• Often methicillin resistant
• S.aureus
• CARRIAGE COLONISATION
• nose, axilla (armpit), perineum (groin)
• 30(general)-60(hospital) of population
• chronic skin ulcers etc.

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MRSA infections

• Wounds
• Post-operative
• Red, inflamed, pus, abscess, breakdown
• Intravenous line infections (bacteraemia)
• Skin ulcers
• Deep abscesses
• Often with bacteraemia
• Pneumonia (lung infection)
• Bacteraemia (bloodstream infection)

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Properties of MRSA

• Bacterium - non-sporing
• SURVIVES
• on skin/hands, in dust, on surfaces
• Removed by washing (soap water)
• Killed by disinfectants
• ANTIBIOTICS
• Resistant to penicillins cephalosporins
• Resistant or sensitive to gentamicin etc
• Sensitive to vancomycin/teicoplanin, linezolid
  and synercid

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HealthCare Associated Infection

• 9 of hospital inpatients
• urinary (catheter associated)
• blood stream (intravenous line associated)
• wounds (surgical site infection)
• respiratory (ventilator associated pneumonia)
• diarrhoea (C. difficile, antibiotic associated)
• Bacteraemia (blood stream)
• 44 of S. aureus are MRSA

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2005 -The challenge of HCAI

• MRSA bacteraemia
• 2001/2 7249
• 2002/3 7373
• 2003/4 7684
• 2004/5 7212

• C. difficile infection
• 2001 22008
• 2002 28986
• 2003 35537
• 2004 43672
• Why?

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1970 2000 a dichotomy

• Microbiology Infection Control
• New antibiotics
• New societies
• New journals
• New guidelines
• New diseases
• Infection control was the province of the IC
  specialists

• Modern medicine
• Increased life expectancy
• Cancer treatment
• Immunosuppression
• Complex surgery
• Cardiac, Neuro
• Orthopaedic
• Chronic illnesses
• Renal dialysis
• Infection a nuisance

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Size of the problem The media view
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MRSA myths (1)

• New threat never been seen before

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Evolution of MRSA

• S. aureus (Ogston, 1880s)
• 1940s serious infections no antibiotics
• 1941 penicillin almost all sensitive
• 1959 95 penicillin resistant (penicillinase)
• 1960 methicillin (resists penicillinase)
• 1961 MRSA discovered
• 1970s small numbers of MRSA
• 1980s localised MRSA outbreaks
• 1990s epidemic MRSA strains widespread

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MRSA myths (2)

• Only a UK problem

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International comparisons

• Prevalence of HCAI
• USA 5-10
• Australia 6
• Norway 7
• England 9
• Denmark 8
• France 6-10
• Netherlands 7
• Spain 8

• MRSA all S.aureus
• Denmark 1
• Netherlands 1
• Austria 11
• Germany 19
• Spain 23
• France 33
• Portugal 38
• Italy 38
• Greece 44
• UK 44

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MRSA myths (3)

• Responsible for all HCAI (300,000) and all HCAI
  deaths (5000)
• ONS Death certificates 2003
• 955 mentions
• 321 principal causes

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MRSA - not the only one!

• DO NOT NEGLECT
• Clostridium difficile
• Glycopeptide resistant enterococci
• ESBL-producing E. coli etc
• Acinetobacter baumannii
• Norovirus

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MRSA myths (4)

• MRSA is a death sentence (or severe disability)
• MRSA ve people are a threat to everyone
• ostracism
• Untreatable by antibiotics
• Vancomycin/teicoplanin, linezolid, synercid

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MRSA myths (5)

• Resistant to disinfectants - NO
• Spreads through air by breathing
• Is everywhere in the hospital environment
• Undercover sampling
• Poor microbiology (dodgy science)
• Tabloid hysteria

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How do we change bad habits?

• Clinical practice protocols
• Cleanliness and hygiene
• hand hygiene
• environmental cleaning
• Management
• emphasis on infection control
• Training
• Built environment

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Clinical practice protocols

• GUIDANCE
• handwashing/hand hygiene
• aseptic procedures
• intravenous line management
• urinary catheter care
• endotracheal tube care
• risk-assessed admission screening
• APPLICATION OF
• audit tool, root cause analysis, HACCP

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Renal Association SA Standards

• Recommendations (August 2002)
• IC policy for MSSA/MRSA
• Screening, prophylaxis, treatment, education,
  hand hygiene, isolation
• 3-monthly screen for nasal SA carriage
• Temporary venous catheter mupirocin or povidone
  iodine at end of session
• HD SA carriers mupirocin /- weekly mup.
• PD mupirocin daily/alt. days to exit site
• PD SA carriers mupirocin erad. or 5 d/4 w

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Audit

• Is it being done?

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Cleanliness and Hygiene

• Contracted out versus in house
• commitment
• Role of the TEAM
• Modern Matron
• Ward Sister staff
• Ward Housekeeper
• Cleaners

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Management

• Director of Infection Prevention Control
• accountability, responsibility, authority
• Bed/patient management
• occupancy challenge (lt85 desirable)
• moving around wards/hospital
• mixing elective and emergency admissions

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Training

• For all staff clinical non-clinical
• Professional training
• Undergraduate (GMC Medical Schools)
• Postgraduate (Foundation years Specialist
  training Postgraduate Deans Royal Colleges)
• Personal development plans
• CPD appraisal

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Built environment

• Age, maintenance
• Single rooms ( aim for 50)
• ventilated lobbies
• Maximum 4 beds per bay
• Design
• no ledges, no carpets, sealed/coved floors,
  impervious soft furnishings
• Ventilation

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A wake-up call..

• We have accepted these infections as normal
• Patients
• Can be very ill
• Can die
• Stay in hospital longer
• May need major surgery
• Significant NHS resources could be better used

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Reducing MRSA HCAIs

• Clinical teams
• Infection control teams
• Management teams