Let MRSA-positive patients live a normal life

Abstract

Methicillin-resistant Staphylococcus aureus (MRSA) infections have represented a serious burden in the USA and in Japan for years [1,2]. The incidence of MRSA is especially high in intensive care units (ICUs). MRSA is also becoming more prevalent in Europe, but with significant differences in the frequency of MRSA between single countries [3]. Patient-to-patient transmission in healthcare settings, usually via contaminated hands, clothes, or equipment of healthcare workers, has been a major factor accounting for the increase in MRSA incidence and prevalence in acute care facilities. More and more patients become MRSA-positive, often causing harmless colonization and sometimes causing infection. Special management of these patients is required in a clinical setting. Guidelines for preventing the spread of MRSA mostly recommend contact precautions and isolation of infected or colonized patients in a single room or cohort. These measures include grouping the patients geographically with designated staff. The recommended measures are very complex, time consuming and expensive. Methicillin resistance in S. aureus bacteraemia is associated with significant increases in length of hospitalization and hospital charges, at least partially as a result of the demanded additional measures [4]. A questionnaire analysis from England showed large variations in MRSA policies in ICUs [5]. As a policy, 24% of the ICUs do not isolate their MRSA patients. Also, in Germany, 34% of the ICUs do not isolate MRSA patients in a single room [6]. Fifteen percent of the English ICUs have specified wards that do not accept MRSA patients. These policies lead to a delay in ICU discharge of 63% [5]. The question which arises is the following: is the evidence for recommendations to control the spread of MRSA, especially isolation in a single room, strong enough and does it justify the additional costs, workload and loads for the patients? A before and after study in two ICUs found no tangible benefit from moving patients, in whomMRSA infection had been detected, into cohort-isolation care [7]. However, a major characteristic of this study is the excellent nursing staff of the participating ICUs, with a nurse-to-patient ratio of 3.3–4.3 per 24 h. Obviously in these circumstances, no benefit fromphysical isolation can be expected, since it will not substantially alter the number of contacts with, or proportion of, nursing staff exposed to MRSA carriers. The study shows the possible influence on results by the attendant circumstances. On the other hand, a systematic review of isolation policies found four series providing the strongest evidence that intensive control measures, including patient isolation, were effective in controlling MRSA [8]. Nevertheless, no well-designed study allows the role of isolation measures to be assessed alone. Hand washing is the most effective and economic intervention shown to reduce transmission of pathogens and nosocomial infection rates. Isolation precautions are unable to increase compliance with hand disinfection [9]. Studies have shown that 80% of staff dressing MRSA-infected wounds may carry the organism on their hands for up to 3 h. This carriage can be almost completely eradicated by immediate washing with liquid soap and water after patient contact [10,11]. In the study by Harbarth et al. [12], 1771 new cases of MRSA were reported in 9 years, including 158 MRSA bacteraemias. For the first 4 years, no control measures were in place and the total incidence of new MRSA cases and MRSA bacteraemias numbers rose rapidly. The first 2 years after the introduction of single-room isolation, together with screening and eradication, totalled to a stabilization of MRSA rates and a start in the decline of MRSA bacteraemias. The addition over the next 3 years of a hand-hygiene programme with documented improved compliance coincided with a yearly fall in MRSA bacteraemias rates, to less than one-third of the pre-intervention level. This work provided stronger evidence that an effective Correspondence and offprint requests to: Christine Geffers, Institute of Hygiene and Environmental Health, Charite – University Medicine, Heubnerweg 6, D 14059 Berlin, Germany. E-mail: christine.geffers@charite.de