Opinion on Millar et al., ‘Are meticillin-resistant Staphylococcus aureus bloodstream infection targets fair to those with other types of healthcare-associated infection or cost-effective?’

Abstract

Millar et al. 1 Millar M. Coast J. Ashcroft R. Are meticillin-resistant Staphylococcus aureus bloodstream infection targets fair to those with other types of healthcare-associated infection or cost-effective?. J Hosp Infect. 2008; 69: 1-5 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar present the hypothesis that the Department of Health (DoH) target for the National Health Service (NHS) in England to reduce meticillin-resistant Staphyloccus aureus (MRSA) bloodstream infections (BSI) has had a detrimental effect on the control of other healthcare-associated infections (HCAIs). However, their argument is based on a premise that activities focused on reducing MRSA BSI are isolated entities, unique to the prevention and control of MRSA BSI and with no beneficial impact on other HCAIs. Furthermore, they present no evidence that this has in fact happened, whereas there is no doubt that the increased attention to HCAIs and the emphasis on infection prevention and control is having a significant beneficial effect on the delivery of safe healthcare in England. The lead author, Dr Millar, like many of us, has spent much of his professional life as a medical microbiologist in an environment where HCAI and the whole issue of infection prevention and control had a very low priority within the medical establishment and NHS management. Now, however, this issue is at the top of the agenda in all NHS bodies and Trust Boards and their Chief Executives are being held to account for delivering safe healthcare with a zero-tolerance approach to avoidable HCAIs. The authors also suggest that the actions aimed at reducing MRSA BSI would not have any beneficial effect on other HCAIs and might lead to a worsening of the situation. This does not fit with the range of activities that has been put in place in the DoH programme. MRSA BSI is the headline infection, the subject of mandatory reporting since 2001, and represents the most severe end of the spectrum of MRSA infections. It is certainly the focus of performance management within the NHS in England, but the package of guidance and action notes within the DoH programme addresses HCAI issues far wider than MRSA BSI. The increased attention to cleanliness and hygiene is perhaps even more relevant to C. difficile, norovirus and Acinetobacter infection than to MRSA BSI itself. Similarly, the antimicrobial prescribing framework guidance is relevant to C. difficile prevention and control and to all HCAIs that are generally caused by antibiotic-resistant organisms (MRSA, extended-spectrum β-lactamase-producing E. coli, Acinetobacter spp., glycopeptide-resistant enterococci). The Saving Lives High Impact Interventions address all HCAI BSI by attention to aseptic practice and proper intravascular device care, all nosocomial urinary tract infections by attention to urinary catheter insertion and care, ventilator pneumonia due to any bacteria in the ventilator care bundle and all wound infections in the surgical site infection bundle. Furthermore, the basic premises of hand hygiene and aseptic clinical procedures are the right approach to the prevention of any HCAIs. Even the most specific MRSA control measure – the requirement to implement screening for MRSA carriage in all patients admitted to NHS Trusts – is appropriate to the control of all MRSA infections, not just BSI.