To the Editor: I wish to comment on Collignon’s recent editorial on methicillin-resistant Staphylococcus aureus (MRSA).1

The crux of the piece is his argument that what we need is interventional studies, not more studies documenting the extent of environmental contamination. This echoes the sentiment held by me and other colleagues working in the areas of infectious disease, microbiology and infection control. We do need more research and we need good data to evaluate interventions. However, we need to go one step further — a step that can and should be taken now, across the country.

In 2006, I was part of a small team that reviewed the infection control program of a major teaching hospital in New South Wales. It became very clear that what is needed in infection control is a change in governance.

At present, there is little ownership of nosocomial infections by clinicians or hospital administrators. Infection control intervention is perceived as belonging to the infection control practitioners, and not really the business of the doctors, nurses and other health workers who are caring for the individual patient. At worst, this attitude regards the necessary barrier precautions as an annoying, meddlesome burden imposed by some external agency. Clearly, such an attitude is unlikely to result in good compliance with containment measures. Infection control units have a very important role in terms of providing advice, consultancy and monitoring. But as long as there remains a general perception that nosocomial infections are solely the province of these units, progress in control is likely to be slow.

One of the recommendations of our review was to change the governance structure as it relates to nosocomial infection. Elements of this included the following:

• Introducing infection control into the job descriptions of senior hospital executives and heads of departments;

• Conducting performance appraisals of these personnel to include infection control indicators;

• Seeking explicit agreement from all senior medical staff regarding compliance with infection control interventions;

• Requiring all departments to regularly and frequently review infection control indicators; and

• Requiring all departments to have regular, formal education sessions in infection control for all medical and nursing staff, including junior staff.

We need a change in the mindset of clinicians. They must accept responsibility for what happens to their patients, including MRSA infections. These complications are no different from any others their patients may experience during their encounter with the hospital system.

In reply: I heartily endorse Chan’s comments. To control infections in our hospitals, we desperately need not only a change in governance, but also a change in attitude. Chief executives of all hospitals, as well as all clinicians (nurses and doctors), need to take personal responsibility for serious infections that occur frequently in our hospitals. To do so, they also need to know how often these infections occur. We need robust and transparent measures — for example, data on health care-associated Staphylococcus aureus bloodstream infections, including methicillin-resistant S. aureus (MRSA),1 and deep-seated prosthetic joint infections.

In recent years, faced with rising numbers of health care-associated infections, especially MRSA infections, the United Kingdom embraced necessary changes in governance. These included the promotion and use of seven key actions,2 with active surveillance and investigation being the first on the list. One of these mandatory surveillance measures was of all bloodstream infections caused by S. aureus (including MRSA)2,3 and the investigation of all episodes caused by MRSA with a “root-cause analysis”.2,4 There are early indications that the changes have successfully reduced the number of MRSA infections: from a peak of 3955 episodes of MRSA bloodstream infection occurring between October 2003 and March 2004, the number had fallen by over 40% to 2376 episodes in the period April 2007 to September 2007.3

Prevention and control of health care-associated infections must be a core part of clinical governance and patient safety programs in all hospitals. Chief executives and all clinical directors need to be aware of the numerous factors that must be given careful attention in order to reduce health care-associated infections. More importantly, they need to ensure that all appropriate steps are taken to prevent infection. This includes basic issues such as making sure that surfaces in clinical areas are adequately cleaned5 and that hand hygiene protocols are complied with — not just some of the time, but all of the time.