Letters
Infectious diseases
Volume 188 - Issue 1

Methicillin-resistant Staphylococcus aureus in hospitals: time for a culture change

Authors:  Peter J Collignon, M Lindsay Grayson and Paul D R Johnson

Med J Aust 2008; 188 (1): 61-64. || doi: 10.5694/j.1326-5377.2008.tb01518.x
Published online: 7 January 2008
Download PDF (327 KB)
Share: Share on Blue Sky Share on Facebook Share on LinkedIn Share by email

In reply: We thank Woollard for his comments on hand hygiene. While important, hand hygiene is just one component of what is needed to decrease the spread of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals. Decontamination of the environment, contact precautions for colonised patients, active surveillance and screening, effective programs to prevent common infections such as intravascular catheter sepsis, good antibiotic stewardship and better hospital design are also indispensable.1

We do not accept that “There have been no properly controlled trials, with clinically important endpoints, of currently recommended hand-hygiene practices”. For instance, the recent study quoted by Woollard showed that hand hygiene reduced infections hospital-wide, using the clinically important endpoint of serious bloodstream infections (MRSA and antibiotic-resistant gram-negative bacteria).2 Thus, at least two large peer-reviewed studies show that alcohol-based hand-hygiene programs reduce hospital-acquired MRSA infections2,3 (Level III evidence4).

There is nothing wrong with using disposable gloves, as suggested by Woollard, provided they are changed every time a health care worker moves between patients. Otherwise, gloves spread MRSA just as efficiently as unclean hands. Applying good-quality hand-hygiene products is less cumbersome than changing gloves and also allows direct human contact, which Woollard reminds us is important to patients.

How MRSA is spread in hospitals is now well known — our problem is getting health care workers to remember to practise good hand hygiene all the time, every day, before and after every patient contact.

The data shown by Ferguson and Van Gessel reaffirm how common and serious a problem we have with MRSA bacteraemia. They estimate there are about five episodes per 100 000 people annually across Australia. However, we believe that the true rate is double this.

The rate of S. aureus bacteraemia (ie, MRSA and methicillin-sensitive S. aureus combined) in Australia is around 35 per 100 000 per year,5 with 27% caused by MRSA.5 This crudely translates to an MRSA rate of 9.5 per 100 000. The rates are probably much higher in the states with more health care-acquired MRSA (New South Wales and Victoria). More recent data suggest that 36% of hospital-acquired invasive S. aureus infections were caused by MRSA, with the highest percentages in NSW (41%) and Victoria (39%).6

It is also worth noting that, when MRSA bacteraemia became notifiable in England in 2001, there was a 50% increase in reported S. aureus bacteraemia episodes.1 This suggests that under-reporting is common in any voluntary reporting scheme, and is also likely for Australian data.

Worryingly, Chen and colleagues point out that MRSA is an even bigger problem in the United States than in Australia. However, we are not far behind.6 Although we share their concerns about legislative impositions, some external controls and measurements can be an advantage. Western Australia, the only Australian state where MRSA is notifiable, has the lowest rates of health care-associated MRSA. While we do not want imposed “one size fits all” legislated controls, we do need change: the practice of the past 40 years has not worked. Every institution needs to have an effective MRSA control program, with components chosen according to the local situation. Institutions should measure MRSA and report centrally, especially if their rates are high and not falling continually (eg, over a year). Shop-floor quality improvement programs with empowered workers are much better than top-down management-imposed regulation (eg, from government).

We need to shake our complacency and that of our health care colleagues, accept clinical leadership and take control. Otherwise, legislative controls will be imposed on us.

Authors

  • Peter J Collignon1
  • M Lindsay Grayson2,3
  • Paul D R Johnson2,4
  • 1. Infectious Diseases Unit and Microbiology Department, Canberra Hospital, Canberra, ACT.
  • 2. Infectious Diseases Department, Austin Health, Melbourne, VIC.
  • 3. Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC.
  • 4. Department of Medicine, University of Melbourne, VIC.

Correspondence: Peter.Collignon@act.gov.au

References

View this article on Wiley Online Library