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Eurosurveillance, Volume 5, Issue 3, 01 March 2000
Articles
Dutch measures to control MRSA and the expanding European Union

Citation style for this article: Wagenvoort JH. Dutch measures to control MRSA and the expanding European Union. Euro Surveill. 2000;5(3):pii=31. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=31

JHT Wagenvoort
Department of Medical Microbiology, Regional Public Health Laboratory, Heerlen, The Netherlands


The Dutch national policy for the prevention of spread of methicillin resistant Staphylococcus aureus (MRSA) has shown that it is possible to suppress and prevent MRSA from becoming endemic in hospitals. Implementation of effective measures against MRSA will also help prevent the spread of other infections in hospitals. The problem of MRSA would benefit from a common European Union policy.

Staphylococcus aureus causes serious systemic infections such as septicaemia, endocarditis, and wound infections as well as being a common commensal. It is the commonest cause of bacteraemia and is one of the top three causes of hospital acquired infections. Effective antibiotics exist, but between 10% and 50% of patients with staphylococcal septicaemia still die (1). The importance of methicillin resistant S. aureus (MRSA) in comparison with methicillin sensitive strains (MSSA) lies not only in their resistance to all beta-lactams but also in their resistance to various other important antimicrobials. The major threat is that MRSA strains seen in hospitals have epidemic potential and add to the pre-existing hospital acquired MSSA infections instead of just replacing them. In past two decades MRSA has spread worldwide, becoming an endemic inhabitant of many hospitals (2). The pathogenicity of MRSA is similar to that of MSSA, but the increasing number of infections in the hospital setting, higher mortality, and additional costs also contribute to the burden of human suffering (3).

MRSA is an important component in the risk profile of the hospital inpatient. Vulnerability to MRSA colonisation and infection increases with the duration of hospital stay, intensive care treatment, previous antibiotic treatment, and previous stay in another hospital where MRSA was present. Surgical wounds and catheters provide easy entry points for staphylococci and local standards of hygiene also affect the risk.

Methods

How have Dutch hospitals brought MRSA under control? Over ten years ago the Working Party for Infection Prevention produced guidelines for the containment of MRSA (4), which have been endorsed by the Health Inspectorate. The mainstay of the guidelines is a ‘search and destroy’ strategy.

  • All patients with MRSA are isolated in private rooms.
  • Patients from foreign hospitals and suspected MRSA carriers are screened and isolated.
  • Contact patients and also health care workers are screened.
  • MRSA positive contacts are treated with body washings with either 4% chlorhexidine liquid soap or 7.5% polividone–iodine shampoo and mupirocin nose ointment, which may lower the bacterial load and therewith the degree of spread. (Healthy people who are usually MRSA positive, presumably most health care workers, are usually decontaminated with such treatment applied for five days.)

Small numbers of MRSA can be identified by taking samples twice within 24 hours of nose, throat, sputum, perineum, urine, skin lesions, and wounds, and culturing using enrichment broth (5). The movement of MRSA carriers between hospitals generates a warning. The policy is for such patients to be readmitted to the same hospital as far as possible. The efforts of infection control practitioners and clinical microbiologists are vital.

Results and discussion

A report on MRSA in Dutch hospitals since the MRSA guidelines were implemented has shown that ‘only small outbreaks occur’ (6). How was this achieved? New MRSA patients registered by the National Institute of Health and the Environment (RIVM) have increased from about 100 in 1988 to around 250 in 1997 (6). Further investigation using questionnaires sent to hospital infection control nurses or infection control committees of the hospitals showed that the number of MRSA clusters rose from 18 to 39 between 1992 and 1997, but the number of cases per cluster remained below ten for 90% of the clusters. Thus, events that could have developed into large outbreaks were successfully quelled. Investigation into the origin of the MRSA from the index patients of clusters revealed that introduction from a foreign country could be established in only a third of index cases. The origin of most index cases was in the Netherlands or remained unknown. This could imply that a ‘national source reservoir’ has developed (6). Around 50% of the MRSA strains detected in the index patients belonged to the well known outbreak strain of phage type III-29. Only 0.5% of S. aureus cultured and monitored by a national surveillance network are MRSA (7).

Another backbone in the prevention of resistant bacteria is the implementation of a strict antibiotic policy in Dutch hospitals. This is steered by local committees and many hospitals produce their own formularies with lists of ‘first choice’ compounds and their indications for use. Rates of resistance of clinically important bacteria are low (8) and older antibiotics continue to be first line drugs in the treatment of serious infections, including those on intensive care units. Resistance problems encountered on these units can spread quickly through a hospital. In response to a MRSA threat, what is the management approach? Containment measures should be ordered and the local ad-hoc MRSA team should convene. The board of directors, medical specialists, nurses, and other health care workers of the hospital are asked to cooperate with, if necessary, additional measures including closure of wards. As many clinicians think that the spread of MRSA in Europe and is inevitable and that resistance is useless, this is no easy task. Reappearances of MRSA are not unusual due to its sustained survival in the inanimate environment (9) and (sometimes prolonged) colonisation of other patients (10). The outcome of this management policy so far is that ‘MRSA is not stronger than hospital hygiene’.

If MRSA becomes endemic, it is almost impossible to get rid of it, even if wards are closed for weeks at a time. In such situations revision of the counteracting measures and adaptation of a more lenient approach to local preferences have been applied according to a risk-assessment approach (11). The Danish example - close national cooperation in preventive isolation, mutual warning system, and antibiotic policy - has shown that it is not quite impossible to reverse a ‘lost cause’ (2). If you can quell your MRSA problem, problems with other resistant bacteria will be relatively easy to manage.

Conclusion

What are the future trends? The implications of MRSA with intermediate resistance to vancomycin is a subject that generates much discussion, as is community spread of MRSA with and without hospital mediation (12). Could MRSA follow the pattern of spread of penicillin resistant S. aureus in the 1950s, spreading in the general population about a decade after its first appearance in hospital, whereby hospital infections seeded the population with antibiotic resistant staphylococci? Seven main reasons to continue the struggle against MRSA are listed in the table. The threat of MRSA will remain a continuing challenge for hospital management. Implementation of measures against MRSA will improve the hygiene generally and lower the levels of bacterial resistance in hospitals against other antimicrobials. The forthcoming possibility created by European Union (EU) policy and European judges to allow free choice of health care outside national borders (13) will increase the potential for spread of MRSA, but the Dutch policy of MRSA containment will continue to benefit patients (2,3). The problem of MRSA needs more than national solutions, however, it requires effective guidance, initiatives, and support by leading policy institutions of the EU.

Table 1. Seven reasons for continuing the struggle against MRSA in the hospital

 

  • Once entrenched in an institution, MRSA is nearly impossible to eradicate
  • MRSA adds to the existing rate of - severe and expensive - S. aureus infections
  • MRSA is at least as virulent as its methicillin sensitive counterpart (MSSA)
  • Sick patient is vulnerable to persistent colonisation and infection
  • Environmental contamination and survival favours endemic settlement
  • MRSA can be contained!
  • Hospital hygiene mirrors total hospital quality management

References

1. Mylotte JM, McDermott C, Spooner JA. Prospective study of 114 consecutive episodes of Staphylococcus aureus bacteremia. Rev Infect Dis 1987; 9: 891-907.

2. Wagenvoort JHT. Resistente Bakterien: ein schwerwiegendes Problem fur die Krankenhaushygiene im vereinten Europa. Hygiene Medizin 1999; 24: 65-70.

3. Rubin RJ, Harrington CA, Poon A, Dietrich K, Green JA, Moiduddin A. The economic impact of Staphylococcus aureus infection in New York City hospitals. Emerg Infect Dis 1999; 5: 9-17.

4. Working Party for Infection Prevention. Management policy for methicillin-resistant Staphylococcus aureus guideline. No 35a. Leyden: Stichting Werkgroep Infectie Preventie, 1995. (http://www.wip.nl)

5. Wagenvoort JHT, Werink TJ, Gronenschild JMH, Davies BJ. Optimization of detection and yield of methicillin-resistant Staphylococcus aureus Phage type III-29. Infect Control Hosp Epidemiol 1996, 17: 208-9.

6. Leeuwen van JW. MRSA in Dutch hospitals: 6 years of surveillance. Infectieziekten Bulletin 1998; 3: 51-4.

7. Neeling de AJ, Leeuwen van WJ, Schouls LM, Schot CS, Veen-Rutgers van A, Beunders AJ, et al. Resistance of staphylococci in the Netherlands: surveillance by an electronic network during 1989-1995. J Antimicrob Chemother 1998; 41: 93-101.

8. Endtz HP, et al. Surveillance of antimicrobial resistance in the Netherlands, 1994-98 (Poster P856) 9th European congress of clinical microbiology and infectious diseases. Berlin, 21-24 March 1999. Clinical Microbiological and Infection 1999; 5(suppl 3): 314-5.

9. Wagenvoort JH, Davies BI, Westermann EJ, Werink TJ, Toenbreker HM. MRSA from air-exhaust channels. Lancet 1993; 341: 840-1.

10. Wagenvoort JHT, Toenbreker HMJ, Werink TJ, Berendsen HHG. Once MRSA, always MRSA? Setting up a hospital patient pre-admission questionnaire. Infect Control Hosp Epidemiol (accepted for publication)

11. Working Party Report. Revised guidelines for the control of methicillin-resistant Staphylococcus aureus infection in hospitals. J Hosp Infect 1998; 39: 253-90.

12. Wagenvoort JHT, Kepers-Rietrae M. Methicillin resistant Staphylococcus aureus (MRSA) as a community strain. Eurosurveillance 1997; 2: 96-7.

13. Struelens MJ, Ronveaux O, Jans B, Mertens R. Methicillin-resistant Staphylococcus aureus epidemiology and control in Belgian hospitals, 1991 to 1995. Infect Control Hosp Epidemiol 1996; 17: 503-8.



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