MRSA Action UK concern over Department of Health's review of MRSA screening policy
Reports that the Department of Health's flagship screening policy for reducing the risks of contracting MRSA is under review is of concern to members of the charity MRSA Action UK. A report in Pulse Today stated "There is limited available evidence that screening all admissions may cost more than risk based screening, without achieving significantly greater reductions in MRSA, and the Department of Health and Health Protection Agency will review the current MRSA screening policy in the light of evidence provided by the audit, to be carried out this month in each acute NHS trust, are published" The report goes on alleging doubts about the policy and that people refusing to be screened may not have their operation at all, something MRSA Action UK were not aware of.
The Department of Health did not invite the charity to give a view on the plans to review the policy's effectiveness or to contribute to the design of the research. Derek Butler was told by the joint lead on the project that the Department of Health knows that they should have involved the charity.
It is not clear why the Department chose not to involve us, but elements that members of MRSA Action UK felt they could have been involved with included interrogating how effective the programme was at helping patients with the suppression of MRSA if they were found to be MRSA positive. Part of the research considers how Trusts manage the process if patients are treated outside of hospital in advance of their surgery. Although the questionnaire has been distributed to NHS Acute Trusts, it is a voluntary survey which may also result in Trusts electing not to take part.
The charity picks up enquiries from patients who are concerned about MRSA screening and the outcome of the results. The nature of some of the concerns may suggest that the information and discussions patients are having with clinicians prior to surgery and on discharge needs reviewing. The work the charity does is not funded by the Department of Health, those who help out do so as volunteers who have been affected by MRSA, so the charity provides an independent service which would have given a valuable insight into the design of the research.
MRSA Action UK believes the research may be fundamentally flawed if its purpose is to assess the screening policy's costs and benefits without considering the patients' experience of the screening process outside of and beyond the hospital setting. It will be difficult to say with any certainty that suppression treatment is being carried out effectively as local policies on suppression treatment vary, and obtaining the greatest benefit from both the programme and the research is in everyone's interests.
The Department of Health's Impact Assessment on the need for screening assumed 7% of patients will be found to be MRSA positive. Although the Pulse report say the figure is believed to be much lower. However, in the UK recent studies report MRSA colonisation rates of 6-14% of patients admitted to hospital (Karas et al, 2009, Bamra et al, 2009) with one third of patients colonised with MRSA going on to develop an infection (Coia et al, 2006), suggesting the 7% may not have been far off the mark, and other research suggests higher levels depending on the demographic of the patients involved.
In terms of day-case patients there may be a case to screen based on risk, recent research suggests it may not cost-effective to screen all vascular day-case admissions where selective screening for patients previously identified as MRSA-positive, or considered high risk is recommended.
Evidence also suggests that MRSA positive patients who are emergency admissions have higher incidence of MRSA bacteraemias. Therefore, in the view of the charity, evidence points to the need for screening all in-patients. In fact we believe that patients should be screened for MSSA and MRSA simultaneously, this may prove more cost effective and productive, since there are more cases of MSSA bacteraemias than MRSA bacteraemias.
The bacteria that cause MSSA infections are similar to those that cause MRSA, with MSSA being susceptible to a range of antibiotics that MRSA isn't. We believe that because the 'search and destroy' strategy (that is screening and destroying or isolating the bacteria) is being employed on MRSA we are seeing the reductions in the numbers of people with MRSA bacteraemias, and believe the approach should be mirrored with the suppression of MSSA prior to surgical procedures. Furthermore screening on discharge should be carried out to reduce the 'revolving door' syndrome where patients are discharged into the community making healthcare associated infections a problem in primary care, with two-thirds of the infections now being attributed as acquired outside of the hospital setting.
Measures that have brought about reductions in MRSA over the past 5 years include attention to aseptic technique, reducing the use of catheters and cannulas - including the length of time they are left in, and very importantly, attention to hand-hygiene. However, there is a long way to go to get every healthcare worker up to the standard required to bring about sustained reductions in avoidable infections.
Hand-hygiene compliance is still lower than it should be. Busy doctors, including in A&E, where research suggests risks are higher, are still not washing hands between patients. We have witnessed this ourselves, Maria Cann said she was in A&E with her relative recently and was observing very closely as she wished to ensure her relative did not come to any harm. "Although care and attention was being paid to inserting a cannula - which was necessary - I saw that busy doctors and other staff were going from patient to patient without washing hands, and this is something we hear constantly from colleagues and when people contact us for help and advice".
She says "I don't understand why we were not asked to contribute to the screening research earlier on, we have a good relationship with the Health Protection Agency with regard to the weekly information that is provided on MRSA and Clostridium difficile, flagging up any issues with the data if these arise - with our experience and the service we provide to patients we should have been invited to contribute. We did suggest revisions to the research questions when these were made publicly available, to draw on information about the patient experience so that the effectiveness of the suppression could be assessed, but our feedback was not taken into account".
The team undertaking the review told MRSA Action UK a separate piece of research will be conducted in relation to the patient experience of screening in the future and the charity has since been invited onto the steering group to assess the findings of the screening research.
MRSA Action UK believe the 7% assumption by the Department of Health does need to be reviewed, however taking a point in time to assess prevalence, and carrying out only a partial study on the measures taking to suppress MRSA positive patients to judge the cost effectiveness of the 'search and destroy' strategy may prove to be folly. Any such recommendation to reduce the programme would, in our view need much more conclusive evidence, surveillance needs to be enhanced in our view rather than reduced due to the evolving epidemiology of MRSA.
Lessons from History
We need to learn from history. An outbreak of MRSA occurred in three hospitals in East Northamptonshire over a 21-month period (April 1991-December 1992). Four hundred patients were colonised or infected. Seven patients died as a direct result of infection. Chest infections were significantly associated with the outbreak. Twenty-seven staff and two relatives who cared for patients were also colonised. A 'search and destroy' strategy, as advocated in the current UK guidelines of the time, and was implemented after detection of the first case. Despite extensive screening of staff and patients and isolation of colonised and infected patients, the outbreak strain spread to all wards of the three hospitals except paediatrics and maternity. A high incidence of throat colonisation (51%) was observed. Failure to recognise the importance of this until late in the outbreak contributed to the delay in containing its spread. Key parts of the strategy which eventually contained the local outbreak were the establishment of isolation wards, treatment of all colonised patients and staff to eradicate carriage and screening of all patients upon discharge from wards where MRSA had ever been detected.
The 'search and destroy' strategy was employed when the outbreak hit the London and the South East, which worked and eventually contained the outbreak, but this policy was later relaxed in the mid 1990s and the strain became endemic in UK hospitals. Lessons from history, especially recent history need to be learned, in 2004 we had the highest proportion of MRSA in Europe and the 'search and destroy' strategy was introduced along with the other measures we have discussed to deal with the problem. The falling numbers of MRSA bacteraemias suggest this is working, however surgical site, catheter and skin infections remain a problem, including in the community setting, suggesting screening and appropriate treatments should be carried out on discharge from hospital and in the community. GPs need to be alert to patients who present with infections and the associated risks of resistant strains.
Identification of patients colonised with MRSA and subsequent isolation and decolonisation is pivotal to the control of cross infection in hospitals. Recent research in the trail-blazing Heart of England hospital clearly demonstrates the impact of rapid MRSA screening on the transmission of MRSA. Screening of surgical patients using rapid testing resulted in a statistically significant reduction in MRSA acquisition. Proof that isolation and decolonisation is important in its control. Blackpool Victoria Hospital is using the rapid test to screen for MSSA simultaneously.
We would expect that the cost benefit analysis of the flagship screening strategy will also take into account the benefits of rapid screening, as the research questions ask what method of screening was used by hospital trusts, and this is an opportunity to really build on what has been achieved and change the way we think about rapid containment and effective treatment to reduce the burden of the MRSA in hospital and in the community.
Treating MRSA in the community
We believe a patient's MRSA status needs to be known when they are discharged from hospital and treated appropriately, the Department of Health do not recommend an approach of treatments used for suppression being used universally, and rightly so in our opinion, it would be unwise to use what weapons we have to fight the bacteria indiscriminately, as bacteria have a habit of evolving and finding ways to develop resistance to our ever diminishing arsenal.
Recent research on the changing epidemiology of MRSA show that the bacterium is challenging the community and suggests it needs to be fought there to prevent the spread of community acquired MRSA (CA MRSA) into the healthcare system, the study underlines the need for surveillance, typing, and constant reassessment of existing strategies to control MRSA. The study was conducted in Iceland and reflects the changes reported worldwide and the effects of globalization. Because of the islands small size and infrastructural characteristics, Iceland provided an ideal setting for the gathering of complete epidemiological data. In the first half of the study (1 January 2000 to 30 June 2004), there were 9 (13%) CA MRSA cases without healthcare associated risk factors compared to 59 health care-associated MRSA cases. This changed significantly in the second half of the study (1 July 2004 to 31 December 2008) to 51 (59%) CA MRSA without healthcare associated risk factors compared to 35 healthcare associated MRSA. 
We may need to review our guidelines to respond to the need for enhanced surveillance, but putting cost forward as the primary need to review the screening programme as the report implies is not solely what this study should be considering. Patients' lives and putting the patient first is our primary concern.
MRSA Action UK
Registered Charity No.1115672
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