MRSA burden and interventions

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Abstract

Infections caused by meticillin-resistant Staphylococcus aureus (MRSA) remain a major problem worldwide. In England, the Department of Health set a target for decreasing MRSA bloodstream infections throughout the country by 50% by 2008, based on the 2003/2004 national figure. To aid hospitals in achieving their individual targets, guidance was provided in the form of care bundles, which were initially related to infection-control practices. Several studies have shown that decreasing the use of fluoroquinolones and/or cephalosporins results in a decrease in MRSA infection rates. In 2007 the Department of Health published guidance on antibiotic prescribing, following which the MRSA bloodstream infection rate dropped more rapidly than in 2006, and the target was met.

Introduction

Meticillin-resistant Staphylococcus aureus (MRSA) infections are a problem across the whole health economy, and have been shown to be associated with a poorer outcome than similar infections caused by meticillin-sensitive strains of S. aureus.1, 2 In England, the number of bloodstream infections rose during the 1990s, and in 2000 the Health Minister announced that reporting of certain healthcare-associated infections, which included MRSA bacteraemia, would become mandatory from April 2001.

The MRSA bacteraemia rates in England peaked in 2003 (Fig. 1). The Department of Health (DH) consequently set a target of reducing the number of MRSA bloodstream infections occurring in hospitals. The target was set at a 50% reduction in the national total of MRSA bacteraemias by 2008, against the 2003/04 baseline.

In 2005 the DH produced guidance for hospitals, which took the form of care bundles, entitled: Saving lives: reducing infection, delivering clean and safe care.3 These high-impact interventions initially focused on infection-control measures for central venous catheter care, peripheral intravenous catheter care, renal dialysis catheter care, urinary catheter care, MRSA screening, and a care bundle for ventilated patients. The introduction of the target and the high-impact interventions, and the support given to hospitals in England by the DH, resulted in a year-on-year decrease in the number of MRSA bloodstream infections (Fig. 2). The decrease was initially small, but increased rapidly during the period 2006-2008.4

Section snippets

Antibiotic prescribing interventions

While infection-control interventions are necessary, interventions involving changes in antibiotic prescribing practices are also important. It is widely recognised that the use of antibiotics provokes collateral damage, i.e. colonisation and subsequent infection with antibiotic- or multidrug-resistant strains of bacteria.

Numerous studies have investigated the antibiotics patients received prior to developing an MRSA infection. Paterson reviewed the literature and concluded that the

Intervention study at the Queen Elizabeth Hospital, King's Lynn

Based on the above-mentioned studies and the SHEA recommendations, an educational intervention study discouraging the use of both intravenous ciprofloxacin and third-generation cephalosporins was performed at the Queen Elizabeth Hospital, King's Lynn National Health Service Trust.13 In this interrupted time series study, the time data were analysed by segmented regression.

An 80% decrease in intravenous ciprofloxacin use, together with a 75% decrease in third-generation cephalosporin use,

Antibiotic prescribing guidance

In 2007 the DH introduced a second clinical target – the reduction of Clostridium difficile infections – together with guidance on antibiotic prescribing, in which the use of fluoroquinolones and cephalosporins was discouraged. It is likely that this guidance, which Cooke and Holmes termed the ‘missing care-bundle’ was at least in part responsible for an accelerated decrease in MRSA bloodstream isolates, and the country meeting the 50% reduction target.14

References (14)

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Funding: LL received an honorarium for writing this article from Wyeth Pharmaceuticals.

Competing interests: LL has received unrestricted educational grants from Aventis, Bayer, GlaxoSmithKline and Wyeth, and honoraria for lectures from Bayer and Bard.

Ethics approval: Not required.

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