MRSA in the United Kingdom status quo and future developments Dietrich Mack Chair of Medical Microbiology and Infectious Diseases The School of Medicine - University of Wales Swansea P R I F Y S G O L C Y M R U A B E R T A W E U N I V E R S I T Y O F W A L E S S W A N S E A
Incidence of commonly reported causes of bacteraemia in England and Wales 1990-1998 Reacher 2000 BMJ 320:213
Antibiotic resistance in bacteraemia isolates in England and Wales 1990-1998 Reacher 2000 BMJ 320:213
Clinical impact of MRSA on first isolation Colonization 43% Local infection 47% Invasive disease 10%
Incidence of resistant Staphylococcus aureus bacteraemia in Wales and England Griffiths 2004 Health Stat Q 2004 Spring 15-22
Mandatory surveillance system for MRSA Mandatory surveillance of MRSA bacteraemias by acute NHS hospital Trusts began in April 2001 Data published annually Naming performance of individual NHS Trusts
Number of blood culture sets reported in the first three years of mandatory MRSA surveillance CDR Weekly 2004 14:29
Number of total S. aureus and MRSA reports in the first 3 years of mandatory MRSA surveillance CDR Weekly 2004 14:29
Methicillin resistance in Staphylococcus aureus bacteraemia reports*: England, Wales, Northern Ireland: January to December 2003. CDR Weekly 2004 14:16
Number of MRSA/MSSA reports - first three years of mandatory surveillance CDR Weekly 2004 14:29
MRSA rates in different trust categories - the first three years of mandatory surveillance CDR Weekly 2004 14:29
(i) Changes to the mandatory surveillance system for MRSA Mandatory surveillance of MRSA bacteraemias by acute NHS hospital Trusts began in April 2001 Data will now be published six-monthly rather than annually. The first six-monthly dataset was published on 7 March 2005 Together with the previous three years data arranged in a six-monthly format There are two main changes to the mandatory surveillance of MRSA bacteraemia being announced: Monthly reporting of MRSA bacteraemias from 1 April 2005 to monitor Trusts trajectory towards meeting their target (ii) Enhancements to the MRSA dataset. The Department of Health has asked the Health Protection Agency (HPA) to develop a new enhanced reporting system for MRSA bacteraemia surveillance, which will allow the capture of more comprehensive data on MRSA, including information on where the infection was acquired.
The start of the Mandatory MRSA bacteraemia Enhanced Surveillance Scheme: 1 October 2005 Mandatory for all NHS Acute Trusts in England from 1 October 2005 Scheme developed by the Health Protection Agency for the Department of Health Trusts will have access to a website that they can use to enter details about each MRSA bacteraemia episode that is detected in their Trust The existing CoSurv surveillance system is also currently undergoing developments and will be ready to accept MRSA bacteraemia enhanced surveillance information in January 2006. Enhanced surveillance will involve collecting patient details for each MRSA bacteraemia episode: NHS number hospital number date of birth sex patient s location date of admission consultant specialty care details at the time the blood sample was taken
Department of Health Mandatory Bacteraemia Surveillance Scheme - MRSA bacteraemia by NHS Trust
Health secretary announces MRSA target Reduce methicillin resistant Staphylococcus aureus (MRSA) bloodstream infections by 50% in hospitals by 2008 Lowering rates of healthcare acquired infections is a top priority All NHS Trusts will have to draw up comprehensive action plans to prevent or isolate MRSA All Trusts will be tasked with achieving an annual reduction up to and beyond March 2008 CDR Weekly, Vol 14 no 46: News
Emergence of methicillin resistant Staphylococcus aureus (MRSA) bacteraemia among children in England and Wales, 1990 2001 Khairulddin 2004 Arch Dis Child 89:378
Enhanced surveillance of MRSA bacteraemia in children to commence in June 2005 13-month study of bacteraemia in children, caused by methicillin-resistant Staphylococcus aureus (MRSA) United Kingdom and the Republic of Ireland Main aim of the study is to obtain a robust estimate of the incidence of MRSA bacteraemia in children Healthcare workers are encouraged to report cases of MRSA bacteraemia in children aged under 16 years and to ensure that isolates are sent to the Staphylococcus Reference Laboratory, HPA Centre for Infections *LabBase is the database that collects laboratory reports of all microorganisms isolated at nearly 400 NHS and other laboratories throughout England and Wales. The database is managed by the Health Protection Agency.
Austria Belgium Bulgaria Crotia Czech Republic Denmark Estonia Finland France Germany Greece Hungary Iceland Ireland Israel Italy Luxembourg Malta Netherlands Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden United Kingdom 60 50 40 30 20 10 0 MRSA rate in blood cultures in Europe (EARSS 2003) MRSA (%)
Evolution of the monthly % methicillin-resistant Staphylococcus aureus (MRSA) and monthly sum of lagged antimicrobial use Aberdeen Royal Infirmary, January 1996- December 2000 Monnet 2004 Emerg Infect Dis 10:1432
Age-specific Staphylococcus aureus bacteraemia voluntary reporting rates* and methicillin susceptibility per 100,000 population, England, Wales, and Northern Ireland:January to December 2003 CDR Weekly 2004 14:16
Prevalence of MRSA in patients of a university hospital Patients > 65 years sampled on 21st in-patient day Staphylococcus aureus carriers: 120/342 (35.1%) MRSA-carrier: 54/342 (15.8 %) MRSA-rate: 54/120 (45.0 %) 8/54 MRSA-carrier status was unknown before!!!! Risk factors: ampicillin (4.1fold), Ciprofloxacin (17.1fold) Hori et al. 2002 J Hosp Infect 50:25-29
Prevalence of MRSA in elderly people in the community Grundmann et al. Nottingham 0.83 % (8/961) Maudsley et al. London 0.78 % (2/258) Abudu et al. Birmingham 1.50 % (4/274) Risk factors: Hospitalisation in prior 6 month Diabetes Past history of MRSA
Increase in MRSA over time in Oxford hospitals Wyllie 2005 BMJ 331:992
Proportion of MRSA in admission blood cultures positive for Staphylococcus aureus Wyllie 2005 BMJ 331:992
Impact of MRSA colonisation MRSA infection on the ICU No MRSA Colonisation Infection Number (N) 211 54 43 Length of stay (d) 6 12.5 26.5 Theaker et al. 2001 J Hosp Infect 48:98-102
MRSA policies and procedures in English intensive care units MRSA screening on ICU 97% Admission 75% Discharge 11% Transmission form other hospital 86% Routine weekly screens 53% Staff screening on ICU 35% Gloves and apron use with any patient 92% Isolation cubicles 90% < 25% of total beds of ICU 50% MRSA isolation policy not in place 24% Discharge to ward side-rooms All patients 13% MRSA-positive 81% Hails 2003 Intensive Care Med 29:481
Cooper 2004 BMJ 329:533
MRSA acquisition on ICU depending on single-room or cohort isolation of colonized patients Cepeda et al. 2005 Lancet 365:295
MRSA acquisition on ICU depending on single-room or cohort isolation of colonized patients Cepeda et al. 2005 Lancet 365:295
MRSA acquisition on ICU depending on single-room or cohort isolation of colonized patients Cepeda et al. 2005 Lancet 365:295
MRSA acquisition on ICU depending on single-room or cohort isolation of colonized patients Cepeda et al. 2005 Lancet 365:295
Hand hygiene frequency 534 handwashing opportunities (one every 3 min) 237 (8 9 per h) high-risk (moving between patients) 50 occasions hand hygiene was undertaken (21% compliance) Cepeda et al. 2005 Lancet 365:295
Enhanced targeted infection control programme Recognition of the problem by senior staff and their taking responsibility for it Intensive support, education and advice from the infection control team Improved ward and theatre hygiene Pre-admission, admission and weekly MRSA screening Isolation and clearance treatment Nursing care pathways for MRSA colonized patients Teicoplanin plus gentamicin surgical prophylaxis Schelenz 2005 J Hosp Infect 60 104
Enhanced targeted infection control programme Schelenz 2005 J Hosp Infect 60 104
Effect of wearing face masks on MRSA colonisation of health care workers 3 MRSA-positive swabs (%) 2,5 2 1,5 1 0,5 0 Nose and throat Nose, throat, hands Lacey et al. 2001 J Hosp Infect 48:308-311 No mask Mask
Postoperative infection with methicillin-resistant Staphylococcus aureus and socioeconomic background Bagger 2004 Lancet 363:706
Strict adherence to hand disinfection is the most successful and least costly way to prevent crossinfection