Skip Navigation


NDT Advance Access originally published online on March 6, 2006
Nephrology Dialysis Transplantation 2006 21(4):835-836; doi:10.1093/ndt/gfl061
This Article
Right arrow Extract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
21/4/835    most recent
gfl061v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (2)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Geffers, C.
Right arrow Articles by Rüden, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Geffers, C.
Right arrow Articles by Rüden, H.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© The Author [2006]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Editorial Comment

Let MRSA-positive patients live a normal life

Christine Geffers and Henning Rüden

Institute of Hygiene and Environmental Health, Charité – University Medicine, Heubnerweg 6, D 14059 Berlin, Germany

Correspondence and offprint requests to: Christine Geffers, Institute of Hygiene and Environmental Health, Charité – University Medicine, Heubnerweg 6, D 14059 Berlin, Germany. Email: christine.geffers{at}charite.de

Keywords: MRSA infections; ICU; preventive infections

Methicillin-resistant Staphylococcus aureus (MRSA) infections have represented a serious burden in the USA and in Japan for years [1,2]. The incidence of MRSA is especially high in intensive care units (ICUs). MRSA is also becoming more prevalent in Europe, but with significant differences in the frequency of MRSA between single countries [3]. Patient-to-patient transmission in healthcare settings, usually via contaminated hands, clothes, or equipment of healthcare workers, has been a major factor accounting for the increase in MRSA incidence and prevalence in acute care facilities. More and more patients become MRSA-positive, often causing harmless colonization and sometimes causing infection. Special management of these patients is required in a clinical setting. Guidelines for preventing the spread of MRSA mostly recommend contact precautions and isolation of infected or colonized patients in a single room or cohort. These measures include grouping the patients geographically with designated staff. The recommended measures are very complex, time consuming and expensive. Methicillin resistance in S. aureus bacteraemia is associated with significant increases in length of hospitalization and hospital charges, at least partially as a result of the demanded additional measures [4].

A questionnaire analysis from England showed large variations in MRSA policies in ICUs [5]. As a policy, 24% of the ICUs do not isolate their MRSA patients. Also, in Germany, 34% of the ICUs do not isolate MRSA patients in a single room [6]. Fifteen percent of the English ICUs have specified wards that do not accept MRSA patients. These policies lead to a delay in ICU discharge of 63% [5]. The question which arises is the following: is the evidence for recommendations to control the spread of MRSA, especially isolation in a single room, strong enough and does it justify the additional costs, workload and loads for the patients?

A before and after study in two ICUs found no tangible benefit from moving patients, in whom MRSA infection had been detected, into cohort-isolation care [7]. However, a major characteristic of this study is the excellent nursing staff of the participating ICUs, with a nurse-to-patient ratio of 3.3–4.3 per 24 h. Obviously in these circumstances, no benefit from physical isolation can be expected, since it will not substantially alter the number of contacts with, or proportion of, nursing staff exposed to MRSA carriers. The study shows the possible influence on results by the attendant circumstances. On the other hand, a systematic review of isolation policies found four series providing the strongest evidence that intensive control measures, including patient isolation, were effective in controlling MRSA [8]. Nevertheless, no well-designed study allows the role of isolation measures to be assessed alone.

Hand washing is the most effective and economic intervention shown to reduce transmission of pathogens and nosocomial infection rates. Isolation precautions are unable to increase compliance with hand disinfection [9]. Studies have shown that 80% of staff dressing MRSA-infected wounds may carry the organism on their hands for up to 3 h. This carriage can be almost completely eradicated by immediate washing with liquid soap and water after patient contact [10,11]. In the study by Harbarth et al. [12], 1771 new cases of MRSA were reported in 9 years, including 158 MRSA bacteraemias. For the first 4 years, no control measures were in place and the total incidence of new MRSA cases and MRSA bacteraemias numbers rose rapidly. The first 2 years after the introduction of single-room isolation, together with screening and eradication, totalled to a stabilization of MRSA rates and a start in the decline of MRSA bacteraemias. The addition over the next 3 years of a hand-hygiene programme with documented improved compliance coincided with a yearly fall in MRSA bacteraemias rates, to less than one-third of the pre-intervention level. This work provided stronger evidence that an effective hand-hygiene programme, allied to single-room isolation, screening and eradication, could reduce MRSA levels and serious invasive infection, even when both were initially present at a high level.

For affected patients, the isolation may have potentially negative consequences, and the possible risks to the critically ill patient inherent in transfer and isolation must be discussed.

One meta-analysis has indicated increased mortality with MRSA, but it is not always possible to extricate the effect of other factors in this analysis, such as delays in instituting appropriate therapy [13]. Some case-control studies indicated that it is the severity of the underlying disease in the patient with MRSA that predicts outcome [14–16]. Critics of isolation policies have raised questions about the quality of care and whether isolated patients receive less attention. For example, isolated patients were less likely than other patients to be examined by physicians during rounds [17]. Another study showed that, compared with non-isolated controls, patients isolated for infection-control precautions experience more avoidable adverse events, express greater dissatisfaction with their treatment, and have less documented care [18]. Patients colonized or infected with MRSA should have the right to the same attention and the optimized individual treatment and care as patients without MRSA.

A strong policy of physical separation alone is not particularly suitable to the control of MRSA. A well-known circumstance is the lack of uniformity in ICUs regarding adherence to basic infection-control procedures. Identification of MRSA-patients as soon as possible is essential to control the spread of MRSA, followed by a rigorous adherence to the standard precautions. Physical isolation of the patient and restriction of movement outside the private room could be a downstream measure. Isolation policies will fail if not appropriately managed and resourced, and we recommend that MRSA management strategies be reviewed by individual hospitals with respect to their available resources and a balanced relationship between costs and benefit. Finding a reasonable way to optimize the search and control of MRSA infections, but not at the expense of the patients, is one of the major tasks in the future.

Conflict of interest statement. None declared.



   References
Top
 References
 

  1. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004; 32: 470–485[CrossRef][Web of Science][Medline]
  2. Kobayashi H. National hospital infection surveillance on methicillin-resistant Staphylococcus aureus. J Hosp Infect 2005; 60: 172–175[CrossRef][Web of Science][Medline]
  3. Tiemersma EW, Bronzwaer SL, Lyytikainen O et al. Methicillin-resistant Staphylococcus aureus in Europe, 1999–2002. Emerg Infect Dis 2004; 10: 1627–1634[Web of Science][Medline]
  4. Cosgrove SE, Qi Y, Kaye KS, Harbarth S, Karchmer AW, Carmeli Y. The impact of methicillin resistance in Staphylococcus aureus bacteremia on patient outcomes: mortality, length of stay, and hospital charges. Infect Control Hosp Epidemiol 2005; 26: 166–174[CrossRef][Web of Science][Medline]
  5. Hails J, Kwaku F, Wilson AP, Bellingan G, Singer M. Large variation in MRSA policies, procedures and prevalence in English intensive care units: a questionnaire analysis. Intensive Care Med 2003; 29: 481–483[Medline]
  6. Gastmeier P, Schwab F, Geffers C, Ruden H. To isolate or not to isolate? Analysis of data from the German Nosocomial Infection Surveillance System regarding the placement of patients with methicillin-resistant Staphylococcus aureus in private rooms in intensive care units. Infect Control Hosp Epidemiol 2004; 25: 109–113[CrossRef][Web of Science][Medline]
  7. Cepeda JA, Whitehouse T, Cooper B et al. Isolation of patients in single rooms or cohorts to reduce spread of MRSA in intensive-care units: prospective two-centre study. Lancet 2005; 365: 295–304[Web of Science][Medline]
  8. Cooper BS, Stone SP, Kibbler CC et al. Systematic review of isolation policies in the hospital management of methicillin-resistant Staphylococcus aureus: a review of the literature with epidemiological and economic modelling. Health Technol Assess 2003; 7: 1–194[Medline]
  9. Kim PW, Roghmann MC, Perencevich EN, Harris AD. Rates of hand disinfection associated with glove use, patient isolation, and changes between exposure to various body sites. Am J Infect Control 2003; 31: 97–103[CrossRef][Medline]
  10. Peacock JE, Jr, Marsik FJ, Wenzel RP. Methicillin-resistant Staphylococcus aureus: introduction and spread within a hospital. Ann Intern Med 1980; 93: 526–532[Abstract/Free Full Text]
  11. Thompson RL, Cabezudo I, Wenzel RP. Epidemiology of nosocomial infections caused by methicillin-resistant Staphylococcus aureus. Ann Intern Med 1982; 97: 309–317[Abstract/Free Full Text]
  12. Harbarth S, Martin Y, Rohner P, Henry N, Auckenthaler R, Pittet D. Effect of delayed infection control measures on a hospital outbreak of methicillin-resistant Staphylococcus aureus. J Hosp Infect 2000; 46: 43–49[CrossRef][Web of Science][Medline]
  13. Cosgrove SE, Sakoulas G, Perencevich EN, Schwaber MJ, Karchmer AW, Carmeli Y. Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a meta-analysis. Clin Infect Dis 2003; 36: 53–59[CrossRef][Web of Science][Medline]
  14. Peacock JE, Jr, Moorman DR, Wenzel RP, Mandell GL. Methicillin-resistant Staphylococcus aureus: microbiologic characteristics, antimicrobial susceptibilities, and assessment of virulence of an epidemic strain. J Infect Dis 1981; 144: 575–582[Web of Science][Medline]
  15. French GL, Cheng AF, Ling JM, Mo P, Donnan S. Hong Kong strains of methicillin-resistant and methicillin-sensitive Staphylococcus aureus have similar virulence. J Hosp Infect 1990; 15: 117–125[CrossRef][Web of Science][Medline]
  16. Marty L, Flahault A, Suarez B, Caillon J, Hill C, Andremont A. Resistance to methicillin and virulence of Staphylococcus aureus strains in bacteriemic cancer patients. Intensive Care Med 1993; 19: 285–289[CrossRef][Web of Science][Medline]
  17. Saint S, Higgins LA, Nallamothu BK, Chenoweth C. Do physicians examine patients in contact isolation less frequently? A brief report. Am J Infect Control 2003; 31: 354–356[CrossRef][Web of Science][Medline]
  18. Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. Jama 2003; 290: 1899–1905[Abstract/Free Full Text]
Received for publication: 15.11.05
Accepted in revised form: 1. 2.06


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Extract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
21/4/835    most recent
gfl061v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (2)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Geffers, C.
Right arrow Articles by Rüden, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Geffers, C.
Right arrow Articles by Rüden, H.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?