COMMENTARY

A Reader and Author Respond to "Spread of MRSA: Past Time for Action"

Dixie Swanson, MD, FAAP; Thomas Ward, MD

Disclosures

May 23, 2008

To the Editor:

I'm a retired pediatrician, and 2 things happened recently that made me wonder whether we are missing a vital point in infection control: making sure that patients are fully bathed every day.

My niece has had 3 bouts of gram-negative sepsis because of an underlying autoimmune disease (HLAB27 + enteropathic spondyloarthropathy). I've spent many a night at the hospital with her. No one except her mother or I ever bathed her. Even in the ICU [intensive care unit], no one bathed her, even though she was sweaty and febrile. (The nurse had time to read the newspaper, though!)

On one admission, she'd been ill at home for several days, and when I got her to the hospital, I helped her shower and shampoo her hair before I got her settled in her room. She was in need of a bath. I wonder how many patients get admitted "dirty." Think about it: If you are sick at home, taking a bath is a lot of work -- it's tempting to skip it. I'll bet that many emergency admissions are of people who have not bathed in 24 hours.

Here are my questions:

  1. Is cost-cutting resulting in patients going unbathed in the hospital? Does this affect infection control? Years ago, every patient got a bath every day, whether they wanted one or not! I think that aides may offer to help someone "clean up," but they are likely thrilled to avoid the hassles of bathing or showering a patient.

  2. Would it be a good idea to do a "decontamination" shower/shampoo on admission to help keep outside germs outside the hospital?

I don't keep up with the literature, but I've asked a few docs I know about these 2 things and they don't know the answers. I think we might be overlooking a big link in infection control.

You'd be in (1) a position to know about these things, and (2) you've got a great bully pulpit to do something about them. Keep up the good work.[1]

Dixie Swanson, MD, FAAP
dixie.swanson@hotmail.com

Reference

  1. Ward T. Spread of MRSA: past time for action. Medscape J Med. 2008;10:32. Available at: http://www.medscape.com/viewarticle/569312 Accessed May 8, 2008.

Author's Response:

To the Editor:

In a recent Medscape editorial, I encouraged that more should be done to control the spread of infection due to methicillin-resistant Staphylococcus aureus (MRSA) within hospitals and the community.[1] Individual responses to my call for more concerted efforts to curtain the spread of this infection were diverse in nature. Included in the comments I received were suggestions that imposing the broad use of isolation practices in hospitals was inconvenient and maybe draconian for patients; that attention to good hygiene had declined throughout our society over the last several decades; and, in addition, several people were concerned with what they believed might be incompletely diagnosed and treated MRSA infections.

Preventing the spread of MRSA infection is the subject of considerable research and discussion. The CDC [US Centers for Disease Control and Prevention] study of severe, or invasive, MRSA infections performed in 2005 that I mentioned in my prior "call for action" has now been updated with new information for the next calendar year.[2,3] In comparison with 2005, CDC researchers reported a 5.8% decline in severe cases of MRSA in 2006. The decline noted was primarily in hospital-associated infections, with little change in the frequency of community-acquired infections. Could this be related to increasing efforts within hospitals to prevent the transmission of MRSA spread? An important study, done at 3 Northwestern Hospitals in Chicago, Illinois, recently reported that adoption of a MRSA screening program performed on all hospitalized patients, coupled with using isolation measures to prevent spread of infection, resulted in a 70% decline in hospital-acquired MRSA rates.[4] Although there remains controversy on the benefits vs costs for use of aggressive MRSA surveillance and containment methods within US hospitals, this study is supportive of the more broad-based approaches long used in most European healthcare facilities.

Over 150 years ago, Florence Nightingale debated with healthcare authorities over the importance of basic hygiene and ventilation to prevent infections within healthcare institutions. Today, there is widespread acceptance of the importance of attention to personnel hygiene and environmental cleaning in curtailing many of today's emerging infections, such as vancomycin-resistant Enterococcus (VRE), Clostridium difficile, and norovirus. Yet, preoccupation with hospital budgets and resultant effects on staffing levels has limited the time nursing staff have for direct patient care and other functions that relate to hospital hygiene. Today, nursing staff have not only the responsibility for cleaning patients, but also for cleaning many of the at-risk portions of the hospital environment. One response from a reader of my recent MRSA commentary was a suggestion that today's hospitals seemed less clean than 30 years ago. Others have echoed this concern over the state of hygiene in our hospitals.[5] Even if we had excellent compliance with handwashing by healthcare personnel, which we don't, the improvements we gain in better hand hygiene are limited in their effectiveness by a potentially heavily MRSA-contaminated hospital environment.

There are downsides in using terms, such as superbug, to describe multiple antibiotic bacteria, such as MRSA. One danger posed by such informal terms is in engendering unnecessary fear in people who become overly concerned about acquiring infection. In fact, we know that most patients who have acquired severe MRSA infections have not just had hospital contact, but also have had either prior surgical or other invasive procedures, and/or have serious, underlying chronic heath conditions. At-risk individuals for severe MRSA infection are a minority of the population. Another potential downside to the use of terms, such as superbug, is that it may encourage some people to seek out antibiotic therapy. Antibiotic-resistant organisms exist because of the pressures of antibiotic use, use that in many instances is likely unnecessary. We would not have antibiotic resistance if we did not use antibiotics. The danger in being too concerned about MRSA or other multiresistant infections is that such worries may increase antibiotic administration, only making for more problems of antibiotic-resistant microbes. The NIH [National Institutes of Health] guidelines on preventing community-acquired MRSA infections (http://www.nlm.nih.gov/medlineplus/mrsa.html) provide practical and commonsense approaches to good hygiene in the home. Those guidelines should be coupled with efforts by patients and their practitioners in being cautious about when antibacterial agents are used.

Good science, adherence to evidence-based guidelines, and compliance with commonsense basic principles of hygiene will allow us to move forward in the global efforts needed to control multiresistant pathogens, such as MRSA.

Thomas Ward, MD
Chief, Infectious Diseases
Portland Oregon VA Medical Center
Portland, Oregon
wardt@ohsu.edu

References

  1. Ward T. Spread of MRSA: past time for action. Medscape J Med. 2008;10:32. Available at: $$www$$/viewarticle/569312 Accessed May 8, 2008.

  2. Klevens RM, Morrison MA, Nadle J, et al; Active Bacterial Core surveillance (ABCs) MRSA Investigators. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA. 2007;298:1763-1771. Abstract

  3. Fridkin S, Bulens S, Zell E, et al. Decreased incidence of nosocomial invasive MRSA infections reported through population-based surveillance in 9 metropolitan areas in the US, 2005-2006. Program and abstracts of the 18th Annual Scientific Meeting of the Society for Healthcare Epidemiology of America; April 5-8, 2008; Orlando, Florida. Available at: http://www.cdc.gov/ncidod/dhqp/SHEA_Abstract3.html Accessed May 13, 2008.

  4. Robicsek A, Beaumont JL, Paule SM, et al. Universal surveillance for MRSA in three affiliated hospitals. Ann Intern Med. 2008;148:409-418. Abstract

  5. BBC Frontline Scotland. Dirty wards blamed for superbugs. BBC News Web site. June 3, 2003. Available at: http://news.bbc.co.uk/1/hi/scotland/2958362.stm Accessed May 8, 2008.

 


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