Basic procedures can help control MRSA, so why is it still such a problem, asks Angie Mezzetti
Everything to do with MRSA seems to have a string of about three or four letters assigned to it. There is the umbrella term for strains of bacteria, MRSA, which stands for methicillin resistant Staphylococcus aureus and this is abbreviated often by medical people as "staph".
There is also the SARI, HPSC, NHO, IHSAB and the HSE all of which are abbreviations for strategies or organisations that have a role to play - along with the Department of Health and each individual healthcare institution - in bringing down radically the high incidence of the disease in Ireland.
There is also EARRS, the European Anti Microbial Resistance Surveillance System, which compares MRSA rates in different countries.
Despite the list of complicated acronyms associated with MRSA, the solutions, according to experts in the field, are actually quite basic. These include good hygiene - both hand cleanliness and environmental hygiene - at the core, together with the capacity to isolate patients with MRSA, spare bed capacity to cope with outbreaks of infections of all kinds, good surveillance and monitoring, and more careful prescribing of antibiotics.
Basically MRSA is a commonly occurring bug that is resistant to the most widely used antibiotics. About 30 per cent of people normally carry MRSA on their skin or up their noses and it only becomes dangerous when it gets into a cut or an open wound, particularly in someone who is not in the best of health anyway.
There are different strains of it and these are monitored by the National Reference Laboratory for MRSA in St James's Hospital in Dublin. Its director is Dr Brian O'Connell who says that 80 per cent of MRSA is caused by one particular type.
"The strain that is prevalent in Ireland at the moment spreads easily. Infections caused by MRSA are more difficult to treat than infections caused by sensitive staphaureus.
"MRSA can cause a wide variety of infections like localised skin infections to more serious infections in bones, joints, heart valves and also in the bloodstream," he says.
He says MRSA is largely hospital acquired but it is not the only cause of infection. The reasons it has spread include the widespread use of antibiotics, which has led to the development of strains that have learned to resist antibiotics.
Another way MRSA is transmitted is through contact with other people's hands or with the environment. Overcrowding and overworked staff is another factor.
"When problems occur with MRSA the breakdown is usually due to overcrowding and people being too busy to wash hands," says O'Connell.
The next important four-letter word associated with MRSA is SARI - Strategy for the Control of Anti-Microbial Resistance. There are two subcommittees who have each published documents, which are now the blueprints for the HSE on treating MRSA in Ireland.
The first is The Control and Prevention of MRSA in Hospitals and in the Community available through the HPSC website - Health Protection Surveillance Centre. This is the main body in Ireland responsible for the monitoring of communicable diseases.
The second is the Guidelines for Hand Hygiene in Irish Healthcare Settings.
Both of these strategy documents were drawn up by key personnel in this specialised area of the healthcare system and set out best practice for hospitals and care institutes to follow to combat not only MRSA but all infections.
These are effectively the blueprints that all hospitals and healthcare institutions must abide by. However, many in the medical area believe the resources are not yet there to allow these standards to be implemented.
Dr Edmond Smyth, consultant microbiologist at Beaumont Hospital in Dublin, says the bed occupancy issue is a real problem not only in his hospital but also throughout Ireland.
"We operate at over 100 per cent bed occupancy so if we need to isolate a patient or close down a ward, there is no flexibility in the system," he says.
"This applies not only to MRSA but also to the winter vomiting bug. There is no fat and it is even impossible to clean the hospital and work when people are working around you," says Smyth.
"This simply doesn't arise in other countries. We had a visiting colleague from Western Australia who said to us that they just close down a ward when they get these problems and decamp the patients to another hospital.
"We just can't do that because we have a very crowded healthcare system. The Scandinavian healthcare model where they have many patients in two or single bed rooms with an 85 per cent bed occupancy rate consequently has very low rates of MRSA of about 1 per cent compared with 55 per cent in Greece and other Mediterranean countries and 42 per cent here."
O'Connell says when problems occur with MRSA there is usually a breakdown in the control structure due to overcrowding. This is an infrastructural issue so it is important to make sure staff are not too busy to wash their hands.
Screening patients to see if they are carrying the MRSA bug is very important he says and this underscores the necessity of having enough single isolation rooms to prevent the spread of MRSA.
Not all hospital-acquired MRSA is preventable despite all the best efforts he says, but the numbers of cases can be minimised through implementation of proper infection control precautions. "Alcohol-based gels and sprays are useful if the hands are not physically dirty."
According to Dr Anthony Staines, senior lecturer at the Department of Public Health Medicine and Epidemiology at UCD, improving hand hygiene and general cleanliness is only part of the answer and he also believes that lowering the bed occupancy levels is vital.
"A lot of the problem is in overcrowding. In the UK they are aiming for 80 per cent bed occupancy to be able to cope with the MRSA problem."
It is not ideal to work at 100 per cent bed occupancy, he argues, to allow for effective cleaning and management and because MRSA patients need to be kept in isolation.
"The record in Ireland last year was 123 per cent occupancy, if we could even aim for 90 per cent bed occupancy that would be a real improvement," says Staines.
He believes we need better primary care and more hospital beds. "There needs to be one isolation unit per ward and we haven't got anywhere near that."
Staines says that medicine has changed so much in the past 20 years.
"People are in hospital now for two reasons, either they are very sick or they have nowhere else to go - such as Alzheimer's patients," says Staines.
"Most of the time hospital staff and management are running around trying to stop things falling over and are working hard to keep the system together with sticking plasters."
Hand hygiene is crucial, he says, to prevent the spread of infections like the MRSA bugs but sometimes staff may be just too busy.
Smyth of Beaumont says staffing levels will have to improve to tackle MRSA.
"We were very disappointed with the Estimates that more funding was not allocated to implement the SARI report," he says. "According to it we should have three or four microbiologists but we have one and a half. We have three ICM nurses [ Infection Control Nurses], we should have five," says Smyth. "In the lab we are short of five scientists while the workload is increasing. At every front we are falling short."
Things are, however, improving in recent weeks on the general level of hygiene and particularly hand washing in hospitals, according to some healthcare workers, with plenty of posters and information leaflets now visible on wards.
One major incentive for hospitals to improve their levels of hygiene is the arrival of the IHSAB. This new statutory body was set up in 2002 to ensure high standards in all areas of the hospital and healthcare system.
IHSAB stands for the Irish Hospital Standards Accreditation Board. Infection control and cleaning standards are part of its brief and in the new year it will be operating unannounced assessments in all hospitals in the country.
Róisín Boland, the chief executive of IHSAB, says they will be asking hospitals not only about what hygiene standards they have but also what sort of monitoring and surveillance programme they have.
"We will be asking what are the incidence rates for MRSA and other bugs and looking to see if a trend was there. We will also be asking how do you manage outbreaks."
This is being done in conjunction with the HSE.
Another motivating factor for improving standards is the possibility of litigation. John Walsh of John F Walsh Solicitors says he is taking on the cases of several people who have contracted MRSA whose conditions have been horrific.
"There are people who cannot work anymore so there is a loss of income involved and some have lost limbs. We know at this stage that the Department of Health has issued guidelines on the standards of hygiene that are necessary," he says.
"It is also known from the hygiene audit that those guidelines have not been observed in many hospitals. What we have to establish is that standards of care have been at an inappropriate level."
As yet no cases have been through the courts in Ireland.
It is important to remember that the patient is the key person in the fight against MRSA, says Stephen McMahon of the Irish Patients Association.
"By having the hospital hygienically clean demonstrates that the person is the key in the minds of the staff."
Patients and their visitors have a role to play in infection control too, he believes. "They can help by not overcrowding with visitors. We also encourage people to report unhygienic practices or dirty conditions to management. It is a team effort."
Fighting the bugs
Suppliers of hygiene products are lining up to bring new products to healthcare institutions to help fight the MRSA bugs but some say they are still waiting to hear what contract will be awarded.
Some healthcare workers bring bottles of gels and sprays around with them in their pockets but these tend to mess up uniforms. A new hands-free unit is being marketed by a Dublin company, Safe-Stride Europe.
The dispenser has a photocell and is a touch-free hand sanitisation unit. "Everything we handle or touch is a germ carrier," according to Ciaran Sweeney of Safe-Stride, "and we are selling these in all sorts of places ranging from the health service, dentists, catering, delis, and food processing to creches for everything from computer keyboards to counting or handling money."