The Dynamics, Magnitude and Scope of MRSA Health Care Associated Infection Concomitant with the Politics in the NHS on the Health Act 2006
From Varied Theories, Policy to Recommended Practices
In the indicated foreword letter of Janice Stevens (2008), she announced the target of the Department of Health to halve the number of Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia by this year. As an infection control nurse, this monograph will discuss about MRSA which requires a stringent study to mitigate and control such perpetrated example of a Healthcare Acquired Infections (HCAI) in cognizant with the implemented Health Act 2006 of the National Health Service (NHS) and in relation to the underlying theories and practices in explaining the policy and how will this affects the MRSA issue-area with the help of digesting NHS geopolitics.
Epidemiological issue of interest contextualized with past, current and future saliency: Understanding the dynamics of MRSA, its nature to diagnostic treatment and preventions (First Section)
MRSA was discovered in 1961 in the United Kingdom (UK) that is alternately known in the public as a “superbug” in the wikipedia’s page (2008), while the MRSA Action UK (2008) opined that this is a strain that is very similar to any other strain of Staphylococcus aureus. That is, some healthy people are carriers, and some develop the types of infections. The observed increased mortality in countries like United States and UK was among MRSA-infected patients that resulted to the increased underlying morbidity. According to www.nhs.uk page (2008), MRSA infections are more difficult to treat due to adamant antibiotic resistance of the bacteria. A prevalent cause is when an MRSA bacteria spread from person-to-person contact with someone positive with MRSA infection, or who was colonized by the bacteria.
MRSA infections are most common in Hospital staff and members. The reason for this premise is that they often have an entry point for bacteria to get into their body, such as a surgical wound, a catheter, or an intravenous tube. However, MRSA is treatable which will depend on the bacterium you’re infected with – Staphylococcus aureus (SA) or only colonized. This treatment is in the form of given antibiotics, which you have to complete the course. According to Hawkes (2007) that a quick test for the drug-resistant bacterium MRSA has helped a London hospital to cut infection rates 40 percent in a single year. In addition, the test was able to detect MRSA in nasal swabs in two hours with the help of effective new technologies, such as rapid tests which can help speed the selection of appropriate interventions. Additionally in Verar’s thesis (2008), MRSA has been a significant nosocomical pathogen globally due to its ability to efficiently resist lactam antibiotics and a high expression of heterogeneity among MRSA suggests that confirmatory test by screening is essential for verification.
This is in line with the study done by Keshtgar et al (2007) that aims to establish a feasible and cost-effectiveness report on rapid molecular screening for hospital that have had acquired MRSA in surgical patients. Consequently, the study showed that MRSA positive patients will undergo a suppression therapy of mupirocin nasal ointment and undiluted chlorhexidine gluconate bodywash that resulted into a significant reduction in staphylococcal bacteraemia during the screening period, although a causal link cannot be established is the caveat of the research work. Similarly, a program perpetuated by Dr. Rao (2008) requiring all emergency admissions in University Hospital Lewisham, which has proven to be highly effective strategy for detection of MRSA colonization, has enabled the trust to identify the origin of MRSA-colonized patients, and has informed their strategy to manage high-risk groups appropriately.
A relative study did by Klevens (2007) uses a surveillance methodology in the presence of Active Bacterial Core system (ABCs) that detected incidence rates and estimated number of invasive MRSA infections and in-hospital deaths among patients. In return, the study concludes that invasive MRSA infection affects certain populations disproportionately. On the other hand, Stevens (2008) stipulates that the Department of Health have issued mandatory HCAI surveillance system in the form of Clostridium difficile and have implemented different capacities i.e. changing practice in a sustainable way which requires learning specifically from the causes of infection. The root cause analysis tool was designed by the National Patient Safety Agency (NPSA) to enable teams to learn how infections were caused and how to plan so that they do not re-occur.
In McCaughey’s book (2006), a staunch anti-infection death advocate of the Committee to Reduce Infection Deaths, have established new skeletal recommendations under the Specialist Advisory Committee on Antimicrobial Resistance (established to advise the government):
- Screen all patients admitted to “high risk” units, such as the ICU, cardiothoracic, orthopedic, and burn units.
- Minimize movements of MRSA positive patients.
- Use gowns and disposable aprons when treating MRSA positive patients.]
- Launder privacy curtains or use disposable curtains.
- Decontaminate trolleys and wheelchairs after patient use.
- Before surgery, attempt to decolonize MRSA positive patients.
- In the recovery area, segregate MRSA positive patients.
This was deliberately discussed by Siegel (2006), a total concise control interventions were introduced in explaining and further elaborating the above skeletal recommendations. These included administrative support, judicious use of antimicrobials, surveillance (routine and enhanced), Standard and Contact Precautions, environmental measures, education and decolonization. These interventions were applied in various combinations and degrees of intensity, with differences in outcome. These intervening recommendations were grouped into seven (7) categories, as studies shown by Siegel:
1. Administrative support.Interventions that require administrative support include:
a) Implementing system changes to ensure prompt and effective communications e.g., computer alerts to identify patients previously known to be colonized/infected with MRSA;
b) Providing the necessary number and appropriate placement of hand washing sinks and alcohol-containing hand rub dispensers in the facility;
c) Maintaining staffing levels appropriate to the intensity of care required; and
d) Enforcing adherence to recommended infection control practices (e.g., hand hygiene, Standard and Contact Precautions) for MRSA control.
2. Education.The focus of this intervention was to encourage a behavioral change through improved understanding of the problem MRSA that the facility was trying to control. Whether the desired change involved hand hygiene, antimicrobial prescribing patterns, or other outcomes, enhancing understanding and creating a culture that supported and promoted the desired behavior, were viewed as essential to the success of the intervention.
3. Judicious use of antimicrobial agents.While a comprehensive review of antimicrobial stewardship is beyond the scope of this guideline, recommendations for control of MRSA must include attention to judicious antimicrobial use. Limiting antimicrobial use alone may fail to control resistance due to a combination of factors; including
a) the relative effect of antimicrobials on providing initial selective pressure, compared to perpetuating resistance once it has emerged;
b) inadequate limits on usage; or
c) insufficient time to observe the impact of this intervention.
Strategies for influencing antimicrobial prescribing patterns within healthcare facilities include education; formulary restriction; prior-approval programs, including pre-approved indications; automatic stop orders; academic interventions to counteract pharmaceutical influences on prescribing patterns; antimicrobial cycling; computer-assisted management programs; and active efforts to remove redundant antimicrobial combinations.
4. MRSA surveillance.Surveillance is a critically important component of any MRSA control program, allowing detection of newly emerging pathogens, monitoring epidemiologic trends, and measuring the effectiveness of interventions. Multiple MRSA surveillance strategies have been employed, ranging from surveillance of clinical microbiology laboratory results obtained as part of routine clinical care, to detect asymptomatic colonization. The following were the different surveillance strategies:
b) MRSA Incidence Based on Clinical Culture Results
c) Molecular typing of MRSA isolates
d) Surveillance for MRSA by Detecting Asymptomatic Colonization
5. Infection Control Precautions.Standard Precautions have an essential role in preventing MRSA transmission, even in facilities that use Contact Precautions for patients with an identified MRSA. Colonization with MRSA is frequently undetected; even surveillance cultures may fail to identify colonized persons due to lack of sensitivity, laboratory deficiencies, or intermittent colonization due to antimicrobial therapy. Therefore, Standard Precautions must be used in order to prevent transmission from potentially colonized patients. Hand hygiene is an important component of Standard Precautions.
On the other hand, the Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are transmitted by direct or indirect contact with the patient or the patient’s environment. A single-patient room is preferred for patients who require Contact Precautions. When a single-patient room is not available, consultation with infection control is necessary to assess the various risks associated with other patient placement options (e.g. chortling or keeping the patient with an existing roommate).
6. Environmental measures.The potential role of environmental reservoirs, such as surfaces and medical equipment, in the transmission of MRSA has been the subject of several reports. While environmental cultures are not routinely recommended, environmental cultures were used in several studies to document contamination, and led to interventions that included the use of dedicated non-critical medical equipment, assignment of dedicated cleaning personnel to the affected patient care unit, and increased cleaning and disinfection of frequently-touched surfaces (e.g., bedrails, charts, bedside commodes, doorknobs).
7. Decolonization.This entails treatment of persons colonized with MRSA, to eradicate carriage of that organism through several regimens that include topical mupirocin alone or in combination with orally administered antibiotics (e.g., rifampin in combination with trimethoprim-sulfamethoxazole or ciprofloxacin) plus the use of an antimicrobial soap for bathing. Decolonization regimens are not sufficiently effective to warrant routine use. Therefore, most healthcare facilities have limited the use of decolonization to MRSA outbreaks, or other high prevalence situations, especially those affecting special-care units. Several factors limit the utility of this control measure on a widespread basis:
1) Identification of candidates for decolonization requires surveillance cultures;
2) Candidates receiving decolonization treatment must receive follow-up cultures to ensure eradication; and
3) Decolonization with the same strain, initial colonization with a mupirocin-resistant strain, and emergence of resistance to mupirocin during treatment can occur.