This article is more than 5 years old. Information may no longer be current.
Treatment protocols for infections, MRSA vary by country, health care system
Click Here to Manage Email Alerts
American and European physicians and surgeons combat surgical site infections and methicillin-resistant Staphylococcus aureus using an array of control procedures that are often not backed by standardized protocols.
Although the plans of attack against MRSA are as varied as the rates of infection in varying countries, all physicians agree that judicious use of antibiotics can greatly reduce the potential for surgical site infection (SSI)-related complications. Knowing rates of infection in the community also is key to managing these infections, said Keith Kaye, MD, MPH, who is an Infectious Disease News Editorial Board member.
“At the moment, we are standardized in terms of measuring and reporting MRSA and SSIs,” he said. “People need to be aware of surveillance data, and epidemiologists and surgeons need to interpret it critically to understand if it is a problem, regardless of the setting or location.”
The United States
Wording on procedures to reduce MRSA rates in acute care hospitals published by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America are vague.
The SHEA and IDSA document states: “Decolonization therapy has also been used in certain patient populations in an attempt to reduce the risk of subsequent S. aureus infection among colonized persons. These populations have included patients undergoing dialysis, patients with recurrent S. aureus infections and patients undergoing certain surgical procedures. Further discussion of this topic is beyond the scope of this document.”
Kaye said that type of wording allows individual health systems to develop and implement protocols to suit their specific needs. Getting too specific with treatment protocols could present problems.
“This is not a one-size-fits-all kind of thing,” he said. “Furthermore, we do not want to see politicians mandating that we have to start screening in all health care settings.”
Kaye said that many steps can be taken before antimicrobials are introduced, including appropriate preparation of instruments, patients and surgical staff, and judicious use of new equipment or procedures that may be linked to higher infection rates. “The kneejerk reaction should not be to use more and broader antibiotics.
“The SHEA and IDSA guidelines say that if you have ‘high’ MRSA rates, you should use vancomycin prophylaxis, but ‘high’ is not really defined,” Kaye said. “Most clinicians and health care system administrators are aware of antimicrobial resistance and take steps to reduce it when developing treatment protocols. This largely eliminates the need for federal mandating.”
The United Kingdom
In the United Kingdom, every trust, or public sector corporation, is mandated to report rates of bacteremia and have those rates meet a certain target.
In a National Health Service (NHS) Department of Health (DH) report published in 2005, the Health Protection Agency Communicable Disease Surveillance Centre found the total number of MRSA-related infections in England’s acute trusts from April to September of that year was 3,580; during those same months in 2001, there were 3,616 infections; 3,584 in 2002; 3,749 in 2003 and 3,525 in 2004.
The DH pointed out in the report that such findings must be “interpreted with care,” and noted the following:
- The individual trust figures do not reflect all MRSA infection or carriage so much as the burden of serious infections associated with MRSA bacteria (or blood stream infections);
- Reports of MRSA infection in a particular trust did not necessarily originate within that trust;
- Trusts vary in specialty and scope — with some of these specialties making them more vulnerable to infection — and so comparing them with one another can be disingenuous;
- During a six-month period, one or two reports in a small trust can cause large fluctuation in that trust’s reported rate.
According to Robert Townsend, a consultant microbiologist with Sheffield Teaching Hospitals in Sheffield, UK, there is often no step-by-step protocol specifically designed to combat or manage MRSA infections, but that all trusts should be adopting a “search-and-destroy approach” to MRSA cases.
“Our guideline simply says to contact the microbiologist,” he said. “The search and destroy screening protocol applies to all admissions to the trust, both elective and emergency.”
According to Townsend, operating such a screening protocol means that surgery can be either delayed to allow decolonization or performed under appropriate antibiotic prophylaxes such as 800 mg teicoplanin and 160 mg gentamycin (eg, teicoplanin/gentamicin).
Townsend credited the screening protocol with being at least partly responsible for making SSIs and MRSA in the United Kingdom less problematic than they have been. He also stressed the role of hygiene in these reductions.
“SSI, particularly with respect to MRSA, is hopefully a decreasing problem in the U.K.,” Townsend said. “If you use the bacteremia rates as a surrogate for severe MRSA infection, then there has been a very real decrease.”
However, SSI and MRSA rates in the United Kingdom remain comparatively high, and Townsend said he was unsure of where to place blame.
He said that the differences between surgical site surveillance and reporting — such as case ascertainment and publication — across the European Union (EU) may be one factor.
“I am not sure whether all EU countries collect and publish the same data in the same way as we do,” he said. Antibiotic prophylaxis procedures may also be different in the United Kingdom than they are in the United States and other parts of the EU, Townsend said.
Bed occupancy rates across the NHS tend to be high “year round,” a fact that can potentially affect infection control practices.
Belgium
The incidence of SSIs depends on the severity of the procedure, according to Christophe Pattyn, MD, PhD, an orthopedist with the Department of Orthopaedic Surgery and Traumatology, at Ghent University Hospital in Belgium. In Belgium, the rate of infections from primary hip or knee procedures is about 1%; revision procedures carry an infection rate between 5% and 10%. MRSA occurs in about 8% of infected cases, he said.
Surgeons in Belgium have also noted a shift in prevalence from S. aureus to Staphylococcus epidermis.
“We are seeing MRSA going down but MRSE going up again,” Pattyn said in an interview. “However, we have the impression that MRSE may begin to go down in two to three years because of prevention programs.”
However, he noted that the incidence of methicillin resistance for both pathogens is estimated at 10%.
Surgeons and nurses have stepped up hygiene protocols to reduce infection rates. Shorter hospital stays also contribute to preventing resistant infections.
“If infection occurs within six weeks after surgery, then we are aggressive to maintain the implant,” he said. “We go back to theater, open the wound, clean it, debride it and, if necessary, we do it again after a week [for] up to three times. If that does not work, then we have to remove the prosthesis.”
The antibiotic treatment typically combines vancomycin and rifampicine. “I think that vancomycin is the most important one,” Pattyn said. “It has good bone penetration when given in adequate doses. Rifampicine works on the biofilm of the prosthesis, but quickly results in resistance when given in monotherapy. Vancomycin also has less chance for resistance compared to rifampicine. But, an objection might be renal failure, so you have to adapt the dose for that problem.”
Germany
About 15% of patients with an infection in Germany will have MRSA, according to Rudolph Ascherl, MD, the medical director of the Orthopaedic Hospital Rummelsberg. In his experience, diabetic foot patients are at high risk for the bacteria, and 35% to 40% of these patients develop an MRSA infection.
Although SSIs and MRSA are growing problems in the country, some surgeons are also noticing more MRSE.
“In my point of view, MRSE is harder to treat than MRSA,” Ascherl told Infectious Disease News. “You cannot decontaminate patients from their skin, and the recurrency rate, in our experience, is as much as in MRSA or a little bit higher.”
He noted that the protocol for preventing and treating MRSA includes proper patient screening, administering prophylaxis and isolating the patient.
To prevent surgical site infections, surgeons commonly use intraoperative doses of vancomycin and rifampin.
Although surgeons in the country are gradually getting a handle on SSIs and MRSA, he noted that the efforts are not enough.
“It costs a lot of money to do all of these screening measures and isolations,” Ascherl said. “Sometimes these patients are not admitted to hospitals because no one wants to admit them. This is a big burden for the hospitals that treat these patients. Sometimes we have up to 14 patients with MRSA.”
Norway
In Norway, the rates of recorded SSI and MRSA are low, according to Eivind Witsø, MD, PhD, a consultant orthopaedic surgeon in the Septic Unit at St. Olav’s University Hospital in Trondheim, Norway.
“According to the Norwegian Surveillance System for Hospital-Acquired Infections, the incidence of superficial and deep postoperative infections after primary total hip arthroplasties are 2.1% and 2.0%,” Witsø said in an interview. “According to the Norwegian MRSA reference laboratorium, there were two MRSA infections registered in the musculoskeletal system in Norway during 2008.”
Patients with MRSA in the country are isolated from the general population, but are otherwise treated in a similar manner as patients with other staphylococci infections. When possible, patients are treated at outpatient clinics, according to Witsø.
“Since antibiotics as we know them today will have less and less importance due to the increasing rate of antibiotic resistance, we have to make other techniques for avoiding infection a priority,” Witsø said.
Molecular epidemiology
Researchers are saving isolates and pathogens on small levels locally, but most SSI surveillance projects that are conducted on a national or multinational level are clinical data that do not involve saving isolates, according to Kaye. Thus, surveillance data on infections are robust, but data on molecular epidemiology are not.
Results of a recent study published in The Lancet indicated that there is molecular heterogeneity in the infecting MRSA strains in Europe.
Although the main burden of MRSA infections on the continent continues to be health care-associated, infections acquired in the community, primarily with USA300, are emerging. The uptick has drawn the attention of European and U.S. health officials.
However, Kaye said that there may not be cause for concern yet. “Certainly the pathogens may be spreading, but there does not seem to be any literature supporting the idea that transmissions are crossing from Europe to the United States, or vice versa. It is not a significant issue.”
ST80-IV remains the most commonly reported strain in Europe, including in Spain and Portugal. In the community, apart from USA300, the ST398-V pig-associated clone recently has been reported more frequently in the Netherlands and Denmark.
Infection rates in some parts of Greece may be similar to rates in the United States; Panton-Valentine leukocidin-positive strains are emerging as a cause of health care-associated infections in Greek hospital settings.
The ST22-IV (EMRSA-15) and ST36-II (EMRSA-16) clones dominate health care-associated MRSA in the United Kingdom. Reports of MRSA infections are sparse and heterogeneous in France, Belgium and Italy, according to the results.
Most carriers of MRSA in Europe are not infected, so many cases remain undetected, according to the researchers. Colonization of other body sites in the absence of nasal colonization is common, which may lead to underestimation of nasal colonization prevalence rates. Cultures for S. aureus may not be done in community or outpatient settings in many countries on the continent. Misclassification of strains may occur as a result of community-associated strains being identified in health care settings.
Kaye said that if CDC wanted to conduct molecular epidemiology, it could, but that the accompanying financial complications may be limiting.
“In the public health vein, knowing what is happening on the molecular level could be helpful in implementing macro-level changes, but for control; but it will not change much for a single hospital.”
As more research is conducted, health care system administrators will have a greater body of evidence on which to draw in developing treatment protocols.
“Current published interventions are quite useful in identifying high risk populations and decreasing risk,” Kaye said. “Beyond that, we simply need continued awareness about MRSA and SSIs being a problem in community and tertiary care hospitals.” – by Rob Volansky, Gina Brockenbrough and Robert Press
For more information:
- Otter JA.Lancet.2010; 10:227-239.doi:10.1016/S1473-3099(10)70053-0.
- MRSA Surveillance System: Results. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_4085951. Published March 7, 2005. Accessed Feb. 8, 2010.
- SHEA/IDSA paper: http://www.journals.uchicago.edu/doi/pdf/10.1086/591061.