Misappropriation of resources for MRSA

The evolving epidemic of methicillin-resistant Staphylococcus aureus infections has brought a new wave of concern and reasonable responses on the part of the infectious diseases community.

The public has responded with near hysteria and industry has capitalized on it with the introduction of new antibiotics and shelves of over-the-counter topical antibiotics in pharmacies and even supermarkets.

Alcohol-based hand gels have appeared at the entrance to many restaurants, health care facilities and public bathrooms. The legal beagles have tracked the scent and found their prey in the hospitals where MRSA lives, bringing with them class action lawsuits against health care facilities and individual physicians.

The medical profession has taken notice and has started to work against the MRSA demon with many of the tools and methods used for the plagues of the Middle Ages — such as cloaks, masks, isolation, astringents, prayers (non-denominational) and even vapors. This tool chest has been expanded with modern technologies, including gloves and increasingly rapid assays for this perceived enemy of the people. The applications of historical methodologies and tools appear to be effective when they are properly applied in the hands of the champions of their causes.

The net effect, however, remains limited and circumspect.

A number of lessons have been relearned about infection control that seem obvious in retrospect. One is the value of hand washing, a mantra of epidemiologists, public health authorities, infection preventionists and the specialists in infectious diseases. Word of its value has reached the public, who have embraced the idea, often changing their routines to wash their hands after contact with others whenever the possibility of acquiring this vicious organism reaches conscious levels. Although it is a promising start, this epidemic response has not had the necessary direction and management, and continues to evolve unguided, fueled by anxiety and reflex actions that are often expensive and unproductive.

One example of the overzealous response to the MRSA problem is the feasibility of hand washing for practitioners in a hospital setting. Evidence-based analysis showed it to be of clear value; however, it was calculated that a compulsive nurse in a hospital setting caring for multiple patients would have to spend an hour or more each shift to be compliant. This sudden but late revelation brought attempts to lessen this time and chafing burden with at least a temporary solution of hand gels.

Don’t ignore MSSA

The inordinate concern that the methicillin-resistant strains are far worse than their methicillin-susceptible (MSSA) relatives is another misinterpretation of the facts. The two strains are distinct with respect to antibiotic sensitivities, but most of their family genes are the same, and they are capable of producing nearly the same array of virulence factors, many of which have not been clearly identified as the culprit for their severity.

The perception that MRSA is more costly, lethal and virulent may be largely a result of inappropriate or late therapy with effective antimicrobial therapy. Staphylococcus aureus continues to take its toll on susceptible and fragile hospital patients with now half of the strains being MRSA. It is not clear, however, that MRSA strains actually take more lives than the MSSA strains. The familiar and old MSSA strains have somehow come to be ignored as they have failed to capture the imaginations of even the infection preventionists. MSSA strains are not isolated with the rigor of the fearful MRSA strains, yet both of them likely take more lives each year than AIDS.

Prevention procedures

The policies and procedures that are now being developed and the data being accumulated is inordinately focused on hospital care as the bastion of defense, almost as the castles were for the royalty seeking safety from the pestilences of the plague.

Unfortunately, the problems we face with this epidemic are much the same, with a pathogen that is pervasive,

cannot be contained, and may be an integral part of our bioload that we are just beginning to understand from an infectious disease perspective.

In fact, hospitals are one of the worst places for a person with a staph infection to be, as health care facilities tend to concentrate infections and are the producers and purveyors of most of the increasingly resistant bacteria, viruses, fungi and even parasites.

Virtually all patients in the hospital who grow MRSA on a surveillance or serious culture are subsequently attacked with antibiotics, thereby further selecting the smartest bugs and encouraging them to be even more productive in defending themselves in a desperate and rational interest in survival. As a result, health care providers are faced with finding more tools to treat these resistant infections that are attacking the castle as enemies from within rather than from afar.

Appropriation of funds to address MRSA in hospitals is an area that needs to be consistently evaluated. For example, an increasing amount of money is now devoted to developing procedures that identify colonized patients before they are even admitted to isolate and potentially “decontaminate” them. The ways by which these pariahs are handled varies considerably among hospitals, as there is not a clear, consistent and cost-effective measure to do so.

I am concerned that we are missing the boat and that our focus on MRSA in hospitals is off base.

The reality is that approximately one-third of the population carries S. aureus in and about their noses asymptomatically, and this population brings it and other pathogens into the hospital every day.

Of that, 10% to 20% is MRSA. If you consider the obvious, there are a lot more people who are not in the hospital than in them – about 1,000 to 1, based on crude calculations and data from Google on hospital discharges and length of stay.

We can further extrapolate that most all our efforts at MRSA control are wasted on the 500 inpatients (based on one-third of hospital patients in the 1,500 hospital beds in Hawaii) compared with the 500,000 in the local population (one-third of Hawaii residents) colonized with staph, and the 50 in patients with MRSA compared with the 50,000 people in the community with MRSA.

There is nothing to indicate the MRSA carriage rate in our hospitals is higher than in the community — in fact, we have found that half of wounds among the huge homeless population in Hawaii have staph and 80% of those are MRSA.

If we are to truly vigorously defend our castles against the constant and insidious threat of MRSA, we must band together as health care and social outreach professionals in a more concerted and concentrated effort to address MRSA in community settings.

Alan Tice, MD, is board certified in infectious disease medicine.