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The document stated that the Government was not on track to meet its target to cut MRSA infection rates.
Kevin Kerr, Consultant Microbiologist and Hon Clinical Professor of Microbiology, Harrogate District Hospital, said:
“The superbug problem has emerged over many years and it is one for which there may be no such thing as a ‘quick fix’. The reasons why we have MRSA are complex – progress in reducing further it should rely on a co-ordinated effort to tackle a wide range of issues.”
Professor Richard James, Director, Centre for Healthcare Associated Infections, University of Nottingham, said:
“C.difficile is undoubtedly a major threat to healthcare systems in the UK and will require drastic improvements in hospital cleaning, the introduction of new technology, better staff training and education of patients to try to reduce the threat.
“The mandatory reporting figures relate to the incidence of MRSA in blood infections. These represent a sever risk to the patient, but are only a small % of the total S.aureus infections in hospital patients.
“The promised reduction in MRSA target does not take into account the very recent emerging threat of community-associated MRSA strains (CA-MRSA) that are now being identified in the UK.
“CA-MRSA strains are distinct from the hospital-acquired ones (HA-MRSA) and infect healthy people in the community and may be more transmissible. Thus far CA-MRSA strains are sensitive to more antibiotics than HA-MRSA strains but it would be surprising if this situation continued due to the extreme selection pressure for resistance that is exerted by antibiotic use.
“The incidence of detection of CA-MRSA in healthy children in Texas, USA is approaching 10%. There is no surveillance of CA-MRSA in the community in the UK although it has already been described as the ‘largest bacterial epidemic the world has seen’.
“Screening of all patients on admission to hospital for surgery, together with isolation nursing until their MRSA status is confirmed, are essential to make a significant reduction in the MRSA figures. At the moment this screening task would overwhelm NHS Microbiology laboratories and there are not sufficient single isolation rooms in our hospitals.”
Dr Ronald R Cutler, Principal Lecturer in Infectious Diseases and Pathology. University of East London, said:
“The fact that MRSA infections are out of control should come as no surprise. Targeting the rise and fall of MRSA bacteraemias only covers a small part of the problem. Carriage and spread from wound infections, staff to staff, patient to patient in hospital environments is still a major problem and other potential ‘hotbeds of infection’ such as nursing homes remain a relative unknown. Current control, hygiene and rapid MRSA detection methods have failed to stop this organism. Recent developments such as the even more antibiotic resistant glycopeptide resistant MRSA (GISA) and the recent spread of the more toxic community acquired MRSA (CAMRSA) with Panton Valentine Leucocidin (PVL) toxin in a hospital does not bode well for the future. More action should be taken to investigate and develop new methods particularly to control spread in hospitals and nursing homes.”
Dr Mark Enright, Senior Research Fellow, Imperial College London, said:
“My view is that it is not surprising that the MRSA target will not be met – I haven’t met anyone in the health services who ever thought it was achievable. The current strategy is centred almost solely on increased handwashing by staff which may have some transient effect on infection rates but the problem of healthcare acquired infections is much more complex and it is here to stay unless the problem is taken seriously.
“Currently hospitals are struggling to contain outbreaks of MRSA and C. difficile and this will only get worse – for example if, as seems likely, nursing staff are made redundant due to financial pressures on NHS Trusts – fewer nurses = more patient contact = increased spread of infections. Measures such as increasing screening and isolation of ‘at risk’ groups would be a good start in addressing the problem but such measures are expensive and will increase waiting lists.”
Dr Andrew Berrington, Consultant Microbiologist, Sunderland Royal Hospital, said:
“The bottom line is that these surveillance schemes are a proxy for what is happening but should not be over-interpreted. Many MRSA and C. difficile infections are a natural consequence of modern healthcare. Many could be prevented by structural improvements. Many could be prevented by rigorous enforcement of basic infection control measures.
“The MRSA target is that MRSA bloodstream infections should be halved – there is no target for MRSA infections as a whole. Doctors have long regarded this as unachievable. This is partly because the data collected include patients admitted with an MRSA bloodstream infection, and also patients whose blood cultures are contaminated with MRSA (ie it was never an infection in the first place). Both of these are problems that can and should be addressed, but the first is not necessarily amenable to prevention by the admitting trust, and the second is a diversion from the real problem. The main concern are those MRSA bloodstream infections that are acquired while under the care of an NHS trust, or that are a consequence of MRSA colonisation acquired while under the care of an NHS trust. Some of these are preventable, first by emphasising basic infection control measures that seek to prevent patients acquiring the organism in the first place (eg hand hygiene, reduction in patient movement etc), and second by reducing the risk that a patient colonised with MRSA will go on to get a bloodstream infection (eg by proper care of intravascular devices). However some, probably most, are not preventable, either because the infrastructure does not exist to stop patients acquiring the organism (eg lack of side rooms, low staffing levels, high levels of patient movement for instance as an unintended consequence of 4 hour A&E waiting times), or because the risk of proceeding to bloodstream infection is inherent in the clinical problem (eg patients need surgery).
“There was also confusion when the target was first set. First it was 50% in three years, then it was 20% year-on-year (which is about 50%), then it was 20% of the total each year (ie 60%), now it’s 50% again. Plus some trusts didn’t report bloodstream infections they deemed contaminants while others did.
“C. difficile is an enormous problem, and is probably getting worse because of the emergence of new strains. However it is fairly meaningless to ask whether it is a bigger or lesser problem than MRSA. The death figures are spurious since they are based on death certificates, which are a poor index of reality. The C. difficile figures are a count of ‘positive tests in over 65s who have a diarrhoeal sample submitted to a lab that follows the rules’, the rules mainly being that all diarrhoeal samples should be tested and no non-diarrhoeal stools should be tested. They don’t include cases in younger patients or cases diagnosed in other ways. They do include patients who might not strictly have C. difficile disease (which by definition requires no other identifiable cause for the problem). The MRSA figures are specifically for MRSA isolated from blood cultures – they do not include other MRSA infections such as wound infections, pneumonia etc, which might be equally serious.”
Dr Alison Holmes, Hammersmith Hospitals NHS Trust and Imperial College London, said:
“Although meeting overall target of 50% is unlikely nationally- there are areas of marked improvement, for instance in London Trusts and in the Acute teaching Trusts there has been a significant decrease in cases, and in our Trust (Hammersmith Hospitals NHS Trust) this has happened in spite of a marked increase in activity.
“It would be more valuable to look at preventing all hospital acquired infections, and providing a safe healthcare system that embeds infection prevention in every aspect of managing a hospital, in every aspect of clinical care, and every step of a patient’s journey.
It should also be realised that prior to beginning of national mandatory reporting, the cases of MRSA blood stream infection had been rising dramatically in England, this has been completely arrested.
“The debate should not just be about the meeting of the target BUT…is the target any help ? I think it has done the following:
1) provided focus on a neglected area in UK acute healthcare, with a major increase in the profile of infection prevention and control
2) provided some valuable external leverage to help drive change in Trusts and resource allocation (ensuring attention even when there are intensely competing priorities)
3) promoting clinician/manager engagement and is beginning to drive organisational accountability and commitment to reduce HAIs as a core priority.”