View of Seattle from HarbourviewMaybe half of you have heard of
MRSA; the other half, including me, have not until now.
MRSA is a methicillin-resistant bacterium.
Methicillin is a successor to and subset of penicillin but as it is toxic to humans and unstable compared to
oxacillin, then the latter is the more preferred treatment. However, the term MRSA is generally used for the bacterium resistant to a wide range of antibiotics.
The problem is this:
In hospitals, patients with open wounds, invasive devices, and weakened immune systems are at greater risk for infection than the general public.
So to the story. Harborview Hospital, in Seattle, had an outbreak of MRSA in 1980, the bacterium being known about since 1968. The standard response is to isolate and decontaminate, using gloves etc. A summary:
But in October, Harborview moved patient No. 9 from the burn unit into the surgical intensive-care unit. There, the germ skipped to the patient in an adjacent bed — the outbreak's patient No. 10. Only in November — five months after Hurst's arrival — did Harborview begin systematically isolating patients.
By then, it was too late. From No. 10, the contagion exploded in the surgical ICU, then swept into the rehabilitation ward. By March 1981, the germ infected or colonized 19 more patients, all linked, by molecular fingerprint, to patient 10.
Nine months after Hurst's arrival, the germ's spread seemed to stop. April passed with no new cases. But in May and June 1981, the pathogen resurfaced — and in an unexpected place: a new burn unit full of patients who had no known contact with the outbreak's previous victims.
Doctors have known since the 1800s that hospital personnel can exacerbate infections by carrying germs from bed to bed and ward to ward. But only now — one year after Hurst's arrival — did Harborview test 182 doctors, nurses and therapists for MRSA.
End of story? No. The University of Virginia hospital also had an outbreak at the time:
The hospital began hunting the germ, screening patients at high risk of getting MRSA — trauma patients, burn patients, any patients with wounds on their skin. Colonized or infected, anyone with the germ was isolated. Right away, the hospital's MRSA cases dropped, from 33 a month, to 25, 21, 19.
ADI
ADI, also known as "active surveillance" and "search and destroy," has split the medical community. Here and there, hospitals would adopt active detection — with stunning results. In the late 1980s, Shadyside Hospital in Pittsburgh eliminated MRSA's spread within five months; its entire screening program cost about as much as treating a single MRSA victim.
However, most hospitals balked at adopting the screening technique:
They advocated broad measures — for example, reinforcing the need for doctors and nurses to wash their hands — that could reduce hospital infections overall.
CDC
Since the 1980s, the "Centers for Disease Control and Prevention" [Atlanta] has issued at least 14 sets of infection-control guidelines for hospitals. Added up, they provide 1,333 recommendations — a bewildering, sometimes inconsistent thicket of alternatives: try this, then that, or if not that, maybe the other thing. ADI has been relegated to maybe the other thing — not dismissed out of hand, nor urged as a matter of routine.
Harborview revisited
While the CDC deliberated, MRSA escalated. The CDC's 2006 recommendations had followed six years of meetings, drafts and revisions. In those same six years, the number of Washington hospital patients with MRSA jumped from 815 a year to 4,643, patient discharge data shows.
Harborview has special problems:
When medical helicopters pick up accident victims clinging to life, they fly them to Harborview, the Pacific Northwest's premier trauma center. Harborview also helps the down and out — prisoners, the mentally ill, people with substance-abuse problems [... and so on.]
On Oct. 16, 2007, the CDC issued a press release that hit like a thunderclap, touching off fear and uncertainty. The agency's experts revealed, for the first time, that MRSA was now killing more people than AIDS. Without a mandatory reporting system to draw upon, the CDC reached its numbers by extrapolating from nine sites — cities and counties mostly.
Whilst Harborview adopted the surgical glove procedure, it still refused to adopt the screening and isolation:
What's more, the hospital's guidelines allowed patients with MRSA to share a room with those not already infected. Harborview "does not routinely isolate patients with MRSA colonization or infection at this time," the guidelines say. If Harborview can't find a MRSA patient a private room, it pairs MRSA patients. Failing that, the hospital will room a MRSA patient with someone who isn't infected or colonized.
By now, it would be fairly obvious to you that one of the main reasons for the balking of hospitals at isolating MRSA carriers among patients is bed numbers and the layout of the hospital rooms, i.e. capacity and that has some validity. The reason it won't stop medical staff moving from room to room is economic, in this difficult climate. That seems less valid.
Can Harborview's situation be extrapolated to include hospitals in the UK? I can't see any reason why not, especially when that hospital is not placing intake criteria on patients, i.e. it is an NHS hospital.
So we have, in the end, a known approach, ADI which, on the stats, seems to be most effective in stopping a bacterium which is "now killing more people than AIDS" and yet, for administrative reasons, is not being adopted and is being fiercely resisted at that.
