Cleaning up their act? By Seamus Ward

24 Mar 05
The MRSA superbug has struck fear into the hearts of hospital patients throughout the UK. But now, with an election expected, the government claims the health service is winning its battle against the drug-resistant bacterium. Seamus Ward investigates

25 March 2005

The MRSA superbug has struck fear into the hearts of hospital patients throughout the UK. But now, with an election expected, the government claims the health service is winning its battle against the drug-resistant bacterium. Seamus Ward investigates

The panic over the MRSA 'superbug' reached fever pitch in the past few weeks, replacing deep vein thrombosis and Sudan 1 as the public's top health scare. The rise of methicillin-resistant Staphylococcus aureus has been blamed on 'dirty' hospitals, and there have been calls to 'bring back matron', conjuring up images of an unseen tide of deadly microbes being turned back by a disapproving glance from Hattie Jacques, the matron of Carry On fame.

However, it is a serious problem. Only this week, an NHS hospital was accused of a 'cover-up' over the death of a two-day-old baby from the superbug. Figures show that the UK and Greece are running neck and neck as the European countries with the highest incidence of blood-borne MRSA. The public is frightened and confused – feelings heightened by the manoeuvrings of the various interest groups and politicians determined to make the bacterium a main battleground in the expected upcoming election.

Unison blames the spread of the bacteria on hospitals contracting out cleaning. The Conservatives blame NHS targets for preventing the closure of affected wards and have promised to hand this power to matrons.

Conservative leader Michael Howard – whose own mother-in-law died from the superbug – says death certificates mentioning MRSA rose from 487 in 1999 to 800 in 2002 and 955 in 2003. He claims it was involved in two in every 1,000 deaths in NHS hospitals and three in every 1,000 in NHS nursing homes, compared with one in 1,000 deaths overall between 1999 and 2003.

The government says figures published by the Health Protection Agency show it is conquering the problem. But these figures are controversial. NHS hospitals have been compelled to collect information on the number of bloodstream MRSA infections since 2001. Up until this month, figures were published annually. Then the HPA released six-monthly figures for the first time, showing infections had dropped by 6% between April and September 2004 and the same period a year before (see graph on page 23).

Health Secretary John Reid hailed the figures as the lowest since mandatory recording began and insisted that the Department of Health was committed to halving infection rates by 2008.

The politicisation of the MRSA debate is evident from the stance taken by the Patients Association. Initially, it told the BBC that the HPA figures bore no relation to what patients were telling it. But later its chair, Michael Summers, added: 'We wish to make clear that we acknowledge that substantial improvements have been undertaken by the secretary of state for health, Dr Reid. The most recent improvements in hospital-acquired infections are beginning to show.'

The National Audit Office also became embroiled in the debate earlier this month after estimating that there had been 5,000 deaths from hospital-acquired infections in 2003. The Office for National Statistics subsequently reported just under 1,000 MRSA deaths for the same period, generating a Guardian leader that claimed the ONS figures introduced 'a calmer voice' to the debate.

However, NAO director Karen Taylor pointed out that its figure was a rough estimate for deaths due to all hospital-acquired infections, not just MRSA. She called for better data for all hospital infections.

Amid all the hyperbole and electioneering, it is not easy to get to the truth about whether the danger from MRSA is increasing or is under control. Many public health specialists are sceptical about the latest figures and wonder if the superbug can ever be reined in once it is widespread in a health system. On the other hand, the incidence of MRSA and other hospital-acquired infections form part of trusts' performance management. This means it can affect their star rating and so has become an issue for trust boards. This should mean the correct steps are being taken to minimise the spread of the bacteria.

Dr Mark Enright, an expert in MRSA at the University of Bath, is one of those sceptical about the Health Protection Agency figures.  'If it is good news, it is the first bit of good news we have had on MRSA. However, I think the timing of the release of these figures may be questionable. It's the first time six-monthly figures have been used, and these figures are the last six-month period that can be analysed before an expected election in May. One wonders if figures showing an increase in MRSA bacteraemia would have been released so quickly. In addition, I am not sure whether a fall of a few hundred cases is significant.'

While the figures could represent a real drop in the number of bloodstream infections, he says that it could also be due to under-reporting. 'Everyone is under pressure to keep their figures low. A patient could have an MRSA wound infection or an abscess and may be sent home. There's no point in keeping them in a hospital bed as they will only be given a course of antibiotics and the patient might feel they don't want to be hanging around the hospital. But when they go home, the infection could get into the bloodstream, which is more dangerous, and they would be readmitted. However, then they would not be counted in these figures as they came from the community. It might not be deliberate but there is some under-reporting.'

He adds that the position improves during the spring and summer months of April to September (see graph). 'In the winter months, you have relative overcrowding of wards and older people tend to be admitted with respiratory illnesses, which makes them more susceptible to MRSA, particularly if they are being intubated in order to hydrate them.'

Another factor is the MRSA infections that are not reported. Although the bacteria can infect organs, such as the stomach, and bones, only bloodstream monitoring is mandatory and these probably account for just 10%–12% of MRSA infections in hospitals. The Health Protection Agency is hoping to produce fuller statistics in the future.

John Reid believes the apparent reduction in the number of infections is due to action taken at the front line, prompted by government campaigns to improve cleanliness and place cleansing gel at each bedside. It has also called into action the 3,000 modern matrons, who have been told to increase the profile of infection control. Each trust should have an action plan on hospital-acquired infection, with its implementation led by its matrons.

One matron spoke to PF but asked not to be named. 'I take infection control seriously but it is only part of my job. Because responsibility is shared with cleaners, the infection control team, ward housekeepers and senior managers, it's hard to know who's in charge,' she says. 'I don't know if giving us the power to close wards is the answer – where would the patients go? And there is so little slack in the system that operations would have to be cancelled.'

She adds: 'Our biggest problem with MRSA is that we can take a blood sample and send it off to be tested but it takes two or three days for the results to come back. By that time, the patient could be moved to another ward or to a different hospital.'

Help may be at hand at Birmingham Heartlands & Solihull Trust. The trust is about to launch a Department of Health-sponsored pilot of a test that produces results in two hours. The test was developed by the trust's own Professor Peter Hawkey from a technique used in the US and will also be piloted at a hospital in London.

'We are hoping to begin as soon as possible but it has not yet been decided whether we will test every patient or just every surgical patient,' says a spokeswoman for the Birmingham trust. 'We have received a grant of around £500,000 for this but we are also working with local businesses to develop antibacterial products such as door handles, bed sheets and maybe even uniforms.'

Despite these initiatives, there is little research into the reasons behind the spread of MRSA. Dr Enright's group at the University of Bath is funded by the Wellcome Trust to study how the bug has spread at a global, national and local level. There are some smaller ongoing research projects but this area is poorly financed, especially by government-funded agencies such as the Medical Research Council and the Department of Health.

'The DoH allocated £3m in 2003 for the study of hospital-acquired infections (not just MRSA) and not a penny of that has been spent yet. Even £3m is quite pitiful – we have costed a comprehensive study of MRSA transmission in a large NHS trust at £1.2m so £3m is not going to fund very many studies of that magnitude,' Dr Enright says.

Health care workers who do not wash their hands between patients is one of the main reasons for the spread of the bacterium. There could be an emergency, they might forget or they might be put off by the harsh nature of many of the cleaning agents used on the wards. 'The best products tend to have high levels of alcohol or chlorhexidine, which can irritate the hands. If you are treating 30 or 40 patients a day you could end up with red, sore skin which will decrease your compliance with hand-washing regimes,' Dr Enright says.

Many commentators and patients believe the spread is linked to dirty wards – certainly Unison feels the switch to contract cleaning has led to a decline in hygiene standards. The union claims the NHS has half the number of cleaning staff it had in 1993 when contracting-out began. 'If we are really going to tackle the superbugs, we must have good cleaning services and to do that we need to increase the number of cleaning staff on the wards,' it says.

But Dr Enright says this is not the source of the problem. 'MRSA can lie about for weeks in bedding or dust but no-one really knows how important this is as a mechanism for spreading it. There is a much greater incidence of MRSA in Japan, Singapore and the US, and certainly Japanese hospitals are cleaner than ours. We should, of course, have clean hospitals but MRSA is a different problem,' he adds.

'At local level, hand hygiene is important but we have a high throughput system where a lot of patients needing specialist care tend to be transferred between hospitals and the infection can spread because of this.'

This is borne out by the Health Protection Agency's figures, which show that specialist teaching hospitals have a higher rate of MRSA than single speciality hospitals (children's units, for example). Patients admitted from nursing homes, which can have a higher level of MRSA infections than hospitals, are also a risk.

High bed occupancy – driven by moves to cut waiting lists – increase the presence of the bacteria, while our use of antibiotics in the past has helped to develop resistant strains. Ideally, 15% to 20% of beds would be empty at any one time so patients with MRSA and other hospital-acquired infections could be isolated, then treated. But many NHS hospitals' bed occupancy runs much higher than this, as they push to reduce waiting lists – a point the government's critics are quick to make.

Both waiting lists and MRSA will be key debating points in the upcoming election – but, without a significant increase in capacity, it appears the NHS will not be able to reduce both.

The science bit

Staphylococcus aureus is a bacterium found in around 30% of people, who carry the germ in their nose or on their skin. It is not normally a risk to healthy people and the majority do not have any symptoms. Like many bacteria, it becomes a problem if patients are run down or injured, or following surgery. It can cause infections if it enters the body, for example through wounds or tubes such as catheters.

It was in the 1960s that a form of Staphylococcus aureus that is resistant to treatment with the antibiotic methicillin - hence its name, MRSA (methicillin-resistant Staphylococcus aureus ) - first appeared . This one strain spread worldwide over the following two decades but appeared to die out in the 1980s. In the 1990s, two novel and different types of MRSA appeared in the UK, one of which is resistant to most antibiotic classes. Together they account for more than 96% of MRSA blood infections in the UK. The infection can be treated with antibiotics such as vancomycin and teicoplanin.

The level of MRSA in each country is measured as a proportion of all Staphylococcus aureus blood infections. In Japan and parts of Asia incidence is almost 70%, while in some parts of the US it's more than 50%. In the UK, it is around 43%. However, this figure is one of the worst in Europe - the Netherland's is 1%, Denmark 0.9%, Finland 0.8% and Sweden 0.7%. The Department of Health believes this is because the UK, unlike these other countries, failed to nip the problem in the bud when it first appeared and the strains found in the UK are more aggressive.