Mike the Mad Biologist

Who coulda thunk it?

There are two frustrating attitudes held by a fair number of antibiotic resistance/infectious disease specialists about MRSA (methicillin resistant Staphylococcus aureus). First, some argue that we really shouldn’t be focusing on MRSA, since it’s already evolved–the cat is out of the bag. Never mind that this particular cat kills more people annually in the U.S. than AIDS. While we obviously can’t prevent the evolution of MRSA (that’s already happened), we can contain the problem: we would rather have one percent of all staph infections be MRSA, rather than the current 62 percent (this is all the more critical, since resistant infection are, for the most part, additional infections–high levels of resistance typically mean that the total number of infections, resistant and sensitive, have increased).

Second, a much more commonly held view is that rigorous infection control in hospitals is not worth the effort. These efforts include screening staff for MRSA (and sending them home if they test positive) and isolating MRSA-carrying patients. So what if it worked in the Netherlands (their ‘search and destroy‘ program) as well as the VA hospitals in the U.S.

Now, Norway joins the club of hospital systems that have not shoved their heads up their assesstuck their heads in the sand:

…Norway’s public health system fought back with an aggressive program that made it the most infection-free country in the world. A key part of that program was cutting back severely on the use of antibiotics.

Now a spate of new studies from around the world prove that Norway’s model can be replicated with extraordinary success, and public health experts are saying these deaths — 19,000 in the U.S. each year alone, more than from AIDS — are unnecessary.

“It’s a very sad situation that in some places so many are dying from this, because we have shown here in Norway that Methicillin-resistant Staphylococcus aureus (MRSA) can be controlled, and with not too much effort,” said Jan Hendrik-Binder, Oslo’s MRSA medical adviser. “But you have to take it seriously, you have to give it attention, and you must not give up.”

….Norway’s model is surprisingly straightforward.

• Norwegian doctors prescribe fewer antibiotics than any other country, so people do not have a chance to develop resistance to them.

• Patients with MRSA are isolated and medical staff who test positive stay at home.

• Doctors track each case of MRSA by its individual strain, interviewing patients about where they’ve been and who they’ve been with, testing anyone who has been in contact with them.

Today, less than one percent of Norway’s staph infections are MRSA. Shamefully, the CDC has been dragging its heels, and only issuing ‘voluntary guidelines’ to hospitals–because the private sector (whether it be profit or non-profit) has shown such a tremendous ability to successfully self-regulate (italics mine):

Dr. John Jernigan at the U.S. Centers for Disease Control and Prevention said they incorporate some of Norway’s solutions in varying degrees, and his agency “requires hospitals to move the needle, to show improvement, and if they don’t show improvement they need to do more.”

And if they don’t?

“Nobody is accountable to our recommendations,” he said, “but I assume hospitals and institutions are interested in doing the right thing.”

Dr. Barry Farr, a retired epidemiologist who watched a successful MRSA control program launched 30 years ago at the University of Virginia’s hospitals, blamed the CDC for clinging to past beliefs that hand washing is the best way to stop the spread of infections like MRSA. He says it’s time to add screening and isolation methods to their controls.

The CDC needs to “eat a little crow and say, ‘Yeah, it does work,'” he said. “There’s example after example. We don’t need another study. We need somebody to just do the right thing.”

The CDC is in a hard place: hospital lobbies are very powerful. But I had hoped that Gerberding’s departure would lead to better policy positions (and this is one reason why I wanted Besser to get the permanent Director’s position)

Not only would it be the right thing to do, but setting this up would be a pretty good economic stimulus–that saves people’s lives.

Comments

  1. #1 Elfie
    January 1, 2010

    I read that news article yesterday and found it quite fascinating – sounds like the results are pretty spectacular.

    So what’s the incentive for the hospital lobby in the US to oppose these guidelines?

  2. #2 Tony P
    January 1, 2010

    Back in 2005 when my grandmother was slowly dying she was in intensive care and had a staph infection that I believe eventually killed her.

    The hospital had full hand sanitizing and glove requirements in place. So how did she get infected in the first place?

  3. #3 Maryn
    January 1, 2010

    That AP article was good (I tweeted it). There are a couple of things that Norway does that the US doesn’t/can’t do: Because it’s a single-payer health system, it can apply antibiotic stewardship and really make it stick; ditto making colonized health workers stay home, because they since they work for one entity they have common work rules.

    But we didn’t need Norway’s example to know that actively screening for MRSA colonization and isolating people who are colonized works; it’s been demonstrated in the US, multiple times, in institutions that had the will to try it. Barry Farr, mentioned in the article, was the first 20 years ago and there have been several dozen others since, from tiny hospitals in Wisconsin to big medical centers in Illinois and Pennsylvania. (It was Evanston-Northwestern’s success, I believe, not the European results, that convinced the VA — though since the VA’s own organization is close to a single-payer model, it may work particularly well there.)

    The fact that US institutions were making this work is what makes the CDC’s decision not to look closer at active screening so remarkable.

    It’s important not to discount the role that Norway’s stringent stewardship plays in their control of MRSA, and stewardship is much, much harder to do in the US context, though there’s a team at Hopkins that has done some interesting stuff with decision-support/order-entry that looks like it has worked well.

    And, excuse the self-toot, if anyone is interested in more on these issues, you can find it in SUPERBUG: The Fatal Menace of MRSA, out in March and currently being blogged here.

  4. #4 Paul Krombholz
    January 2, 2010

    What happens to the colonized health workers? Do they lose their jobs? Are they “typhoid marys” for ever?

  5. #5 MartinDH
    January 4, 2010

    Isn’t in the hospital’s interest to have MRSA patients? They can charge for a longer stay and all the attendant medications, tests &c.

    Until the insurance companies refuse to cough up for treatment of MRSA infections acquired in that hospital, until people sue en masse for negligence, then they will not take the stringent control actions necessary.

    Hit ‘em in their pockets.

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