The Dutch experience shows it is possible to get on top of MRSA and other superbugs - but it will be costly. Meanwhile, some UK hospitals are pioneering simple but effective strategies that could help turn the tide of deadly infections, writes Alison Moore
With English hospitals likely to miss their target of cutting MRSA infections by half next year, many clinicians and managers are wondering what they can try next to reduce hospital-acquired infections.
While MRSA rates have come down - helped by a clean hands campaign - rates of Clostridium difficile continue to rise and new superbugs continue to cause concern.
What could England learn from abroad? Holland has one of the lowest MRSA rates in Europe while we have one of the highest.
In the Netherlands, MRSA is kept in check through a 'search and destroy' approach which goes beyond the containment methods used in the UK. The programme involves isolating and screening high-risk patient groups; screening low-risk groups; strict isolation of carriers; and treatment of people carrying MRSA.
Patients are risk assessed by looking at a number of factors, including whether they are coming from another hospital, especially one outside the Netherlands; whether they are known carriers; whether they have been on a ward where transmission has occurred. Some groups are known to be higher risk - for example, pig farmers (transmission is thought to have occurred between pigs and humans).
Patients at highest risk - those known to be carriers or who have had a positive culture sample - are isolated and staff are gowned, gloved and masked when they are in contact with them. Patients in medium-risk groups are isolated until their MRSA status is known. No special precautions are taken with low-risk groups unless their culture samples reveal MRSA.
These precautions also affect staff - workers coming into the Dutch healthcare system are tested before they start work. Any staff member who is a carrier is not allowed to care for patients until their cultures are negative.
The Netherlands does have community-acquired MRSA but these measures prevent it spreading between vulnerable patients in hospital. By treating carriers, the opportunities for spread in the community are also limited.
Some hospitals in the US have adopted similar 'active surveillance' methods - including weekly cultures of patients in high-risk areas such as intensive care units. The aim is to detect transmission 'reservoirs' and treat asymptomatic patients and staff.
US studies suggest there are considerable cost savings in screening and isolation, compared with treating infected patients.
Could such measures be introduced here? The Department of Health says that 'search and destroy' was used in the UK until the 1990s. Ironically, it was stopped because there was an increase in the number of MRSA cases and 'by 1997 it was endemic in NHS hospitals UK guidance had to change as it was no longer possible to apply the same methods to larger numbers of staff and patients'.
Re-introducing such methods would undoubtedly be costly and resource intensive. It would require the NHS to send staff home until they were free or 'decolonised' of MRSA. Isolating patient carriers would require many more single rooms (or at least cohort nursing).
At the moment, the NHS is unlikely to have sufficient isolation facilities to do this and achieve other targets, especially around access times. One Dutch expert recently highlighted the inability to isolate as the reason the UK could not cope with MRSA in the 1990s.
Trevor Payne, director of facilities at University College London Hospitals foundation trust, points out that many new-build hospitals do have plenty of single rooms, which will make isolation easier. New layouts of units could also help cut infections. But there would be greater problems reshaping older hospitals.
As carriers typically don't display MRSA symptoms and are likely to be coming into hospital for entirely different reasons, the reasons for screening would need to be carefully explained to them. Patients might also be isolated simply because they had been placed in the next bed to a carrier. Does the public understand enough to accept these precautions?
Proponents of 'search and destroy' are clear that if it is introduced vigorously enough and hospitals (and other institutional settings such as nursing homes) follow the rules, there could be a significant impact on MRSA rates.
But the cost - in terms of an NHS running at less than full capacity for some time - would be enormous. Trusts would be unlikely to do it unilaterally, for fear of the financial consequences. Lower bed occupancies - allowing for isolation or cohort nursing - would be a key requirement (Britain's problems coincided with a sharp rise in bed occupancy).
The need for speed
'In Holland, they have kept bed occupancy low and have the ability to shut wards as soon as they have a case. We could not do that,' says UCLH microbiologist Dr Peter Wilson.
Current British guidelines emphasise the routine screening of high-risk patients. However, there is no routine screening of staff, and patient isolation for those infected or colonised is 'dependent on the facilities available and the associated level of risk'.
Screening elective patients pre-admission is widely used and can help keep down MRSA rates. But emergency patients are obviously treated before test results are known. Unfortunately, this means that, if any tests are done, it may be too late to stop transmission to healthcare workers and other patients.
Quicker tests for MRSA could reduce transmissions. Standard tests take three days, but UCLH is now using a four-hour test. These quick tests are more expensive but a business case was made for introducing them because lowering MRSA rates meant some beds could be closed.
At Great Ormond Street Hospital in London there is a policy of routinely screening all patients on admission for MRSA, reflecting the particular nature of the hospitals' patients, who are likely to have been transferred from other medical facilities rather than being admitted direct from the community. This means they are seen as being at higher risk of MRSA.
However, though this policy had been in place for several years, compliance with it was historically low. But linking information from two computer systems in the hospital has enabled staff to quickly identify not only which patients have not been screened, but any who require isolation because they have tested positive.
A computer program written by Paul Lock at Great Ormond Street Hospital for Children trust interrogates the patient administration system to discover the location of each patient within the hospital. This is then linked to information from the pathology computer system which records who has been screened and what that screening showed. Ward staff can then check who has not been screened within 48 hours of admission and who needs to be isolated through the staff intranet.
That may sound simple but, incredibly, it is thought to be the first time in the NHS that computer information has been linked in this way to alert ward staff about MRSA risks.
Dr James Soothill, the consultant microbiologist who thought up the system, says: 'We are now screening consistently over 90 per cent [of patients] for MRSA. We really do know what is going on in the hospital. This is a very obvious solution and ought to be happening worldwide.'
The system can be used to check on other screening tests or to flag up other patients who need isolation; faecal samples are also screened for resistant gram-negative bacteria and the nose and throat swabs taken for MRSA testing can also be tested for other bacteria. In the first three years of the system, the percentage of patients screened for MRSA through swabs rose from 57 to 92.
But Great Ormond Street is fortunate in having good isolation facilities, which means that cases can be not only swiftly identified but also housed appropriately. Many hospitals would struggle to house MRSA patients in cubicles.
And methods which tackle the environment could also have some effect. UCLH is introducing new computer keyboards which are easy to clean and light up if they are not cleaned within a prescribed time. A quarter of the hospital's old keyboards in wards tested positive for MRSA. Again, the investment in new equipment has been justified by potential reductions in cases of MRSA - and other superbugs could also be reduced.
Heart of England foundation trust in Birmingham is trialling the use of silver ion coatings on hospital equipment. These inhibit the growth of bugs, including MRSA. None of these measures alone is likely to eliminate MRSA but they could all make a difference.
In the longer term, new drugs to deal with MRSA and other hospital-acquired infections may hold out hope - although the process of developing and testing them takes many years. In the short term, one drug already licensed for other conditions could offer a solution.
Professor Malcolm Young, of Newcastle University, used new computer techniques to identify which proteins needed to be targeted to kill off MRSA. Then existing drugs were examined to see if they could provide a 'match'. One drug, whose name has not been revealed, did - and could potentially be used within two or three years.
The worst is yet to come
It's a familiar pattern: scientists think they have discovered a miracle cure for a nasty disease, then something nastier comes along.
This is unfortunately happening with MRSA, where community-acquired strains of the disease are now causing unexpected deaths among young and generally healthy people.
These community-acquired strains produce a toxin called Panton-Valentine leukocidin (PVL), which destroys white blood cells. If this enters the body through a cut, it can kill within days - far faster than 'normal' MRSA strains. There is some evidence that measures used to control MRSA in hospital - hand hygiene and isolation - can stop further transmission but the problem is identifying these outbreaks quickly.
Worryingly, there have recently been cases of PVL-positive community-acquired MRSA at the University Hospital of North Staffordshire trust. A patient and a healthcare worker died and a number of others were infected.