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Superbug outbreaks

26th September 2007

Following a steady stream of reported hospital outbreaks of healthcare associated infections (HAIs or HCAIs) around the UK over the last two years, the NHS’ ongoing battle against hospital ‘superbugs’ is far from over.

infectiousdisease1

What are HCAIs?

Healthcare associated infections is the term adopted by the NHS to refer to any infection by an agent which has been acquired by a patient as a consequence of their treatment, or by a member of staff in the course of their duties. They are commonly known as superbugs but technically this term should only be used to refer to those which have multiple resistance to a range of antibiotics, and are therefore much harder to treat and eradicate.

Major healthcare associated infections

MRSA (Methicillin-resistant staphylococcus aureus)

MRSA is perceived as the original ‘superbug’ afflicting the NHS, though some argue it should not be referred to as one, as some antibiotics still work against it. Staphylococcus aureus is a bacterium which can cause skin, wound and urinary tract infections, or pneumonia and blood stream infections if it enters the body. Most strains of S. aureus are sensitive to antibiotics and are treated effectively, but MRSA is a strain that has developed resistance to the antibiotic methicillin. New strains of S. aureus continue to emerge with greater resistance to antibiotics.

Panton Valentine Leukocidin (PVL) is a toxin produced by some strains of S. aureus, including MRSA. PVL-positive MRSA came to public attention late in 2006 with a serious outbreak at the North Staffordshire Trust which affected 14 people, two of whom died. However, PVL-positive MRSA is not officially a HCAI as it is most commonly found in the community. Community associated MRSA makes up 12% of all MRSA cases.
 
Clostridium difficile (C. difficile)

C. difficile is a bacterium which is naturally present in the gut where it is kept under control by other bacteria. When it grows out of control it can cause diarrhoea, fever, nausea and abdominal pain, and can prove life threatening in the very young and old. Recent research found that it may persist despite antibiotic treatment, because of its ability to change its genetic structure and so neutralise antibiotics. Some strains have been found to produce more toxins than others and cause more severe symptoms and higher mortality rates. C. Difficile is now considered to be endemic in the NHS. It is now considered the biggest threat due to a major rise in cases and higher mortality rates compared to MRSA.
 
Enterococci

Enterococci are bacteria found in faeces. They can cause urinary tract, wound, and blood stream infections. Some enterococci have developed resistance to the glycopeptides group of antibiotics and are known as glycopeptide-resistant enterococci (GRE).

Orthopaedic surgical site infections

Used to describe any infection of the wound site following surgery. Symptoms can include pain, swelling, pus and fever.

How common are HCAIs?

The Health Protection Agency has been responsible for the mandatory reporting of HCAIs since 2001. Ongoing reviews of hospitals have shown that cases of the superbug MRSA are falling in England but rates of clostridium difficile continue to rise.

Between April 2006 and March 2007, there were 6,378 reported cases of MRSA compared with 7,096 for the previous year, a fall of 10%. This reduction has continued throughout 2007. In general, 69% of cases of MRSA occur in the over 65s. London has the highest incidence of MRSA, despite significant decreases in recent years.

This compares with the much higher figure of 15,592 reported cases of C difficile in patients aged 65 and over in England in the first quarter of 2007 and this figure is rising by around 7% per annum.

Each year 300-400 deaths are attributed to MRSA while the figure for C Diff has risen to well over 1000.

How do we compare to other countries?

The UK does not compare well with other countries’ infection rates. In the developed world, between 6% and 10% of hospital patients acquire HCAIs. England is at the upper end of that range at 9%. In the UK, the proportion of S. aureus blood stream infections which are MRSA is 44%. In Denmark and the Netherlands it is just 1%.

The Dutch operate a strict ‘search and destroy’ policy with MRSA which the UK plans to learn from. This includes screening and detection before hospital admission, routine isolation of infected patients, higher staffing ratios per patient, and thorough cleaning regimes.

What is being done to tackle HCAIs in the UK?

Staff, trusts, unions and governing bodies have argued, sometimes controversially, that a number of factors have caused the rise in HCAIs in recent years. These include:

  • High bed occupancy levels. 
  • Juggling of patients from ward to ward
  • Busy staff having less time to attend to personal hygiene
  • Outsourcing of hospital cleaning contracts.

The main lines of attack against HCAIs are:

  • Limited screening of patients before admission 
  • Varying antibiotic prescribing regimes.
  • Personal hygiene, especially hands.
  • Better care of wounds and other sites where tubes or catheters are inserted. 
  • Cleanliness of the environment. 
  • Availability of isolation facilities for infected patients (eg single rooms). 
  • Separating elective and emergency patients. 
  • Minimising patient transfers between wards

Experts have commented that much has been done to introduce simpler and cheaper measures such as hand hygiene, but that this is not sufficient without more expensive measures being implemented as well. It has been suggested that C. difficile has continued to spread unchecked whilst the attention has been on MRSA, because infection control measures have only partially been introduced. For example, alcohol hand rubs, now widely adopted to stop the spread of MRSA, do not work on C. difficile. Proper hand washing with soap and water is required.

What does the future hold?

There is a continuous stream of news highlighting new hospital outbreaks and new ways to tackle them, whether by changing hospital uniforms or introducing new antibiotics. However, at this stage it does not look like the government target for halving MRSA cases between 2004 and 2008 will be met and the NHS is currently struggling to contain C Difficile. Even so, this is a war that the NHS can’t afford to lose. There is now such a concerted effort to control HAIs it cannot be too long before substantial progress is seen.


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