Methicillin-resistant Staphylococcus aureus (MRSA) infection

Individuals colonised with MRSA may also serve as a 'reservoir' of MRSA that may spread to other patients. This may happen, for example, if hospital staff attending to a colonised or infected patient become contaminated or colonised with MRSA themselves (often only briefly) and spread the bacteria to other patients with whom they subsequently have contact. These patients may in turn become colonised and/or infected. The spread of MRSA (or for that matter other bacteria) between patients is called cross-infection. In addition, MRSA may be spread via contaminated equipment or through the environment.

Some strains of MRSA are particularly successful at spreading between patients and may also spread between hospitals, presumably when colonised patients or staff move from one hospital to another. These strains are known as epidemic MRSA (or EMRSA for short). During the 1990s there was a marked increase in infections caused by MRSA in hospitals in the UK due to the emergence and spread of two particular stains of EMRSA known as EMRSA-15 and EMRSA-16.

MRSA infections in the community

Patients may be colonised with MRSA when they leave hospital, and there has long been concern that MRSA might spread from hospitals into the community.

In recent years increasing numbers of cases of MRSA infection in the community have been seen in many countries around the world, particularly the USA. However, investigations of these cases have shown that in many instances, the strains of MRSA found in patients in the community are distinct from those strains seen in hospitals and it now appears that these so called 'community-associated MRSA' have evolved independently of hospital MRSA. Although infections with 'community-associated MRSA' occur frequently in some countries, they are uncommon in the UK.

Studies in the USA and other countries have shown that the 'community-associated MRSA' often cause infections in previously healthy individuals who lack the risk factors seen in hospitalised patients. Many of these strains have a toxin called the Panton-Valentine leucocidin (usually referred to as 'PVL') which may contribute to their increased ability to cause infections.

Luckily, 'community-associated MRSA' are frequently susceptibility to a wide range of antibiotics (apart from those belonging to the penicillin class). As further evidence of their independent evolution, 'community-associated MRSA' are generally susceptible to a wider range of antibiotics than are hospital strains.

Can the spread of MRSA be controlled?

There are several steps that may be undertaken to minimise the spread of MRSA between patients.

- • Hospital staff should wash their hands scrupulously before and after having physical contact with patients, using soap or rapidly acting antibacterial alcohol solutions.
- Patients colonised or infected with MRSA may be kept away from other patients by being placed in separate rooms, either alone or with other patients who also have MRSA. Access to such rooms should be restricted to essential personnel.
- Hospital staff should wear gloves and disposable gowns prior to having physical contact with MRSA patients. Before leaving the room, they should discard these safely, and wash their hands.
- Visitors and carers likely to have a lot of physical contact with patients should also wear disposable gloves and gowns. All visitors should wash their hands before leaving the room.
- MRSA can survive on inanimate objects or surfaces such as linen, sinks, floors and even mops used for cleaning. For this reason, areas where MRSA patients are nursed should be thoroughly cleaned using disinfectants.

How is infection or colonisation with MRSA diagnosed?

To diagnose MRSA infection, specimens such as a swab of an infected wound or a sample of blood are taken from the patient. These are sent to a microbiology laboratory, where bacteria present in the specimen are cultured and identified. This process may take several days.

In addition, sometimes more rapid tests which detect the DNA (the genetic material) typically found in MRSA may be undertaken. Colonisation with MRSA is detected similarly, using swabs of a person's skin or from the inside of the nose.

How is MRSA treated?

Patients colonised with MRSA Patients colonised with MRSA may have a special antibiotic called mupirocin applied onto their skin (Bactroban) or the inside of their nose (Bactroban nasal). This helps to eliminate the MRSA and reduces the risk of the bacteria spreading either to other sites on the patient's body, where they might cause infection, or to other patients. Some strains of MRSA are, however, resistant to mupirocin.

Individuals colonised with MRSA may also wash their skin and hair with suitable disinfectants, such as chlorhexidine.

Patients infected with MRSA

Patients with infections due to Staphylococcus aureus often need antibiotics. Infections due to normal strains of Staphylococcus aureus are often treated with flucloxacillin, but this is ineffective against MRSA. To make matters worse, MRSA are often also resistant to other types of antibiotics such as erythromycin and ciprofloxacin.

Although MRSA are resistant to many drugs, most remain susceptible to the antibiotics vancomycin and teicoplanin. Infections due to MRSA are therefore often treated with one or other of these drugs. Both must be administered by infusion or injection, and for this reason, they are used for treatment only in hospitalised patients. Injection of vancomycin into muscle is painful and thus not used, while rapid administration into a vein may produce an allergic-type reaction (the so-called 'red man' syndrome). To overcome these problems, vancomycin must be given by slow infusion into a vein. In contrast, teicoplanin may be safely administered by injection into muscle or rapid infusion into a vein.

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