To the Editor: The recent editorial by Collignon and colleagues emphasised the importance of infection control mechanisms in reducing patient harm from antibiotic-resistant organisms.1 It focused on disinfection of the hands of health care workers in hospitals. However, a vigorous education and surveillance program in a hospital in Victoria failed to achieve compliance among health care workers of even 50%.2 Top of the list of self-reported factors leading to poor compliance is “skin irritation and dryness associated with the use of hand hygiene agents”.3

There have been no properly controlled trials, with clinically important endpoints, of currently recommended hand-hygiene practices. With the likely poor compliance rates, such trials would likely fail.

A different approach might be more effective. Reducing skin contact between health care workers, patients and their immediate environment seems logical. Data show that skin contact produces two-step transfer of material in 82% of cases.4 The Victorian study did include gloving as an alternative to disinfection in measuring hand-hygiene compliance.2 However, in what might be a backward step, a recent study concluded that physicians should be encouraged to shake hands with patients!5

Perhaps an educational campaign to avoid skin contact with environmental surfaces and other health care workers, with use of disposable gloves for patient contact, could be the basis of a successful trial to address more effectively the transmission of antibiotic-resistant organisms in hospitals.

To the Editor: The magnitude and distribution of the problem of health care-associated methicillin-resistant Staphylococcus aureus (MRSA) in Australia can be gauged from the report of a forum on MRSA control conducted at the Australasian Society for Infectious Diseases (ASID) in March 2007.1 This report contrasted approaches to control of health care-associated MRSA and quantified the population incidence rate of health care-associated MRSA bacteraemia across Australia from data derived from direct surveillance systems (Box). Reporting of MRSA infections is thought to be complete from all jurisdictions except Victoria and New South Wales. Figures for Victoria were extrapolated from accurate surveillance data representing 50%–60% of events. The degree of incompleteness of reporting in NSW could not be determined, and a range based on reports to NSW Health over 3 years was used. Overall morbidity of health care-associated MRSA in Australia is much higher, as only a minority of MRSA infections lead to bacteraemia.

The ASID report estimated that between 699 and 924 cases of bacteraemia would be prevented if other states and territories reduced their incidence of MRSA bacteraemia to that of Western Australia through implementation of more stringent infection control measures. The mortality of MRSA bacteraemia is 8%–50% (average, 29%).2 A recent study showed that more than half (59%) of such deaths were directly attributable to MRSA3 rather than other non-infective causes. These outcome proportions provide a minimum estimate of between 120 and 158 preventable deaths per annum in Australia directly caused by health care-associated MRSA — comparable to the annual South Australian road toll.

As identified recently in the Journal by Collignon and colleagues, there are significant structural barriers to achieving infection control — especially inadequate isolation resources and pressure on bed stock.4 Other dimensions of the MRSA problem include the high incidence of MRSA in many aged care facilities, the epidemic emergence of community strains of MRSA (best described in the recent report from WA on MRSA notification data up until 20025), the possibility of significant zoonotic reservoirs,6 and the role played by imprudent antibiotic use.

MRSA colonisation or infection needs to be made a nationally notifiable disease, with a system in place to enable typing of isolates. As in WA, such a system would enable more effective identification of MRSA carriers before hospital admission, the detection of emerging epidemic strains, and timely investigation of MRSA outbreaks occurring in community groups, such as in aged care facilities. Most importantly, all states and territories need to adopt, and provide resources for, consistent, stringent approaches to surveillance, prevention and control of health care-associated MRSA that are in keeping with internationally recommended approaches. Given the scale of preventable injury occurring in many states, MRSA control must be made one of the highest priorities for patient safety.

To the Editor: The recent editorial by Collignon and colleagues challenged Australian physicians and health care leaders to confront the rising burden of methicillin-resistant Staphylococcus aureus (MRSA).1 Compared with Australia, the United States has a bigger problem with MRSA; more than 60% of all hospital-acquired S. aureus infections are now caused by MRSA.2

Appropriately, the medical community has made an urgent call for action. For example, the Institute for Healthcare Improvement (a not-for-profit organisation based in the US that aims to improve health care throughout the world) incorporated specific MRSA prevention measures into its recent 5 Million Lives Campaign (see http://www.ihi.org/ihi). One of these prevention measures, a recommendation for active surveillance, has generated controversy. Specifically, the cost-effectiveness of this strategy is still vigorously debated in the infection control literature.3 At present, it is unclear what surveillance testing method should be used in the laboratory, and whether testing should be done for all patients or just those identified as high risk.

The cry for help from community activists in the US and the United Kingdom has reached the ears of their legislative representatives. In two northern US states, lawmakers are considering bills that require universal active surveillance in their hospitals. Mandating resource-stretched health systems to implement obligatory active screening is not a prudent use of resources. The Society for Healthcare Epidemiology of America and the US Association for Professionals in Infection Control and Epidemiology recently published a joint position paper opposing this legislative activity, noting that data in support of active surveillance have been restricted to high-risk populations.4 We support this position and remind readers that active surveillance does not obviate the need for adherence to basic and consistent hand-hygiene practices.

Complacency and lack of clinical leadership remain the greatest challenges in the efforts to reduce the transmission of MRSA. Why do we accept this epidemic as a fact of life as our health care workers complacently contribute to the nosocomial transmission of MRSA? By implementing simple prevention policies, feedback of data on nosocomial transmission of MRSA, and increased infection-control education, we have achieved a 22% reduction in MRSA infections in our network of community hospitals.5 Still, we acknowledge the absence of a zero-tolerance approach to failures in hand-hygiene practices. More needs to be done. We challenge our clinical leaders to demand higher standards for hand hygiene. Most cases of nosocomial MRSA transmission represent failures of basic hygiene practices. The problem is surmountable. Infection control is not a skill of a few, but the responsibility of every team member. The onus is on all of us.

In reply: We thank Woollard for his comments on hand hygiene. While important, hand hygiene is just one component of what is needed to decrease the spread of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals. Decontamination of the environment, contact precautions for colonised patients, active surveillance and screening, effective programs to prevent common infections such as intravascular catheter sepsis, good antibiotic stewardship and better hospital design are also indispensable.1

We do not accept that “There have been no properly controlled trials, with clinically important endpoints, of currently recommended hand-hygiene practices”. For instance, the recent study quoted by Woollard showed that hand hygiene reduced infections hospital-wide, using the clinically important endpoint of serious bloodstream infections (MRSA and antibiotic-resistant gram-negative bacteria).2 Thus, at least two large peer-reviewed studies show that alcohol-based hand-hygiene programs reduce hospital-acquired MRSA infections2,3 (Level III evidence4).

There is nothing wrong with using disposable gloves, as suggested by Woollard, provided they are changed every time a health care worker moves between patients. Otherwise, gloves spread MRSA just as efficiently as unclean hands. Applying good-quality hand-hygiene products is less cumbersome than changing gloves and also allows direct human contact, which Woollard reminds us is important to patients.

How MRSA is spread in hospitals is now well known — our problem is getting health care workers to remember to practise good hand hygiene all the time, every day, before and after every patient contact.

The data shown by Ferguson and Van Gessel reaffirm how common and serious a problem we have with MRSA bacteraemia. They estimate there are about five episodes per 100 000 people annually across Australia. However, we believe that the true rate is double this.

The rate of S. aureus bacteraemia (ie, MRSA and methicillin-sensitive S. aureus combined) in Australia is around 35 per 100 000 per year,5 with 27% caused by MRSA.5 This crudely translates to an MRSA rate of 9.5 per 100 000. The rates are probably much higher in the states with more health care-acquired MRSA (New South Wales and Victoria). More recent data suggest that 36% of hospital-acquired invasive S. aureus infections were caused by MRSA, with the highest percentages in NSW (41%) and Victoria (39%).6

It is also worth noting that, when MRSA bacteraemia became notifiable in England in 2001, there was a 50% increase in reported S. aureus bacteraemia episodes.1 This suggests that under-reporting is common in any voluntary reporting scheme, and is also likely for Australian data.

Worryingly, Chen and colleagues point out that MRSA is an even bigger problem in the United States than in Australia. However, we are not far behind.6 Although we share their concerns about legislative impositions, some external controls and measurements can be an advantage. Western Australia, the only Australian state where MRSA is notifiable, has the lowest rates of health care-associated MRSA. While we do not want imposed “one size fits all” legislated controls, we do need change: the practice of the past 40 years has not worked. Every institution needs to have an effective MRSA control program, with components chosen according to the local situation. Institutions should measure MRSA and report centrally, especially if their rates are high and not falling continually (eg, over a year). Shop-floor quality improvement programs with empowered workers are much better than top-down management-imposed regulation (eg, from government).

We need to shake our complacency and that of our health care colleagues, accept clinical leadership and take control. Otherwise, legislative controls will be imposed on us.