28 August 2002
Ministry Of Health Guidelines To Tackle MRSA
The Ministry of Health today released Guidelines for tackling methicillin-resistant staphylococcus aureus (MRSA), as
part of its ongoing commitment to improve the quality of New Zealanders' health services.
The Guidelines for MRSA, a bacterium that is increasingly common in the community and can cause problems within
hospitals or resthomes, have been drawn up by an expert group convened by the Ministry of Health.
"MRSA and other antibiotic resistant bacteria are a major problem facing hospitals all over the world," said Ministry
spokesperson Dr Don Matheson.
"Not only can it slow the recovery of individual patients but if it is not contained with intensive infection control
measures it can occasionally force the temporary closure of wards or operating theatres and disrupt the normal daily
business of a hospital."
Dr Matheson, Deputy Director-General of Public Health, said the guidelines released today are an update of guidelines
first promulgated by the Department of Health in 1992. The draft update was sent to people working in infection control
for their feedback, and a consultation document was then released to ensure other interested parties could provide input
into the guidelines.
Dr Matheson said they have been written to allow flexible approaches reflecting differences in the local practices and
epidemiology of MRSA.
"The guidelines should be used by individual facilities to develop their own MRSA policy. However, it is strongly
recommended that facilities within a region reach local consensus on how to manage MRSA. This is particularly important
for the transfer of patients who carry the MRSA bacteria between health care facilities," said Dr Matheson.
MRSA is increasing in the community, which in turn increases the chances of someone carrying it into hospital where it
can have serious consequences for people whose immune systems are already under stress.
Dr Matheson said microbiologists now recognised the inevitability of bacteria mutating and developing a resistant strain
at some point.
"Rigorous application of basic hygiene and infection control procedures in health care facilities is a key factor in the
control of MRSA."
Dr Matheson said the prudent use of antibiotics by doctors and patients in the community and in health care facilities
is also critical and essential to limit the development and spread of resistant organisms.
The guidelines are available on the Ministry of Health website ( www.moh.govt.nz) under publications.
BACKGROUND
MRSA is increasing in the community, which in turn increases the chances of someone carrying it into hospital where it
can have serious consequences for people whose immune systems are already under stress.
Organisms that are resistant to commonly used antibiotics are a growing global concern. This is not only because
infection involving resistant organisms increases the complexity and cost of treatment but also because in some cases
the infection may become untreatable.
Generally New Zealand has relatively low levels of antibiotic resistance, but there are concerns about some key
pathogens such as methicillin-resistant staphylococcus aureus (MRSA). This is why the Ministry of Health has redrafted,
and is now releasing Guidelines for its control.
The extent of the problem
Staphylococcus aureus is a natural inhabitant of skin and mucous membranes such as the nose and perineum, and about 30
percent of adults are colonised. Simple colonisation has no adverse impact on healthy people, but in certain situations
it may cause disease, including skin abscesses, post operative wound infections, septicaemia and pneumonia, particularly
in people who are already ill. Fewer antibiotics can be used to treat methicillin-resistant staphylococcus aureus, so it
is desirable to minimise its occurrence.
The incidence rate of methicillin resistance among staphylococcus aureus isolated in NZ is relatively low. In 2000,
based on data collected and collated from hospital and community labs throughout NZ, the rate of methicillin-resistance
was approx seven percent (actual 6.9 percent). In comparison, rates in some countries, such as parts of Australia, the
United Kingdom, and the United States, are as high as 40-50 percent. At the other extreme, several countries in northern
Europe (eg, Denmark, the Netherlands and the Scandinavian countries) have rates as low as one percent.
Since the mid-1990s, the incidence of MRSA has been increasing in NZ. Between 2000 and 2001, there was a 38 percent
increase in MRSA isolations (from 5148 isolations to 7092). Back in 1995, there were just over 1000 isolations during
the year. During the last few years, the increase in MRSA rates has been mainly driven by the spread of a
multiresistant, hospital-acquired strain ? EMRSA-15. This strain originated in Britain, appears to be very
transmissible, and now accounts for about 40 percent of the MRSA in NZ.
Surveillance
Surveillance of MRSA, and other infectious diseases, is important to characterise the epidemiology or pattern of
infections and identify risk factors. Our current surveillance has helped define which MRSA strains are more easily
transmitted. This enables Health Care Facilities to take extra stringent infection control measures when one of these
strains is isolated.
NZ has had very comprehensive, on-going national surveillance of MRSA since the first reported case in 1975. All
isolates are referred to ESR so that they can be characterised and the epidemiology of MRSA in NZ analysed and
described. Data on MRSA are regularly disseminated and published. The Ministry of Health funds this surveillance.
Such comprehensive, on-going surveillance is rare. For example, Australia and the United States do not have such
national surveillance systems. However, some of the northern European countries with low rates have intensive
surveillance systems.
Control
MRSA is highly transmissible in health care settings - hospitals and long-term care facilities. It is transmitted from
person-to-person, most often on the hands of health staff, and also, but probably less commonly through the air by
activities such as bed-making. Some strains can be difficult to control.
It is desirable to focus control efforts in health and long-term care facilities. Good infection control procedures, in
particular scrupulous attention to hand hygiene, are the key to minimising the risk of MRSA and other
antibiotic-resistant organisms. These are the responsibility of each facility.
The guidelines propose key activities for control covering: Infection control procedures Criteria for screening of
patients and staff Management of patients and staff with MRSA Management of outbreaks Surveillance Laboratory procedures
Is widespread antibiotic usage associated with the increase in MRSA?
Appropriate antibiotic use is essential in the control of the emergence and spread of resistant organisms. Antibiotic
use ? and especially misuse ? is irrefutably linked to the development of resistance. Therefore, the prudent use of
antibiotics is an essential part of any programme to limit the development and spread of resistant organisms. The New
Zealand Infection Control Standard states that all health and disability care institutions should have policies to
promote the appropriate use of antibiotics; that is, prescribing guidelines that maximise therapeutic impact while
minimising toxicity and the development of resistance (Standards New Zealand 2000). Major health and disability care
institutions should have antimicrobial resistance surveillance programmes, and information on the prevalence of
resistance should be made available to prescribers. Additional strategies to address antibiotic resistance and
hospital-acquired infections are identified in An Integrated Approach to Infectious Disease: Priorities for Action
2002?2006 (Ministry of Health 2001).
Guidelines
The guidelines have been developed in response to the changing epidemiology of methicillin-resistant staphylococcus
aureus (MRSA) in New Zealand. The process involved reviewing the previous guidelines, local epidemiological data, other
published guidelines, and relevant recent research. It was decided at the outset to utilise the experience and knowledge
of those involved in the management of MRSA in New Zealand by putting out draft guidelines for consultation. Two
consultation periods produced a significant number of helpful comments. The writing group strove to ensure that the
recommendations reflect published data and majority opinion within the country.