Surveillance for S aureus bacteraemias is compulsory

Editor—Van Belkum and Verbrugh's editorial on methicillin resistant Staphylococcus aureus (MRSA) focused on the Dutch experience.¹ It was England that first detected methicillin resistance in S aureus,² and despite the apparent disappearance of these strains in the United Kingdom in the 1970s their descendants are causing problems now.

The first epidemic strain of MRSA, EMRSA-1, seemed to be indistinguishable from that reported from eastern Australian hospitals and caused many hospital outbreaks in the Thames regions, with spread beyond. This was superseded by EMRSA-15 and EMRSA-16, the prevalent strains in England in the 1990s.

Control in the early days was along “search and destroy” lines, but difficulties controlling MRSA in an unsupportive working, political, and financial environment led to the belief that spread was inevitable. In the United Kingdom there was much debate on whether we should “live” with MRSA, using a universal precautions approach. A risk assessment approach, especially protecting high risk areas such as cardiothoracic and orthopaedic wards, was generally favoured.³

MRSA accounted for 3984 reported bacteraemias with methicillin susceptibility information in England and Wales in 2000, compared with 66 in 1991—that is, 42% of S aureus bacteraemias in 2000 compared with 2% in 1991. The rise has been across all regions and is superimposed on a steady incidence of methicillin susceptible S aureus. These are much worse figures than those in the Netherlands, where infection control teams maintain control largely with the search and destroy approach. The limited published evidence indicates that community MRSA in England still largely reflects spread from hospitals.

The editorial referred to controlling antibiotic use. This is good practice, but the evidence for impact on the control of MRSA is weak. The many confounding factors in the hospital environment make it difficult to evaluate the relation between antibiotic use and the burden of MRSA.⁴ As outbreaks are predominantly of one strain, cross infection probably accounts for a far greater attributable fraction of disease than antibiotic use.

The emergence of a new, more resistant strain (EMRSA-17) in England and the description of glycopeptide resistance in Scotland reduce therapeutic options and highlight the need to raise the profile and resources for infection control. The political climate in England is changing, with growing focus on controlling both infections associated with health care and antimicrobial resistance. This has culminated in the establishment of a compulsory surveillance system for S aureus bacteraemias.⁵

The minister of health undertook that rates of MRSA infection according to hospital activity would be published by named acute NHS trusts for 2001. This will clearly focus chief executives' minds on infection control.