Introduction

Methicillin-resistant Staphylococcus aureus (MRSA) is a significant infection-causing bacteria, since it causes potentially life threatening infections and also shows resistance to treatment with usual antibiotics. Hospital-acquired MRSA infections are associated with increased morbidity and mortality [1–3].

The prevalence of MRSA shows a huge variety across Europe with values from less than 1% in northern Europe to >40% in southern and western Europe. For several European countries, increasing MRSA rates over the last years have been described, whereas other countries observed a decreasing trend [4, 5]. To reduce MRSA rates or maintain a low endemicity in the healthcare setting, a sufficient MRSA management is essential [6, 7].

MRSA-specific infection control policies were surveyed in European intensive care units (ICUs) and surgical departments (SDs) to describe possible differences in MRSA management.

Materials and methods

The study was embedded in the Hospital in Europe Link for Infection Control through Surveillance (HELICS) Project, a European collaboration of national surveillance networks [8–10]. HELICS was initiated in order to harmonize the national surveillance activities in the individual countries. Therefore, HELICS participants developed surveillance modules for nosocomial infections in ICUs and for surgical site infections (SSI). The co-ordination of this surveillance has now been transferred to the European Centre for Disease Prevention and Control (ECDC).

For the survey, infection control policies in (a) ICUs regarding central venous catheters (CVC) and (b) SDs performing hip procedures were investigated by questionnaires. Questionnaires also contained questions about MRSA-specific infection control measures such as the availability of bedside alcohol hand-disinfection, isolation precautions, decolonization, and screening methods. Questionnaires were created and presented at a HELICS meeting in November 2003.

In 2004, all national surveillance networks were invited to participate in the study. Each participating network translated the questionnaire into its national language and sent it to the participating ICUs/SDs. Local infection control personnel was asked to fill in patient care parameters which were actually performed. All data received from the questionnaires were checked for plausibility and entered into a database. The data were analyzed descriptively. Results were given as feedback to the individual networks in order to validate data and to allow them to draw their own conclusions.

Results

Ten national networks (Belgium, Finland, France, Germany, Hungary, Lithuania, Poland, Slovenia, Sweden and Spain) sent descriptive data from 526 ICUs and 223 SDs (Tables 1, 2). Participating hospitals had a median of 437 beds and were mainly public hospitals (73%). The median number of single rooms was three per ICU and per SD. Participating SDs performed 120 HIP procedures in the median.

Table 1 Structural characteristics of the participating intensive care units (n = 526)
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Table 2 Structural characteristics of the participating surgical departments (n = 223)
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Patients stayed in the ICUs in median from 2 days in Sweden to 7 days in France and Poland. The nurses-to-patient ratio was very similar in the various ICUs with the exception of Finland, where the situation seems to be much better.

The prevention measures concerning MRSA varied between the participating countries (Tables 3, 4). Availability of bedside alcohol hand-disinfection was high in Belgium, France, and Slovenia and it was much higher in participating ICUs than in SDs (86 vs. 59%).

Table 3 Characteristics concerning the MRSA management of the participating intensive care units (n = 526)
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Table 4 Characteristics concerning the MRSA management of the participating surgical departments (n = 223)
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The isolation of MRSA patients in single rooms was described for the majority of the participating SDs (87%) and ICUs (84%). Decolonisation of MRSA patients was more often accomplished in the participating SDs especially in countries like Belgium, Slovenia, and Germany. Surveillance cultures of contact patients who were exposed to newly identified MRSA patients were obtained in approximately three-fourths of all SDs (72%) and ICUs (75%). Patients coming from other wards or other hospitals were screened for MRSA on admission to an ICU more often than on admission to a surgical ward (51 vs. 24%).

Discussion

In this study, patient care parameters concerning MRSA prevention were obtained from ten European countries in order to reflect MRSA management at a broad level.

A study at an international level has several disadvantages: interpreting data of an international study is not so easy since the participating hospitals are not representative for a country nor for Europe as a whole. The acquired data for the current study may also rather overestimate the situation, because all participating ICUs and SDs attended a national surveillance network and therefore may have an advance in infection control due to an increased focus on surveillance and other infection control measures.

Since this study is based on questionnaire rather than on observation, it might be possible that prevention measures were overestimated by the person who filled in the questionnaire relative to practices actually accomplished.

Nevertheless, this survey shows interesting results: various key infection control measures are implemented unequally in Europe. Possible reasons for these differences have been already discussed in the literature [10–12]. Each country’s epidemiology of antibiotic resistant microorganisms itself may also lead to regional distinctions in the compliance with infection control measures. Variations were also seen between participating ICUs and SDs. SDs performed decolonization procedures more frequently, whereas ICUs put more emphasis on hand-disinfection availability and screening methods. Maybe the implementation of these measures is easier on an ICU, typically a bounded space with an average of ten beds, than in an SD, which may include several different units in one hospital.

Which control measures contribute to a low or a decreasing MRSA prevalence?

In a study of practices and MRSA prevalence in Europe, MacKenzie et al. [13] showed significant associations between a lower MRSA prevalence and (a) the use of alcohol-based solutions for hand hygiene and (b) placement of MRSA patients in single rooms. Regarding the single prevention measures in the current study, it stands out that countries with low MRSA endemicities, such as Finland and Sweden [4], showed a high compliance for availability of bedside alcohol hand-disinfection and isolation procedures, which supports the findings by MacKenzie et al. [13]. In France, a country with a decrease in its MRSA rate [5], participating ICUs showed data concerning the availability of bedside alcohol hand-disinfection which were the highest of all participating hospitals. This also seems to eminently be the situation in Slovenia, another country with decreasing MRSA proportions over the last years [4]. The compliance with evidence based recommendations in Slovenia was the highest in Europe: in Slovenian ICUs, seven of all nine control measures sampled were described as being performed with a compliance of 90% or more. ICUs and SDs focused on the screening of contact patients, patients coming from long term care facilities, other hospitals or other countries. In addition, in the participating Slovenian hospitals, all ICUs and 90% of the SDs described the use of barrier precautions before contacting the patient. For the reduction of MRSA rates and maintenance of low endemicity, the implementation of screening in combination with isolation measures was also described by Bootsma et al. [14].

The data surveyed in the present study suggest that the intensive implementation of various prevention measures may improve a country’s MRSA prevalence and thereby contribute to a better outcome of patients treated in the corresponding hospitals.

This development should be seen as an encouraging example of national handling of multiresistant pathogens and should stimulate infection control professionals to pursue further initiatives [6, 7, 15] to limit the spread of MRSA.