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'Do we have to enforce non-compliance before we settle on more achievable guidelines?'

Mark Cole
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Antimicrobial resistance (AMR) is one of the biggest threats to global health. 

An independent review commissioned by the government estimated that a failure to address the problem could result in 10 million world deaths by 2050 at a cost £66 trillion.

As well as morbidity, mortality and economic costs associated with AMR, the management of multi-drug-resistant organisms continues to cause an abundance of operational challenges for NHS trusts. 

In particular, MRSA has become something of a cause celebre. First noted in 1961 epidemic strains began to gain a foothold in healthcare systems throughout the 1990s. This culminated in 4,451 hospital-acquired MRSA bacteraemia’s in 2007/8. The escalating problem of MRSA resulted in considerable media attention and this coupled with public anxiety was enough to prompt political action.

”Many may feel a return to a risk-based approach a retrograde step”

For some time, European colleagues had advocated a more aggressive search and destroy policy to bring MRSA under control. In 2010 the Department of Health (DH) in England responded in kind and introduced universal screening of patients at hospital admission for MRSA carriage.

Since, bacteraemia’s have fallen by 81% and similar declines have been witnessed in surgical site infections caused by MRSA and death certificates that mention the organism. This was not attributed to any single factor but was enough for the DH to produce further guidance advising a return to a more focused, cost-effective method of screening.

However, these are only recommendations and how far trusts will heed them is a moot point. Screening has become a part of the narrative of how MRSA was brought under control and many may feel a return to a risk-based approach a retrograde step.

Carbapenem antibiotics are often seen as antibiotics of last resort and resistance was always going to be a case of when and not if. Indeed, carbapenemase-producing enterobacteriaceae (CPE) are beginning to gain purchase in the NHS in much the same way that MRSA did in the early 1990s.

CPE are a major concern because of the limited treatment options and high mortality rates. In response, Public Health England (2013) produced a set of national guidelines in the form of a toolkit to promote early detection, management and control.

The toolkit was evaluated by NHS trusts in 2016 and the guidance around ’high-risk’ patients, pre-emptive isolation and serial screening was seen as unworkable in medium and large sized trusts.

Reflecting back on MRSA, a change to screening was made in part because of the falling incidence of infection, but it was also a pragmatic decision.

Prevalence in new admissions was low (1.5%), and compliance with the existing policy was poor, only 61% of patients screened, half isolated and a quarter not receiving suppression therapy. It is plausible that this will become even more challenging for CPE as bed capacity, single room availability and staffing levels have all become more acute.

“Once guidance has been publicised, it is not easily retracted”

Rectal screening is more invasive and can be resisted by staff and patients. Moreover, if it is positive, there is no treatment for colonisation.

Typically, colonisation precedes infection. Due to the seriousness of CPE a proactive but measured approach of screening is necessary. The question is whether an assessment that categorises any hospital admission in London, the North West of England, or outside the UK in the last 12 months as ‘high-risk’ is a little too conservative.

Clearly a survey of influential decision-makers in the NHS thinks it is. But as seen with MRSA, once guidance has been publicised, it is not easily retracted, particularly in an organisation like the NHS that can be sensitive to risk. Successful implementation of a screening programme will be hindered if the complex factors that relate to its practical execution are not considered.

MRSA screening has been through a number of incarnations before arriving at its current, most understated approach.

Do we have to enforce non-compliance before we settle on more achievable guidelines? Perhaps we can learn from history.

Dr Mark Cole is senior lecturer at the University of Manchester

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