The Pharmaceutical Journal
Vol 273 No 7320 p535
9 October 2004

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Holistic approach to MRSA is needed

The 2004 British Pharmaceutical Conference and Exhibition “Medicines: from cell to society” took place at Manchester International Convention Centre from 27–29 September

BPC 2004 summary

Tackling methicillin-resistant Staphylococcus aureus in hospitals requires a multidimensional, holistic approach, according to Phil Wiffen, formerly a pharmaceutical adviser on antimicrobial resistance at the Department of Health and now part of the Cochrane review team. And pharmacists have a key role to play in several areas, not just in promoting the prudent use of antibiotics, he added.

To illustrate his point, Mr Wiffen went through the action areas for combating MRSA, as set out in the Department of Health’s “Winning ways” document (see Panel). Four out of the seven action points could benefit enormously from pharmacists' involvement, he said.

Pharmacists’ roles

First, pharmacists can help make real inroads into reducing reservoirs of infection. A common source of MRSA infection is feeding lines in patients requiring TPN (total parenteral nutrition), Mr Wiffen explained. Pharmacists have expert knowledge about the components of TPN and how they support microbial growth. “We need pharmacists to be an integral part of TPN teams”, he said.

As well as understanding the composition of TPN, pharmacists can also appreciate the science behind disinfecting equipment such as feeding lines. But this skill is often under-used and pharmacists should become more involved in advising in this area, he added.

Second, hospital pharmacists need to protect themselves and their patients from infection by maintaining high standards of hygiene. “Clinical pharmacists often believe that they do not have physical contact with patients,” he said, “but this can be a misperception.” Pharmacists often shake a patient’s hand, and could thereby transfer MRSA, he said. In addition, they touch drug charts and bottles of medicines, all of which can then become contaminated with MRSA.

Mr Wiffen suggested that protocols for pharmacy staff working on wards should be drawn up and that they should include hand washing directions. The protocols are relevant to both clinical pharmacists and ward-based technicians, he stressed. In particular, there needs to be awareness that pharmacy staff need access to alcohol hand gels and, if they are carrying out ward-based work, they need to use them, rather than just be part of the supply chain handing them over to doctors and nurses, he said.

Third, the type of management structure and organisation a trust needs to have in place to help it combat MRSA includes having senior pharmacists as members of its management team, a set up that helps to ensure pharmacists’ contributions are properly realised.

Fourth, encouraging better prescribing of antimicrobials is a key area in which pharmacists should become involved, Mr Wiffen explained. He advocated the development of specific clinical roles for pharmacists and technicians to support prudent prescribing. Much has been achieved in this direction, especially as a result of the £12m funding for clinical pharmacy initiative announced by the Department of Health last year, he noted. But a lot also remains to be done. For example, when he made an internet search of hospitals’ antibiotic prescribing policies and guidelines, he found several that did not even mention MRSA. Another area yet to be exploited to its full potential is joint initiatives between primary and secondary care, he added.

It is also important not just to concentrate on “chapter five” antimicrobials (ie, the antimicrobials for oral and intravenous use listed in chapter five of the British National Formulary), he said. Prescribing data for “chapter five” drugs show that their use has been steadily reducing, but the prescribing of “less obvious” antimicrobials, such as those combined with corticosteroids in preparations for the skin, is increasing. “This may well be contributing to part of the resistance problem,” Mr Wiffen said.

As with the other dimensions in the fight against MRSA, both “restrictive” (ie, telling prescribers that they can only use certain antibiotics) and “educational” (ie, providing suitable training) need to be adopted when promoting better antimicrobial use, he pointed out. That way, the number of MRSA bacteraemia cases, currently standing at an average of 65 per year for a 1,000-bed hospital, representing a 5 per cent increase since the financial year 2001–02, might start to reduce.

Evidence base for interventions

Pharmacists and other hospital staff should look for evidence to back up the interventions they make and recommend to others when trying to combat MRSA, according to Jonathan Edgeworth, consultant microbiologist at Guy’s and St Thomas’ Hospital NHS Trust, London.

Mr Edgeworth conceded that this could be difficult. For example, a study reported in the BMJ looked at 4,382 abstracts, 254 papers and 46 reviews to find out whether isolation worked as a means of controlling MRSA. Out of all of these, there were no randomised studies and only four studies had been preplanned. “Best evidence” came from six studies, four of which found the measure to work, one of which found it to fail and one of which found it to work for a period of time before failing.

Reasons for the poor evidence base included that infection control measures could not be randomised, Mr Edgeworth said. Also, interventions are generally started at the height of an outbreak, which will progress back to endemic status anyway, he added. Moreover, multiple actions are usually taken, and so it is difficult to assess the influence of any particular single intervention.

Nevertheless, pharmacists need to look for evidence and if appropriate, carry out their own studies. For example, preliminary work carried out at the intensive care unit of his trust suggests that a variety of measures, including the use of nasal chlorhexidine, might help control MRSA. However, it is important to look at the wider implications of any interventions, he stressed. For example, he is aware that there is evidence to suggest that nasal vancomycin might reduce MRSA infection levels, but there are obvious reasons relating to antibiotic resistance why this is not a good strategy to adopt.

Although progress in establishing an evidence base for interventions has been slow, science has progressed rapidly in other aspects of the fight against MRSA, Mr Edgeworth said. Tools such as genetic sequencing and bacterial microarray can be used to explore the genetic make up of colonies involved in a particular incidence of infection and to determine whether they have, for example, incorporated additional virulence genes not routinely seen in that particular strain.