Background

Staphylococcus aureus (S. aureus) is the cause of the most hospital-acquired infections worldwide. Thereby infections are particularly susceptible to being caused by Methicillin-resistant Staphylococcus aureus (MRSA), for which there are only few, if any, possibilities of antibiotic therapy. It has been clearly demonstrated by various authors that methicillin resistance is directly associated with increased mortality and morbidity with S.aureus infections. Moreover there is a strong statistical trend towards death owing to nosocomial MRSA infection and bacteremia as compared with susceptible S.aureus. Apart from more serious, and often lethal, courses of disease the occurrence of MRSA causes a large additional amount of work and very expensive consequences for the hospitals because of extended infection control measures; in extreme cases the closure of whole wards. Nosocomial infections with MRSA lead to a longer stay in hospital as well as to additional costs owing to increased nursing care and costs for infection management (e.g. isolation in a single room) and limited antibiotic therapy only with expensive (e.g. Linezolid) antibiotics and substances with known adverse reactions (e.g. Vancomycin).

Engemann et al., 2003, found additional average costs caused by patients with MRSA surgical site infections (SSI) of $92.363. In addition to that, the increasing amount of care for seriously ill patients and the rising number of complex medical measures aggravate this situation in hospitals. With increasingly empty coffers in our health system this could lead to hardly more resolvable conflicts. In the last 10 years an increase in the MRSA rate from 2% to approx. 25% was observed in Germany. In the Netherlands and Scandinavia a stable rate under 3% has been recorded for years. It must be said that the occurrence of MRSA is not inevitable. Particularly for the Netherlands, adhering to a consequent "search and destroy" policy, MRSA felt off to very low rates and is now under control. In many other countries no efforts are made to control the nosocomial spread of MRSA, resulting in MRSA rates exceeding 80%. Within these settings, MRSA becomes resistant to all available antibiotics, as is the case in Japan, where up to 30% of all MRSA infections are untreatable. Also in the USA, MRSA isolates resistant to all antibiotics are reported at the moment. This being so, the fact that no effective new antibiotics will be available within the next 20 years is quite disturbing. Based on valid evidence, the major concern now is that many bacteria, like MRSA, will follow this pattern (Vancomycin resistant Enterococci, Extended Spectrum Beta-Laktamase resistant bacteria). The structures of a network to combat MRSA can be easily used also to reduce the incidence of other multiresistant micro-organisms. MRSA does not always develop ex novo from susceptible S.aureus under antibiotic pressure, but represents a discrete number of clones which spread throughout the world. MRSA should therefore be regarded as a classic epidemic infection disease that spreads from patient to patient because of insufficient hygiene measures. The only way to combat this organism is a consistent "search and destroy" procedure that strictly follows standard hygiene protocols, together with a rational antibiotic policy and continuing education of people in the health service as well as the broader public.

Community acquired CA-MRSA – The New threat

Until now the MRSA problem was considered to be a strictly nosocomial problem. The emergence of MRSA in patients without established risk factors outside hospitals signifies a new threat. These so called “community acquired”- (CA-) MRSA represent a new stage of danger for the population worldwide and also in Germany and in the Netherlands. Additionally it becomes apparent by newer studies that the portion of MRSA rises also outside of hospitals and therefore leads to large problems in out-patient departments, ambulatory dialysis mechanisms as well as nursing homes. Since the past efforts towards the fight against MRSA in both countries were concentrated on the hospitals these efforts must expand to outpatient sectors. Sooner or later most of these CA-MRSA colonized patients will enter the hospitals adding to the already existing nosocomial problem. Up to now the non-existence of awareness, training, insufficient co-ordination of the main participants in the health service, the missing alignment of the proceedings, the lack of consistent follow-up assistance after dismissal from the hospital through organizational or financial reasons and the absence of sufficient infectious supply of MRSA patients form largest obstacles.