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Cleaning in the ICU: strong evidence, strong convictions and a dose of reality ?. APR Wilson, G Moore, D Smyth, R Jackson, J Singleton, E James, V Gant, S Shaw, M Singer G Bellingan University College London Hospitals Royal Free Hospital. What do we know about MRSA transmission?.
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APR Wilson, G Moore, D Smyth, R Jackson, J Singleton, E James, V Gant, S Shaw, M Singer G Bellingan
University College London Hospitals
Royal Free Hospital
How it is MRSA transmitted – Hands?
Why don’t some patients get MRSA?
Where are patients colonised?
How effective is isolation of MRSA patients?
Yap, Gomersall et al.(Hong Kong) Clin Infect Dis 2004; 39: 511
Observational report of MRSA incidence on ICU
100% compliance with contact precautions during SARS
8 fold INCREASE in MRSA during this period
Returned to baseline after return to normal precautions
Jernigan (Charlottesville 1996)
Prospective, Neonatal ICU
4.8% colonised/infected – single strain
Contact, cohort, surveillance staff + patients
Transmission rates Isolation 0.009/day Not isolated 0.14/day p<0.0001
Carrier of pathogen known or unknown
Near patient surfaces
Hands of staff and visitors
London Teaching Hospitals with >1000 admissions/year
Hospital a) no bacteraemias in 6 months
Hospital b) 1 bacteraemia in 14 months
Hospital c) 12 bacteraemias in 12 months
Hospital a) chlorhexidine wash daily for all, CVC bundles, no 3 way taps, rapid screening, isolation, linezolid for specific cases, standard plus precautions for all.
Hospital b) chlorhexidine wash daily for all, CVC bundle, full gowns, rapid screening, no isolation.
Hospital c) rapid screening and chlorhexidine for positive cases, CVC bundles, no 3 way taps, isolation, standard plus precautions for all.
We could not identify a major source for environmental transmission of MRSA.
Enhanced cleaning may not reduce colonisation or infection
Isolation may not reduce colonisation or infection
Clearly a broad “attack” on the environment, the patient and ICU processes can reduce MRSA rates
Does it matter that we don’t know which of these are effective…???
It would be great if infection control techniques could be based on evidence rather than conjecture.