MRSA; a slightly more practical suggestion (UPDATE: not so much)

by Daniel on March 23, 2005

Any maiden aunts who read CT possibly ought to skip this post, as it contains, in the interests of plain speaking on an issue where squeamishness might cost lives, one use of the “v-word“. I’m back on an old pedantic hobby-horse; the epidemiology of MRSA and the British political culture’s dangerous and annoying refusal to understand it properly. But this time, I have an actual policy suggestion.

This is obviously first and foremost a human tragedy, but it won’t be made any less tragic by being made the basis of an ill-informed policy debate. Poor little Luke Fenton died of septicaemia caused by MRSA, and there is some debate over whether the hospital attempted to avoid putting this on his death certificate in order to “cover up poor standards of hygiene”. There is apparently going to be an inquiry into what the source was of that MRSA.

However, I greatly fear that this inquiry is going to provide the baby’s mother with any comfort at all, because it is really quite likely that the source of the infection was her vagina. As I mentioned in the post linked above, MRSA does not for the most part live in “dirty wards”; it lives in people. About a third of people in the British Isles are “colonised” by some form of strep bacteria; I suspect that I’m one of them, because if I get a cut on my hand I have to be a bit careful or sometimes it flares up with impetigo, and that’s an infection that can quite commonly be caused by streptococcus aureus. That’s why I wash my hands pretty obsessively if I’m ever visiting someone in hospital.

Birth is a messy old business, and it’s quite easy for a baby to pick up a strep infection if the mother has it; I know one kid round our way who was really quite ill with strep immediately after his birth, and thank God that it wasn’t methicillin-resistant. In America, they screen expectant mothers to see if they’re colonised by streptococcus, so that they know to take appropriate precautions. It’s common ground that nosocomial infections are too high in the NHS and should be reduced, and anyone with any sense knows that clean wards are better than dirty ones. But it would be a much more appropriate reaction to Luke Fenton’s death if we were to start asking for streptococcus screening of expectant mothers than to start rehearsing talking points about hospital cleaners and “matrons”.

UPDATE: Paul Orwin emails me to say that the MRSA bug is a staphylococcus, not a streptococcus. Not sure how damaging this schoolboy error is to my more general point; I suspect “really quite damaging” is the answer. The kid I know definitely caught a streptococcus infection at birth rather than a staphylococcus, but I think that both kinds of bug do form colonies on the skin so I doubt it is medically impossible or even implausible for something similar to have happened here. I suspect, however, that general screening for them both might be quite difficult since it took the hospital quite a while to confirm the presence of MRSA in Luke Fenton’s blood sample. So I suppose that I will have to argue for streptococcus screening without being able to hitch it to the popular bandwagon of MRSA. Bugger.



Andrew Bartlett 03.23.05 at 6:37 pm

I made a point on my blog that dirty wards do not produce MRSA, if anything they provide an environment in which antibiotic resistant bacteria are unlikely to evolve (though certainly might thrive). I also pointed out that the driving force behind the evolution of antibiotic resistant populations of bacteria is not the result of lazy nurses, or even the privatization of cleaning contracts (though this must be corrected if we are to deal with the far more mundane problem of dirty wards), but inappropriate antibiotic prescription. Nothing annoys me more than the ‘antibac’ trend in household products (okay, that is an understatement – lots of thinsg annoy me a lot), or the party politicisation of MRSA cases. If we are to arrest the decline in viable antibiotics (and antibiotic targets) we actually have to talk about the removal of choice in health care. We will have to adopt a line of ‘you will take this to completion, or you will take nothing at all’. We certainly cannot continue with the ‘customerization’ of patients, which, in America, allows them (us) to shop between doctors until we get what we want – if we have the money.
Oh, yeah, and we need to shoot the managers of the US cattle ranchers. But, of course, the externalised costs of pumping their cows full of antibiotics to boost growth will be borne by people the world over – in a potentially devestating fashion if the range of antibiotics are drastically reduced and become available only to the very wealthy.


Paul Orwin 03.23.05 at 7:02 pm

Daniel, well done on the correction. I think there is more than one way to look at it. As for the dirty wards vs. people issue, well, it’s both, I’m afraid. A bit more about the organisms in question;

Group B strep (which is the one that colonizes the vagina, and causes neonatal strep infections), is not an organism linked with high levels of antibiotic resistance. Screening for it is very common in the US, and I suspect most other developed countries (I don’t actually know about the UK, but frankly, I’m surprised if it isn’t).

Virtually everyone is colonized in the throat by Streptococcus pneumoniae, and/or Streptococcus pyogenes (Group A Strep or GAS). These can cause a variety of infections, but are amenable to antibiotic treatment; for a more complex story, see the vast medical literature).

Staph epidermidis (“epi”) colonizes the skin, and doesn’t cause disease in healthy people, but is a very serious cause of nosocomial infections (hospital).

Staph aureus(and as a subset of this, MRSA) also colonizes the skin, as well as the nose, throat, and vagina, and causes very serious infections in an array of sites, most notably skin infections (boils, carbuncles, furuncles), pneumonias, and toxic shock syndrome as well as septicemia. These infections can be hospital as well as community acquired. Until recently, all MRSA cases were hospital acquired, but several recent reports (one from my Ph.D. advisor’s lab, one by my cousin! weird) have documented cases of severe disease caused by community acquired MRSA. The epidemiology of MRSA cases is absolutely critical. I have nothing to say about the legalities of the particular case (shame on any hospital that won’t tell the truth about a patient’s death), but the spread of MRSA is an important issue.


Paul Orwin 03.23.05 at 7:21 pm

A comment in response to Andrew (yes, I am trying to avoid grading exams, why do you ask?).
You are quite right to point out other, perhaps even more serious sources of antibiotic resistance. However, there is a strong case to be made that MRSA in particular arises due to the confluence of several factors.
1) S. aureus is very good at picking up elements of DNA that may contain antibiotic resistance genes; this is well demonstrated in the literature.
2) S. aureus causes a great many serious and not so serious conditions requiring treatment with high dose antibiotics.
3) S. aureus is a very frequent colonizer of the human skin and nose.
4) Because of the frequency of S. aureus colonizations and infections, hygienic standards for protection against S. aureus spreading through a ward are higher than for many other organisms.
So, here’s the deal. MRSA surely arose from the confluence of all these factors, as well as the one’s Andrew describes. However, stopping the current spread of it depends mostly on a couple of things; 1) Hospital staff (d’oh) with clean hands (i.e., without hospital staph…ugh), clean instruments, and clean supplies 2)Introduction of new antibiotics or treatment regimens, such as combination therapies, that can reduce the levels of MRSA in an infected patient.


dsquared 03.24.05 at 4:12 am

Comments are working a bit … erratically, and I have managed to screw up my WordPress password, but someone else emails me to say that apparently swabs from the mother have come back negative. Thank God the poor woman has been spared that piece of news; I’d guess that the next most likely candidate is hospital staff not following handwashing practices.


Steve LaBonne 03.24.05 at 8:56 am

“I’d guess that the next most likely candidate is hospital staff not following handwashing practices.” Alas, many things I’ve heard incline me to believe that that’s a good deal more common than we’d like to think. But Andrew of course also has a very good point about the irreponsible use of antibiotics. That problem has been widely discussed for years and it’s discouraging that so little has been done about it.


cloquet 03.24.05 at 12:50 pm

I’ve heard it said that if you want to avoid these infections, avoid the big and well known hospitals because they have the most resistant bugs. So, in other words, if your pregnancy is looking to be a normal one, it’s probably more safe to have a baby in a rural or country hospital than to go to one of the big ones in the city.


Daniel 03.24.05 at 4:02 pm

hmmm, on grounds of risk of infection, that might be right, but for almost any other of the things that can go wrong in a childbirth, I would guess not so much.


Paul Orwin 03.24.05 at 4:18 pm

Daniel et al,
A quick google search turned up several resources (for the full list, search “Group B Strep screening UK”). According to a couple of resources on that search, the rate of GBS neonatal infection is about 10x lower in UK than in US, leading to a lower effectiveness of screening. I am inclined to think it is a very good idea for pregnant women and their concerned families to get info on GBS testing, and ask their physician for the test. I am not in the least bit convinced that the reasoning for not testing is sound. It is absurdly cheap, and it seems like saving babies from dying of infectious disease is worth doing (this doesn’t even begin to deal with the costs of septic neonates…). Anyway, that’s my semi-informed $0.02.

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