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While a matter of much concern and discussion in the United States, methicillin-resistant Staphylococcus aureus (MRSA) also is arising in some rather bizarre manifestations in Europe.

MRSA in Europe: Dutch pigs and the UK press

MRSA in Europe: Dutch pigs and the UK press

Strange tales of farmers, mops, and politicians

While a matter of much concern and discussion in the United States, methicillin-resistant Staphylococcus aureus (MRSA) also is arising in some rather bizarre manifestations in Europe.

For example, a distinct strain of community-acquired MRSA has found an unlikely reservoir in pigs in the Netherlands, resulting in swine herders being subject to screening upon hospital admission, a clinician recently reported in San Francisco at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC).

Little is known about the ongoing outbreak, but some 100 infections have occurred in pig farmers, reported Christina M.J. Vandenbroucke-Grauls, MD, PhD, an epidemiologist at the Academy Medical Center in Amsterdam. "It's a community-acquired MRSA, [causing] all kinds of infections," she said at an ICAAC press conference. "[The farmers] have mainly skin infections going from simple boils to very extensive infections. The pig farms are huge in the Netherlands; we have thousands of pigs in big barns. Now that we have this problem in the Netherlands, it would be wise to screen [to determine] whether it is also here in the United States. It would be a matter of taking cultures and seeing what you find."

The Netherlands is known for its aggressive "search-and-destroy" approach to MRSA and thus reports among the lowest levels of clinical isolates of the pathogen in Europe. Though aggressive surveillance measures already are in place at many Dutch hospitals, the question, "Are you a pig farmer?" now is being added to the risk assessment efforts.

One of the first cases was found in July 2004, when clinicians unexpectedly found MRSA in the preoperative screening cultures of a 6-month-old girl before thoracic surgery.1 Neither the girl nor her family had traditional risk factors, but the girl remained colonized despite repeated decolonization attempts. Subsequently, the girl's parents were found to be positive for MRSA. The family lived on a farm and raised pigs, which were found to be carrying the same strain.

The strain colonizing swine is genetically distinct from other CA-MRSA strains and is resistant to tetracycline. At this point, it is unclear whether it is arising through antibiotic-laced feed or whether it entered the swine population through animals or some combination of both. "These are the questions we all have in the Netherlands," she said. "Some years ago, we had problems with VRE in the Netherlands. People were carrying it in their intestinal tracks, and then it was shown that these enterococci came from cattle, pigs, and chickens. It was assumed that it was because in the animal feed, there was an antibiotic that is very close to vancomycin."

That situation led to a ban on certain antibiotics in animal feed, an action which ultimately may be necessary to vanquish the CA-MRSA reservoir in pigs.

MRSA moves from mops to politicians

Meanwhile, across the channel English clinicians are dealing with garish tabloid headlines, public outcry and mandatory infection reporting requirements for MRSA and other infections. While Clostridium difficile now is starting to get its share of the front page, the British media have gone through something of an obsession with MRSA. For example, the Sunday Mirror in London reported in an article titled "Filthy Hospitals: The Mop of Death," finding a hospital mop with "300 times the safe limit of the superbug MRSA." MRSA bacteraemias now are subject to mandatory reporting by UK hospitals, and the press have heavily focused on hospital cleanliness as the root cause of patient infections.

"The media want simple solutions; the politicians want simple sound bites. Alison Holmes, MD, epidemiologist in the department of infectious diseases at the Imperial College of London, said at ICAAC. "So what is the solution? Of course this is it: It's mops [and hospital cleanliness]. There has been a lot of coverage of mops. There were stories about 'the mop of death' and some other fantastic tabloid headlines about mops. If you keep banging on that cleaning is the only solution, you really are distracting [from other interventions]."

Indeed, a British medical journal recently addressed the issue in a study, concluding that "it was not possible to demonstrate a consistent relationship between hospital cleanliness . . . and the incidence of MRSA bacteraemia. The large sizes of the data sets make it unlikely that a true correlation was missed. While a high standard of hospital cleanliness is a worthwhile goal, it is not helpful to repeatedly link MRSA control measures with improvements in standards of environmental cleanliness."2

The press coverage has been so intense that journalism researchers in England reported well over 1,000 MRSA press stories in 2005. "The interest is extraordinary," Holmes said. "We really need to recognize the role of the press and public awareness."

Robert Spencer, MBBS, an epidemiologist in the UK's Health Protection Agency, told ICAAC attendees that the issue has become so politicized that the Labor Party was criticized in headlines charging that hospital bugs have tripled since it came to power.

"Now we are we going to get rid of Mr. Blair as you are probably aware and elect [member of Parliament] David Cameron so everything will be alright then," he said with dry humor. "The tabloid press make out that if you do get one of these superbugs, you're dead. There's no treatment. And it's a virus, because a virus is always more deadly than a bacteria. So we are quite used to this in the UK, but suddenly the public became aware that in actual fact there are organisms out there in the community that can cause just as much damage as when you go into [the] hospital."

That was due to the highly publicized death of a young Marine who died of overwhelming sepsis due to a community staph strain after scratching his leg in a military exercise. Amid the public and press scrutiny, UK hospitals are reporting MRSA bacteraemias and have set a goal of 50% reduction in the national total of MRSA bloodstream infections by 2008.

"The Health Protection agency was quoted as having a 'cautious optimism' about improving MRSA bacteremia rates," Holmes said. "I think reaching the target of a 50% [reduction] nationally is going to be unlikely. However, I really do think that the mandatory reporting and target setting can actually be extremely useful and really improve the profile of infection prevention and control."

References

  1. Voss A, Loeffen F, Bakker J, et al. Methicillin-resistant Staphylococcus aureus in pig farming. Emerg Infect Dis 2005; Dec. Available from www.cdc.gov/ncidod/EID/vol11 no12/05-0428.htm.
  2. Green D, Wigglesworth N, Keegan T, et al. Does hospital cleanliness correlate with methicillin-resistant Staphylococcus aureus bacteraemia rates? J Hosp Infect 2006; 64:184-186.