What do disparate parts of the world such as Denmark, Sweden, Norway, Holland, Western Australia, and other Scandinavian countries have in common? From an infectious diseases perspective, they all have similarly low rates of healthcare-associated MRSA (and other antibiotic-resistant bacteria) despite being developed countries/regions with sophisticated healthcare. Denmark’s success in controlling healthcare-associated MRSA despite initial high rates of infection was alluded to in an earlier post, but similar stories of success can be found in the other countries/regions mentioned.

Why have the hospitals in these countries/regions succeeded whereas others (including in Singapore) have failed? Before any commentary, however, it is worthwhile to note that it is extremely difficult to be sure how much of success in controlling these bacteria can be ascribed to human intervention, much less to each component of human intervention such as different infection control practices (As a digression, this has led to much controversy and debate among infection control experts, and subsequently to a rise in the popularity of “bundles”, one example being the “Reducing MRSA” bundle developed by the Institute of Healthcare Improvement). Bacterial clones rise and wane over time (linked article behind a paywall), appearing to have an evolutionary clock of their own that we have barely started to understand. Such waves of epidemicity (and their subsequent fall) have clearly been documented in MRSA (see link here and here, there is a better article in Nature Reviews Microbiology, but it is behind a paywall).

Nonetheless, the countries/regions with low healthcare-associated MRSA rates share similar practices that are quite distinct from others, and these practices are implemented at a country- or state-wide level. They are best described by a term coined and popularised by the Dutch – “search and destroy”:

  1. MRSA is a notifiable infectious disease.
  2. High-risk groups for MRSA carriage are all isolated and screened for MRSA. This applies to both patients as well as healthcare staff. Healthcare staff from other countries, for example, are screened prior to having patient access in their hospitals.
  3. Low-risk groups for MRSA carriage are also screened, but only isolated if they are positive for MRSA (after which their contacts in their ward are screened, as now they are at risk for MRSA colonisation/infection).
  4. Healthcare staff taking care of MRSA-infected patients do so with strict attention to infection control, including using gowns, gloves and masks to prevent transmission.
  5. An MRSA eradication strategy is implemented for infected healthcare staff and patients. In certain settings, this strategy is also applied for their household members and contacts.

Such measures are extraordinarily costly, not to mention intrusive (especially with regards to treatment of the entire household). Nonetheless, the “search and destroy” strategy has become a cultural norm – although this occasionally has been challenged – in these parts of the world. How are such costs justified? Mostly by projecting cost savings from the control of such bacteria, an example being given here where an epidemic MRSA from UK was brought under control only after extraordinary measures well beyond what was described above. This is something that the rest of the world can do well to learn, to mitigate the financial and system-wide pain of implementing strict MRSA control policies.

Are these countries/regions free from MRSA (beyond the usual importation from foreign staff/patients that were initially missed) then? Remarkably, the answer seems to be no, despite the success of hospital MRSA control. The MRSA threat in these parts of the world come largely from community-associated and live stock (mostly porcine)-associated MRSA, testifying to the unique ability of the organism to adapt to the environment. But these are stories for another time.