The National Disease Surveillance Centre, NDSC, collects data from hospitals on methicillin resistant staphylococcus aureus, MRSA, bacteraemia — otherwise known as bloodstream infection or "blood poisoning" — as part of the European Antimicrobial Resistance Surveillance System, EARSS. EARSS is a voluntary system and as such not all hospitals participate; nevertheless, the participating hospitals in Ireland represent at least 95% of the population, the highest level of participation of any country involved in EARSS. Thus the EARSS data for Ireland approximates the true total number of cases of MRSA bacteraemia in Ireland. In 2003 there were 477 cases of MRSA bacteraemia reported in Ireland.
MRSA is a resistant form of a common bacterium, known as staphlococcus aureus. The proportion of staphlococcus aureus bacteraemia caused by MRSA in Ireland in 2002 was 42.7%. The proportion for the last quarter of 2003 was 41.7%. Overall there does not seem to have been a significant increase in the proportion of infections caused by MRSA in recent years. However, the proportion is one of the highest among European countries participating in EARSS. The level of antibiotic resistance in Ireland to MRSA is one of the highest in Europe, second only to the UK and Malta. Two of the reasons for this, and the responses to date, are as follows.
One of the common strains of MRSA in Ireland is highly contagious and it is particularly difficult to control its spread. This strain is also seen in the UK and partially explains the reason both the UK and Ireland have such high rates. The national MRSA reference laboratory, at St James's Hospital, can now identify individual strains of MRSA and reports this back to each hospital. Having this information helps each hospital to identify whether it has a problem with a particular strain of MRSA and to decide on appropriate control measures.
There is an overuse of antibiotics in hospitals. The SARI hospital antibiotic sub-committee has completed draft guidelines for hospitals on promoting prudent use of antibiotics. Many of the regional SARI committees have also appointed clinical pharmacists to individual hospitals to improve antibiotic prescribing habits. A pilot project on promoting more rational use of antibiotics has been funded by my Department, through the SARI national committee, and has recently commenced in the Midland Health Board region. The treatment of MRSA is governed by protocols developed by those experts treating the condition and involves a range of interventions such as antibiotic treatment, proper infection control and general medical management.
In 1999, my Department asked the National Disease Surveillance Centre, NDSC, to evaluate the problem of antimicrobial resistance in Ireland and to formulate a strategy for the future. The NDSC gave detailed consideration to these issues and drew up a strategy for the control of antimicrobial resistance in Ireland, SARI, which I launched on 19 June 2001. This report contains a wide range of detailed recommendations to address the issue of antimicrobial resistance, including a strategy to control the inappropriate use of antibiotics. The SARI recommendations can be grouped into five main categories, as follows: surveillance of antimicrobial resistance; monitoring of the supply and use of antimicrobials; development of guidance on the appropriate use of antimicrobials; education of health care workers, patients and the general public; and development of principles on infection control in the hospital and community setting.
The strategy for the control of antimicrobial resistance in Ireland recommended that a national SARI committee be established to develop guidelines, protocols and strategies regarding antimicrobial resistance. This committee was established in late 2002 and as part of its remit provides advice to the regional SARI committees in each health board area which were established as a result of the strategy's recommendations. The national SARI committee comprises a wide range of experts in the field.
Tackling the problem of antimicrobial resistance is a multi-faceted issue, which will require action on a number of fronts. Implementation of the strategy is taking place on a phased basis and will take a number of years to complete. To date approximately €16 million has been allocated by my Department to health boards to enable them to put in place measures to control antimicrobial resistance. It is ultimately a matter for each health board CEO to determine the priorities in each region. These priorities should take account of the recommendations in the SARI report and also the recommendations put forward by each regional SARI committee.
Much of the funding is designated for improving hospital infrastructure for control of infection and for appointing additional microbiologists, infection control nurses and other health care professionals involved in the control of infection. Some progress remains to be made to meet the numbers of such professionals required, as outlined in the SARI report, but significant progress has been made with additional appointments over the past two years.
At national level MRSA bacteraemia is now included in the revised list of notifiable diseases, so hospitals are now legally required to report cases of serious MRSA infection to the departments of public health in the regional health boards and to the NDSC.
The SARI infection control sub-committee has recently completed a consultation process on national guidelines for hand hygiene in health care settings. Hand hygiene is a key component in the control of MRSA and the final guidelines will be available within the next two to three months. The sub-committee is also updating national guidelines on the control of MRSA and it is hoped that these will be available later this year. Each of the health boards has a regional SARI committee and these committees have been developing regional interventions to control hospital infection, including MRSA.