Monday, 6 April 2009

Q & A: MRSA Screening and decolonisation

Q: Dear Donal, does the new guidance apply to day case access surgery, renal biopsies, day case ward iron infusions, regular haemodialysis attendances? What is the evidence that decolonisation reduces the risks of MRSA sepsis in these settings? This policy has significant operational implications and is expected to be in place by 1 April 2009. Dr Chris Winearls, Consultant Nephrologist, Oxford.

A: Dear Chris, thank you for your email of 2 March concerning MRSA screening and decolonisation. MRSA is as you know a serious and significant problem in the dialysis population and renal medicine is listed as one of the high risk areas in the MRSA screening – operational guidance. Good progress is being made in reducing MRSA blood stream infections in renal services by a combination of general measures and improvement in vascular access, much of the later based on the innovative approach you have taken in Oxford coupled with the implementation of the professional societies guidance on vascular access.

FAQs on the DH website include guidance on how to treat dialysis patients – they should be screened on admission to the dialysis programme and then at regular intervals thereafter. The FAQs acknowledged that some patients, such as renal patients will be tested more than once.

Renal is not exempt from the general screening policy for admissions. In other words, just as a surgical case is to be screened, so should all elective renal admissions. My interpretation is that out-patient procedures such as out-patient intravenous iron infusions are excluded.

The guidance note justifies the screening/decolonisation by citing the high risk of infections, but I am not aware of a detailed evident base for screening within the speciality of nephrology.

There is one study that supports this approach -
Nasal carriage of MRSA; the prevalence, patients at risk and the effect of elimination on outcomes among out-clinic haemodialysis patients. European Journal of Medical Research 2007, July 26; 12/7): 284-8; Lederer SR, Riedelsdorf I, Schiffl H.

I understand that some UK groups are now studying the effect of screening and decolonisation for the dialysis population and I hope that will provide a better evidence base for the effectiveness of decolonisation within our speciality in due course.