Multi-resistant bacteria and spinal cord injury - an insight into practices throughout Europe Authors: Gunilla Åhrén, 1 st executive of ESCIF, Jane Horsewell, President of ESCIF Background The burden of infections due to multi-resistant bacteria is increasing worldwide. The various authorities in different countries have made a great effort informing and educating their health care systems on how to address this issue. Especially the growing problems of Meticillinresistent Staphylococcus aureus (MRSA) have been high on the agenda. The map, from the European Centre for Disease Prevention and Controls database EARS- Net, describes the situation in 2011 on MRSA isolates. The Nordic countries have a much lower incidence than the rest of Europe even though the situation in some countries has improved recently. The situation for bacteria in the bowel, e.g. E.coli and Klebsiella that produce extended spectrum betalactamases (ESBL) with resistance to third-generation cefalosporins or those with carpanemases or other resistance genes causing carbapenem-resistant enterobacteriaceae (CRE)* the trend indicates increasing problems. The incidence of CRE in the Nordic countries is lower than for Europe in general; however the incidence is also going up in the Nordic countries. The increasing problems with CRE are rapidly becoming a real threat to public health and especially to higher risk groups, for instance people living with spinal cord injuries (SCI). * CRE is called ESBLcarba in the Nordic countries. In the report we will refer to it only as CRE.
People with SCI have a higher risk of contracting and, thus, spreading these bacteria than the population in general. This can adversely affect their possibility to receive an optimal rehabilitation and to sustain comprehensive SCI management. ESCIF received a notification in 2011 from a member organisation that their members experienced problems obtaining care and rehabilitation due to problems with MRSA. Therefore ESCIF decided to carry out a survey on how the Spinal Cord Injury Units (SCIU) address these problems in connection to SCI. ESCIF believes it is important that the level of awareness and knowledge on this issue is raised among persons living with SCI and among SCI specialists. Purpose to investigate the level of awareness at the SCIUs in Europe to deal with the increasing problems of multi-resistant bacteria to assess if it has any bearing on rehabilitation for persons with SCI to formulate a report or statement with recommendations in this area from ESCIF to educate and recommend persons with SCI on how to behave in connection to MRSA and ESBL or CRE is to contribute to a raised level of knowledge and awareness among the SCI specialists Method We used a web-based survey comprising two questionnaires on MRSA (Appendix 1) and ESBL or CRE (Appendix 2). The member organisations in ESCIF were asked at the ESCIF congress 2012 in DeRijp, the Netherlands if they were interested in taking part in the study. The participating member organisations received a letter with information about the survey (Appendix 3). Their task was to identify the respondents and send in the respondents contact information. The respondents were the chief physicians and/or the head of the nursing personnel at the SCIUs in the relevant country. The respondents were then sent an e-mail containing an information letter (Appendix 4) and a unique log-in link for their SCIUs to the survey.
Results The web-based survey was opened in January 2013. It was planned to be closed in May 2013 but, due to late identification of respondents in some countries in combination with numerous reminders sent to the respondents, the survey was not closed until September 2013. The survey was sent to 106 SCIU in 18 European countries. 15 countries (83 %) responded but the response rate from the SCIUs varied largely (Table 1). These SCIUs treat 3,974 SCI inpatients and 11,612 outpatients yearly. Table 1. Response rate per country and in Europe (i.e. the combined rates of the countries sampled) Country number SCIU s MRSA CRE number % number % Austria 4 2 50 2 50 Belgium 7 2 29 3 43 Czech Republic 7 5 71 5 71 Denmark 2 2 100 2 100 Finland 4 3 75 2 50 Germany 1 0 0 0 0 Iceland 1 1 100 1 100 Ireland 1 1 100 1 100 Italy 16 4 25 4 25 Lithuania 3 3 100 3 100 Netherlands 7 1 14 1 14 Norway 3 1 33 0 0 Romania 1 0 0 0 0 Slovenia 1 0 0 0 0 Spain 13 5 38 3 23 Sweden 22 16 73 16 73 Switzerland 3 2 67 2 67 United Kingdom 10 1 10 1 10 Europe 106 49 46 46 43
The total reported number of MRSA-positive patients increased from 120 to 162 during the period 2008 2011 (Figure 1). The number of SCIUs that answered Don t know decreased from 21 to 12 units during these years. Denmark, Iceland, Ireland and the Netherlands were unable to report for the whole period. Figure 1. Reported number of MRSA-positive patients in 2008-2011 per country The total reported number of patients with ESBL/CRE increased from 170 to 490 during the period 2008 2011 (Figure 2). The number of SCIUs that answered Don t know decreased from 24 to 13 units during the same period. Denmark, Iceland, Ireland and the Netherlands were unable to report. Figure 2. Reported number of patients with ESBL/CRE 2008-2011 per country
Level of awareness 15 countries report that it is required by law to report MRSA cases and 7 that it is required to report ESBL/CRE; however different SCIUs within the same countries report conflicting information. All countries report that they have national, regional or local general health care guidelines for MRSA and ESBL/CRE but it is uncommon that the countries have SCI specific guidelines. Once again different SCIUs within the same countries report conflicting information. All the SCIUs report that they have guidelines for basic hygiene practices and an infection control unit or professional that can be consulted for specific health care procedures. However, 4 SCIUs report that they do not get support from professionals in infectious/contagious diseases if the patients are in-patients at the SCI unit. 44 % of the SCIUs reports that their MRSA-positive patients are assigned to a doctor specialising in infectious/contagious diseases. 45 % of the SCIUs screen/cultivate for MRSA on admission however 86 % will do so if the patient has been treated abroad and 69 % if the patient has been treated in a risk region within the country. Whether the SCIUs track and record where the MRSApositive person has become infected varies widely (Table 2). 24 % screen/cultivate MRSA-negative patients regularly. 44 % of the SCIUs screen/cultivate other patients regularly in the unit while caring for MRSA-positive patient. 63 % of the SCIUs will screen other patients if a previously unknown patient is detected as MRSA-positive. 45 % of the SCIUs screen/cultivate for ESBL/CRE on admission. Table 2. Do you track and record how/where MRSA-positive patients have become infected? Country Hospital Long term care facilities Community Abroad No Don't know Austria 0 0 0 0 2 0 Belgium 0 0 0 0 2 0 Czech Republic 5 1 0 0 0 0 Denmark 1 0 0 1 1 0 Finland 2 1 1 2 1 0 Iceland 0 0 0 0 1 0 Ireland 0 0 0 0 1 0 Italy 3 0 0 0 1 0 Lithuania 3 0 0 0 0 0 Netherlands 0 0 0 1 0 0 Norway 0 1 0 1 0 0 Spain 4 2 1 1 1 0 Sweden 8 4 4 6 6 1 Switzerland 2 2 2 2 0 0 United Kingdom 1 1 1 1 0 0 Europe 29 12 9 15 16 1
45 % of the SCIUs screen/cultivate members of staff who have worked/received care abroad or in a risk region within the country for MRSA. 43 % of the SCIUs report that MRSA-positive staff members are allowed to work with patients, 24 % report that this is not allowed and 33 % do not know. 20 % of the SCIUs allow staff members with skin lesions to work with MRSA-positive patients. 72 % of the SCIUs report that they have a SCI-specific registry, but only half of those units report MRSA-positive findings in the registry. Bearing on rehabilitation for persons with SCI 43 of the SCIUs keep the MRSA-positive patients in the unit and 47 retain those with ESBL/CRE. 88 % of the MRSA-positive patients have single rooms, own toilet and shower, while the figure for patients with ESBL/CRE is 74 %. Patients with ESBL/CRE who do not have diarrhoea are, in general, allowed to move freely about the ward. If they have diarrhoea their mobility is restricted but they are not necessarily isolated. All the SCIUs use contact precautions when caring for MRSA-positive patients. Only 14 % of the SCIUs use dedicated personnel to treat MRSA-positive patients; all of these units are located in the Nordic countries. 4 SCIUs have dedicated personnel for treating patients with ESBL/CRE. 63 % of the SCIUs report that the same SCI care and rehabilitation is offered to MRSApositive patients (Table 3). To the question If no, what is the difference? the SCIUs specified the difference as: it is a matter of isolation and training in the room not posing a risk to other patients sometimes the patients get transferred to an unit for infectious/contagious diseases but SCI teams go there to treat the patient or they stay in close contact with the unit it can be hard to get a place in the intensive care unit, surgery They might have few single rooms and too few personnel so the secondary rehabilitation suffers not admitted to swimming facilities, nor physical training facilities, or the training kitchen
Table 3. Are MRSA-positive patients offered the same SCI-care and rehabilitation as MRSA-negative patients? Country Yes No Don't know Austria 1 1 0 Belgium 2 0 0 Czech Republic 2 3 0 Denmark 0 2 0 Finland 2 1 0 Iceland 0 0 1 Ireland 1 0 0 Italy 4 0 0 Lithuania 2 1 0 Netherlands 0 1 0 Norway 1 0 0 Spain 1 4 0 Sweden 13 3 0 Switzerland 1 1 0 United Kingdom 1 0 0 Europe 31 17 1 To the question If an SCI patient is transferred to a unit for infectious/contagious diseases, how do you provide for the patient s need for SCI-care and rehabilitation? the SCIUs give different answers reflecting different routines: a team is sent daily to the other unit to care for the patients we act as consultants to the other unit the other unit takes over the responsibility for the patient s rehabilitation 78 % of the SCIUs will admit a MRSA-positive outpatient to the unit if care is needed for SCI complications; otherwise patients will be hospitalised in a unit for infectious/contagious diseases. 84 % of the SCIUs that offer secondary or follow-up rehabilitation periods will offer these to MRSA-positive patients. 60 % of the SCIUs do not know if there are any rehabilitation centres in their country that do not accept MRSA-positive persons for rehabilitation. Having ESBL/CRE does not seem to affect access to SCI-care and rehabilitation although 61 % of the SCIUs do not know if there are any rehabilitation centres in their country that do not accept persons that carry ESBL-positive bacteria.
63 % of the SCIUs have written information on MRSA for the patients. None of the SCIUs in Italy, Lithuania or the Netherlands report that they have written information for the patients. 40 % of the SCIUs provide notification cards with information that the person carries MRSA and 28 % of the SCIUs have notification cards for the next of kin. None of the SCIUs in Czech Republic, Ireland, Italy, Lithuania, the Netherlands or Norway report that they have notification cards for the patients. Nor do they, apart from Italy, have notification cards for the next of kin and neither do Spain. 43 % of the units have written information on CRE for the patients. All the SCIUs inform their patients about the importance of practising good hand hygiene. Conclusion and Recommendations Even though the level of awareness of MRSA and ESBL/CRE is generally high and guidelines exist in all the participating countries, the knowledge of and compliance to these guidelines differs between the SCIUs within the same countries. This calls for serious discussions on this subject between the SCIUs. An important consideration should be the use of dedicated personnel in the care of these patients. The screening process for both MRSA and ESBL/CRE needs attention. Even though welldocumented procedures exist for screening, not all SCIUs comply with these, especially when it comes to other patients in the unit and staff members. Only half the SCIUs that have SCI specific registries report MRSA findings; if this were done consistently, it would provide a useful tool in monitoring and combating the problem. In those SCIUs where the care and rehabilitation possibilities for MRSA-positive patients are currently restricted, special attention should be given to the ways in which other SCIUs tackle the problem to ensure that no SCI patient lacks relevant care and rehabilitation.