Making MRSA carriage a crime?

A new chapter has been added to our successful MRSA Search and Destroy policy. Yesterday, a healthcare professional, providing homecare to elderly, testified on Dutch television (item starts @ 12.30 minutes) how unnoticed MRSA carriage had influenced her and her family’s life. It is very laudable that she was willing to share her experience, but it was kind of spooky that she felt that she could only do this if unrecognizable, as if the underworld was still after her and her family. Apparently, MRSA carriage has become a criminal or shameful thing.

The story in short: In a remote, rural and watery part of the Dutch Kingdom several outbreaks of MRSA were identified involving subjects in nursing homes, elderly homes and receiving home care. In one of these outbreaks a healthcare worker providing home care to elderly appeared MRSA carrier, as were her family members. MRSA eradication therapy (with mupirocin I presume) was immediately successful in the family members, but not in the healthcare worker. She received multiple unsuccessful treatments, until tonsillectomy was performed. All this had an enormous impact on her wellbeing. The item also displayed a 93-year old “survivor of MRSA carriage” still living on her own in apparent splendid isolation (although perfectly suited for infection control, I presume she had lived there most of her life). Part of her MRSA carriage treatment included movement restrictions, and she was not allowed to join the annual day out in Lunteren.

The newsworthy aspect was (I think) that MRSA is spreading outside hospitals, which is considered a healthcare threat. Do we really see more community spread of MRSA? If so, there are (at least) 3 explanations: (1) patients are faster discharged, increasing the risk of transferring unnoticed MRSA from hospital to community; (2) MRSA has become more transmissible in the community (or in the hospital); (3) we look better (and 1 and 2 may not apply).

The average length of hospital stay has declined over the years, but I am not sure whether short hospital stay increases community spread. Shorter stay may reduce the likelihood of being identified as MRSA carrier (and thus more unknown MRSA carriers going from hospital to community), but it also lowers the risk of acquiring MRSA from unnoticed sources in the hospital. Strain adaptation is possible. Yet, no information was provided on the type of MRSA, from which I conclude that this was not livestock-associated MRSA. But even if so, I don’t think we have evidence supporting strain adaptation leading to higher community transmission. That makes option 3 viable: the better you look the more you see (reciprocal of the House of God rule #11: If you don’t take a temperature, you can’t find a fever).

And what about the healthcare threat? Wo have not seen more MRSA bloodstream infections, but do see more data demonstrating that the mecA gene is not dramatically changing the disease course (and outcome) of S. aureus infections. Yet, the bad reputation of MRSA is obvious and in this community setting it seemed to approach the reputation of Ebola, leading to panic and seemingly unnecessary measures. Jan Kluytmans emphasized that MRSA management in the homecare setting should be executed by professionals, as in hospitals. I fully agree, in order to limit transmission, but most importantly to protect MRSA carriers from misinformed/uneducated search & destroyers.

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