MRSA and other resistant bacteria : prevalence, patient and staff experiences, wounds and infection control

Abstract

Antibiotic resistance has become a major and serious global problem in healthcare. Limited treatment options for infections caused by these organisms can lead to increased morbidity and mortality. Sweden has a low prevalence of antibiotic resistance compared to most other countries but this presents an increasing problem for society and healthcare even in Sweden.

The overall aim of this thesis was to illuminate potential problems related to antibiotic resistance from different perspectives: assessing the prevalence of resistant bacteria methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) or other resistant bacteria, and associated wound types, patient and health staff experiences when confronted with resistant bacteria infection, and the occurrence of such infections in the nursing home environment.

In the first study a total of 2172 patients admitted to hospital or as out-patient visit at a University hospital during one day were examined with the purpose to identify all wounds, wound types and wound characteristics, and to identify bacteria in all wounds, particularly MRSA, VRE and multi-resistant Gramnegative rods. Four hundred and eight (19%) patients had a total of 668 wounds. Of these, 248 wounds, from 216 patients were cultured. Two unknown MRSA-patients were identified. No patient with VRE was found and there was a low prevalence of other multi-resistant bacteria.

In the second study fifteen patients with MRSA infected wounds were interviewed. The aim was to ascertain and describe patients’ knowledge, perceptions and experiences of being MRSA-positive. The interviews were analyzed according to qualitative content analysis. From the analysis three categories and one overall theme were identified. Results showed that information about the MRSA diagnosis often caused a shock-like reaction. The patients’ perception of being MRSA-positive was that it was stigmatizing like the plague or leprosy; they felt dirty and a severe threat to their environment. Fears of infecting someone else and being rejected were commonly expressed. Knowledge and empathy from staff involved in their care was crucial to optimise patients’ experiences. Staff’s needs of education to meet patients’ demands for information, and to prevent spread of antibiotic contamination was essential.

In the third study eight nurses and seven assistant nurses from different hospital wards and nursing homes were interviewed regarding their experiences of caring for MRSA-positive patients. Qualitative content analysis was carried out when analysing the data and three themes were identified during the process. Stress and too high workload were factors which were described to cause concerns in the caring situation. A major concern was that nurses felt at risk of becoming infected themselves and then transmitting the infection to other patients and to family members. Knowledge and ignorance about MRSA affected the nurses’ caring; ignorance made them afraid and insecure while knowledge and understanding shaped confidence in their role as caregivers.

In the fourth study 560 residents in a total of 67 wards, in nine nursing homes were investigated for prevalence of MRSA, VRE and extended-spectrum β-lactamase (ESBL) - producing Enterobacteriaceae and if carriage of resistant bacteria was related to antibiotic treatment, other risk factors and/or staff´s adherence to guidelines for infection control. In all 296 staff members were interviewed and observed. No resident was positive for MRSA or VRE. Fifteen residents were found to be ESBL-positive. Usage of antibiotics was higher in wards where ESBL-positive residents were detected and there was an indication that there was transmission of ESBL between residents. Staff´s adherence to infection control guidelines sometimes revealed shortcomings but no significant difference regarding adherence to the guidelines could be found.

In conclusion: Prevalence of MRSA appears low in both hospitalized patients, out-patients and nursing home residents. Adherence to infection control guidelines among healthcare staff, however, needs further improvement. MRSA colonized patients experienced psychological pressure and stigmatization. Knowledge and empathy from staff involved in their care is crucial to optimise patients’ experiences. Staff education to meet patients' demands for information and the prevention of contamination is essential.