Perfect culture for a 'superbug'

A killer bacterium resistant to antibiotics is haunting hospitals. Now doctors fear MRSA may spread into the community, says Liz Hunt

"My mother lived through the Holocaust, but she said that in those last few weeks her suffering was almost as bad." Eight months after Frida Jax died in a London hospital, her daughter Vivien Roth cannot speak of her without tears.

Her death from pneumonia and blood poisoning linked with a hospital "superbug", resistant to antibiotics, is hard for the family to accept.Mrs Jax, 83, went into St Mary's Hospital, Paddington, in March 1995 in good general health, despite a fractured pelvis following a fall. She was a strong, independent woman, living an independent life in her own flat in north London. But within weeks she had been reduced to a frail, tremulous old lady, with a weeping, infected abdominal wound that would not heal. Surgeons operated twice but when the wound burst open a third time they decided there was nothing more they could do. She died in June.

The spectre of the hospital "superbug" continues to haunt the health service. Around 80 hospitals a month are reporting cases of methicillin resistant staphylococcus aureus (MRSA) or "hospital staph" - the bacterium that precipitated Mrs Jax's death - to the Public Health Laboratory Service (PHLS). At the Princess Alexandra Hospital in Harlow, Essex, last week an orthopaedic ward was closed and three patients whose skin was colonised with MRSA - they did not have the infection - have had to be isolated.

MRSA came to prominence here in the early to mid-Eighties when there was a marked rise in the incidence of hospital outbreaks. Some strains spread with such ease that they became known as epidemic MRSA or EMRSA.

Every ward closure, every death due to MRSA, prompted headlines in the local press. To the man in the street it was the first real evidence of what scientists knew: that antibiotic resistance was not just an interesting laboratory observation but something that would compromise man's apparent supremacy over infectious disease.

MRSA does not necessarily cause more serious infections than other strains but treatment is more difficult, requiring more powerful - possibly more toxic - and expensive antibiotics. Vulnerable patients are the weak and elderly, those with debilitated immune systems due to illness or drugs, and those with open wounds. The ideal breeding grounds are hospital high- dependency units with their complement of the seriously sick and high use of antibiotics. Multi-resistant microbes can become endemic in such environments.

The incidence of MRSA fell during the late Eighties but since 1992 two new strains have emerged, EMRSA 15 and 16, spreading to a large number of hospitals and resulting in a steady rise in reported cases.

Stringent infection control is the most effective defence against the spread of "superbugs". The Department of Health, the Hospital Infection Society and the British Society for Antimicrobial Chemotherapy regularly update guidelines. There are fears, however, that financial cutbacks and staff shortages are taking their toll in this area, too. A surge in cases is the result.

Dr Rosamund Cox, a consultant microbiologist at Kettering General Hospital in Northamptonshire, suggests that many hospitals do not have the resources to implement fully the most recent - and toughest - guidelines, issued last year by the DoH and the PHLS. These deal not only with MRSA but other threatening drug- resistant microbes and point the way to infection control for a future, described recently in Science magazine as the "post- microbial era".

The implications for hospitals are alarming but the prospect for those outside is worrying, too. Professor David Greenwood, from the Division of Microbiology at Queen's Medical Centre in Nottingham, points to the "slow inexorable increase" of antimicrobial resistance in the community.

Hard evidence of the spread of the superbug into the commmunity is coming from America, with anecdotal reports from the UK and other European countries. But in a recent issue of the Lancet, Professor Greenwood wrote: "... there are fears that resistant hospital microbes and respiratory pathogens, including penicillin-resistant pneumococci and multi-resistant staphylococci, are being introduced into playgroups, nurseries, and residential and nursing homes."

A spokeswoman from St Mary's says that Mrs Jax was nursed in isolation and treated in accordance with its policy for infectious disease control and that the family had discussed her case with the hospital's chief executive and medical director. However, the Roths are still concerned by some of the events on the ward where Mrs Jax was treated. After her admission to hospital Mrs Jax suffered a burst ulcer (possibly a side-effect of the pain-killing drugs) which required surgery, but she appeared to make a good recovery. Four days later, however,the Roths learnt the wound was infected with MRSA, and Mrs Jax would need to be isolated in a side-room. Staff donned protective gowns to enter.

"They made quite light of it and we weren't alarmed about the infection," Michael Roth, her son-in-law, says. "But we noticed that the microbiologist who came in one day was very cross. She said that staff hadn't been following the five-day protocol for cases of MRSA."

Nurses told the Roths that another patient on the same ward had MRSA, too. "We wondered why they hadn't closed the ward but they said it wasn't necessary," Mrs Roth says. They also wondered why, if the infection was serious enough to warrant isolation, they were allowed in and out of the room with no other advice than to wash their hands.

One day, two weeks after the first operation,Mrs Jax's infected wound burst open and part of her bowel protruded through. The Roths were told she needed another operation to repair the wound, although they protested that she was getting weaker. The second operation failed and within days the wound was weeping again. That night, Mrs Jax's consultant told the Roths that they would attempt to bind the wound and make her as comfortable as possible. He warned there was only a 10 per cent chance of her survival. "It was the most horrible experience of my life," Mrs Roth recalls, "watching my mother go from being a lively, healthy woman to this frail, weak old lady."