Visit to King's College Hospital,
4 November 1997
1. Seven members of the Sub-Committee,
with staff, visited King's College Hospital on Denmark Hill.
2. Professor Mark Casewell,
Professor of Medical Microbiology, introduced the hospital: a
London teaching hospital, with approximately 1,000 beds including
100 high-dependency beds and 3,500 admissions per month; the UK
centre for liver transplants, which carry a high risk of hospital-acquired
infection and would be impossible without antibiotics; and an
academic centre for the study of antibiotic-resistant organisms
and hospital infection control.
3. Professor Casewell gave
a general introduction to the issues surrounding resistance. The
organisms of most concern at King's are MRSA,
Klebsiella and other coliforms; VRE; and MDR-TB. Of these, VRE
alone is sometimes literally untreatable; Professor Casewell described
the experience, unnerving to a doctor trained in the age of antibiotics,
of facing a patient with an infection where no treatment exists.
He drew our attention to the medico-legal question, whether patients
coming into hospital should be forewarned of the risk of contracting
a resistant infection. Commenting on the theory that "the
era of antibiotics is over", he remarked that, if so, this
would have profound consequences for modern medical and surgical
4. Professor Casewell is
not convinced that resistance to vancomycin is due to use of avoparcin
in animals. He pointed out that the USA does not use avoparcin
but has plenty of VRE; and he referred to unpublished research
suggesting that the vancomycin-resistance transposons in humans
and animals are distinct. He admitted being "out on a limb"
on this issue.
Medical Microbiology Laboratory
5. We visited the laboratory,
and saw susceptibility/resistance testing in progress. Three years
ago King's set up a bench dedicated to screening for MRSA; now
15,000 tests are carried out each year, costing about £40,000
for consumables, £25,000 for staff, and £55,000 in indirect
6. Professor Casewell regards
the development of an overnight test for MRSA as a top-priority
research project. He described the close relationship between
the medical microbiologist and the clinician as "pivotal",
and a great asset to UK medicine, shared by Spain, Holland and
Scandinavia, but not found in France, Germany, southern Europe,
the USA or Japan, where the hospital laboratory is more like a
cheaper "results-only factory".
7. At King's, 6-7 per
cent of patients contract a hospital-acquired infection; 10-20
per 1,000 become colonised with MRSA; and 2-4 per 1,000 become
infected with MRSA. Professor Casewell knows of no other UK hospital
with such firm incidence data. He considers that such data ought
to be compiled nationwide, as they are in Spain and the USA. He
acknowledged the problems of inadequate IT, and reluctance to
publish poor figures.
Infection Control Team
8. We met two nurses from
the Infection Control Team. The full Team is unusually well-staffed:
one doctor, three nurses, a secretary and an IT specialist. The
nurses explained how, when notified of an infection, they inspect
the ward, talk to the patient and their family, and give instructions
to the nurses and other staff. To clear patients colonised with
MRSA, they use Bactroban, a nasal form of mupirocin invented at
King's. Decolonisation typically takes one to three weeks. When
patients are discharged, a letter is written to the receiving
institution or GP. Sometimes other hospitals, and even other units
within King's, will not receive a patient unless they have a negative
screen for MRSA. In King's catchment area, there is no infection
control team in the community; this was felt to be a serious failing.
9. The nurses reckoned that
factors making for poor infection control include a poor environment,
low morale, inadequate staffing and excessive use of agency staff.
Professor Casewell contrasted the UK approach, tailoring infection
control to the circumstances of the ward or patient, with the
US approach of universal precautions: the UK approach seems to
be more effective in practice.
10. Dr Jim Wade, Infection
Control Doctor, explained that MRSA is endemic in King's, as in
most hospitals in the South East of England, and that therefore
it was necessary to a certain extent to "ride the wave".
Screening and search-and-destroy methods were targeted at those
patients and units most at risk. Two or three times a year it
might be necessary to restrict admissions to a particular ward
while an outbreak was dealt with; the extreme step of closing
a ward, with all its consequences for patients and the Trust,
was taken only rarely.
11. We visited an orthopaedic
ward: a long room of the Nightingale type. Isolation is not practical
in such a setting, so patients colonised with MRSA are moved;
there was currently a colonised patient in a two-bed side ward,
effectively blocking the other bed. Across the hospital, 16 patients
with MRSA were currently in isolation.
12. Infection control on
this ward was evidently effective: there had been no ward closure,
or even an outbreak of more than two related infections, for about
three years. Universal screening for MRSA had been tried, but
was not found to be cost-effective, so was not currently done.
13. We asked about handwashing:
at King's, nurses use a good liquid soap, without antiseptic,
and this seems to be effective. We also asked about "bank"
and "agency" nurses: the proportion of temporary nursing
staff on a ward can range from 10 per cent to as much as
50 per cent; agency nurses pose a particular challenge to
infection control, since they are not screened and may be unfamiliar
with local infection control procedures.
14. Professor Casewell commented
that three features of current hospital practice militate against
infection control: the lack of side wards and isolation facilities
(King's has 63: 22 in medicine, 5 in surgery, 19 in specialties
and 17 in the private wing); the downgrading of the ward sister,
who should be a senior nurse in a position to keep tight control
of procedures even for temporary staff; and the acute shortage
of beds in London, brought about by the Tomlinson Report, which
led to "hot-bedding"he gave examples from King's
of an 18-bed liver transplant ward which saw 51 changes in bed
occupants in four days, and a 12-bed ward which in the same period
15. Mr Matthew Porteous,
Consultant Orthopaedic Surgeon, and Janice Allen, Senior
Ward Sister, handed in the attached note of recommendations.
Intensive Care Unit
16. We visited the Intensive
Care Unit, where up to one patient in two will contract a hospital-acquired
infection. In the last four years, there have been three deaths
possibly attributable to MRSA after heart surgery, and one from
VRE. There have also been deaths from Gram-negative organisms
such as Klebsiella; these are different in that the pathogen is
not acquired from the hospital environment, but is already present
in the patient before becoming invasive. The ward had two isolation
rooms, with both positive and negative pressure ventilation. (Positive
stops bacteria from the general environment reaching the patient;
negative stops bacteria from the patient getting into the hospital.)
However, some highly-dependent patients cannot be safely isolated
because their medical condition is unstable and requires constant
17. Dr Max Ervine,
Consultant Anaesthetist, said that the ICU tends to import MRSA
from elsewhere. He drew attention to the problem of moving colonised
and infected patients out to other parts of the hospital, because
of the general shortage of side-wards.
18. Dr Anton Pozniak
spoke about multi-drug-resistant TB. The incidence in London is
low but rising, and the cost of each patient to the NHS is very
high. MDR-TB kills 46 per cent of HIV-negative sufferers,
and a much higher proportion of those who already have HIV. The
USA had experienced many outbreaks in 1990-92, following the dismantling
of public health prevention programmes in the 1980s; he hoped
that the same mistake would not be made here.
19. He mentioned the two
recent outbreaks of MDR-TB in London, involving eight patients
(all HIV+) at the Chelsea and Westminster, and seven patients
(six HIV+) at St Thomas'. These outbreaks had been contained;
but in Argentina one HIV unit had suffered an outbreak which infected
162 people and killed 146 of them. Two particular problems of
such outbreaks were the difficulty of tracing everyone who might
have had contact with the infected persons, and the real hazard
to medical staff.
20. Prescribing policies
King's has recently tightened up its antibiotic policies. One
way in which such policies are implemented is through "restrictive
reporting" by the laboratory, whereby the microbiologist
reports in the first instance only those susceptibilities which
would enable the referring doctor to treat within the policy.
(E.g. if the bacterium is susceptible to antibiotics A and B,
and the policy is to prefer A, only susceptibility to A is reported.)
Restrictive reporting is common practice in England, but not elsewhere.
Professor Casewell noted that levels of resistance tend to be
lower in countries with rigorous prescribing policies (e.g. Scandinavia,
the Netherlands), and higher in countries with less control (e.g.
southern Europe, the USA).
21. Prisons TB is
unusual in UK prisons. However, there was support for the suggestion
that prison medical services should be more integrated with the
22. Leg ulcers Dr
M Edmonds, a consultant physician, showed horrific pictures of
the effect of MRSA on leg ulcers in diabetic patients.
23. Research Dr Mufti,
Consultant Haematologist, said that research in this area, both
health services research (e.g. into whether cohort nursing or
isolation makes for better infection control) and biomedical research
into alternative approaches to infection, was badly needed and
under-funded, and the pharmaceutical industry could not be relied
upon to make the running. It was suggested that this would be
a good call on the NHS Research and Development budget.
24. It was suggested that
the UK is not as good at educating the public in these matters
as, for instance, the USA or Germany; and that the contribution
of the media was particularly disappointing.
Resistant BacteriaA Surgical Viewpoint
25. These bacteria are here
to stay; the development of increasingly resistant strains seems
inevitable. It may be possible to slow this process by a more
meticulous antibiotic prescribing policy.
2. These bacteriaparticularly
methicillin resistant Staphylococcus aureus (MRSA)pose
an infection risk in all surgery. The consequences of such infection
in Trauma and Orthopaedics are devastating as most operations
in this specialty involve the insertion of foreign material (e.g.
a plate for a fracture or a hip or knee replacement), infection
of which usually leads to the need for removal of the metalwork
and total failure of the operation. Infection of this type in
the elderly carries a significant mortality.
3. Eradication of these bacteria
has not worked and it seems more practical to adopt a policy of
containment such as we use in this hospital. The work of the Control
of Infection Team has been highly effective in implementing this
policy at King's and minimising disruption of the service.
4. This policy is not universal
and considerable difficulty can be experienced in inter-hospital
transfers of patients who have not been screened for MRSA which
can incur delays of up to a week. The adoption of an NHS-wide
policy in this respect is advocated.
5. The layout of older hospitals
with large open wards and few if any single rooms does not lend
itself to the easy isolation of patients infected with or carrying
resistant bacteria, without a significant impact on service provision.
6. Temporary staff on wards
are reluctant to nurse MRSA patients as there is no provision
for their sick leave if they become carriers of the bacteria.
7. Provision should be made
to recognise persistent carrying of resistant bacteria by nursing
and medical staff as an industrial disease.
|Consultant Orthopaedic Surgeon
||Senior Ward Sister
See the evidence of Dr R Hill of King's, p 417. Back