Korczak Dieter, Schöffmann Christine
GP-Forschungsgruppe, Institut für Grundlagen- und Programmforschung, Munich, Germany.
GMS Health Technol Assess. 2010 Mar 16;6:Doc04. doi: 10.3205/hta000082.
Methicillin-resistant Staphylococcus aureus (MRSA) are dangerous agents of nosocomial infections. In 2007 the prevalence of MRSA is 20.3% in Germany (Oxacilline-resistance according to EUCAST-criteria [EUCAST = European Committee on Antimicrobial Susceptibility Testing]).
Which measurements are effective in the prevention and control of MRSA-infections in the hospital?How effective are contact precautions, screening, decolonisation, education and surveillance?Which recommendations can be given to health care politics on the basis of cost-effectiveness studies?Have there been any adverse effects on patients and clinical staff?What kind of liability problems exist?
Based on a systematic review of the literature studies are included which have been published in German or English language since 2004.
1,508 articles have been found. After having surveyed the full text, 33 medical, eight economic and four ethical/juridical studies are included for the Health Technology Assessment (HTA) report. The key result of the HTA report is that different measurements are effective in the prevention and control of MRSA-infections in hospitals, though the majority of the studies has a low quality. Effective are the conduction of differentiated screening measurements if they take into account the specific endemic situation, the use of antibiotic-control programs and the introduction and control of hygienic measurements. The break even point of preventive and control measurements cannot be defined because the study results differ too much. In the future it has to be more considered that MRSA-infections and contact precautions lead to a psycho-social strain for patients.
It is hardly possible to describe causal efficacies because in the majority of the studies confounders are not sufficiently considered. In many cases bundles of measurements have been established but not analyzed individually. The internal and external validity of the studies is too weak to evaluate single interventions. Hygienic measurements prove to be effective in combination with other measurements. But it cannot be said which of the single measurements (gloves, washing hands, wearing gowns or masks) has the strongest effect on the reduction of MRSA. It is irritating that there are high differences in the compliance concerning hand hygiene between different studies. A general decolonisation is questionable for different reasons: first because of the side-effects for patients, second because of the high rate of spontaneous remissions in the untreated control group, third because of the differentiated process from colonisation to infection. Severalfold Hawthorne effects have been reported. One of them is that the competition between hospitals to reduce MRSA-rates leads already to a reduction.
It is evident that selective screening programs of risk patients considering the particular MRSA-prevalence are of use. The application of rapid tests seems to be only recommendable for risk patients and a high MRSA-prevalence. The improvement of the compliance of hand hygiene should be the basis of any prevention strategy. Training of staff members (with feedback mechanisms) is effective to improve compliance and to optimise the use of antibiotics. Antibiotic management programs are effective as well. Obviously multimodal approaches can lead to overadditive effects. Therefore the catalogue of preventive and control measurements has to be further evaluated. Good cost-efficacy studies are missing in Germany. The psychosocial effects of MRSA-infections are not researched in Germany. There is only punctual information on the risk management of hospitals.
耐甲氧西林金黄色葡萄球菌（MRSA）是医院感染的危险病原体。2007年，德国MRSA的患病率为20.3%（根据欧盟抗菌药物敏感性试验委员会[EUCAST = European Committee on Antimicrobial Susceptibility Testing]的苯唑西林耐药标准）。
哪些措施对预防和控制医院内的MRSA感染有效？接触预防、筛查、去定植、教育和监测的效果如何？基于成本效益研究，可向卫生保健政策提出哪些建议？对患者和临床工作人员是否有任何不良影响？存在哪些责任问题？
基于对文献的系统综述，纳入自2004年以来以德语或英语发表的研究。
共找到1508篇文章。在对全文进行筛选后，33篇医学、8篇经济和4篇伦理/法律研究被纳入卫生技术评估（HTA）报告。HTA报告的关键结果是，不同措施对预防和控制医院内的MRSA感染有效，尽管大多数研究质量较低。如果考虑到特定的地方流行情况进行差异化筛查措施、使用抗生素控制方案以及引入和控制卫生措施，这些措施是有效的。由于研究结果差异太大，无法确定预防和控制措施的盈亏平衡点。未来必须更多地考虑到MRSA感染和接触预防会给患者带来心理社会压力。
由于大多数研究没有充分考虑混杂因素，因此很难描述因果效力。在许多情况下，已经建立了一系列措施，但没有单独进行分析。研究的内部和外部有效性太弱，无法评估单一干预措施。卫生措施与其他措施结合使用时被证明是有效的。但无法确定单一措施（手套、洗手、穿隔离衣或戴口罩）中哪一项对降低MRSA的效果最强。令人恼火的是，不同研究之间手部卫生的依从性差异很大。由于不同原因，普遍去定植存在疑问：首先是因为对患者有副作用，其次是因为未治疗的对照组自发缓解率很高，第三是因为从定植到感染的过程存在差异。已经报道了多种霍桑效应。其中之一是医院之间为降低MRSA率而进行的竞争已经导致了MRSA率的降低。
显然，考虑到特定的MRSA患病率，对高危患者进行选择性筛查计划是有用的。快速检测似乎仅适用于高危患者和MRSA患病率高的情况。提高手部卫生的依从性应是任何预防策略的基础。对工作人员进行培训（并建立反馈机制）对提高依从性和优化抗生素使用是有效的。抗生素管理计划也很有效。显然，多模式方法可能会产生超加性效应。因此，预防和控制措施目录必须进一步评估。德国缺乏良好的成本效益研究。德国没有对MRSA感染的心理社会影响进行研究。关于医院风险管理只有零散的信息。
