Select Committee on Science and Technology Seventh Report


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[81], 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 practice.

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 He pointed out that the USA does not use avoparcin but has plenty of VRE; and he referred to unpublished research suggesting that the vancomycin-resistance transposons in humans and animals are distinct.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 costs.

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.

Surgical Ward

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 saw 22.

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 attention.

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 NHS.

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.

Public education

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.

Antibiotic Resistant Bacteria—A 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 bacteria—particularly 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.
Matthew Porteous Janice Allen
Consultant Orthopaedic Surgeon Senior Ward Sister

81   See the evidence of Dr R Hill of King's, p 417. Back

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