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MRSA in the Dutch-German border region (Euregio)

A.W. Friedrich The prevalence of Methicillin-resistant Staphylococcus aureus (MRSA) isolated from blood cultures is about 20 times lower in the Netherlands than in Germany. (1) The reason for this has been attributed to the stringent Dutch search and destroy policy and to optimized antibiotic stewardship. (2) Recently, mathematical simulations revealed how even regions with medium or high MRSA prevalence, as hypothesized for Germany, can control and reduce MRSA by adopting strategies for screening and precautionary isolation. Therefore, in the Dutch-German border region, healthcare institutions can learn from each other and the adaptation of the Dutch strategy in German healthcare facilities might help to prevent the intra and inter hospital spread of MRSA.

Since 2005 we have a Dutch-German cross-border network EUREGIO MRSA net (3) and in 2009 the EurSafety Health-net (http://www.eursafety.eu/) was built as a cross-border network of hospitals and other healthcare institutions in the central part of the Dutch-German border region. Two major problems were addressed in an area wide prospective multi centre study:

• Since data on the prevalence of patients admitted with MRSA were lacking in the German region and since there was an indication for a increasing prevalence of MRSA in the Dutch region, the hospitals in both regions started characterizing the actual prevalence of MRSA among patients. An enhanced surveillance system was introduced in the Euregio Twente/Münsterland, where risk-based admission screening and a search and follow strategy was introduced. Transmural case management of MRSA patients was established by the regional doctor’s organization Kassenärztliche Vereinigung Westfalen-Lippe.

• In parallel, since 2009, a mandatory notification for MRSA in blood cultures and in CSF was introduced in the German region.MRSA In 2010 and 2011 respectively 3342 (4,1 per 100.000 inhabitants) and 4129 (5,5 per 100.000 inhabitants) cases of MRSAB were reported in Germany. The incidence of all MRSA in Germany is unknown. Data for a whole area have been gathered for the first time in the Euregio project. After implementing a risk-based search and follow strategy in 2008, the incidence of MRSA in 2010 in the hospitals in the German border region was 232 per 100.000 inhabitants. This is 10 times higher than the incidence in the Dutch region (24,5 per 100.000 inhabitants/www.mrivm-nl/mrsa). In 2010 the incidence of MRSA blood culture in the German region was 3,4 per 100.000 inhabitants and 3,9 per 100.000 inhabitants in 2011 - this is one of the lowest incidences in Germany but higher than the incidence in the Dutch region.

Figuur 1 MRSA in the Dutch-German border region

Figure 1 The Euregio project region (2009-2015) with 4 northern project regions belonging to the EurSafety Health-net and the EurSafety EMR in the Euregio Maas-Rhine

The molecular characterization of MRSA on both sides of the border shows a difference in molecular types. The SPA types in the majority of epidemic strains in hospitals in the German region differ from the SPA types in the Dutch region. On both sides, livestock-associated MRSA is found as most prevalent or on the German side as 3rd most prevalent spa types in patients admitted to the hospitals (figure 1 and 2).

Figuur 2 MRSA in the Dutch-German border region

Figure 2 SPA types 2010/2011 on the Dutch side of the Euregio (n= 376) registered within the project

Since MRSA is increasingly detected in patients with lacking classical nosocomial risk factors, it becomes questionable whether ‘search’ policies based on screening of defined risk groups are sufficient for the reliable identification of MRSA patients.

I thank all cooperating colleagues within the Euregio projects, especially Dr. Ron Hendrix (Labmicta, Enschede and UMCG. Groningen) and Robin Köck (Dept of Microbiology and Dept of Hygiene, University Hospital Münster) who contributed directly to the data shown in this presentation.

Author

A.W. Friedrich, Dept. Medical Microbiology, University Medical Center Groningen

Correspondence:

A.W. Friedrich | a.w.friedrich@med.umcg.nl

References

  1. http://ecdc.europa.eu/en/activities/surveillance/EARS-Net/database/Pages/database.aspx
  2. Wertheim HFL, Vos MC, Boelens HAM, et al. Low prevalence of methicillin-resistant Staphylococcus aureus (MRSA) at hospital admission in the Netherlands: the value of search and destroy and restrictive antibiotic use. J Hosp Infect 2004;56:321–325.
  3. Friedrich AW, Daniels-Haardt I, Köck R, Verhoeven F, Mellmann A, Harmsen D, van Gemert-Pijnen JE, Becker K, Hendrix MG. 2008. EUREGIO MRSA-net Twente/Münsterland - a Dutch-German cross-border network for the prevention and control of infections caused by methicillin-resistant Staphylococcus aureus. Euro Surveill. 28;13(35).
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