Evidence for Community Transmission of Community-Associated but Not Health-Care-Associated Methicillin-Resistant Staphylococcus Aureus Strains Linked to Social and Material Deprivation: Spatial Analysis of Cross-sectional Data.

BACKGROUND: Identifying and tackling the social determinants of infectious diseases has become a public health priority following the recognition that individuals with lower socioeconomic status are disproportionately affected by infectious diseases. In many parts of the world, epidemiologically and genotypically defined community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA) strains have emerged to become frequent causes of hospital infection. The aim of this study was to use spatial models with adjustment for area-level hospital attendance to determine the transmission niche of genotypically defined CA- and health-care-associated (HA)-MRSA strains across a diverse region of South East London and to explore a potential link between MRSA carriage and markers of social and material deprivation. METHODS AND FINDINGS: This study involved spatial analysis of cross-sectional data linked with all MRSA isolates identified by three National Health Service (NHS) microbiology laboratories between 1 November 2011 and 29 February 2012. The cohort of hospital-based NHS microbiology diagnostic services serves 867,254 usual residents in the Lambeth, Southwark, and Lewisham boroughs in South East London, United Kingdom (UK). Isolates were classified as HA- or CA-MRSA based on whole genome sequencing. All MRSA cases identified over 4 mo within the three-borough catchment area (n = 471) were mapped to small geographies and linked to area-level aggregated socioeconomic and demographic data. Disease mapping and ecological regression models were used to infer the most likely transmission niches for each MRSA genetic classification and to describe the spatial epidemiology of MRSA in relation to social determinants. Specifically, we aimed to identify demographic and socioeconomic population traits that explain cross-area extra variation in HA- and CA-MRSA relative risks following adjustment for hospital attendance data. We explored the potential for associations with the English Indices of Deprivation 2010 (including the Index of Multiple Deprivation and several deprivation domains and subdomains) and the 2011 England and Wales census demographic and socioeconomic indicators (including numbers of households by deprivation dimension) and indicators of population health. Both CA-and HA-MRSA were associated with household deprivation (CA-MRSA relative risk [RR]: 1.72 [1.03-2.94]; HA-MRSA RR: 1.57 [1.06-2.33]), which was correlated with hospital attendance (Pearson correlation coefficient [PCC] = 0.76). HA-MRSA was also associated with poor health (RR: 1.10 [1.01-1.19]) and residence in communal care homes (RR: 1.24 [1.12-1.37]), whereas CA-MRSA was linked with household overcrowding (RR: 1.58 [1.04-2.41]) and wider barriers, which represent a combined score for household overcrowding, low income, and homelessness (RR: 1.76 [1.16-2.70]). CA-MRSA was also associated with recent immigration to the UK (RR: 1.77 [1.19-2.66]). For the area-level variation in RR for CA-MRSA, 28.67% was attributable to the spatial arrangement of target geographies, compared with only 0.09% for HA-MRSA. An advantage to our study is that it provided a representative sample of usual residents receiving care in the catchment areas. A limitation is that relationships apparent in aggregated data analyses cannot be assumed to operate at the individual level. CONCLUSIONS: There was no evidence of community transmission of HA-MRSA strains, implying that HA-MRSA cases identified in the community originate from the hospital reservoir and are maintained by frequent attendance at health care facilities. In contrast, there was a high risk of CA-MRSA in deprived areas linked with overcrowding, homelessness, low income, and recent immigration to the UK, which was not explainable by health care exposure. Furthermore, areas adjacent to these deprived areas were themselves at greater risk of CA-MRSA, indicating community transmission of CA-MRSA. This ongoing community transmission could lead to CA-MRSA becoming the dominant strain types carried by patients admitted to hospital, particularly if successful hospital-based MRSA infection control programmes are maintained. These results suggest that community infection control programmes targeting transmission of CA-MRSA will be required to control MRSA in both the community and hospital. These epidemiological changes will also have implications for effectiveness of risk-factor-based hospital admission MRSA screening programmes.

The impact of meticillin-resistant Staphylococcus aureus on patients with advanced cancer and their family members: A qualitative study.

BACKGROUND: Little is known about the impact of meticillin-resistant Staphylococcus aureus on patients with advanced cancer, such as its impact on the quality of life of this vulnerable group. To date, research on meticillin-resistant Staphylococcus aureus in the palliative care setting has had a quantitative focus. AIM: The purpose of this study was to explore the impact of a meticillin-resistant Staphylococcus aureus diagnosis on patients and their carers. DESIGN: This article reports upon a qualitative interview study of nine patients with advanced cancer and meticillin-resistant Staphylococcus aureus and nine family members (n = 18). Framework analysis was used to analyse the data. SETTING/PARTICIPANTS: Patients and family members of patients with advanced cancer either admitted to the specialist palliative care unit or receiving palliative care in the hospital setting, who had a laboratory confirmed diagnosis of meticillin-resistant Staphylococcus aureus colonisation, were considered for inclusion in the study. RESULTS: Four themes were identified using framework analysis: reactions to receiving a meticillin-resistant Staphylococcus aureus diagnosis, the need for effective communication of the meticillin-resistant Staphylococcus aureus diagnosis, the enigmatic nature of meticillin-resistant Staphylococcus aureus, and lessons to guide the future care of meticillin-resistant Staphylococcus aureus patients. CONCLUSION: This article indicates that meticillin-resistant Staphylococcus aureus can have a significant impact on advanced cancer patients and their families. This impact may be underestimated, but early and careful face-to-face explanation about meticillin-resistant Staphylococcus aureus and its implications can help patients and their families to cope better with it. These findings should be considered when developing policy relating to meticillin-resistant Staphylococcus aureus management and infection control in specialist palliative care settings.

["I cannot kiss my wife"- An Analysis of Daily Experiences of MRSA-carriers]. / "Meine Frau kann ich nicht küssen" ­ Eine Analyse des Erlebens von MRSA-TrägerInnen.

Objectives: There are no data available on the quality of care after discharge from hospital and only limited data are available on the psychosocial effects of being an MRSA carrier within the German health system. Methods: Patients who tested positive for MRSA in the previous year were invited to take part in focus groups. Results: 2 focus groups with a total of 9 MRSA-carriers were conducted. The level of knowledge about MRSA differed between participants. In some cases, lack of information led to uncertainty and inappropriate measures to counteract MRSA. Some participants restricted their social contacts, especially to children, in order to prevent transmission. Patients experienced stigmatization in the health care system more often in inpatient care than in the outpatient sector. Only in a few cases both eradication therapy and swabs for control purposes were carried out. Conclusions: Information about the appropriate treatment and management of MRSA should be made available to patients more easily; in particular, patients need to be informed that MRSA is no threat to healthy individuals. Despite the desire of MRSA-carriers to become MRSA negative, treatment and control of MRSA seem to have low priority in the ambulant health care sector in Germany.

Being Met as marked - patients' experiences of being infected with community-acquired methicillin-resistant Staphylococcus aureus (MRSA).

BACKGROUND: It is known that patients who acquired methicillin-resistant Staphylococcus aureus (MRSA) in hospitals suffer and feel as plague. Moreover, the patient interaction with nurses and physicians is described as frightening. Little is known about patient experiences after having acquired CA-MRSA concerning care and everyday life. AIM: To reveal and interpret otherwise healthy patients' lived experiences of receiving care and their everyday life after having acquired community MRSA (CA-MRSA). METHODS: A phenomenological hermeneutic approach guided by Ricouer was conducted. Interviews with twelve patients were transcribed verbatim into a text. The text was analysed in three phases: naive understanding, structural analysis and comprehensive understanding to reveal a possible being in the world. In this study, this referred to what it means to be infected with CA-MRSA. RESULTS: The findings indicate that patients who acquired MRSA experience a changed body image. They suffer from ignorant and frightened behavior from healthcare workers, social contacts, and also of being bullied by colleagues. Despite this, patients assume great responsibility for protecting others. However, knowledgeable staff alleviate suffering and bring peace of mind to the patients. CONCLUSIONS: Preventing patient's feelings of being a pest, an outsider living with fear, requires urgent education and understanding about resistant bacteria and how to meet an infected patient. The results describing patients, affected with MRSA, may contribute and touch the readers to better understanding of patient's changed body image and suffering and how to mitigate these feelings.

The stigmatization dilemma in public health policy--the case of MRSA in Denmark.

BACKGROUND: Multi-resistant bacteria pose an increasing and significant public health risk. As awareness of the severity of the problem grows, it is likely that it will become the target for a range of public health interventions. Some of these can intentionally or unintentionally lead to stigmatization of groups of citizens. DISCUSSION: The article describes the phenomenon of stigmatization within the health care area by discussing the concept in relation to AIDS and psychiatric diagnosis. It unfolds the ethical aspects of using stigmatization as a public health instrument to affect unwanted behaviours e.g. smoking. Moreover it discusses stigmatization as an unintended albeit expected side effect of public health instruments potentially used to counter the challenge of multi-resistant bacteria with particular reference to the Danish case of the growing problems with Methicillin-resistant Staphylococcus aureus (MRSA) within pig production. We argue that using stigmatization as a direct means to achieve public health outcomes is almost always ethically illegitimate. Autonomy and dignity considerations count against it, and the cost-benefit analysis that might by some be taken to outweigh these considerations will be fundamentally uncertain. We further argue that interventions where stigmatization is a side-effect need to fulfil requirements of proportionality, and that they may fall prey to 'the stigmatization dilemma', i.e. the dilemma that arises when all policy options are potentially stigmatizing but stigmatize different groups. When this dilemma obtains the decision-maker should choose the intervention that does not lead to permanent stigmatization and that stigmatizes as few as possible, as briefly as possible, and as little as possible.

Measuring Outcomes: Pain and Quality of Life 48 Months After Acute Postoperative Total Knee Prosthetic Joint Infection.

BACKGROUND: Measuring HRQOL is simple, inexpensive, permits the health status to be measured over time, and is useful to compare or initiate treatments and evaluate results, facilitating homogenization in patient inclusion. OBJECTIVES: To evaluate disease-specific and generic HRQOL and influence of associated factors in patients undergoing open debridement for acute postsurgical knee prosthetic joint infection after TKR at 12 and 48 months after completing antibiotic treatment and considered cured of infection. METHODS: Health-related quality-of-life measures were administered at baseline (WOMAC) and 12 and 48 months (WOMAC and SF-36) in patients with prosthesis retention, no symptoms of infection, and CRP (≤ 1 mg/dL). RESULTS: Thirty patients were included, and 24 were evaluated at 48 months. WOMAC scores improved significantly (P < 0.01) at 12 and 48 months. The effect size was 0.72 for stiffness, 2.01 for pain, and 2.15 for function. At 48 months, improvements were greater (P < 0.02) except for stiffness. The most frequently isolated microorganisms were Staphylococcus aureus (14 patients) and coagulase-negative staphylococci (9 patients). SF-36 physical role, bodily pain, emotional role, and mental health dimension scores at 12 and 48 months were significantly worse in patients with isolates of Staphylococcus aureus (P < 0.05). CONCLUSIONS: Health-related quality-of-life measures detected significant differences in outcomes in patients infected by S. aureus compared with patients infected by other microorganisms. HRQOL measures may provide useful complementary information on outcomes after acute postoperative infection.

Notification card to alert for methicillin-resistant Staphylococcus aureus is stigmatizing from the patient's point of view.

BACKGROUND: The importance of alerting health care systems of patients carrying multidrug-resistant bacteria (MRB) is highlighted in numerous guidelines. In the absence of electronic alert systems, notification cards are often recommended, but have rarely been evaluated. We evaluated patient experiences of receiving and using a methicillin-resistant Staphylococcus aureus (MRSA) notification card. METHODS: Two cohorts of patients given a card when identified for the first time as a carrier in 1999-2003 and 2008-2010, responded to questionnaires distributed in 2004 and 2011, respectively. The response rate in 2004 was 92 (38 females)/129 and in 2011 was 110 (55 females)/209. In addition, 63% and 49%, respectively, followed the encouragement to provide written comments to the questions. These were analysed using a qualitative method. RESULTS: The patients took responsibility not to infect others, reported high usage, and acknowledged the importance of the card to inform health care institutions about their carrier status, despite experiencing fear, disrespect, lack of knowledge, and unprofessional behaviour when presenting it to personnel. Alarmingly these stigmatizing experiences were more frequent in 2011. Professional behaviour was reported from the infectious disease clinic. A majority of the patients were unaware of how they had acquired MRSA. CONCLUSIONS: The MRSA notification card was felt to stigmatize the patient, which makes its use questionable. Other alert methods need to be developed. Most importantly, the study demonstrates the importance for these patients to meet staff educated about MRB. Thus, there is an urgent need to educate health care professionals at all levels.

Treatment, outcome and quality of life after Fournier's gangrene: a multicentre study.

AIM: The object of this study was to describe the course of Fournier's gangrene and assess quality of life in a group of affected patients. METHOD: We evaluated patients who received inpatient treatment for Fournier's gangrene at five hospitals in northern Germany from 1995 to 2010. Surviving patients were asked to take part in a clinical follow-up and complete the Short-Form 36 (SF-36) quality-of-life questionnaire and a disease-specific questionnaire including a physical examination. RESULTS: Of the 86 patients, 72 (83.7%) were men. The mean age of the patients was 57.9 ± 13.9 (25-89) years. The mean length of hospital stay was 52.0 ± 54.0 (1-329) days. Fourteen (16.3%) patients (eight men) died primarily from Fournier's gangrene. The most common aetiological event was anogenital abscess formation (n = 24; 27.9%). Seventy-one (82.5%) patients had a mixed polymicrobial infection. SF-36 physical role functioning (P = 0.010), physical functioning (P = 0.008), general health (P = 0.010) and physical health summary (P = 0.006) scores were significantly lower than those of the normal population. Deterioration in sexual function was reported by 65% of the patients. CONCLUSION: Patients with Fournier's gangrene experience persistent physical and mental health problems for a long period of time following their primary hospital stay and must receive long-term care from a variety of specialists, otherwise the disease leads to an increase in the duration of morbidity and a decrease in quality of life.

MRSA model of learning and adaptation: a qualitative study among the general public.

BACKGROUND: More people in the US now die from Methicillin Resistant Staphylococcus aureus (MRSA) infections than from HIV/AIDS. Often acquired in healthcare facilities or during healthcare procedures, the extremely high incidence of MRSA infections and the dangerously low levels of literacy regarding antibiotic resistance in the general public are on a collision course. Traditional medical approaches to infection control and the conventional attitude healthcare practitioners adopt toward public education are no longer adequate to avoid this collision. This study helps us understand how people acquire and process new information and then adapt behaviours based on learning. METHODS: Using constructivist theory, semi-structured face-to-face and phone interviews were conducted to gather pertinent data. This allowed participants to tell their stories so their experiences could deepen our understanding of this crucial health issue. Interview transcripts were analysed using grounded theory and sensitizing concepts. RESULTS: Our findings were classified into two main categories, each of which in turn included three subthemes. First, in the category of Learning, we identified how individuals used their Experiences with MRSA, to answer the questions: What was learned? and, How did learning occur? The second category, Adaptation gave us insights into Self-reliance, Reliance on others, and Reflections on the MRSA journey. CONCLUSIONS: This study underscores the critical importance of educational programs for patients, and improved continuing education for healthcare providers. Five specific results of this study can reduce the vacuum that currently exists between the knowledge and information available to healthcare professionals, and how that information is conveyed to the public. These points include: 1) a common model of MRSA learning and adaptation; 2) the self-directed nature of adult learning; 3) the focus on general MRSA information, care and prevention, and antibiotic resistance; 4) the interconnected nature of adaptation; and, 5) the need for a consistent step by step plan to deal with MRSA provided at the time of diagnosis.

MRSA--global threat and personal disaster: patients' experiences.

AIM: To ascertain and describe the patients' knowledge, perceptions and experiences of being methicillin-resistant Staphylococcus aureus (MRSA) positive. BACKGROUND: Antibiotic resistant bacteria are a serious global threat. MRSA can cause wound infection, pneumonia, septicaemia and mortality. This qualitative study has focused on patients' experiences of living with MRSA. METHODS: Fifteen patients with MRSA-infected wounds were interviewed. All data were transcribed verbatim and analysed according to content analysis. FINDINGS: Information about the MRSA diagnosis often caused a shock-like reaction. Patients' perception of being MRSA positive was stigmatizing as plague or leprosy; they felt dirty and felt that they were a severe threat to their environment. Fears of infecting someone else and being rejected were commonly expressed. The key findings emerged as a theme: Being exposed to others' shortcomings and being a threat to others' health. Three categories were identified: understanding and emotional reactions, treatment by the healthcare professionals and consequences and expectations. Gaps in both patient and staff knowledge of MRSA led to unnecessary misunderstandings, causing fear, social isolation and suffering. CONCLUSIONS: Living with MRSA can be extremely stressful for the patients. Knowledge and empathy from staff involved in their care is crucial to optimize patients' experiences. Staff education to meet patients' demand for information and prevent contamination is essential.

A staff questionnaire study of MRSA infection on ENT and general surgical wards.

Methicillin-resistant Staphyloccocus aureus (MRSA) infection has received much attention in both the medical and non-medical press. However, it is not widely encountered on ENT wards, given the profile of short-stay, relatively well patients, although its impact seems to be increasing. We wished to explore the knowledge and attitudes towards MRSA on general surgical and ENT wards, and see if there were any significant differences between specialties, or between doctors and nurses. A 13-item questionnaire with a Likert scale response with six knowledge questions and seven attitude questions was prepared. It was completed anonymously by all nursing and medical staffs on the ENT and general surgical wards of a large District General Hospital. ENT doctors displayed the lowest knowledge and attitude scores; however, this only attained significance in terms of the knowledge of the difference between infection and colonization. Overall, nurses displayed significantly more positive attitudes towards MRSA patients than doctors, but knowledge scores were not significantly different between professions. The study suggests a lack of knowledge about and preponderance of negative attitudes towards MRSA amongst ENT doctors. The difference between colonization and infection is not well understood. Reasons for this may include the relative rarity of MRSA cases on ENT wards.

Patients' experiences of being infected with MRSA at a hospital and subsequently source isolated.

BACKGROUND: Patients infected with methicillin-resistant Staphylococcus aureus (MRSA) during a large outbreak of E-MRSA 16 between 1997 and 2001 at Sahlgrenska University Hospital, Sweden, were moved from their speciality ward to the Clinic of Infectious Diseases for care in source isolation as long as the patient needed hospital care. AIM: To get knowledge regarding patients' experiences who contracted MRSA at the hospital and subsequently source isolated at the Clinic of Infectious Diseases. METHOD: The interviews were designed according to qualitative research. Six patients, aged 35-76 years, who contracted MRSA at Sahlgrenska hospital and subsequently source isolated for at least 1 week were interviewed. The interviews were tape-recorded and an inter-subjective analysis was accomplished. FINDINGS: The study found that the patients felt violated for having contracted MRSA at the hospital and the isolation was described as traumatic, albeit accepted because they took responsibility for not spreading MRSA. The patients felt that they did not receive rehabilitation on the same conditions as other patients and lacked information about MRSA. They felt vulnerable due to negative reactions from the nursing staff, family members and other patient's surroundings. CONCLUSION: Patients who contract MRSA need information about what the MRSA contagion involves. There is a great need for an elevated knowledge of MRSA among staff members. An increased awareness of how the contagion spreads will allay fears of MRSA among staff and patients. The source isolation should be as short as possible to minimise the feeling of confinement.

How to reduce the negative psychological impact of MRSA isolation on patients.

MRSA is contagious and difficult to treat, and the isolation of infected patients is recommended by the Department of Health. However, isolation can have a negative psychological impact on patients and is controversial. This literature review explores the effects of isolation based on three themes: isolation environment and psychological impact; stigma of MRSA; and nursing care.

Pediatricians' perspectives on the impact of MRSA in primary care: a qualitative study.

BACKGROUND: The incidence of skin and soft-tissue infections (SSTIs) has rapidly increased among children in primary care settings since the emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). Recent treatment recommendations emphasize CA-MRSA as the primary cause, performing incision and drainage (I&D) as the primary therapy, and not prescribing antibiotics for uncomplicated cases. It is unknown how this epidemic has impacted primary care pediatricians in terms of their practice patterns and barriers they face to providing recommended therapies. METHODS: 3 Focus groups among 29 primary care pediatricians in the San Francisco Bay Area were conducted. Transcripts were reviewed and coded into major themes by two investigators using modified grounded theory. RESULTS: Substantial changes in clinical practice have occurred since the emergence of CA-MRSA. These include increased office visits for SSTIs, patients with multiple recurrences and transmission within households. Additionally, our participants reported increased visits for mild skin problems due to media reports contributing to fears about CA-MRSA. Participants routinely prescribed antibiotics for SSTIs, however, few performed I&D. Few were aware of recent SSTI treatment recommendations. Barriers to prescribing antibiotics with CA-MRSA activity included concerns about side-effects and lack of local epidemiologic data showing that it is the primary etiology. Barriers to performing I&D included lack of training, resources and skepticism about its necessity. Important clinical challenges included increased time demands for follow-up visits and patient education along with the lack of evidence-based strategies for preventing recurrent infections and household transmission. CONCLUSION: CA-MRSA has influenced the presentation and treatment of SSTIs especially in terms of case numbers and recurrences. Barriers to providing recommended therapies can be addressed through improved dissemination of treatment guidelines and epidemiologic data. Studies are urgently needed to improve the evidence-base for treatment and prevention strategies.

A case of resolution of an acute psychotic episode after high fever.

Fever (pyretotherapy) was used for psychosis during the turn of the 19th century, but pyretotherapy (ie, the treatment of a disorder by inducing fever) fell out of use after the introduction of convulsive methods. Here, we report on a case of schizoaffective disorder and review classical and recent literature on fever and psychosis. The patient developed auditory hallucinations, persecutory delusional ideas, and was terrified soon upon his arrival in a foreign country. After being treated for 12 days with olanzapine and haloperidol, he developed a fever due to urinary infection; his creatine phosphokinase levels were high, prompting the suspension of antipsychotics. Psychotic symptom resolution followed immediately fever abatement. Antipsychotics were reintroduced at lower dosages. He was discharged asymptomatic with a prescription of olanzapine 15 mg/day and haloperidol 3 mg/day. The time course of symptom resolution in this patient suggests that fever had a beneficial role in this case. The associations between body temperature changes and psychotic symptoms need to be further studied.

Predictors of asking medical personnel about handwashing: the moderating role of patients' age and MRSA infection status.

OBJECTIVE: The study investigates patients' behaviours protective of methicillin-resistant Staphylococcus aureus (MRSA), asking doctors and nurses about handwashing before examination, and its relations with the Theory of Planned Behaviour (TPB) variables and knowledge. We expected that MRSA infection status and age might moderate relations between the behaviour and its predictors. METHODS: A total of 171 individuals (59% with MRSA; 54% of 65 years or older) who had contact with the Patients Association and MRSA Support groups filled out questionnaires. RESULTS: Across the groups beliefs about ability to control own behaviour were the best predictors of intention and behaviour, except for non-MRSA patients older than 65 years, for whom knowledge about MRSA infection remained the sole predictor of behaviour. The amount of explained variance of behaviour was twice as high among younger patients compared to older ones. CONCLUSIONS: The study indicates limitations of the predictive value of the TPB among older patients. The results support the importance of beliefs about ability to control own behaviour in predicting an error-preventive action. PRACTICE IMPLICATIONS: Enhancing control beliefs may promote asking medical personnel about handwashing. Interventions aiming MRSA prevention should target different cognitions or knowledge depending on patients' age and MRSA infection status.

Patient perceptions of osteomyelitis, septic arthritis and prosthetic joint infection: the psychological influence of methicillin-resistant Staphylococcus aureus.

INTRODUCTION: Patients form their own representations of their illness, which can be important determinants of their coping and influence outcome. Our aims were to (i) assess patient perceptions of osteomyelitis, septic arthritis and prosthetic joint infection, (ii) compare perceptions of methicillin-resistant Staphylococcus aureus (MRSA) with non-MRSA infection and (iii) investigate the emotional aspects of these infections. METHODS: A questionnaire was developed from the 'Illness Perception Questionnaire' of Weinman et al.with additional questions assessing emotional response. This was offered to all patients with osteomyelitis, septic arthritis and prosthetic joint infection attending the Liverpool Hospital Infectious Diseases Outpatient Clinic during a 3-month period. RESULTS: There were 91 respondents--25 with MRSA infection, 14 with MRSA colonization and 52 without MRSA. Seventy-nine per cent of all respondents felt that their infection was very serious and 76% felt their infection had had major consequences on their life. On multivariate analysis MRSA was associated with a greater emotional effect; the consequences and emotional effects of infection were greater in younger people and prosthetic joint infection was associated with less sense of control or cure. CONCLUSION: Osteomyelitis, septic arthritis and prosthetic joint infection have a significant effect on an individual. Ongoing support and education are important, particularly for the young, those with prosthetic joint infection and patients with MRSA.

Patients' feelings about hand washing, MRSA status and patient information.

The purpose of this study was to explore patient opinion about asking healthcare professionals to wash their hands before a clinical procedure and to explore if methicillin-resistant Staphylococcus aureus (MRSA) status and access to patient information about infection control would influence the patients' anxiety about asking. A descriptive survey was undertaken using a semi-structured questionnaire. The questionnaire was distributed to a randomized convenience sample of 185 inpatients across all departments of an acute NHS Trust hospital (response rate 58.9%). Spearman's rank order and Kendall Tau-b tests were used to analyse specific correlations. Respondents were more confident than anxious about being involved in a campaign that empowered patients to ask staff to wash their hands. Patients were more anxious to ask if their previous admission episodes were fewer, if their knowledge of MRSA was high and if there was less information about infection control available. Patients who had contracted MRSA in the past were less anxious, as they had a better understanding of the disease. In addition, more patients felt less anxious about asking staff to wash their hands if staff wore a badge saying 'It's OK to ask'.

Signs of stigma and poor mental health among carriers of MRSA.

BACKGROUND: Many countries have implemented guidelines to prevent transmission of meticillin-resistant Staphylococcus aureus (MRSA). Important contextual factors of stigma can be identified in the context of MRSA. Over the past decade, concerns have been raised over a possible stigmatizing effect of these actions. AIM: To identify and quantify the occurrence of MRSA-associated stigma, and to explore its association with mental health in a country with an MRSA 'search and destroy' policy. METHODS: In 2014, a questionnaire study among 57 Dutch MRSA carriers (people that carry MRSA without signs of MRSA infection) was performed. Stigma was measured with an adjusted version of the Berger HIV Stigma Scale. Mental health was measured with the five-item RAND Mental Health Inquiry. FINDINGS: Thirty-two (56%) MRSA carriers reported stigma; of these, eight (14%) reported 'clear stigma' (Berger score >110) and 24 (42%) reported 'suggestive for stigma' (Berger score 76-110). Educational level, female sex and intensive MRSA eradication therapy were associated with higher stigma scores. Poor mental health (RAND score <60) was reported by 33% of MRSA carriers. Stigma and mental health scores were inversely correlated. Stigma was experienced most frequently in healthcare settings, and was seldom experienced in the religious community or at sport facilities. CONCLUSION: A substantial proportion of MRSA carriers reported stigma due to MRSA, and stigma was associated with poor mental health. Anticipation of MRSA-associated stigma is warranted, both in the way that care is delivered by hospital staff and in the way that care is organized within the hospital.