Care for MRSA carriers in the outpatient sector: a survey among MRSA carriers and physicians in two regions in Germany

Methicillin-resistant Staphylococcus aureus (MRSA) has a prevalence of around 2.2 % in newly admitted patients to German hospitals [1] and can be detected in 18–20 % of inpatients’ derived Staphylococcus aureus isolates [2]. To diminish the overall load of MRSA, a bundle of measurements is recommended both, on the hospital level (e.g., isolation) and on the individual level (e.g., decolonization therapy) [3]. While the spread of MRSA is especially problematic in the inpatient sector, transmissions can be initiated by MRSA carriers readmitted to the hospital. In order to interrupt the MRSA transmission, not only measures in the hospital but also follow-up and decolonization of patients in the outpatient sector is necessary. Meyer et al. [4] reported that decolonization therapy can be applied successfully in the outpatient sector and pointed out that a close cooperation between outpatient and inpatient sector is necessary. However, a follow-up system for MRSA carriers (or carriers of other multiresistant pathogens) across sectoral borders (inpatient vs. outpatient) is missing in Germany, and we could not find any international studies concerning this subject. The German College of General Practitioners and Family Physicians (DEGAM) had published guidelines for the diagnosis and therapy of MRSA in the outpatient sector in September 2013 (three months before the survey). These recommendations are in accordance with the ones of the KBV (National Association of Statutory Health Insurance Physicians) published earlier. Both recommend MRSA screening for patients with an increased risk of being MRSA-positive, as well as three control swabs 48 h, 3–6 months and 12 months after application of a decolonization therapy. This treatment is recommended for all MRSA carriers; however, in case of factors that might decrease the success such as chronic wounds, the physician can opt out. The guidelines recommend up to two decolonization therapies before consulting a specialist, e.g., a MRSA network. The treatment should comprise a bundle of measures (nasal ointment, mouthwashes, and daily disinfection of hair and skin for 5 days). Accompanying measures should include daily change of clothes, bedding and towels, and disinfection or daily change of hygiene utensils [5].

In order to improve treatment of MRSA in the outpatient sector, reimbursement of the costs for MRSA screening, control swabs, and decolonization therapy was introduced in April 2012 by the Federal Joint Committee (“Gemeinsamer Bundesausschuß”), and the reimbursement is now paid by statutory health insurances. It is noteworthy, that only the costs for nasal ointment (mupirocin) are covered by the statutory health insurances. The impact of this reimbursement has not been studied yet.

In addition, risk perceptions regarding MRSA are likely to cause stigmatization of MRSA carriers, as was described for the UK [6] and for Sweden [7]. Up to now, nothing is known about the perception of stigmatization due to MRSA in the daily life of MRSA carriers after discharge from hospital in Germany [8]. Greiner [9] demonstrated a considerable loss of quality of life for patients with MRSA infection, but no data are available about the quality of life of MRSA carriers without symptoms of MRSA infection.

Therefore, our study aimed at assessing knowledge, attitude, and practice related to MRSA among MRSA carriers and among physicians in outpatient care in two regions of Germany after the introduction of an additional reimbursement for MRSA specific care. In addition, we studied the perceived stigmatization and quality of life in MRSA carriers. Beside this quantitative approach, we initiated focus groups with MRSA carriers from the same study population [10].

We analyzed knowledge, attitude and practice among MRSA carriers and physicians in the outpatient sector in Germany after the introduction of reimbursement for MRSA related therapy. Physicians displayed heterogeneous knowledge and level of activity regarding MRSA specific aspects. Almost one third of the responding MRSA carriers stated that no healthcare professional had ever talked to them about MRSA. Thirty percent claimed that their quality of life deteriorated due to MRSA and one third experienced stigmatization due to MRSA or exerted self-stigmatization.

Similarly,the reduction of social contacts and leisure activities among MRSA carriers was also reported in a Swedish study [7] and in our own focus groups, where participants reported the reduction of social contacts, e.g., to their grandchildren as a consequence of the MRSA finding [10]. Such behaviour is generally not recommended in official guidelines [12]. Nevertheless, some MRSA carriers seem to overestimate the risk associated with MRSA for healthy and non-hospitalized individuals. It might be advisable to proactively address this topic in patient information leaflets and physician-patient consultations.

Some participants reported a rejection by health care services like a nursing home or a rehabilitation clinic because of MRSA. Further studies are necessary to investigate to which extent the medical treatment of the underlying conditions is negatively influenced by a positive MRSA status.

MRSA carriers who sought additional information about MRSA on the internet or by reading newspapers could answer more knowledge questions correctly. This suggests that publicly available information on MRSA is used by MRSA carriers and has a positive effect on their knowledge. Hence, the quality and availability of public information on MRSA is important. Thirty percent of the respondents claimed that no healthcare professional had ever talked to them about MRSA. Astonishingly, some of these also reported the application of a decolonization therapy. In these cases, either the decolonization therapy has been applied without a proper clarification or the responding MRSA carriers did not remember the education about MRSA. Respondents gave, however, more inconsistent answers in this area: only 71 respondents reported at least one decolonization therapy, whereas 90 reported the application of nasal ointment. These contradictions also underline the lack of specific knowledge of the MRSA carriers. Around 30 % of the answers to the knowledge questions were “don’t know”, which indicates rather substantial deficits in the knowledge among MRSA carriers. The need for more information was also a key finding in qualitative studies from Great Britain and Sweden [6, 7]. Participants of our qualitative part of the study also reported a need for more and adequate information [10]. The regulation of the German National Association of Statutory Health Insurance allows reimbursement for ten minutes of conversation about MRSA twice during the treatment process [13]. Taking the complexity of the topic into account, it seems challenging to give adequate information in ten minutes, which could in part explain the information deficit of the MRSA carriers.

Rather surprisingly, 42 % of the responding physicians stated that there was not enough information available on MRSA. Various organizations in Germany (Robert Koch- Institute, Association of Health Insurance Doctors etc.) have detailed, freely available information on MRSA on their websites. In order to raise awareness of MRSA among physicians in the outpatient sector, it might not be sufficient to make information available through internet but it might be essential to additionally spread information proactively through medical journals or leaflets.

Only one third (33.3 %) of the MRSA carriers in our study reported to have received control swabs in the outpatient sector. This can be put in the context to the results of the survey among physicians, which showed a huge heterogeneity in their activity towards MRSA. Correspondingly, only half of the MRSA carriers reported a decolonization therapy, even though it was recommended for all patients except those with underlying conditions like, e.g., dialysis. However, the application of a decolonization therapy was not associated with the presence of these conditions among patients in our study population. So why did only half of the patients get a decolonization therapy? One reason could be that MRSA diagnosis is not always reported in the discharge letter. According to a recent report of the European Observatory on Health Systems and Policies “communication between GPs and hospitals is problematic” in Germany [14] as well as in some other European countries [15]. According to this report, in Spain, e.g., the cooperation between sectors is standard practice and has been facilitated by shared electronic clinical record and IT systems [14]. One possibility to overcome the sectoral gap might be the establishment of infection control teams taking care of the diagnosed MRSA carriers beyond the discharge from hospitals. Furthermore, it might be difficult for the physicians to develop routines with regard to MRSA due to the small number of cases. Kock et al. [2] estimated 132,000 MRSA cases in German hospitals per year; distributing them on the 37,353 general practitioners (GPs) in Germany in 2013 [16], one GP would see on average 3.5 MRSA carriers per year. This is quite comparable to the median of 5 MRSA carriers that were reported by the physicians in our data. This small number might result in a vicious circle: physicians attach little importance to MRSA, do not seek information about MRSA, and underestimate the number of patients at risk for MRSA, therefore apply screening measures too seldom, and consequently have low numbers of MRSA carriers among their patients.

Only few respondents reported that all recommeded measures (disinfectant washing etc.) were applied. One reason could be that only the costs for nasal ointment are covered by the health insurances, the carriers having to bear the rest of the costs themselves. The other reason could be, that physicians do not believe all the measures to be necessary: only one third (36 %) agreed fully with the general recommendations. The poor adherence and low agreement with the recommendations might be due to a lack of studies showing the effectiveness of the various recommended measures as was highlighted before by Faetkenheuer et al. [17]; however, we have no insight from our study to which aspects of the recommendations exactly the physicians do not agree and why. Studies exploring the effectiveness of (outpatient) decolonization therapy and the effectiveness of its single components could improve the acceptance of these measures.

Relevance attributed to MRSA and experience with application of MRSA specific therapy were highly heterogeneous among physicians in the outpatient sector. Raising the awareness towards MRSA in the outpatient healthcare sector appears imperative to improve treatment of MRSA carriers. Additionally, health care professionals should be aware of possible stigmatization and of the fact that lack of adequate information can result in inappropriate deprivation of social contacts. MRSA carriers need more and adequate information about MRSA. This information should include the fact that MRSA is no threat to healthy people.