Signs of stigma and poor mental health among carriers of MRSA

Perceptions of Carriership of Extended-Spectrum Beta-Lactamase (ESBL)-Producing Bacteria: A Qualitative Study

The spread of antimicrobial resistance is a global health concern, and resistance mediated by Extended-Spectrum Beta-Lactamases (ESBLs) can cause major consequences. The aim of this study was to explore individuals' perceptions of their daily life and how they cope after being diagnosed with carriage of ESBL-producing bacteria. A qualitative study was conducted with a descriptive design. Data were collected through individual interviews with 24 persons having ESBL carriership, via a semi-structured interview guide. The data were analyzed using qualitative content analysis. The informants' perceptions on "Living with uncertainty about carriership that impacts oneself and others" were interpreted. Experiences of altered behaviors and sentiments due to ESBL carriership were described, as ESBL carriership was perceived to have a psychosocial impact on many informants. Ambiguous and inconsistent information tended to exacerbate these perceptions. The results of this study emphasize the importance of conveying individualized information, both at the time of diagnosis of ESBL carriage and thereafter. This study was not registered.

The association between socioeconomic factors and the success of decolonization treatment among individuals diagnosed with methicillin-resistant Staphylococcus aureus: A cohort study from 2007 to 2020

OBJECTIVES

To examine associations between socioeconomic factors and (1) adherence to methicillin-resistant Staphylococcus aureus (MRSA) posttreatment follow-up swab sampling after 1 and 6 months and (2) successful decolonization treatment.

DESIGN

Cohort study with 2 years of follow-up. Data on patients diagnosed with MRSA were extracted from a regional MRSA database and national registries. We used a cluster-based logistic regression model to estimate the adjusted odds ratios (aOR) and 95% confidence interval (CI) for associations between socioeconomic factors and decolonization treatment.

SETTING

Danish primary health care.

RESULTS

The rate of adherence to posttreatment follow-up swab sampling among 2,536 cases 1 month after decolonization treatment was 66% (95% CI, 64%-68%), and it decreased to 30% (95% CI, 28%-32%) after 6 months. Living in intermediate municipalities (76-159 inhabitants/km2) or having retired were associated with completed posttreatment follow-up swabs 1 month after decolonization treatment: aOR, 1.40 (95% CI, 1.2-1.74) and aOR, 2.67 (95% CI, 1.16-6.13), respectively. The rate of successful decolonization treatment 2 years after initiating treatment was 36% (95% CI, 34%-38%). Factors associated with successful decolonization treatment included individuals with higher education (aOR, 1.62; 95% CI, 1.22-2.15), early retirees (aOR, 1.63; 95% CI, 1.12-2.38), those living in intermediate municipalities (ie, 160-900+ inhabitants/km2; aOR, 1.35; 95% CI, 1.08-1.68), and those living in predominantly urban municipalities (ie, 160-900+ inhabitants/km2; aOR, 2.04; 95% CI, 1.5-2.76).

CONCLUSIONS

Disparities in the effect of decolonization treatment and adherence to MRSA follow-up sampling among MRSA-positive individuals appear to be largely explained by the level of education, area of residence, and employment status.

Estimated Roles of the Carrier and the Bacterial Strain When Methicillin-Resistant Staphylococcus aureus Decolonization Fails: a Case-Control Study

Methicillin-resistant Staphylococcus aureus (MRSA) is a common bacterial pathogen that frequently colonizes healthy individuals, with potential to cause invasive infection. In Denmark, to keep the prevalence low, MRSA carriers are recommended to undergo decolonization treatments, but achieving decolonization is challenging. Knowledge about the factors contributing to decolonization is scarce. We aimed to identify bacterial genome and clinical factors influencing MRSA decolonization. We identified all new MRSA patients above 2 years of age within the Hvidovre catchment area, Copenhagen, Denmark, in 2017 and 2018. Carriers were defined as chronic carriers (cases) if they were MRSA positive after two or more treatments and as nonchronic carriers (controls) if they were MRSA free after the first or second treatment. Using whole-genome sequencing (WGS), we constructed a pangenome of bacterial strains. With the incorporation of bacterial genome and clinical patient data, machine learning and multivariate analyses were performed to determine the factors associated with decolonization. A total of 477 MRSA carriers were included. An age of ≥13 years was significantly associated with nonchronic carriage. We identified 278 bacterial genetic features that were statistically significantly associated with chronic carriage (P < 0.05 by Fisher's exact test). Chronic MRSA carriage was predicted with 68% accuracy using a combination of bacterial genome data and patient clinical data. Decolonization success is multifactorial. Apart from the 68% predicted accuracy found in this study, we estimate that the remaining 32% is a result of host factors and microbiome composition. IMPORTANCE Carriage of methicillin-resistant Staphylococcus aureus (MRSA) and other multiresistant bacteria is a prerequisite for infection and transmission. Successful decolonization treatment removes these risks. We aimed to identify bacterial genome and host clinical factors that influence MRSA decolonization to estimate the roles of the carrier and the bacterial strain, respectively, when decolonization fails. The long-term goal, beyond this study, is to optimize decolonization success, minimize MRSA transmission, and, ultimately, improve the quality of life of MRSA carriers.

Considering the precautionary principle and its application to MRSA and SARS-CoV-2 as emerging novel pathogens of their time

In the 1980s Contact Precautions were introduced as a precautionary measure to control the emerging threat of antimicrobial resistance in hospitals, particularly methicillin resistant Staphylococcus aureus (MRSA). Today, antimicrobial resistance remains a concerning global public health threat, and a focus for hospital patient safety priorities. In late 2019 a novel respiratory virus described as SARS-CoV-2, was reported. Just as MRSA had prompted control measures developed in the context of limited information and understanding of the pathogen, public health control measures against SARS-CoV-2 were promptly and strictly implemented. Whilst SARS-CoV-2 control measures were successful at containing the virus, numerous detrimental socio-economic and health impacts have led to a rebalancing of harms versus benefits and loosening of restrictions. Conversely, evidence collated over the past 50 years, suggests that Contact Precautions are not superior to well-applied standard infection prevention and control precautions in controlling MRSA acquisition in hospitals. Several harms associated with Contact Precautions, affecting patient safety, financial costs, and organisational culture, are described. However, rebalancing of hospital MRSA control policies has been slow to materialise. This commentary invites infection prevention and control policy makers to reflect and revise policies for the control of MRSA in hospitals so that harms do not outweigh benefits.

Nursing care for patients carrying multi-drug resistant organisms: Experiences, intention to use protective equipment and ability to comply with measures

AIMS

The aims of the study were to explore the impact of caring for patients carrying multi-drug resistant organisms on nursing staff and identify factors predicting their intention to use personal protective equipment and their ability to comply with advised infection prevention and control measures.

BACKGROUND

Carriage of multi-drug resistant organisms and corresponding infection prevention and control measures have a major impact on patients. Limited research has been done to investigate the impact of caring for these patients on nursing staff.

DESIGN

A cross-sectional design.

METHODS

Online survey among Dutch nursing staff in various healthcare settings. Prediction analyses were conducted using random forest. The STROBE checklist was used preparing the manuscript.

RESULTS

974 respondents were included. The majority of nursing staff reported to have experience in caring for patients carrying multi-drug resistant organisms. Relevant dilemmas in daily practice were identified. Important predictors of the intention to use protective equipment were practicing hand hygiene, usable protocols, favourable attitudes and perceptions, as well as knowledge. Important predictors of the ability to comply with advised measures were usable and findable protocols, a suitable work environment and practicing hand hygiene.

CONCLUSION

We have gained comprehensive insight into experiences, attitudes, perceptions, knowledge and dilemmas in daily practice of nursing staff caring for patients carrying multi-drug resistant organisms. To enhance their intention to use protective equipment and their ability to comply with advised measures, activities should focus on improving hand hygiene and the usability of protocols. Additionally, efforts are needed to improve knowledge, provide better resources and a more supportive work environment. All of which need to be specifically tailored to each healthcare setting.

RELEVANCE TO CLINICAL PRACTICE

The results can be used in the development of interventions to improve nursing care while reducing the unfavourable impact on nursing staff and supporting adherence to advised measures.

Ethics and antibiotic resistance

INTRODUCTION OR BACKGROUND

Antibiotic resistance raises ethical issues due to the severe and inequitably distributed consequences caused by individual actions and policies.

SOURCES OF DATA

Synthesis of ethical, scientific and clinical literature.

AREAS OF AGREEMENT

Ethical analyses have focused on the moral responsibilities of patients to complete antibiotic courses, resistance as a tragedy of the commons and attempts to limit use through antibiotic stewardship.

AREAS OF CONTROVERSY

Each of these analyses has significant limitations and can result in self-defeating or overly narrow implications for policy.

GROWING POINTS

More complex analyses focus on ethical implications of ubiquitous asymptomatic carriage of resistant bacteria, non-linear outcomes within and between patients over time and global variation in resistant disease burdens.

AREAS TIMELY FOR DEVELOPING RESEARCH

Neglected topics include the harms of antibiotic use, including off-target effects on the human microbiome, and the lack of evidence guiding most antibiotic prescription decisions.

Justice in control of methicillin-resistant Staphylococcus aureus transmission: a fair question to ask?

Active surveillance cultures and contact precautions is a strategy to control the transmission of methicillin-resistant Staphylococcus aureus (MRSA) within healthcare facilities. Whether to implement this strategy to routinely screen and isolate inpatients with MRSA in non-outbreak (endemic) settings, or to remove it and use standard infection control precautions only is scientifically and ethically controversial, in view of the potential adverse effects of contact precautions on patients. To support the use of standard precautions only, it has been argued that active surveillance to identify patients who are asymptomatically colonised with MRSA to place them in contact precautions is unjust or unfair to these patients in various ways. This paper will unpack and examine four distinct arguments, which are advanced from a medical ethics or quality improvement ethical framework, for why this is so. Our analysis shows that while these arguments highlight the injustice of current practices, they do not provide strong ethical reasons for justifying the removal of active surveillance and contact precautions to control MRSA transmission and infection. An implication of our arguments is that the ethical frame for evaluating prevention and control strategies for MRSA, a multi-drug resistant bacteria, should shift from healthcare to primarily public health. From a public health ethics perspective, whether a strategy is unjust, or how ethically significant its lack of fairness is, depends on assessing the evidence for its public health effectiveness and necessity in a given setting, and the extent of the harms and burdens patients with MRSA bear when they are on contact precautions, which remain matters of scientific debate or uncertainty. As an ethical consideration in the debate, the chief normative implication of justice is to provide us further reasons to revise current active surveillance-contact precautions practices, and for the need for research and interventions to minimise their potential adverse effects on patients.

A phenomenological exploration of source isolation in patients infected with multi-drug resistant organisms

BACKGROUND

The physical isolation of patients colonised or infected with multi-drug resistant organisms is a requirement in hospitals considering the risk of infecting other patients, healthcare workers and visitors. However, how these patients experience isolation in the current environment is not fully understood from the literature.

AIMS

To explore and interpret the lived experience of the source isolation in patients infected with MDROs within an Australian setting.

DESIGN

Hermeneutic phenomenology was utilised as the philosophical framework.

METHODS

Unstructured in-depth face to face interviews were conducted with 20 patients infected with multi-drug resistant organisms who were physically isolated. Data was collected from February-2018 to January-2019 at two large teaching hospitals in the Sydney metropolitan area. The interviews were recorded, transcribed verbatim, analysed using thematic analysis by three researchers, and then subsequently interpreted, drawing insights from the relevant phenomenological notions.

RESULTS

Three key findings emerged from the study as: Living in a changed space - developed from the participants' struggle to cope with being physically confined to a room that made them feel imprisoned. Living in a changed body - emerged from the participants who described their bodies as 'different' because of bacteria that conventional medicine could not destroy permanently but kept relapsing. Striving to survive - developed from participants who spoke about means of enduring some unfavourable experiences.

CONCLUSION

The essence of the lived experience of the phenomenon of source isolation from the perspectives of patients who become infected with MDROs emerged as Being-in-a-changed-world.

IMPACT

While source isolation is an important procedure for preventing and controlling transmissible infection; it often results in adverse psychological experiences. An understanding of this finding from the patients' perspectives is essential for nurses and other healthcare workers involved in their care to maintain a balance between infection control isolation and psychological needs.

Invisible epidemics: ethics and asymptomatic infection

Interactions between microbes and human hosts can lead to a wide variety of possible outcomes including benefits to the host, asymptomatic infection, disease (which can be more or less severe), and/or death. Whether or not they themselves eventually develop disease, asymptomatic carriers can often transmit disease-causing pathogens to others. This phenomenon has a range of ethical implications for clinical medicine, public health, and infectious disease research. The implications of asymptomatic infection are especially significant in situations where, and/or to the extent that, the microbe in question is transmissible, potentially harmful, and/or untreatable. This article reviews the history and concept of asymptomatic infection, and relevant ethical issues associated with this phenomenon. It illustrates the role and ethical significance of asymptomatic infection in outbreaks, epidemics, and pandemics–including recent crises involving drug resistance, Zika, and Covid19. Serving as the Introduction to this Special Issue of Monash Bioethics Review, it also provides brief summaries of the other articles comprising this collection.

Infection control measures in times of antimicrobial resistance: a matter of solidarity

Control measures directed at carriers of multidrug-resistant organisms are traditionally approached as a trade-off between public interests on the one hand and individual autonomy on the other. We propose to reframe the ethical issue and consider control measures directed at carriers an issue of solidarity. Rather than asking “whether it is justified to impose strict measures”, we propose asking “how to best care for a person’s carriership and well-being in ways that do not imply an unacceptable risk for others?”. A solidarity approach could include elevating baseline levels of precaution measures and accepting certain risks in cases where there is exceptionally much at stake. A generous national compensation policy that also covers for costs related to dedicated care is essential in a solidarity approach. An additional benefit of reframing the questions is that it helps to better acknowledge that being subjected to control measures is a highly personal matter.

Association between hospital outbreaks and hand hygiene: Insights from electronic monitoring

BACKGROUND

Hand hygiene (HH) is an important patient safety measure linked to prevention of healthcare-associated infection yet how outbreaks affect HH performance has not been formally evaluated.

METHODS

A controlled interrupted time series was performed across five acute-care academic hospitals using group electronic monitoring. This system captures 100% of all hand sanitizer and soap dispenser activations via a wireless signal to a wireless hub divided by a previously validated estimate of the number of daily HH opportunities per patient bed multiplied by the hourly census of patients on the unit. Daily HH adherence 60 days prior and 90 days following outbreak on inpatient units was compared to control units not in outbreak over the same period, using a Poisson regression model adjusting for correlation within hospitals and units. Predictors of HH improvement were assessed in this multivariate model.

RESULTS

In the 60 days prior to outbreak, units destined for outbreak had significantly lower HH adherence compared to control units (IRR of 0.91 (95% CI 0.90-0.93; p <0.0001). Following outbreak, the HH adherence among outbreak units increased above controls (IRR 1.04, 95% CI = 1.02-1.06; p <0.0001). Greater improvements were noted for outbreaks on surgical units, involving antibiotic-resistant organisms and enteric outbreaks, as well as those where healthcare workers became ill.

CONCLUSIONS

Hospital outbreaks tend to occur on units with lower HH adherence and are associated with rapid improvements in HH performance. Group electronic monitoring of HH could be used to develop novel prospective feedback interventions designed to avert hospital outbreaks.

Psychological outcomes of MRSA isolation in spinal cord injury rehabilitation

STUDY DESIGN

Retrospective secondary analysis with a quantitative, matched-pairs design. Patients isolated due to methicillin-Resistant Staphylococcus aureus (MRSA) were matched with controls without MRSA infection admitted to a multi-bedded ward, based on: gender, injury level, injury severity (AIS grade), age at the time of injury and year of admission.

OBJECTIVES

Determine the implications of MRSA-related infection isolation on spinal cord injury patients' anxiety, depression, appraisals of disability, perceived manageability and pain intensity. Hypotheses predicted patients who were isolated due to MRSA during inpatient stay would demonstrate poorer psychological health outcomes at discharge in comparison with non-isolated matched controls.

SETTING

National Spinal Injuries Centre, England, UK.

METHODS

Secondary analyses were conducted on pre-existing data based on patients' first admission for primary rehabilitation. Psychometric scales were used to measure outcome variables. Assessments were repeated at the time of admission and discharge.

RESULTS

Nonparametric longitudinal analyses using the nparLD package in R were conducted. Relative treatment effects demonstrated that there were no significant differences between groups across all outcome measures. There was a significant effect of time (admission vs discharge) on perceived manageability and pain intensity, indicating improved outcomes at discharge. There was no difference in the overall length of stay between the isolated and non-isolated groups.

CONCLUSIONS

Isolation experienced by rehabilitation inpatients with spinal cord injury with MRSA had no effect on a series of psychological outcomes. Engaging with rehabilitation had a positive impact in reducing pain unpleasantness and increasing perceived manageability of spinal cord injury, irrespective of infection isolation.

Limited multi-drug resistant organism related stigma in carriers exposed to isolation precautions: an exploratory quantitative questionnaire study

BACKGROUND

Isolation precautions are applied to control the risk of transmission of multi-drug resistant organisms (MDROs). These precautions have been associated with adverse effects, such as anxiety and depression. This study aimed to quantify stigma among MDRO carriers and its association with perceived mental health and experienced quality of care.

METHODS

A quantitative questionnaire study was performed in MDRO carriers exposed to ≥3 days of isolation precautions during hospitalization. Items derived from the Consumer Quality Index questionnaire (CQI) were used to assess perception of care. Stigma scores were calculated using the recently modified Berger Stigma Scale for meticillin-resistant Staphylococcus aureus (MRSA). Mental health was measured with the RAND Mental Health Inventory. The Spearman rank correlation test was used to assess the association between stigma score and RAND mental health score.

FINDINGS

Of the 41 included carriers, 31 (75.6%) completed both questionnaires. The experienced quality of care was 'good' according to CQI score. Twenty-four percent reported not to have received proper explanation about MDRO carriership from healthcare workers (HCWs). MDRO-associated stigma was reported in 1/31 (3.2%). Poor mental health was self-reported in 3/31 (9.7%). There was no correlation between stigma score and RAND mental health score (Spearman correlation coefficient: 0.347).

CONCLUSIONS

In this study, MDRO carriers exposed to ≥3 days of isolation precautions did not report stigma. This contrasts with a recent study that investigated MRSA-associated stigma and may be explained by contact plus airborne isolation protocols in MRSA compared with contact isolation alone in most other MDROs. Also, the psychological impact may be of a different magnitude due to as yet unknown reasons.

Perceptions of Dutch nurses carrying methicillin-resistant Staphylococcus aureus: a qualitative study

Background

Carriers of methicillin-resistant Staphylococcus aureus (MRSA) experience a variety of personal and social consequences, despite the asymptomatic nature of carriage. Some of these consequences are inherent to the application in practice of strict infection prevention guidelines. However, the experiences of nurses carrying MRSA have not been documented. This study aimed to describe the experiences of nurses carrying MRSA to get insight into the impact of MRSA carriage on nurses in a country with a “search-and-destroy” policy for MRSA.

Methods

A qualitative study was conducted among eighteen nurses who experienced MRSA carriage and were working in healthcare organizations in the Netherlands (e.g. hospitals, nursing homes and home care). Semi-structured interviews were conducted using an interview guide. The interviews were audio tape recorded, transcribed and analyzed using thematic analysis.

Results

MRSA carriage has an impact on the life of nurses during four distinct phases: becoming aware of carrying MRSA, processing information and guidance, experiencing consequences of carriage and, when applicable, a life after eradication of MRSA. Each phase was found to be associated with negative consequences. The impact of MRSA carriage on the daily life of nurses is mostly influenced by the experience of consequences of MRSA carriage – including a ban to work with patients, eradication treatment with antibiotics, and social isolation from others – despite the asymptomatic nature of MRSA carriage itself. In addition, lack of information and guidance increased the impact of carriage.

Conclusions

This study shows nurses experience various consequences of MRSA carriage, despite the asymptomatic nature of carriage. The work ban, eradication treatment and social isolation influenced the nurses’ work-related future, personal health and social environment. The impact of carriage may be reduced by clear information and guidance, and support from others. Therefore, sufficient information and guidance needs to be given to MRSA carriers by healthcare organizations.

A Capability Perspective on Antibiotic Resistance, Inequality, and Child Development

Nussbaum’s capability theory by drawing attention to multiple determinants of wellbeing provides a rich and relevant evaluative space for framing antibiotic resistance. I consider the implications of antibiotic resistance for child development and adult capabilities. There are common risk factors for childhood growth stunting and the spread of infectious diseases in both antibiotic sensitive and resistant forms. The interaction between infectious diseases, antibiotic resistance and growth stunting illustrates a clustering of disadvantage. The control of antibiotic resistance requires wide-ranging cooperative action. Cooperation is predicated on an expectation of equitable access to effective antibiotics. This expectation is confounded by inequality both in access to antibiotics, and in the risk that available antibiotics will be ineffective. Securing child development (and adult capabilities) requires that inequalities both in access to antibiotics and in risk factors for the dissemination and transmission of antibiotic resistance are addressed. Inequality undermines the cooperative activity that is control of infectious diseases and compounds the threat to the securing of capabilities that arises from antibiotic resistance.

Source isolation and patient wellbeing in healthcare settings

Multi-resistant bacteria pose an increasing and significant challenge to public health. Isolation precautions in patients with multi-drug-resistant bacteria and other communicable infectious agents can be associated with adverse effects. Although few would dispute the need for such practices in preventing the spread of transmissible infections, patients' perspectives of isolation suggest that the imposed environment creates barriers to their physical, social and emotional needs. This article reviews the literature to uncover any reliable evidence supporting the assertion that the experience of isolation in healthcare settings impacts adversely on patient wellbeing. Database searches identified 25 relevant papers published between 1990 and 2017. A number of studies claimed to have uncovered an association between negative patient experiences and isolation.

The stigmatisation of source isolation: a literature review

Background

Isolation precautions in patients with multi-drug-resistant bacteria and other communicable infectious agents can be associated with adverse effects. Patients' perspectives of isolation suggest that the imposed environment and procedures create barriers to their physical, social and emotional needs.

Aims

The purpose of this paper is to review the literature to uncover any reliable evidence supporting the assertion that stigma is a significant characteristic of the experience of source isolation in healthcare settings.

Methods

The methodological framework of Arksey and O'Malley was applied to this review. A total of 14 papers identified from 189 abstracts screened were included in the review.

Results

The research reviewed suggests a clear association between stigmatisation and isolation in which stigma does have a direct negative effect on patients placed in hospital isolation. None of the studies found evidence to the contrary.

Conclusions

The implications of this literature review for policy-makers and healthcare professionals suggest that when isolation or other forms of constraint are implemented and in use, patients must be provided with strengthened forms of support, including social and emotional support, and given access to healthcare of optimal quality to prevent the associated adverse effects of isolation as much as possible.

Severe acute respiratory distress syndrome (ARDS) induced by human adenovirus B21: Report on 2 cases and literature review

Severe pneumonia and ARDS caused by human adenovirus B21 infections (HAdV-B21) is a rare, but a devastating disease with rapid progression to multiorgan failure and death. However, only a few cases were reported so far. Infections appear associated with increased disease severity and higher mortality in infected critically ill patients. Possible factors contributing to infection are underlying psychiatric disease resulting in institutionalization of respective patients, and polytoxicomania. Controlled data on the therapy of severe adenovirus infections are lacking and remains experimental. In conclusion, data on HAdV-B21 infections causing severe pneumonia or ARDS are scarce. Controlled clinical trials on the therapy of adenovirus pneumonia are non existent and thus there is no established therapy so far. ICU physicians should be aware of this potentially devastating disease and further studies are needed.

Ethics of Infection Control Measures for Carriers of Antimicrobial Drug-Resistant Organisms

Many countries have implemented infection control measures directed at carriers of multidrug-resistant organisms. To explore the ethical implications of these measures, we analyzed 227 consultations about multidrug resistance and compared them with the literature on communicable disease in general. We found that control measures aimed at carriers have a range of negative implications. Although moral dilemmas seem similar to those encountered while implementing control measures for other infectious diseases, 4 distinct features stand out for carriage of multidrug-resistant organisms: carriage presents itself as a state of being; carriage has limited relevance for the health of the carrier; carriage has little relevance outside healthcare settings; and antimicrobial resistance is a slowly evolving threat on which individual carriers have limited effect. These features are of ethical relevance because they influence the way we traditionally think about infectious disease control and urge us to pay more attention to the personal experience of the individual carrier.

Out of the silos: identifying cross-cutting features of health-related stigma to advance measurement and intervention

BACKGROUND

Many health conditions perceived to be contagious, dangerous or incurable, or resulting in clearly visible signs, share a common attribute - an association with stigma and discrimination. While the etiology of stigma may differ between conditions and, sometimes, cultural settings, the manifestations and psychosocial consequences of stigma and discrimination are remarkably similar. However, the vast majority of studies measuring stigma or addressing stigma through interventions employ a disease-specific approach.

MAIN BODY

The current paper opposes this siloed approach and advocates a generic concept of 'health-related stigma' in both stigma measurement and stigma interventions. Employing a conceptual model adapted from Weiss, the current paper demonstrates the commonalities among several major stigmatized conditions by examining how several stigma measurement instruments, such as the Social Distance Scale, Explanatory Model Interview Catalogue, Internalized Stigma of Mental Illness, and Berger stigma scale, and stigma reduction interventions, such as information-based approaches, contact with affected persons, (peer) counselling, and skills building and empowerment, were used successfully across a variety of conditions to measure or address stigma. The results demonstrate that 'health-related stigma' is a viable concept with clearly identifiable characteristics that are similar across a variety of stigmatized health conditions in very diverse cultures.

CONCLUSION

A more generic approach to the study of health-related stigma opens up important practical opportunities - cross-cutting measurement and intervention tools are resource saving and easier to use for personnel working with multiple conditions, allow for comparison between conditions, and recognize the intersectionality of many types of stigma. Further research is needed to build additional evidence demonstrating the advantages and effectiveness of cross-condition approaches to stigma measurement and interventions.

Experiences and consequences of living with extended-spectrum β-lactamase-producing bacteria: A qualitative study

BACKGROUND

The number of people who become carriers of antibiotic-resistant extended-spectrum β-lactamase (ESBL)-producing bacteria is steadily increasing. A carrier of ESBL can potentially be stressful for individuals, affecting their daily lives.

METHODS

The purpose of this study was to increase the understanding of experiences and consequences of being an ESBL carrier. A modified version of the grounded theory was used to analyze 16 open interviews.

RESULTS

The analysis resulted in the core category "to handle the new life situation." The results showed a lack of information being passed by attending doctors to study participants about ESBL and the consequences for their daily lives. This insufficient information initially caused fear and anxiety, leading to participants instead searching for information themselves using the Internet. Armed with this information, they developed strategies to continue with their lives as before. As patients they experienced staff that were respectful, showed no stigmatization toward ESBL carriership, and used correct hygiene routines.

CONCLUSIONS

When the information from the attending doctor about ESBL carriers is insufficient, patients often use the Internet to obtain additional information. With the use of this information, patients develop strategies to cope with their lives.

The majority of MRSA colonized children not given eradication treatment are still colonized one year later. Systemic antibiotics improve the eradication rate

BACKGROUND

Colonization with methicillin-resistant Staphylococcus aureus (MRSA) can cause endogenously derived infections and be a source of transmission to other people. Neither colonization time of asymptomatic MRSA colonization nor the effect of treatment aiming at MRSA eradication in children has been thoroughly investigated.

METHODS

Two hundred ninety-three children <18 years in the mandatory follow-up program for MRSA-carriers in Malmö, Sweden were evaluated. Samples from the throat, nares, perineum and skin lesions from each child were screened for MRSA with a PCR-based broth enrichment method. PVL presence and spa-type were evaluated in a majority of cases. The sampling was repeated approximately every 6 month after initial detection. When three consecutive sets of negative samples during at least a 6-month period were obtained, the MRSA was considered permanently eradicated. MRSA eradication treatment given, on clinical grounds during follow-up, was noted.

RESULTS

One year after detection 62% of the untreated children were still MRSA positive and after 2 years 28%. MRSA throat colonization and having MRSA positive household contacts significantly prolonged the observed colonization time. Topical MRSA eradication treatment was successful in 36% of cases and in 65% if systemic antibiotics were added. Presence of PVL correlated with shorter observed colonization time in the older age group and with increased eradication success among throat carriers.

CONCLUSION

MRSA throat colonization and having MRSA positive household contacts prolongs the time of MRSA colonization in children. Systemic antibiotics enhance the effect of MRSA eradication treatment.