Clinical Microbiology Services are Essential for Diagnosis, Treatment and Prevention of MRSA and other Nosocomial Pathogens in Libyan Healthcare Facilities.

In this edition of the Libyan Journal of Medicine, Zorgani and co-workers report on the value of clindamycin in treating infections in burn patients caused by staphylococci with special reference to methicillin-resistant Staphylococcus aureus (MRSA)[1]. They studied 110 isolates of Staphylococcus aureus and determined that inducible resistance to clindamycin occurred in two-thirds of MRSAs, but was not seen with methicillin-sensitive S. aureus (MSSA). The ‘D-test’ (which is so called because of the shape of inhibition produced on the plate) was recommended for use in local microbiology laboratories to determine inducible resistance in staphylococci [2, 3]. Most routine laboratories may find it easier to rely simply on the results of erythromycin testing. Clindamycin can be reported as being sensitive in staphylococci that are sensitive to erythromycin. MRSAs are typically resistant to erythromycin and so clindamycin is unlikely to be effective in the treatment of most MRSA infections. Alternative agents are available that have established efficacy in the treatment of MRSA infections. These include the glycopeptides (vancomycin & teicoplanin), linezolid, daptomycin, tetracyclines and tigecycline [4].

What is most interesting about this paper is that an alarming 59% of S. aureus isolates were MRSAs. Clearly this study was not meant to be a surveillance study, but it has highlighted the presence of significant nosocomial infections in Libya. If one assumes that these isolates are representative of the trends in the Tripoli Burn Centre then the presence of such a large proportion of S. aureus isolates as MRSA indicates that the unit (and probably many other specialist units all over the country) are in the grip of endemic problems with highly resistant nosocomial organisms. MRSA has probably been circulating in Libyan hospitals for at least 2 decades. On a visit to the microbiology laboratory at the 7th April Hospital in Benghazi in 1993 it came to my attention that many of the S. aureus isolates, when tested accurately, were in fact MRSAs.

There is very little information in the international literature about nosocomial infections in Libya whereas they are a cause of considerable morbidity and mortality in the industrialised and developing countries. In the latter more than 25% of all hospital admissions develop nosocomial infections and these rates can be 20 times higher than in developed countries [5, 6].

There is a responsibility by public and private healthcare providers in Libya to microbiologically investigate patients with suspected nosocomial infections to ensure that appropriate antimicrobial treatment can be given. These investigations require well-equipped, properly manned and accredited microbiology laboratories. Such laboratories are now rare in Libya. In a dysfunctional healthcare environment it is easy to scale down or eliminate laboratory services because of the perceived expense while channelling limited funds only to clinical services. Poorly-run microbiology laboratories end up producing unreliable results which clinicians ignore. Lack of reliable microbiological laboratory services leads clinicians to the widespread use of empirical (blind) antimicrobial therapy with patients being offered a variety of antimicrobials until the curative one is found. Empiricism in the use of antimicrobials without proper microbiological investigations encourages the development of antibioticresistant nosocomial pathogens. As these organisms are not being identified, clinicians are forced to use different types of antimicrobials many of which will have no beneficial effect on the patient but will increase the pool of nosocomial pathogens, thus further aggravating the situation. This abuse of antimicrobials only exacerbates the problem of nosocomial infections and frustrates clinicians in their attempts to cure infections. The availability of nearly all antimicrobials on an over-the counter basis in Libya further complicates the problem. Economising on microbiology laboratory services is a false economy because the spread of nosocomial organisms leads to infections that are more expensive to treat. Each case of Clostridium difficile diarrhoea costs the UK health service an average extra of about $6000 [6]. Diagnosing accurately the microbial cause of each nosocomial infection becomes ever more important when one considers the need to limit the spread of hospital pathogens from patient to patient. It is very difficult to enforce infection prevention and control measures without laboratory support [7]. Outbreaks can continue indefinitely in hospitals and remain totally undetected.

It should also be noted that more than 70% of all health care decisions in the UK relating to prevention, diagnosis, and treatment of disease involve a pathology investigation. Investing in medical laboratory services is no longer a luxury, but is essential if the healthcare requirements of the population are to be taken seriously.