32 Chapter 2 treating this subset of MRSA carriers is justifiable as stated in the Dutch guideline. Overall, the last report of the Dutch health council to the Ministry of Health in 2006, advising the continuation of the ‘search and destroy’ policy, is still valid [13]. Efficacy and cost-effectiveness have been demonstrated in the past [10,14]. The semi recent history of the United Kingdom is an extra confirmation of the effectiveness of this approach. In the UK, a similar strict MRSA policy was carried out in the 1980s. After the policy was tempered in the 1990s, the percentage of methicillin resistance in Staphylococcus aureus bacteremia increased steeply from <2% to >30% [28,29]. This percentage is now lower due to rigorous measures on hygiene and the mandatory reporting of MRSA, as part of a major public health infection prevention campaign [30]. To our knowledge, this study is the first to map the MRSA cascade of care. Although the methodology does not enable the quantification of the leakage within the different cascade steps, it does provide specific targets for the optimization of the cascade. The central position of GPs in the healthcare system is a characteristic of the Netherlands. However, the targets for optimization and proposed interventions could be translated to settings where GPs do not hold a central position, with a greater focus on hospitals. A limitation of the study is the fact that all results were self-reported. Answers are subject to bias, and potential targets may have been missed. Furthermore, the majority of the respondents were from one region in the Netherlands, which is mainly an urbanized area. In regions with more agriculture and more livestock-associated MRSA, knowledge about MRSA and attitudes towards MRSA carriership may differ [31]. Another limitation is the fact that the response rate was unknown as a result of the various ways (e.g., newsletters) that the questionnaire was distributed. Assuming that the GPs with an affinity with MRSA were more inclined to respond, bias would be in favor of an overall knowledge of the policy. We believe that the identified barriers are valid, even if the response rate were to be relatively low. Conclusions In conclusion, the results of this survey and the derived cascade of care reveal that there are barriers in the uptake of the ‘search and destroy’ MRSA policy in the Netherlands. Low health-provider familiarity with the policy, lack of GP guidelines on the topic, and financial constraints are key factors. To optimize the continuity of the cascade of care, interventions should be aimed at supporting healthcare professionals in the execution of the ‘search and destroy’ policy. Eventually, this will be beneficial both on the population level and for the individual patient.
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