Getting to zero despite ca mrsa
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The document discusses strategies for controlling methicillin-resistant Staphylococcus aureus (MRSA) in healthcare settings. It describes the ideal "search and destroy" strategy of isolating and screening high-risk patients, decolonizing MRSA carriers, and taking consistent action when transmissions occur. However, it notes many healthcare facilities do not fully implement this strategy due to difficulties identifying at-risk patients and constraints like staffing issues. The document advocates for universal precautions like isolating MRSA-positive patients, promoting hand hygiene, and providing feedback to help facilities improve and reduce MRSA rates.
Getting to zero despite ca mrsa
- 1. Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13 Andreas Voss, MD, PhD Professor of InfecCon Control RUNMC & CWZ Nijmegen, The Netherlands ¤ E-‐MRSA ¤ HA-‐MRSA (HO-‐CA-‐MRSA, HO-‐LA-‐MRSA) LA ¤ CA-‐MRSA (CO-‐HA-‐MRSA, CO-‐LA-‐MRSA) HA ¤ LA-‐MRSA CA The only type I am interested in: ¤ IDCWYCI-‐JTMHTFI-‐MRSA* * I Don’t Care What You Call It – Just Tell Me How To Fix It – MRSA (Sco^ Weese) CA-‐MRSA HA-‐MRSA LA-‐MRSA “Li^le brother” “Main problem” “Giant trouble” MRSA bacteremia in Europe! CA-‐MRSA HA-‐MRSA LA-‐MRSA Source: EARSS report Andreas Voss, MD, PhD 1
- 2. Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13 ¤ Search & Destroy (Control) strategy to avoid introducCon of MRSA into health-‐care se#ngs and reduce the chance of transmission: ² NaConal MRSA guidelines (WIP) ² NaConal detecCon methods (NVMM) ² Use fast and reliable detecCon methods ¤ IsolaCon and screening of risk-‐paCents on admission ² at all Cmes ¤ Placement in isolaCon room ² colonized and infected paCents ² with anteroom and negaCve pressure ¤ DecolonizaCon of MRSA carriers ¤ Gloves, gowns and face-‐masks ¤ Consequent acCons when transmissions occur ² for all entering the room ² screening of all paCents and HCWs at risk ² MRSA-‐posiCve HCWs not allowed to work ¤ Handhygiene ¤ IsolaCon and screening of risk-‐paCents on admission ² can’t determine paCents at risk ² only certain departments! ² not when too busy/weekends ² only infected paCents ¤ No decolonizaCon of MRSA carriers ¤ Non-‐consequent acCons when transmissions occur ² screening of all paCents but not HCWs à consequently MRSA-‐posiCve HCWs may conCnue to spread Andreas Voss, MD, PhD 2
- 3. Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13 MRSA BSI episodes 2000 1800 Year and quarter 1600 1400 BBC World news 1200 1000 800 600 400 200 0 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 2005 2006 2007 2008 2009 Counts of MRSA bacteraemia Courtesy: A.DATA ARE(HPA, Sept 2009) FOR WIDER CIRCULATION * Pearson PROVISIONAL NOT V. Jarlier et al. Arch Intern Med 2010 IsolaCon IntervenCons ¤ IsolaCon IntervenCons ¤ Placement of paCents with MRSA infecCons or ¤ PromoCon of Hand Hygiene colonizaCons in single-‐bed rooms whenever possible ¤ Barrier precauCons for paCents with MRSA infecCons ¤ IdenCficaCon of paCents with MRSA or colonizaCons such as: infecCons or colonizaCons ² disposable gloves worn before and discarded aier paCent ¤ Feedback contact ² disposable aprons worn for extensive contacts (eg, bed ¤ Annual reports making) ² small equipment (eg, stethoscope) dedicated to the paCent. Andreas Voss, MD, PhD 3
- 4. Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13 PromoCon of Hand Hygiene ¤ Hand washing with disinfectant soap aier contact with paCents with MRSA infecCons or colonizaCons before leaving the room ¤ An insCtuConal campaign for promoCng the use of alcohol-‐ based hand-‐rub soluCons in place of hand washing ² launched in 2001 ² Training materials to the infecCon control teams (slide shows, 200 000 brochures, and 14 000 posters) ² formal le^ers by the general director asking all administrators, heads of departments, and chief nurses to support the campaign. Should we ask universal precauCons ? IdenCficaCon of MRSA PaCents Feedback ¤ Feedback to the local hospital community on the results (MRSA ¤ Passive surveillance through rouCne clinical specimens rates and progress in program implementaCon). ¤ AcCve surveillance (screening) by culturing nares of paCents with a high risk of MRSA colonizaCon, eg, intensive Annual report care unit (ICU) paCents and contacts of MRSA paCents ¤ Each hospital reporCng to the central administraCon ¤ Quick noCficaCon and flagging of new paCents with MRSA ² size of the infecCon control team infecCons or colonizaCons by laboratories to medical teams ² implementaCon of the program ¤ IdenCficaCon of MRSA paCent rooms and charts (sCcker) ² organizaCon of audits (eg, on hand hygiene) ¤ Informing units to which paCents with MRSA are transferred. ² feed-‐back ² progress of the iniCaCve has been annually presented during meeCngs of infecCon control teams and bacteriologists from all AP-‐HP hospitals, What is CA-‐MRSA? Andreas Voss, MD, PhD 4
- 5. Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13 CA-/HA-MRSA: Age Distribution! ¤ ProspecCve cohort study of MRSA infecCons idenCfied in 12 Minnesota laboratories in 2000 ¤ 1100 MRSA infecCons ² 131 (12%): community-‐associated ² 937 (85%): health care-‐associated ¤ Epidemiological definiCon Naimi et al. JAMA 2003; 290: 2976-84 Naimi et al. JAMA 2003; 290: 2976-84 CA-/HA-MRSA: Underlying conditions! CA-/HA-MRSA: Infection type! Predominantly skin and soi Cssue infecCons No underlying condiCons as risk factor Naimi et al. JAMA 2003; 290: 2976-84 Naimi et al. JAMA 2003; 290: 2976-84 CA-/HA-MRSA: Susceptibility! Enriched with SCCmec IV, PVL and other exotoxins SCll suscepCble to most other classes of anCbioCcs Naimi et al. JAMA 2003; 290: 2976-84 Naimi et al. JAMA 2003; 290: 2976-84 Andreas Voss, MD, PhD 5
- 6. Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13 CA-/HA-MRSA: Clonal spread! ¤ Aboriginals ¤ NaCve Americans (indians, eskimos) ¤ Jails ¤ Saunas ¤ Sport teams ¤ Homosexual men ¤ Military recruits ¤ Day Care Centers CA-‐ strains geneCcally unrelated to HA-‐MRSA " SSTI caused by CO-‐MRSA in a non-‐outbreak seFng (Atlanta, Q3+4 2003) " 384 persons with documented CA-‐SSTI due to S. aureus King et al Ann Intern Med 2006;144:309-‐317 ¤ Aboriginals ¤ NaCve Americans (indians, eskimos) ¤ Jails nearly ¾ ¤ Saunas MRSA ¤ Sport teams ¤ Homosexual men nearly 90% ¤ Military recruits US 300/400* ¤ Day Care Centers * 99% (155 of 157) of the typed CA-‐MRSA isolates were USA 300 ¤ Animal lovers ? King et al Ann Intern Med 2006;144:309-‐317 Andreas Voss, MD, PhD 6
- 7. Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13 st Fir es cas • 2004: 23% • 2006: 50% • 2010: >70% m far a pig ds of un gro the on ing W liv HC : a to r -‐ fac ly risk On Wulf et al. Eurosurveillance 2008;13 Andreas Voss, MD, PhD 7
- 8. Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13 900 851 854 Import HA HACO CA Each person only included once, 800 unless a new subtype is found 240 R. Skov 2009 705 220 71% of the MRSA cases in Copenhagen area R. Skov 2009 700 659 were community-onset MRSA (CO-MRSA) 200 600 547 180 No. of isolates 500 160 No. of isolates 400 140 120 300 229 100 200 80 77 97 104 100 60 100 46 54 67 34 41 40 0 20 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 0 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Andreas Voss, MD, PhD 8
- 9. Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13 v 36.4% of 11 CA-‐MRSA and 43.9% of 66 HA-‐MRSA harbored SCCmec type IV/IVA. v Type IV/IVA has become the most common SCCmec type in ... lines between categories may be “graying,” with inpaCents of a Swiss university hospital. community-‐associated strains encroaching on v SCCmec type IV/IVA is present in both CA-‐MRSA and HA-‐MRSA hospitals, and health-‐care associated strains limiCng its use as a marker for CA-‐MRSA. entering the community. Stranden et al. InfecCon 2009;37:44 ¤ we have all kind of SSCmec-‐types in the hospital (including IV and V) ¤ we have healthcare outbreaks of ST398-‐MRSA and CA-‐MRSA strains ¤ we have HA-‐MRSA strains in the community, in pets and in livestock animals ¤ MRSA -‐ it’s not graying, it is gray! CA-‐MRSA HA-‐MRSA LA-‐MRSA CA-‐MRSA HA-‐MRSA LA-‐MRSA Just-‐MRSA Is this sCll a possiblity? Andreas Voss, MD, PhD 9
- 10. Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13 ¤ We know the risk factors for HA-‐MRSA ² foreign admission/dialysis, adopCon, known outbreaks, (nursing homes) ¤ We know the risk factors for LA-‐MRSA ² pig-‐ and calf-‐farming (poultry) ² (but this may change) ¤ We know some of the risk factors for CA-‐MRSA ² but can’t use them for S&D Import HA HACO CA ¤ Consequent decolonizaCon of all MRSA 240 R. Skov 2009 71% of the MRSA cases in Copenhagen area 220 carriers (especially outside the hospitals) is of 200 were community-onset MRSA (CO-MRSA) The Danish curbed this outbreak by upmost importance ! 180 ”destroying” the community sources 160 No. of isolates ² works with HA-‐MRSA 140 120 ² should work with CA-‐MRSA 100 80 ² trouble LA-‐MRSA 60 40 20 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 ¤ To a certainly level it may be the major components that count not the details: While important other factors count: ¤ Compliance with basic infecCon control ² Good epidemiology measures in all (healthcare) se#ngs ² Screening ¤ Infrastructure of healthcare se#ngs ² IsolaCon (single room and glove and gowns) ² Hand hygiene ¤ HCW-‐paCent/client raCo ² CommunicaCon ¤ AnCbioCc use ² DecolonizaCon ¤ Farming (!) & food (?) Andreas Voss, MD, PhD 10
- 11. Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13 June 25-‐28, 2013 Geneva Switzerland www.icpic2013.com Andreas Voss, MD, PhD 11