Prevention and Control of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus
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Transcript of Prevention and Control of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus
Prevention and Control of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus
John A. JerniganDivision of Healthcare Quality Promotion
Centers for Disease Control and PreventionApril 29, 2008
The findings and conclusions in this presentation/report are those of the authors and do not necessarily represent the views of the Centers
for Disease Control and Prevention
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Source: Hidron et al., abstract presentation, SHEA 2008
Most Invasive MRSA Infections Are Healthcare-Associated
Healthcare-Associated
Community-Associated
Source: ABCs Population-based surveillance System, Klevens et al. JAMA 2007
14% 86%
n=8,987
In the US in 2005 there were:– 94,360 invasive MRSA infections– 18,650 associated deaths
Why is the Emergence of MRSA as a Healthcare Pathogen Important?
Has emerged as one of the predominant pathogens in healthcare-associated infections
Treatment options are limited and less effective– higher morbidity and mortality
High prevalence major influence on unfavorable antibiotic prescribing, which contributes to further spread of resistance– prevalent MRSA more glycopeptide use more
glycopeptide resistance (VRE VRSA) more linezolid/daptomycin use more resistance
Why is the Emergence of MRSA as a Healthcare Pathogen Important?
Adds to overall S. aureus infection burden Represents a failure to contain transmission of drug-
resistant bacteria – A marker for our ability to contain transmission of
important pathogens in the healthcare setting– Learning how to successfully control of MRSA is likely to
have benefits that extend to other pathogens
Hiramatsu, et al. Trends in Microbiology 2001;9:486
The emergence of MRSA has been due to transmission of relatively few clones, not de novo
selection
100
%
80%
60%
Athletes
Prisoners
Children
Hospital StrainHospital Strain
MissouriCalifornia
Texas
Pennsylvania
Texas
MississippiColorado
Georgia
Missouri
Tennessee
USA300-114USA100USA200
CommunityCalifornia
Pneumonia (AL, AR, IL, MD, TX, WA) 1
00%
80%
60%
Athletes
Prisoners
Children
Hospital StrainHospital Strain
MissouriCalifornia
Texas
Pennsylvania
Texas
MississippiColorado
Georgia
Missouri
Tennessee
USA300-114USA100USA200
CommunityCalifornia
Pneumonia (AL, AR, IL, MD, TX, WA) 1
00%
80%
60%
Athletes
Prisoners
Children
Hospital StrainHospital Strain
MissouriCalifornia
Texas
Pennsylvania
Texas
MississippiColorado
Georgia
Missouri
Tennessee
USA300-114USA100USA200
CommunityCalifornia
Pneumonia (AL, AR, IL, MD, TX, WA) 1
00%
80%
60%
Athletes
Prisoners
Children
Hospital StrainHospital Strain
MissouriCalifornia
Texas
Pennsylvania
Texas
MississippiColorado
Georgia
Missouri
Tennessee
USA300-114USA100USA200
CommunityCalifornia
Pneumonia (AL, AR, IL, MD, TX, WA) 1
00%
80%
60%
Athletes
Prisoners
Children
Hospital StrainHospital Strain
MissouriCalifornia
Texas
Pennsylvania
Texas
MississippiColorado
Georgia
Missouri
Tennessee
USA300-114USA100USA200
CommunityCalifornia
Pneumonia (AL, AR, IL, MD, TX, WA) 1
00%
80%
60%
Athletes
Prisoners
Children
Hospital StrainHospital Strain
MissouriCalifornia
Texas
Pennsylvania
Texas
MississippiColorado
Georgia
Missouri
Tennessee
USA300-114USA100USA200
CommunityCalifornia
Pneumonia (AL, AR, IL, MD, TX, WA)
A Few CA-MRSA Strains Cause Most Community Outbreaks
Key Prevention Strategies
Prevent infection Diagnose and treat infection
effectively
Use antimicrobials wisely
Prevent transmission
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
Clinicians hold the solution!
Source: Burton et al., abstract presentation, SHEA 2008
Key Prevention Strategies
Prevent infection Diagnose and treat infection
effectively
Use antimicrobials wisely
Prevent transmission
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
Clinicians hold the solution!
Preventing transmission is an important part of MRSA control
Entire healthcare-associated MRSA problem caused by spread of a few clones
Preventing widespread colonization minimizes circulating pool of resistance genes that can contribute to cycle of increasing multi-drug resistance (e.g. VRSA is likely a product of widespread colonization with VRE and MRSA)
Improving antibiograms helps ease pressure for broad spectrum antibiotic use and preserves effectiveness of preferred antimicrobial agents
Preventing colonization helps prevent infections– Including those that might happen post-discharge (newly
colonized patients have up to 30% risk of infection in the ensuing year)
Most Healthcare-Associated Invasive MRSA Infections Have Their Onset Outside of the
Hospital
Healthcare-Associated (community-onset)
Community-Associated
14% 59%
28%
Healthcare-Associated (hospital-onset)
Source: ABCs Population-based surveillance System, Klevens et al. JAMA 2007
Regional Spheres of Influence Within Spectrum of Inpatient Care
Hospital A
Hospital B
Nursing Home 1
Nursing Home 4
NH 2
Nursing Home 3
Hospital c
Predicted Number of EMRSA-15 Outbreaks During 1993-98, United Kingdom
Source: Austin JID 1999;179:883
30% transmission
900
700
600
500
400
300
200
100
800
100%80%60%40%20%
30% Duration
30%bothEM
RS
A-1
5 o
utb
rea
ks
199
3-1
9 98
% of Facilities Implementing Intervention
How best to prevent MRSA Transmission in Healthcare Settings?
Controversial subject– standard precautions versus standard
plus barrier (i.e. contact precautions)?– Should contact precautions be used
only on those identified by clinical cultures?
• Due to “iceberg effect”, many colonized patients unrecognized base on clinical cultures alone
• Should active surveillance be used to identify carriers?
– If so, in what settings?
HICPAC Guidance On Management of Multidrug-Resistant Organisms (MDROs) in
Healthcare Settings
First Tier: General Recommendations For All Acute
Care Settings
Second Tier: Intensified Interventions
If endemic rates not decreasing, orif first case of important organism
HICPAC MDRO Guidance (acute care)
First Tier: General Recommendations For All Acute Care Settings
Administrative engagement– Make MDRO prevention and control an organizational patient safety
priority– Implement a multidisciplinary process to monitor and improve
healthcare personnel (HCP) adherence to recommended practices– feedback on facility and patient-care unit trends in MDRO incidence
and adherence measure Education and training of personnel Judicious use of antimicrobial agents Standard precautions for all patients Contact Precautions for patients known to be infected or colonized
(masks not routinely recommended) Monitoring of trends over time to determine whether additional
interventions are needed
HICPAC MDRO Guidance (acute care)
Indications for moving to second tier– First case or outbreak of an epidemiologically
important MDRO– When endemic rates of a target MDRO are not
decreasing despite implementation of and correct adherence to the first tier measures
HICPAC MDRO Guidance (acute care)
Second Tier: Intensified Interventions For Acute Care Settings
Active surveillance cultures from patients in populations at risk at the time of admission to high-risk area, and at periodic intervals as needed to asses transmission.
– Contact Precautions until surveillance culture known to be negative Additional recommendations for intensifying:
– administrative engagement/correction of systems failures– Education and training of personnel/adherence monitoring– Judicious use of antimicrobial agents– monitoring of trends
Cohorting of staff to the care of MDRO patients only Enhanced environmental measures Consult with experts on case-by-case basis regarding use of decolonization
therapy for patients or staff If transmission continues despite full implementation of above, stop new
admissions to the unit.
MDRO and CDAD Module
Multidrug-Resistant Organism (MDRO) andClostridium difficile-Associated Disease (CDAD)
Module
MDRO and CDAD Module
Organisms Monitored:
-Methicillin-Resistant Staphylococcus aureus (MRSA) (option w/ Methicillin-Sensitive S. aureus (MSSA)
-Vancomycin-Resistant Enterococcus spp. (VRE)
-Multidrug-Resistant (MDR) Klebsiella spp.
-Multidrug-Resistant (MDR) Acinetobacter spp.
-Clostridium difficile-Associated Disease (CDAD)
Protocol available online at:http://www.cdc.gov/ncidod/dhqp/nhsn_MDRO_CDAD.html
Goal of the MDRO and CDAD Module
Provide a mechanism for healthcare facilities to report and analyze data that will inform infection control staff of the impact of targeted prevention efforts
MDRO and CDAD Module
Reporting Requirements and Options Include:
Required:-Infection Surveillance (not required for CDAD)
Optional:-Proxy Infection Measures:
-Laboratory-Identified (LabID) Event
-Prevention Process Measures:-Monitoring Adherence to Hand Hygiene-Monitoring Adherence to Gown and Gloves Use-Monitoring Adherence to Active Surveillance Testing
-Active Surveillance Testing (AST) Outcome Measures
NHSN MRSA Metrics Metric Description Calculation Comment
1 Nosocomial MRSA Infection Rate # NHSN MRSA infections/1000 pt-days
By selected patient-care location only (i.e., MICU, SICU, etc.); uses NHSN criteria to define infections
2 Incidence Rate of Hospital-Onset MRSA Based on Clinical Cultures
# 1st MRSA specimens /1000 pt-days
Hospital-wide is easiest, can also restrict to selected locations; evaluating same locations as Metric 1 may be most useful; uses positive culture data only3a Incidence Rate of Hospital-Onset
MRSA Bloodstream Infections (BSI) Based on Clinical Cultures
# MRSA BSI specimens /1000 pt-days
3b Admission Prevalence MRSA BSI Rate (community-onset infections)
# MRSA BSI specimens /1000 admissions
4 Direct MRSA Acquisition # new MRSA cultures /1000 pt-days
Requires data from active surveillance testing (AST) program; selected locations only
5 Adherence to Process Measures Compliance Rate Requires data from observational assessment and/or from AST program; selected locations only
6 Central Line-Associated Bloodstream Infections (CLABSI) (all pathogens)
# CLABSI/1000 line days By selected locations only; requires following the Device-Associated Module-CLABSI protocol
Opportunities for MRSA Prevention Research
Impact of focusing on high risk units Use of topical antimicrobials/antiseptics for eradicating or suppressing S.
aureus colonization– Chlorhexidine bathing of patients (targeted to colonized patients
versus high-risk groups)– Use of topical antibioitics for decolonization (e.g. mupirocin)
Risk factors for healthcare-associated, community-onset (HACO) MRSA Impact of hospital-based prevention programs on HACO Use of mathematical modeling to understanding inter-facility transmission
dynamics and implications for prevention Novel techniques for changing organization culture as a means to
improve adherence
Conclusions
The burden of MRSA remains high in US healthcare settings
Community-associated MRSA (CA-MRSA) infections are emerging rapidly in many areas, but population-based estimates suggest that most MRSA infections are healthcare-associated
Epidemic strains of MRSA originally associated with the community have emerged as important causes of hospital-acquired infections
MRSA infections and transmission can be prevented, even in endemic settings in the US
Effective control programs must be multifaceted, and broad institutional commitment, including measurement of impact, is required for successful implementation
Acknowledgments
Rachel Gorwitz Kate Ellingson David Kleinbaum Val Gebski Jonathan Edwards Pei-Jean Chang Alexander Kallen Scott Fridkin Monina Klevens Jeff Hageman Fred Tenover Melissa Morrison Teresa Horan
Robert Muder Rajiv Jain The Active Bacterial Core
Surveillance Investigators/Teams
Dawn Sievert Deron Burton Alicia Hidron Dan Pollock
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