Treatment Options for MRSA Pathways to Excellence INS Orlando June 2, 2007

1. Treatment Options for MRSAPathways to ExcellenceINS Orlando June 2, 2007 Alan D Tice, MD, FACP John A Burns School of Medicine University of Hawaii alantice@IDLinks.com www.OPAT.com (this presentation available)

2. Alan D Tice MD, FACPInfectious Diseases Specialist University of Hawaii - Medical School Private Practice and Community Health Centers IDSA � Quality Measures Task Force OPAT Guidelines Partners: Astellis, Cubist, Merck, Pfizer, Replidyne, Roche, Schering, INS, IDSA, APIC, ACP, AMA, Surfrider Foundation

3. Intravenous Therapy Infections in the United States >150 million vascular devices sold >5 million central venous lines 200,000 cases of bloodstream infections -Central lines most frequent cause of nosocomial bacteremia -15% mortality

4. Staphylococcus aureus in the Community

5. Here we have plotted theprevalenceo MRSA, MR CNS and VRE reported from nosocomial infections. These pathogens account for over half of the bloodstream infections among ICU patients. In 1999 the prevalence of MRSA has broken the 50% mark for ICU patients, and VRE has reached 25%.Here we have plotted theprevalenceo MRSA, MR CNS and VRE reported from nosocomial infections. These pathogens account for over half of the bloodstream infections among ICU patients. In 1999 the prevalence of MRSA has broken the 50% mark for ICU patients, and VRE has reached 25%.

6. CA-MRSA Prevalence is Increasing

7. CA-MRSA PrevalenceVaries by RaceEstivariz EIS �03

8. CA-MRSA Findings

9. CA-MRSA Outbreaks Often first detected as clusters of abscesses or �spider bites� Various settings Sports participants: football, wrestlers, fencers Correctional facilities: prisons, jails Military recruits Daycare and other institutional centers Newborn nurseries and other healthcare settings Men who have sex with men

10. St. Louis RamsCA-MRSA Abscesses Association with BMI>30 Recent Abx use Lineman/Linebacker Abx use 2.6 scripts/yr for Rams 0.2 scripts/yr for gen pop�n Common USA 300 clone

12. Staphylococcus aureus - virulence factors Enzymes Catalase, coagulase, hyaluronidase, clumping factor, beta-lactamases Toxins Alpha through delta and leukocidin Other toxins Epidermolytic, enterotoxins, exotoxins, toxic shock syndrome toxin, superantigens Growth factors Resistance mechanisms for antibiotics METHICILLIN RESISTANCE NOT A VIRULENCE FACTOR � it is a therapy factor

13. CA-MRSA Differs from HA-MRSA HA-MRSA SCCmec II USA 100, 200 PVL Rare Resistant to multiple agents CA-MRSA SCCmec IV USA 300, 400 PVL Common Resistant mainly to oxacillin and erythromycin USA 300

14. CA-MRSA Predominantly Causes Skin Disease

19. Necrotizing fasciitis

20. Staphylococcus aureus Where does it come from?

22. S. aureus ColonizationNHANES Nasal Swab Survey 2001-2, Kuehnert et al.

23. Organisms Associated with Infection Staphylococcus non-aureus Staphylococcus aureus Enterococci Candida albicans Some Gram-negative rods

27. Risk factors for Catheter-related Infection Patient Characteristics Therapy Catheter Infusion devices Maintenance protocols Staff training and experience

28. Patient Risk Factors Leukopenia or immune suppression Presence of other infections Severity of illness Hospitalization duration and location Age Self care abilities

29. Therapy Risk Factors Infusates Osmolality, pH chemotherapy, antibiotics Number of drugs Frequency of dosing Duration of use

30. Source of Infections Extralumenal (65%) Patient skin Hands of personnel Intralumenal (30%) Hands of personnel, hub Hematogenous seeding Contaminated IV fluids

31. Catheter Risk Factors Small catheters better Large vein better Need space in vein for blood flow Multi-lumen catheters have more risks

35. Catheters and Infection Risk Type of catheter Diameter Number of lumens Catheter materials Catheter function Site of insertion

36. Risk of Bloodstream infection by Catheter Type Steel needle <2/1000 days Peripheral catheter <2/1000 Non-tunneled catheter 20/1000 Tunneled catheter 3/1000 PICC line 2/1000 PORT 1/1000

37. Bacterial Colonization

39. Catheter Care to Prevent Infection Inspection daily Protocols for dressing changes Special training and experience Surveillance system for infections

42. IV Teams and Catheter-related Infections(per 100 catheters)

43. Dressing for Central Lines Sterile technique Insertion: gloves, gown, mask, field Dressings: gloves, mask Dressing changes As needed Gauze at least every 3 days Transparent at least every 7 days Antiseptic skin cleaning Alcohol, iodine, chlorhexidine

44. Managing Infections Early detection Culture blood from each line and label specifically Remove catheter when able Culture catheter tip when removed Antibiotic therapy early Infuse proper port or lumen Antibiotic lock technique

45. Antibiotic Lock Technique Antibiotic in line or port with last flush May avoid parenteral therapy Label blood cultures carefully Be sure correct line entered

47. IV antibiotics for MRSA Vancomycin � Q12 hours Clindamycin � Q8 hours, 2/3 resistant Daptomycin � Q24 hours Linezolid � IV and PO � Q12 hours Tigecycline (Tigacyl) � Q12 hours Quinupristin/dalfopristin (Synercid) CLINICAL TRIALS Dalbavancin � Q week Telavancin Oritavancin Cephalosporins

48. Oral Antibiotics for MRSA

49. Hospital Care Expensive (over $1,000 per day) 5% nosocomial infection rate (>$2,500 each) Highly-virulent microbes Tremendous spectrum of pathogens High rates of antimicrobial resistance OPAT a reasonable alternative 1/1000 Americans

50. OPAT Survey � Emerging Infection Network 2004 Experience of infectious diseases consultants with outpatient parenteral antimicrobial therapy: results of an emerging infections network survey. Chary A, Tice AD, Martinelli LP, Strausbaugh LJ Clinical Infectious Diseases. 2006 Nov 15;43(10):1290-5.

51. OPAT SURVEY 454 EIN members responded (54%) Average of 19 OPAT patients per month More than 13,000 patients 90% treated at home 68% reported serious infectious diseases or other complications 1951 cases extrapolated

52. Responsible for OPAT day-to-day

53. OPAT Complications(more than 13,000 cases)

54. OPAT Complications 13 IDs reported unexpected deaths on OPAT 14 cases 16 IDs reported being sued

55. OPAT Resources IDSA Practice Guidelines for OPAT - Clinical Infectious Diseases, 2004 www.idsociety.org Handbook for Outpatient Parenteral Therapy - A Tice � 2006 Web page: www.OPAT.com

56. Ideas to Prevent Infection Antibiotic-impregnated catheters Silver, chlorhexidine Minocycline, rifampin Topical antibiotics � mupirocin (Bactroban), retapamulin Anticoagulants to prevent fibrin thrombi Flush: heparin, EDTA Systemic: low-dose coumadin, ASA, other New catheter materials Performance measures and payment for quality

57. Consortium for Performance Improvement (AMA sending to NQF � CMS/Medicare)Performance measure for Anesthesia Patients for whom central venous catheter (CVC) was inserted with all elements of maximal sterile barrier technique (cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis) followed

58. Future Considerations Better devices and equipment Better care with more CRNIs Better Biodefense with ICPs Better antibiotics Rapid assay for MRSA Quarantine, isolation

61. Summary and conclusions about IV therapy Infections of IV catheters a common and serious problem in the hospital and at home Staphylococcus aureus a serious risk and problem yet it colonizes normal people Infections can be reduced by Careful evaluation of patient, treatments, catheters IV therapy team Infection Control � Biodefense important Sterile technique, barrier precautions, standards for maintenance Send home on OPAT

62. Summary and Conclusions about MRSA MRSA a formidable foe � be prepared Evaluate carefully � history and physical Culture early and appropriately Be aggressive with antibiotic therapy if signs of infection � spectrum and duration Do not overuse antibiotics Learn to live with MRSA � Go swimming Don�t pick your nose

64. Treatment Options for MRSAPathways to ExcellenceINS Orlando June 2, 2007 Alan D Tice, MD, FACP John A Burns School of Medicine University of Hawaii alantice@IDLinks.com www.OPAT.com (these slides available)