Infectious Disease in Correctional Facilities Summit IDCFS

1. Infectious Disease in Correctional Facilities Summit (IDCFS) 1st Annual Infectious Disease in Correctional Facilities Summit Florida Hotel and Conference Center, Orlando I, Roger Sanderson, have no financial or commercial interests to disclose to the meeting participants.

3. Staphylococcus aureus

4. Disease Manifestations due to Staphylococcus aureus Skin and soft tissue infections Impetigo Cellulitis Osteomyelitis Pneumonia Endocarditis Septic phlebitis Catheter infections Surgical site infections Toxic shock syndrome Septicemia Septic arthritis

5. Staphylococcus aureus S. aureus commonly found on skin of healthy people Major cause of mortality before the advent of penicillin Penicillin greatly reduced mortality due to S. aureus Resistance to penicillin quickly developed Methicillin was introduced to treat penicillin resistant strains Methicillin resistance was reported in 1961 Methicillin Resistant S. aureus (MRSA) is now a global problem

6. Resistant infections areassociated with: Increased morbidity Prolonged treatment and hospital stays Greater direct and indirect costs Prolonged periods in which individuals are infectious Greater opportunities for spread of infection

7. Healthcare-Associated MRSA(HA-MRSA) Leading cause of nosocomial pneumonia, surgical wound infection, and bloodstream infection Established risk factors include Current or recent hospitalization Recent surgery Residence in long-term care facilities Dialysis Invasive device use Typical resistance profile - Resistant to many classes of antimicrobials in addition to beta-lactams

8. Community-Associated MRSA CA-MRSA Reports began in 1980s of MRSA occurring in the community in patients without established risk factors Younger patients Indigenous peoples and racial minorities Outbreaks have been reported in: Injection drug users Players of close-contact sports Prison/jail inmates Military recruits Group Homes (developmentally disabled) Men who have sex with men Unlicensed tattoo parlors

9. What is different about CA-MRSA? They are distinct from HA-MRSA Typically susceptible to a number of classes of antibiotics Commonly presents as skin and soft tissue infections One common community clone, the USA 300, typically carries the Panton-Valentine Leucocidin toxin Gene (PVL) and other toxin genes

10. Typical Antibiogram for CA-MRSA in Florida

11. What do these outbreaks of CA-MRSA have in common? MRSA skin infections occur most frequently among persons where the 5 C's are present: Crowding Contact (Frequent skin-to-skin) Compromised skin (cuts or abrasions) Contaminated items and surfaces, Lack of Cleanliness

15. Community Associated MRSA:A Problem in Florida? Laboratory Surveillance of Staphylococcus aureus in Florida Quest Diagnostics Laboratory, who serves clinics and physician offices has provided the DOH with all their S. aureus culture results for the state After removal of duplicate cultures for individuals there were: 8,299 isolates for 2003 17,309 isolates for 2004 35,986 isolates for 2005 48,953 isolates for 2006

21. Increasing Prevalence of Methicillin-Resistant Staphylococcus aureus Infection in California Jails Staphylococcus aureus clinical isolates obtained from patients who were inmates of the San Francisco County jail system showed an increase in the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) from 29%, in 1997, to 74%, in 2002; 91% of the MRSA isolates carried staphylococcal chromosomal cassette mec (SCCmec) type IV.

22. Methicillin-Resistant Staphylococcus aureus Infection in the Texas Prison System Recent reports indicate that correctional facility inmates may be at elevated risk for contracting methicillin-resistant Staphylococcus aureus (MRSA) infection because of overcrowding, poor hygiene, and high rates of diseases causing immunosuppression. The present study of 299,179 Texas inmates who were incarcerated between 1999�2001 indicated an incidence of 12 MRSA infections/1000 person-years. Note: with ~ 98,000 inmates in Florida there would be over 1,000 MRSA infections / year if we had the same rate as Texas Inmates with circulatory disease, cardiovascular disease, diabetes, end-stage liver disease, end-stage renal disease, human immunodeficiency virus infection or acquired immunodeficiency syndrome, and skin diseases all exhibited elevated rates of MRSA infection.

27. Goal To provide the maximum protection to the staff and inmates from acquiring a resistant organism while preserving the institutional security and quality of life of inmates with the resistant organisms

28. Additional Goal It is important to note the goal is to control MRSA in the institution and not eliminate MRSA.

29. Some Important Concepts There is no single remedy for controlling MRSA A coordinated multidisciplinary approach is required Infection control measures are essential Measures to limit or eliminate inappropriate antibiotic use must take place in order to control resistance

30. Colonization vs. Infection Colonization - is the presence, growth, and multiplication of the organism without observable clinical symptoms or immune reaction Infection - refers to invasion of bacteria into tissue with replication of the organism. Infection is characterized by isolation of the organism accompanied by clinical signs of illness such as either fever, elevated white blood count, purulence (pus), pneumonia, inflammation (warmth, redness, swelling), etc.

31. Why would active surveillance work? This schematic helps illustrates the problem. The reservoir of spread for MRSA is both colonized and asymptomatic or colonized patients. Both types of patients shed organisms into their environment which can then be accidentally carried by healthcare workers or on inanimate objects to other vulnerable hospitalized patients. Why would active surveillance work? This schematic helps illustrates the problem. The reservoir of spread for MRSA is both colonized and asymptomatic or colonized patients. Both types of patients shed organisms into their environment which can then be accidentally carried by healthcare workers or on inanimate objects to other vulnerable hospitalized patients.

32. Reservoirs of MRSA Infected individuals including inmates and staff Systemic signs and symptoms of infection Usually requires treatment and possible antibiotics Antibiotic treatment cures infections BUT does not necessarily eliminate the carriage state Colonized individuals including inmates and staff No signs or symptoms of infection Silently carry MRSA Environment

33. Diagnosing skin infections There are a number of infectious organisms that can cause skin lesions along with a number of non-infectious causes Culturing the site is the only way to determine what the organism is Laboratory report can give antibiotics sensitivity information that may be useful in treatment and epidemiologic investigations

34. Presentation of MRSA in the Corrections Environment MRSA presentation can include any of a number of disease manifestations However, the most common presentation are soft tissue infections such as boils, abscesses, furuncles, carbuncles etc.

36. MRSA Transmission in Correctional Facilities The main mode of transmission of MRSA is via hands including those of inmates and staff The infected or colonized individual can be the source of transmission Environmental surfaces contaminated with body fluids containing MRSA can also be a source of transmission

37. Don�t be quick to blame spiders for those �spider bite� wounds! Misdiagnosis of methicillin resistant Staphylococcus aureus (MRSA) infections as spider bites has been occurring throughout the United States. This misdiagnosis impedes the proper treatment of the infection and facilitates the spread of the infection.

38. �Spider Bites� and CA-MRSA When questioning an inmate about the �spider bite� ask if the spider was ever seen. So why spiders? In the mind of patient � this may be the thought process involved The site hurts and bug and spider bites hurt This �bite� hurts a lot so it must be a spider bite! Note: Brown Recluse Spiders are rare to non- existent in Florida

39. Prevention Strategies Early Detection! Evaluation of inmates who complain of painful or draining skin lesions Surveillance for skin infection in inmates and refer for medical evaluation

40. Control Plan Have a facility infection control plan HAND HYGIENE / HANDWASHING Communications Follow standard precautions Education - Personnel, Inmates, Visitors and Family members

41. Preventing CA-MRSA Skin Infections and Transmission in Inmates Ensure availability of soap and water Encourage good hygiene Discourage sharing of towels and personal items Establish cleaning schedules for equipment Cover wounds and provide wound care and dressing change on a set schedule Reduce barriers to health care clinics for potentially infectious disease Encourage the reporting of skin lesions and assess new inmates for skin lesions Regularly clean bathrooms in prisons, jails Wash laundry with detergent and/or bleach in hot water and use hot dryer

42. Standard Precautions for Health Care workers include: Hand hygiene / handwashing- after touching contaminated items Gloving - when touching blood, body fluids, secretions, excretions and contaminated items Masking � if aerosol of infectious material expected Gowning Appropriate handling of laundry

43. Contact Precautions include: In addition to standard precaution contact precautions include: Patient Placement � private room or cohorting Gloves when entering the room and removal before leaving the room Wear a gown when entering the room Limit the movement of the patient Use dedicated noncritical patient-care equipment

44. So Why All the Fuss About Hand Hygiene? Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings. Hand hygiene reduces the incidence of healthcare associated infections. CDC estimates that each year nearly 2 million patients in the United States get an infection in hospitals, and about 90,000 of these patients die as a result of their infection. More widespread use of hand hygiene products that improve adherence to recommended hand hygiene practices will promote patient safety and prevent infections. Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings. Hand hygiene reduces the incidence of healthcare associated infections. CDC estimates that each year nearly 2 million patients in the United States get an infection in hospitals, and about 90,000 of these patients die as a result of their infection. More widespread use of hand hygiene products that improve adherence to recommended hand hygiene practices will promote patient safety and prevent infections.

45. Hand Hygiene Program: Adequate hand hygiene is the simplest effective infection control measure for preventing and containing MRSA infections! Correction staff and inmates should be periodically provided education on the importance of hand hygiene and effectiveness of hand hygiene techniques. It is not enough just to tell people to wash your hands they have to have access to soap, water and towels. The institution�s hand hygiene program should be monitored for compliance

46. Decolonization Therapy Decolonization is of unproven benefit in controlling a MRSA outbreak in the correctional setting and should therefore be considered on a case by case basis. Decolonization does not eradicate colonization in all treated persons and does not prevent recolonization following future exposures to MRSA Decolonization is not recommended for routine use for MRSA. The overuse of mupirocin (Bactroban) has been associated with resistance to this agent

47. Summary Alcohol-Based Handrubs: What benefits do they provide? Require less time More effective for standard handwashing than soap More accessible than sinks Reduce bacterial counts on hands Improve skin condition In summary, alcohol-based handrubs provide several advantages compared with handwashing with soap and water, because they not only require less time, they also act faster. In addition, alcohol-based handrubs are more effective for standard handwashing than soap, are more accessible than sinks, are the most efficacious agents for reducing the number of bacteria on the hands of healthcare workers, and can even provide improved skin condition. In summary, alcohol-based handrubs provide several advantages compared with handwashing with soap and water, because they not only require less time, they also act faster. In addition, alcohol-based handrubs are more effective for standard handwashing than soap, are more accessible than sinks, are the most efficacious agents for reducing the number of bacteria on the hands of healthcare workers, and can even provide improved skin condition.

48. The Role of the Environment in Transmission of MRSA Transmission from environmental sources is known to be a source of infection Survival time of S. aureus on environmental surfaces can be days to weeks Contaminated personal items can include towels, razors, soap, clothing, lubricants Shared equipment can be a source of transmission of MRSA � especially sports equipment

49. Antibiotic Prescribing Practices Antibiotics therapy should be monitored for appropriate use The overuse of antibiotics especially broad-spectrum antibiotics should be discouraged!

50. Screening and surveillance Medical intake screening should include evaluation for skin infections Bacterial cultures should be routinely monitored Staff should refer inmates who have potential skin infections to health services Food handlers should be monitored for skin infections

51. Transporting and Transferring Inmates With Skin Infections Inmates should be fully evaluated prior to transfer to another institution If an inmate has MRSA transferring should be delayed until the infection is resolved if possible Receiving institution should be fully aware of inmates condition Escort officers should be educated on infection control measures that should be utilized when transporting inmates

52. Infection Control: Containment Inmates diagnosed with MRSA should be evaluated for the risk of transmission to others Those at high risk for infecting other should not be in the general population Inmates with non-draining lesions or draining lesions that can easily be covered by a simple dressing can be in the general population but MUST be educated about hand-hygiene and personal hygiene. Compliance with good hygiene should be monitored.

53. Environmental Control An EPA approved disinfectant should be used in cleaning environmental surfaces. Environmental surveillance cultures are of limited benefit and should not normally be done. Inmates with MRSA infections should have a separate shower and toilet if possible. If this is not possible surfaces should be decontaminated prior to use by uninfected inmates.

54. Management of Skin and Soft Tissue CA-MRSA Abscesses Most MRSA infections are treated by good wound and skin care: keeping the area clean and dry, washing hands after caring for the area, carefully disposing of any bandages, and allowing the body to heal. Aggressive drainage of accessible fluid collections is essential in the treatment of skin lesions. MRSA infections may resolve with incision and drainage alone without antibiotic therapy. Sometimes treatment requires the use of antibiotics. If antibiotics are needed, it is important to use the medication as directed. If the infection has not improved within a few days after seeing the healthcare provider, the inmate should be seen again. Treat with appropriate antibiotics. The choice of antibiotics should be bases on the antibiotic susceptibilities. Broad spectrum antibiotics should be discouraged.

56. Antibiotic Treatment of CA-MRSA Bases on the antibiotic resistant patterns seen in Florida skin infections can be treated effectively with oral antibiotics such as: Trimethoprim-sulfamethozazole Or Clindamycin Note: if isolate is erythromycin resistant, in vitro, clindamycin resistance may develop during therapy Vancomycin should not be routinely given for MRSA!

57. Outbreak Management A line list should be used to track MRSA cases An epidemiological investigation should be conducted to determine if there is a common source among cases. The segregation or cohorting of cases that are potentially contagious should be implemented as a control strategy. Emphasis should be placed on education of inmates and staff.

58. Education Education should reinforce the importance of: Hand washing Good personal hygiene Routine showering Maintenance of a clean cell Regular laundering of bed linens Self-reporting of all skin lesions Refraining from any injection drug use, tattooing and sexual contact with other inmates

59. Reporting of MRSA to the Health Department Single cases of MRSA are not reportable to the County Health Department Outbreaks of MRSA or other infectious organisms are reportable to the health department The health department can assist in developing prevention strategies and investigating outbreaks.

60. A New Concern There have been multiple reports of fatal CA-MRSA pneumonia and sepsis in immunocompetent children and adults In Florida, we have seen MRSA deaths in adults co-infected influenza and septic deaths in individuals with skin abscesses both in the community and in the corrections system

62. --- Reportable--- CA- S. aureus Deaths A new rule change this year will include the reporting of all community associated S. aureus deaths Community associated is defined as: No Hospitalization in the last year No admission to a nursing home, skilled nursing facility, or hospice within the last year No dialysis within the last year No surgery within the last year Deaths should be reported to the local county health department immediately

63. Any questions?