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MRSA Prescreening and Eradication: New England Baptist Hospital Experience

MRSA Prescreening and Eradication: New England Baptist Hospital Experience. David H. Kim, MD Director of Medical Education New England Baptist Hospital Boston, MA. New England Baptist Hospital. 150-bed adult medical/surgical hospital located in Mission Hill area of Boston

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MRSA Prescreening and Eradication: New England Baptist Hospital Experience

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  1. MRSA Prescreening and Eradication:New England Baptist Hospital Experience David H. Kim, MD Director of Medical Education New England Baptist Hospital Boston, MA

  2. New EnglandBaptist Hospital • 150-bed adult medical/surgical hospital located in Mission Hill area of Boston • Orthopaedic subspecialty hospital & “Center of Excellence” • Acute inpatient discharges: • 75% Orthopedic • 8% General Surgery • 17% Medical • Orthopaedic Surgery ~ 10,000/cases a year

  3. Total Inpatient Volume Massachusetts MarketOrthopaedic Surgery

  4. New England Baptist HospitalMarket Growth ~ 11%

  5. Methicillin-resistant Staphylococcus Aureus

  6. S. Aureus Most important pathogen in SSI Most SSI caused by strains carried by patient into hospital Anterior nares main niche Nasal carriage of S. aureus is risk factor for SSI [Kluytmans et al, Clin Microbiol Rev 1997]

  7. MRSA vs. MSSA Infection associated with higher mortality[Melzer et al, Clin Infect Dis 2003] Survive in dry conditions & on inanimate surfaces up to 20 days [Clarke et al, Ir Med J 2001] Prevalence increasing

  8. History of MRSA Resistance to PCN within 1 yr By 1950’s, 3/4 of S. aureus strains PCN-resistant Today, 90-95% clinical strains PCN-resistant 1959—methicillin (1st antistaph PCN) introduced 1st MRSA strain within 2yrs 60% of clinical S. aureus strains isolated from ICU’s are MRSA

  9. Linezolid Introduced in 2000 for MRSA • Resistant strain reported within 1 year • [Tsiodras et al, Lancet 2001]

  10. Daptomycin • Introduced in 2003 for MRSA • Resistant strain reported within 2 years • [Mangili et al, Clin Infect Dis 2005]

  11. Vancomycin Resistance Recognized after almost 40 yrs 1st glycopeptide-intermediate S. aureus (GISA) isolated in Japan in 1996 [Hiramatsu et al, J Antimicrob Chemother 1997] High level resistance appeared in Detroit in 2002 vanA gene complex acquired from VRE [Centers for Disease Control and Prevention, MMWR Morb Mortal Wkly Rep 2002] 2nd strain in Philadelphia 3rd strain in New York

  12. MIC Creep Increases in vancomycin MIC in both MRSA & MSSA over time [Rhee et al, Clin Infect Dis 2005] Largest study of >6000 S. aureus isolates over 5 yrs in California university hospital Drift towards reduced susceptibility ing percentage of isolates with MIC ≥ 1.0 μg/mL 19.9% in 2000 70.4% in 2004[Wang et al, J Clin Microbiol 2006]

  13. MIC Creep ’d vancomycin failure rate in MRSA infections in setting of ’d MICs [Sakoulas et al, J Clin Microbiol 2005]

  14. Surgical Site Infection (SSI) Increased costs Median hospital stay increased 2 wks Rehospitalization rates doubled Overall costs tripled [Whitehouse et al, Infect Control Hosp Epidemiol 2002]

  15. SSI Costs Capitation DRGs do not cover cost of treating nosocomial infection (considered “preventable”)

  16. Risk of SSI Increased in Nasal Carriers Nasal carriage only independent risk factor for S. aureus SSI in orthopaedic implant surgery Kalmeijer et al, Infect Control Hosp Epidemiol 2000 SSI rate 2-9x higher in carriers Kluytmans et al, Clin Microbiol Rev 1997 Perl et al, Ann Pharmacother 1998 Wenzel et al, J Hosp Infect 1995 In S. aureus SSI, S.aureus isolates from wound match nares 85% of time Perl et al, N Engl J Med 2002

  17. Risk Factors forS. Aureus SSI Observational study of 357 cardiac surgery patients 27% nasal carriers SSI rate 6.4% S. aureus in 64% 8/16 infections in nasal carriers Independent risk factors Diabetes (RR 5.9) Reoperation (RR 3.1) S. aureus nasal carriage (RR 3.1) [Munoz et al, J Hosp Infect 2008]

  18. Risk of MRSA Nasal Carriage Case-control study of 308 vascular surgery pts (nasal swabs) 11.4% MSSA carriers 4.2% MRSA carriers 2.9% on admission 1.3% acquired in hospital Transfer from another dept or facility risk factors for MRSA carriage MRSA infection rate 30.8% in MRSA carriers 0.68% in noncarriers [Morange-Saussier et al, Ann Vasc Surg 2006]

  19. Environmental Reservoirs MRSA infected/colonized pts contaminate rooms, contribute to endemic MRSA Prospective study of 25 MRSA pts Sampling of isolation rooms 53.6% of surface samples positive 28% of air samples 40.6% of settle plates Isolates identical or closely related in 70% of patients [Sexton et al, J Hosp Infect 2006]

  20. Environmental Reservoirs [Sexton et al, J Hosp Infect 2006]

  21. Potential Airborne Transmission [Sexton et al, J Hosp Infect 2006]

  22. Airborne Transmission MRSA counts remain elevated for up to 15 minutes after bed making Consider air ventilation & filtration Keep doors closed [Shiomori et al, J Hosp Infect 2002]

  23. Inadequate Patient Space 18-month prospective study Addition of fifth bed to four-bed bay ’d relative risk of MRSA colonization 315% [Kibbler et al, J Hosp Infect 1998]

  24. Long-term Care Facilities 44% of environmental surfaces tested positive for MRSA [Asoh et al, Intern Med 2005]

  25. Decolonization of Carriers Intranasal mupirocin (Bactroban) Eradicates nasal colonization in most patients Reduces S. aureus infections Herwaldt, J Hosp Infect 1998; Kluytmans et al, Infect Control Hosp Epidemiol 1996; Tacconelli et al, Clin Infect Dis 2003 (dialysis) Cimochowski et al, Ann Thorac Surg 2001; Kluytmans et al, Infect Control Hosp Epidemiol 1996 (Cardiovasc) Gernaat-van der Sluis et al, Acta Orthop Scand 1998 (ortho) Perl et al, N Engl J Med 2002 (mixed)

  26. Mupirocin and the Risk of S. Aureus (MARS) Study [Perl et al, N Engl J Med 2002] • University of Iowa • Prospective randomized double-blind placebo-controlled • 4020 enrolled, 3864 analyzed • Elective cardiothoracic, general, oncologic, gyn, neuro surgery • Rate of S. aureus SSI (primary endpoint) • 2.3% in mupirocin pts • 2.4% in placebo pts • No reduction in rate of S. aureus SSI • Among nasal carriers, risk of nosocomial S. aureus infection decreased by half (7.7% to 4.0%)

  27. MARS Study [Perl et al, N Engl J Med 2002] • Mupirocin nasal swab for up to 5 days • Chlorhexidine shower for cardiothoracic pts night before & morning of surgery • Power analysis • 4046 pts to detect 50%  in S. aureus SSI (estimated reduction of 2.8% (57 pts) to 1.4% (28 pts) with 85% power • 4030 enrolled, 3551 completed study • 82.6% received at least 3 mupirocin doses

  28. MARS Study Infection Rates Risk of S. aureus infection among nasal carriers cut in half S. aureus SSI 4.5x higher in carriers receiving placebo 84.6% isolates from SSI pts identical between wound & nares 39 different strains among 77 patients Mupirocin resistance in 6/1021 (0.6%) isolates over 4 yrs

  29. Effect of Universal Screening: University of Geneva Hospital[Harbarth et al, JAMA 2008] • Prospective interventional cohort with crossover • 21,754 pts (multiple surgical subspecialty wards) • Rapid screening + standard infection control measures vs. standard measures alone • MRSA Screening before or on admission by PCR • Standard infection control for MRSA carriers • Contact isolation • Gown, mask, gloves • Adjusted perioperative abx • Mupirocin & chlorhexidine x 5 days • Universal rapid MRSA admission screening did not reduce nosocomial MRSA infection

  30. Incidence of MRSA Infections [Harbarth et al, JAMA 2008]

  31. Harbarth et al: Results • 94% (10,193/10,844) screened • 21,754 pts--70% power to detect reduction in MRSA infection rate from 0.9% to 0.6% • 5.1% (515 pts) MRSA-positive • No difference in MRSA SSI rate • 0.99% (76 pts) without screening • 1.14% (93 pts) with screening • 57% (53/93 pts) with nosocomial MRSA infection during screening period were MRSA-free on admission • 31% of MRSA carriers identified after surgery • 43% of MRSA carriers identified before surgery rec’d appropriate abx prophylaxis

  32. Harbarth et al • None of MRSA carriers detected during outpatient preop visits developed MRSA infection • all received decolonization treatment & appropriate antibiotic prophylaxis • 57% of infections hospital-acquired

  33. Preoperative Decolonization University of Pittsburgh Prospective observational study Total joint arthroplasty 1966 patients 636 screened (nasal) 26% positive for S. aureus (164/636) 23% MSSA (147/636) 3% MRSA (17/636) 1330 control (not screened) [Rao et al, Clin Orthop Relat Res 2008]

  34. Pittsburgh Protocol Decolonization Pts educated 1 wk preop Mupirocin nasal ointment BID x 5 days Chlorhexidine bath QD x 5 days

  35. Pittsburgh Results

  36. Pittsburgh Results No increase in infection from other pathogens Estimated economic gain of $231,741/yr

  37. NEBH Experience: Background • FY06 - 46 SSI in 8986 surgical pts (0.5%) • National rate for orthopedic SSI ~ 1.5% • 57% SSI due to S. aureus • 16 (35%) MSSA • 10 (22%) MRSA • PFGE of isolates documented community acquired strains

  38. Anonymous Nasal Surveillance Cultures • February 2006--133 anonymous nares cultures after patient anesthetized • Results: • 38 – S. aureus (29%) • *5 - MRSA ( 4%) • all previously undiagnosed • *no precautions used in OR, PACU or nursing units • *Cefazolin used for antibiotic prophylaxis

  39. Screening Proposals • February 2006 – prepared three screening proposals with costs 1) Traditional nasal cultures - 3 day results $245,000.00 2) Purchase rapid PCR equipment $337,338.00 3) Lease rapid PCR equipment $259,990.00 • March 2006 –Board approval of equipment purchase

  40. Implementation – 8 Months • March – October 2006 • Weekly meetings: • surgical services, infection control, micro, administration, & medical staff members • July 2006 – letter to surgeons • July 17, 2006 – initiated pilot on Spine Service • August 2006 – letter to medical staff • September 2006 – initiated universal program for all inpatient surgery

  41. Policy & Procedure Formalization • Protocol developed for all departments & units affected • OR Scheduling • Patient Access • Prescreening Unit • Pre-surgical unit • OR • PACU • Nursing Units • Microbiology Lab • Ancillary Departments: Housekeeping, Central Transport, Radiology, etc.

  42. NEBH Program: Preoperative Outpatient Screening • Nasal swabs during prescreening • Microbiology Laboratory PCR detects presence of bacteria-specific DNA • Cepheid GeneXpert • Results within 24 hrs for S. aureus, 2 hrs for MRSA • Topical decolonization protocol for patients found to be carriers of S. aureus or MRSA

  43. Topical DecolonizationProtocol • Intranasal 2% mupirocin ointment (Bactroban) BID x 5 days • Shower with 2% chlorhexidine (Hibiclens) daily x 5 days • Patients called by PASU to initiate treatment protocol • Repeat call to document compliance • MRSA carriers re-screened prior to surgery • Contact precautions if 2nd MRSA screen positive • Vancomycin preop antibiotic prophylaxis for all patients with history of MRSA carrier status

  44. Results • Study group (7/17/06 to 9/30/07) • 7019 patients screened • 5122 (73.0%) non-carriers • 1588 (22.6%) S. aureus positive • 309 ( 4.4%) MRSA positive

  45. S. aureus & MRSA SSI Rate • 13/7019 (0.18%) SSI cases in screened patients • 7/5122 (0.14%) in noncarriers (0.14%) • 1/5122 MRSA (0.02%) • 6/5122 S. aureus (0.11%) • 6/1897 (0.31%) in carriers • 3/309 + MRSA (0.97%) • 3/1588 + S. aureus (0.19%) • SSI rate higher in carriers, highest in MRSA carriers

  46. MRSA & S. Aureus SSI Rates • Time Period Inpatient surgeries Total SSI SSI Rate FY06 (no screening) 10/01/05-07/16/06 5293* 24 0.46% FY07 (prescreening) 07/17/06-09/30/07 7019** 13 0.18% *historical controls **study group • 61% Reduction in S. aureus/MRSA SSI Rate

  47. 50% Reduction in MSSA SSI 60% Reduction in MRSA SSI MRSA SSI Rate MSSA SSI Rate 0.26% 0.18% 0.13% 0.06% 10/01/05-07/16/06 07/17/06-09/30/07 10/01/05-07/16/06 07/17/06-09/30/07

  48. Study Limitations • Use of historical controls

  49. Problem with Historical Controls • [Kalmeijer et al, Clin Infect Dis 2002] • University of Amsterdam, The Netherlands • Prospective double-blind, placebo-controlled • 614 pts • Elective ortho surgery with implants (hip, knee, spine) • Eradication rate 83.5% mupirocin, 27.8% placebo • No reduction in SSI rate (primary outcome) • Rate of endogenous S. aureus infection 5x lower

  50. SSI Rate • Spontaneous disappearance of deep infections (SSI surveillance effect?) • Implications for use of historical controls [Kalmeijer et al, Clin Infect Dis 2002]

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