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PI – Rodney E. Rohde, PhD, MS, SV, SM(ASCP) CM MB CM

Methicillin Resistant Staphylococcus aureus ( MRSA): Carriage and Conversion Rates in Nursing Students – An Interim Report. PI – Rodney E. Rohde, PhD, MS, SV, SM(ASCP) CM MB CM Associate Dean for Research, College of Health Professions Associate Professor, Clinical Laboratory Science

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PI – Rodney E. Rohde, PhD, MS, SV, SM(ASCP) CM MB CM

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  1. Methicillin Resistant Staphylococcus aureus (MRSA): Carriage and Conversion Rates in Nursing Students – An Interim Report PI – Rodney E. Rohde, PhD, MS, SV, SM(ASCP)CMMBCM Associate Dean for Research, College of Health Professions Associate Professor, Clinical Laboratory Science Cheryl Rowder, PhD, RN, CCRC (Seton Hospital now) Thomas L. Patterson, MS, BS, MT (ASCP) Gerald D. Redwine, M.ED., MT(ASCP) Bob Vásquez, PhD Emilio Carranco, M.D. 1

  2. The information/data within this PPT has been published. • Please see the following article for complete information & citation for credit: • Rohde, R.E., Rowder, C., Patterson, T., Redwine, G., Vásquez, B., & Carranco, E. Methicillin Resistant Staphylococcus aureus (MRSA): An Interim Report of Carriage and Conversion Rates in Nursing Students. Clin Lab Sci, 2012 ;25(2):94-101.

  3. Study Support • 2010 TSAHP Research Grant Award • THANK YOU! • Texas State University, College of Health Professions, Dean’s Office, CLS Program, School of Nursing (SON) • Texas State University Research Enhancement Grant (Gerald Redwine, CLS Dr. Cheryl Rowder, Seton Hospital, & Dr. Barbara Covington, SON – Round Rock)

  4. Objectives - Overview • Microbiology & epidemiology of Staphylococcus aureus & MRSA background • Purpose / Goals of study • Methodology / Preparation • Analysis • Interim results • Discussion / Implications • Final thoughts SON Director Marla Erbin-Roesemann, PhD, RN & CHP Dean Ruth Welborn, PhD, RN

  5. What is Staphylococcus aureus? • Gram-positive cocci in clusters. • Multiple infection sites: skin, bones, lungs, or blood. • Transmission (infection versus colonization) • Methicillin resistant Staphylococcus aureus (MRSA)- resistant to the broad-spectrum antibiotics commonly used to treat it • 1st reported in U.K. in 1961 (Jevons, 1961); Seven years later, after the resistant strain had become widespread in Japan, Europe, and Australia, the first case of MRSA in the U.S. was reported in 1968 at a Boston hospital (Barrett, McGehee, & Finland, 1968). • Worldwide, an estimated two billion people carry some form of S. aureus; of these, up to 53 million (2.7% of carriers) are thought to carry MRSA. In the U.S., 95 million carry S. aureus in their noses; of these, two and a half million (2.6% of carriers) carry MRSA (Graham, Lin, & Larson, 2006).

  6. Staphylococcus aureus Staphylococcus epidermidis Coagulase negative Coagulase negative Coagulase positive Coagulase positive

  7. Grape-like clusters of Staphylococci Gram positive

  8. Folliculitis “staph infection?” Spider bites?

  9. MRSA! Healthcare associated infections (HAIs) have become one of the most costly and deadly growing public health threats of our time. The CDC estimates that MRSA has surpassed HIV as the leading cause of morbidity and mortality in the U.S. (CDC, 2010) “not your Grandma’s bug anymore”

  10. Risk Factors Hospital Associated (HA-MRSA) • Hospitalization • Long-term care facilities • Invasive devices • Recent antibiotic use • Weakened immune system

  11. Risk Factors Community Associated (CA-MRSA) • Age? • Contact sports • Sharing • Weakened immune system • 1, 2-3, >4 Abx & drug class • Crowded or unsanitary conditions

  12. Epidemiology • SA a colonizer of healthy mucous membranes and skin of humans and many other animals. • Other than shedding by humans, the environment appears to play a negligible role in the ecology of this organism. • In humans it demonstrates a niche preference for the anterior nares, especially of adults. • Three patterns in healthy people: • Persistent carriers (~20%) • Intermittent carriers (~ 60%) • Never colonized (20%)

  13. What is the usual clinical expression of MRSA infection? • Spider bite • Turf burn • Impetigo • Boil • Abscess Source: Mark Grubb, MD Source: LA County Health Department Source: CDC Source: CDC Source: CDC

  14. Spectrum of Disease • Fever, PAIN! • >80% skin and soft tissue infection (SSTI) • Abscesses • Furuncles • Carbuncles • Cellulitis • Local swelling, redness, heat • Painful lesion or pimple with or without drainage • Misdiagnosed as spider bites Source: CDC

  15. Spectrum of Disease • Severe / invasive infection sites: • Lungs • Bloodstream • Bone • Joints • Surgical sites • Complications of preceding SSTIs • Or viral respiratory tract infections (especially flu) Source: CDC

  16. Purpose & goals of this study* • (1) Assess initial prevalence or acquisition of S. aureus & MRSA in a cohort of nursing students over five semesters (~ two years) of clinical care experiences in a variety of settings, • (2) to examine the antibiotic sensitivity of MRSA isolates by microbiological susceptibility testing, and • (3) to conduct an univariate analysis for identify of risk factors significantly associated with nasal carriage of S. aureus & MRSA in a population of nursing students at a four year public university. • (4) The purpose of this project seeks to add to the knowledge of risk for acquisition and length of time to colonization of MRSA for healthcare workers (HCWs). First documented study! *Study is at ½ way point – study will be complete in May 2012

  17. Study Methodology / Preparation • A longevity (time-series) prospective cohort design will be applied to determine the rate of S. aureus and MRSA carriage in a cohort of nursing students at Texas State and to describe exposures (risk factors) associated with carriage. • IRB approval from Texas State University – San Marcos (#2010F5693). • Data collection and analysis will be continuous from September 2010 through May 2012. • Eligible participants were all Texas State University students over the age of eighteen. (N = 87) • Purposive sampling strategy • Questionnaire for demographics & risk factors

  18. Study Methodology / Preparation • Informed consent (Nursing & CLS faculty) • Questionnaire (CLS) • Age • Gender • Ethnicity • Possible MRSA exposure • Knowledge of MRSA • Hospital admission and work • Intravenous drug use • Dorm living status • Jail • Athletic involvement • Clinical care experiences (contact isolation, area of work, etc.) • Nasal Swab (Self-administered with CLS supervision)

  19. Study Methodology / Preparation

  20. Study Methodology / Preparation • A positive MRSA swab will represent an end point for a participant. • Medical intervention will be recommended by Dr. Carranco (Student Health Center). • Post treatment tests will verify a negative nasal swab.

  21. Laboratory Methods 1) Streak nasal swab on Mannitol Salt Agar (screen) and Chromagar (confirmatory).

  22. Laboratory Methods 2) Incubate Mannitol Salt Agar (MSA) plates for 24-48 hours. -Selective and Differential media Staphylococcus spp. S. aureus

  23. Laboratory Methods 3) Perform Catalase test and Latex Agglutination test (Staphytect).

  24. Laboratory Methods 4) Correlate MSA with Chromoagar plate. *mauve-colored colonies = MRSA BBL™ CHROMagar™ Family of Products A Lean Approach to Testing BBL™ CHROMagar™ MRSA, supplemented with chromogens and inhibitory agents, is used for the qualitative direct detection of nasal colonization by MRSA.

  25. Analysis • Statistical analysis will be performed using: • Stata, version 12 • Descriptive, demographics • Generalized estimating equations (GEE) to obtain population-averaged panel logistic regression models • Allow for AR(1) error process • Data screened for missing and/or out of range values, sparse cell frequency counts, and the sample size to number of cells ratio

  26. Results – baseline • Enrollment = 87/96 participants (90.6%) • Demographics (August 2010) • Ages 20 to 58 years (mean 24.5; median 23; mode 20) • Age group of 20-24 (68.9%) was greatest; 25-29 (16.1%); 30-34 (10.1%); 35-39 (2.2%); 40+ (2.2%) • Gender: Male to female ratio • 11 (12.6%) to 76 (87.4%) • Ethnically, Caucasians (74.7%) and Hispanics (12.6%) made up the majority of the population. • AA (3.4%), Asian (8%), other (1.1%)

  27. Results - 3rd wave • Enrollment = 70/86 participants (~81%) • Demographics (May 2011) • We found that with respect to sex and race however, attrition had not affected sample composition in any meaningful way. • Furthermore, because this study will continue, we will expect to recover participants in the next wave of data collection.

  28. Discussion • The prevalence of S. aureus in our cohort of nursing students was not similar to previously reported studies of 19% to 37% as reported by Bischoff, et al. (2004). • Also, age, gender, chronic sinusitis, medical student status, and hospitalization were associated with carrier status for S. aureus (Bischoff et al., 2004, p. 485) but not our study. • Equally, this study found diametrically opposed findings from those of Rohde, et al. (2009) in that hospitalization was not related to carrier risk but did replicate the results of previous studies that time spent in the hospital setting as either a volunteer or healthcare worker increased this risk.

  29. Discussion • MRSA colonization in our nursing student cohort did not increase in this interim report of a longitudinal study. • S.aureus colonization remained stable as predicted in most point prevalence studies (25-30%). • Species colonization other than S.aureus (e.g. S. epidermidis, S. haemolyticus) increased to significant levels which may play an important role in nosocomial transmission understanding.

  30. Implications • Few studies have examined conversion of populations • Cross-sectional studies may provide point prevalence but do not fully explain progression from one form to another • S. aureus is a known risk factor for conversion to MRSA, but little is known of conversion from S. spp. to S. aureus. • Our study to date found a statistically significant rise in rates of S. spp. associated with time spent as either a volunteer or worker in healthcare • indicates a potential risk for healthcare providers for conversion to positive status and for potential risk to patient safety. • While (most) healthcare providers are not screened for MRSA or any staphylococci, yet they are expected to care for patients who are positive with use of contact isolation. Is this enough?

  31. Points to Ponder • This project offers a powerful, collaborative and synergistic research opportunity between two College of Health Professions units – CLS and Nursing. • Students in both units will be able to apply real-world clinical experience in the teaching and research realm • All investigators will strengthen the bridge between the classroom and research arena • A strong research foundation at TX State – CHP is growing, specifically in the realm of MRSA prevalence, understanding, and knowledge • A strong hybrid translational research focus is being developed across education and public health/clinical domains

  32. Control Prevention Wash your hands and/or use gels! Education – demand a culture & antibiogram! Don’t share fomites! Use antibiotics appropriately! Be aware of risk factors & environment! KPC (the new MRSA?), VRE, C. diff Closing comments

  33. At work!

  34. PI Background • Rohde, R.E. Denham, R., & Brannon, A. (Summer, 2009). Methicillin Resistant Staphylococcus aureus: Nasal Carriage Rate and Characterization in a Texas University Setting. Clinical Laboratory Science, 22(3): 176-184. • 60/203 (29.6%) colonized with S. aureus & 15/203 (7.4%) with MRSA. There were 108 (53.2%) dorm students that participated in this study. Of those, 34 (31.5%) were positive for S. aureus colonization, and seven (6.5%) were positive for MRSA colonization. Risk for hospitalization & boil/skin infection. • Felkner, Marilyn, R. E. Rohde, Ana Maria Valle-Rivera, Tamara Baldwin, and L.P. (Sky) Newsome.  Methicillin Resistant Staphylococcus aureus Nasal Carriage Rate in Texas County Jail Inmates.  Journal of Correctional Health Care, 2007;13(4): 289-295. [Top Ten most cited article JCHC] • 28.5% S. aureus & 4.5% MRSA in TX jail (N = 403); Risk for any incarceration, healthcare, & boil/skin. • Dissertation Topic: Methicillin Resistant Staphylococcus aureus (MRSA): Knowledge, Learning, and Adaptation.

  35. Bibliography 1.  Chi C, Wong W, Fung C, Yu K, Liu C. Epidemiology of community-acquired Staphylococcus aureus bacteremia. J Microbiol Immunol Infect 2004 02;37(1):16-23. 2.  Loffler CA, Macdougall C. Update on prevalence and treatment of methicillin-resistant Staphylococcus aureus infections. Expert Rev Anti Infect Ther 2007 12;5(6):961-81. 3.  Mainous AG, Hueston WJ, Everett CJ, et al. Nasal carriage of Staphylococcus aureus and methicillin-resistant S aureus in the united states, 2001-2002. Ann Fam Med 2006 03;4(2):132-7. 4.  Gorwitz RJ, Kruszon-Moran D, McAllister SK, and others. Changes in the prevalence of nasal colonization with Staphylococcus aureus in the United States, 2001-2004. J Infect Dis 2008 05/01;197(9):1226-34. 5.  Banning M. Transmission and epidemiology of MRSA: Current perspectives. Br J Nurs 2005 //2005 May 26-Jun 8;14(10):548. 6.  Krziwanek K, Luger C, Sammer B, and others. MRSA in Austria--an overview. Clin Microbiol Infect 2008 03/05;14(3):250-9. 7.  Miller LG, Perdreau-Remington F, Rieg G, Mehdi S, Perlroth J, Bayer AS, Tang AW, Phung TO, Spellberg B. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in los angeles. N Engl J Med 2005 04/07;352(14):1445-53. 8. Lowy FD. Staphylococcus aureus infections. N Engl J Med 1998 08/20;339(8):520-32. 9.  Kenner J, O'Connor T, Piantanida N, and others. Rates of carriage of methicillin-resistant and methicillin-susceptible Staphylococcus aureus in an outpatient population. Infect Control Hosp Epidemiol 2003 06;24(6):439-44. 9.  Stubbs E, Pegler M, Vickery A, et al. Nasal carriage of Staphylococcus aureus in australian (pre-clinical and clinical) medical students. J Hosp Infect 1994 06;27(2):127-34. 10.  Graham PL, Lin SX, Larson EL. A U.S. population-based survey of Staphylococcus aureus colonization. Ann Intern Med 2006 03/07;144(5):318-25. 11.  Klevens RM, Morrison MA, Nadle J, et al. Invasive methicillin-resistant Staphylococcus aureus infections in the united states. JAMA 2007 10/17;298(15):1763-71. 12.  Campbell KM, Vaughn AF, Russell KL, et al. Risk factors for community-associated methicillin-resistant Staphylococcus aureus infections in an outbreak of disease among military trainees in san diego, california, in 2002. J Clin Microbiol 2004 09;42(9):4050-3. 13. Centers for Disease and Prevention. Invasive MRSA. Retrieved June 1, 2008, from www.cdc.gov/ncidod/dhqp/ar_mrsa_Invasive_FS.html. 14. Tenover FC, Lancaster MV, Hill BC, Steward CD, Stocker SA, Hancock GA, O'Hara CM, McAllister SK, Clark NC, Hiramatsu K. Characterization of staphylococci with reduced susceptibilities to vancomycin and other glycopeptides. J Clin Microbiol 1998 04;36(4):1020-7. 15. Smith TL, Pearson ML, Wilcox KR, Cruz C, Lancaster MV, Robinson-Dunn B, Tenover FC, Zervos MJ, Band JD, White E, Jarvis WR. Emergence of vancomycin resistance in staphylococcus aureus. glycopeptide-intermediate Staphylococcus aureus working group. N Engl J Med 1999 02/18;340(7):493-501. 16. Tsiodras S, Gold HS, Sakoulas G, Eliopoulos GM, Wennersten C, Venkataraman L, Moellering RC, Ferraro MJ. Linezolid resistance in a clinical isolate of staphylococcus aureus. Lancet 2001 07/21;358(9277):207-8. 17.  Weiner, R. Methicillin-Resistant Staphylococcus aureus on Campus: A New Challenge to College Health. J American College Health 2008 56:4: 347-350.

  36. Bibliography 18.  Wertheim HFL, Melles DC, Vos MC, et al. The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis 2005 12;5(12):751-62. 19.  von Eiff C, Becker K, Machka K, et al. Nasal carriage as a source of Staphylococcus aureus bacteremia. study group. N Engl J Med 2001 01/04;344(1):11-6. 20.  Smith TL, Pearson ML, Wilcox KR, et al. Emergence of vancomycin resistance in staphylococcus aureus. glycopeptide-intermediate Staphylococcus aureus working group. N Engl J Med 1999 02/18;340(7):493-501. 21.  Saïd-Salim B, Mathema B, Kreiswirth BN. Community-acquired methicillin-resistant Staphylococcus aureus: An emerging pathogen. Infect Control Hosp Epidemiol 2003 06;24(6):451-5. 22.  Gupta K, Macintyre A, Vanasse G, Dembry L. Trends in prescribing beta-lactam antibiotics for treatment of community-associated methicillin-resistant Staphylococcus aureus infections. J Clin Microbiol 2007 12/17;45(12):3930-4. 23.  Nguyen DM, Mascola L, Brancoft E. Recurring methicillin-resistant Staphylococcus aureus infections in a football team. Emerg Infect Dis 2005 04;11(4):526-32. 24.  Centers for Disease Control and Prevention. Methicillin-resistant Staphylococcus aureus infections among competitive sports participants—Colorado, Indiana, Pennsylvania, and Los Angeles County, 2000-2003. MMWR Morb Mortal Wkly Rep 2003 08/22;52(33):793-5. 25.  Goodman RA, Thacker SB, Solomon SL, et al. Infectious diseases in competitive sports. JAMA 1994 03/16;271(11):862-7. 26.  Lindenmayer JM, Schoenfeld S, O'Grady R, et al. Methicillin-resistant Staphylococcus aureus in a high school wrestling team and the surrounding community. Arch Intern Med 1998 04/27;158(8):895-9. 27. Decker MD, Lybarger JA, Vaughn WK, et al. An outbreak of staphylococcal skin infections among river rafting guides. Am J Epidemiol 1986 12;124(6):969-76. 28.  Beam JW, Buckley B. Community-acquired methicillin-resistant staphylococcus aureus: Prevalence and risk factors. J Athl Train 2006 07;41(3):337-40. 29.  Huang H, Cohen SH, King JH, and others. Injecting drug use and community-associated methicillin-resistant Staphylococcus aureus infection. Diagn Microbiol Infect Dis 2008 04/21;60(4):347-50. 30. Turabelidze G, Lin M, Wolkoff B, et al. Personal hygiene and methicillin-resistant Staphylococcus aureus infection. Emerg Infect Dis 2006 03;12(3):422-7. 31. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med 2006 08/17;355(7):666-74. • Shittu A, Lin J, Morrison D, et al. Identification and molecular characterization of mannitol salt positive, coagulase-negative staphylococci from nasal samples of medical personnel and students. J Med Microbiol 2006 03;55:317-24. • Schneider-Lindner V; Delaney JA; Dial S; Dascal A; Suissa S. Antimicrobial drugs and community-acquired methicillin-resistant Staphylococcus aureus, United Kingdom. Emerg Infect Dis. 2007 Jul;13(7):994-1000.

  37. Acknowledgements • Thanks to • Nursing cohort participants, Texas State University • Clinical Laboratory Science (CLS) students, Texas State, Classes of 2011 & 2012 • Dr. Carmen Adams, CLS, Texas State • Dave Falleur, CLS Chair • Dr. Ruth Welborn, Dean, CHP, Texas State • Dr. Marla Erbin-Roesemann, Dr. Barbara Covington & Rita Zapata Mokarzel, School of Nursing, TX State • CTMC San Marcos (Microbiology Abx susceptibility work!) • TX State SHC

  38. Questions?!? www.txstate.edu/~rr33 rrohde@txstate.edu

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