Moving from Infection Control to Infection Prevention: A Journey through MRSA

1. MRSA Moving from Infection Controlto Infection Prevention:A Journey through MRSA PATIENTS C DIFF Joan M. Ivaska, BS, MPH, CIC

2. Objectives • Participants will understand the differences between infection control and infection prevention. • Understand the epidemiology of MRSA • Understand risk factors for MRSA • Review current MRSA management trends • Discuss MRSA prevention and control strategies

3. Cardo et al. Infection Control and Hospital Epidemiology , Vol. 31, No. 11 (November 2010), pp. 1101-1105

4. Visitors and Family Staff/ Medical Staff

5. What is the role of Infection Prevention and Epidemiology? • Epidemiology is the cornerstone of public health • Inform policy decisions and evidence-based medicine • Identify risk factors for disease • Target prevention strategies • Infection control addresses factors related to the spread of infections within the health-care setting (whether patient-to-patient, from patients to staff and from staff to patients, or among-staff) • Interruption of outbreaks When we are not proactive in doing the right thing, we invite others to define the right thing for us Wikipedia, September 2011

6. What is the difference between control and prevention? • Control: • to exercise restraining or directing influence over • to have power over • to reduce the incidence or severity of especially to innocuous levels • Prevent: • to be in readiness for • to act ahead of • To keep from happening or existing www.merriam-webster.com/dictionary

7. A Tale of Two Cows Adapted from Daniel Saman, DrPH, MPH, CPH, HealthWatchUSA.com,2012.

8. Definitions • CA-MRSA: Community-acquired MRSA • HA-MRSA: Healthcare-associated MRSA • Nosocomial: infection acquired while in the hospital • SSTI: Skin and Soft Tissue Infection

9. Staphylococcus aureus • Staphylococcus aureus: • common cause of infection in the community • Lives on skin, in nose, in soil, water, dead plant material • Causes colonization or infection • Methicillin-resistant Staphylococcus aureus (MRSA): • Increasingly important cause of healthcare-associated infections since 1970s • In 1990s, emerged as cause of infection in the community

10. Antibiotic resistance in S. aureus • Penicillin, 1950 • Methicillin (= all β-lactam antibiotics), 1961 • Tetracycline, Co-trimoxazol, rifampin, clindamycin, macrolides, quinolones • Vancomycin, intermediate-R, 2000 • Vancomycin, high-level-R, 2002 • Linezolid, Daptomycin?

11. MRSA in Healthcare • Historical Risk Factors • Prolonged hospitalization • Prolonged antimicrobial use • Stay in an intensive care or burn unit • Exposure to a colonized/infected person • Residence in a nursing home • Age >65 • Common infections include surgical wound infections, urinary tract infections, bloodstream infections, and pneumonia

12. Outbreaks of MRSA in the Community • Often first detected as clusters of abscesses or “spider bites” • Various settings • Sports participants • Inmates in correctional facilities • Military recruits • Daycare attendees • Native Americans / Alaskan Natives • Men who have sex with men • Tattoo recipients • Hurricane evacuees in shelters

13. MRSA Skin and Soft Tissue Infections

14. Comparison of Invasive Disease Incidence per 100,000 Population, 2008 • Neisseriameningitidis 0.3 • Haemophilusinfluenzae 1.5 • Group B Streptococcus 7.5 • Streptococcus pneumoniae 14.5 • MRSA 29.5 http://www.cdc.gov/abcs/reports-findings/surv-reports.html

15. Infections Colonization Sites Wertheim H, et al. Lancet Infect Dis, 2005, 5: 751-762

16. MRSA Was the Most Commonly Identified Cause of Purulent SSTIs Among Adult ED Patients (EMERGEncy ID Net), 2004 to 2008 59% (98% USA300) 38% 40% 44% 53% 72% 58% 62% 57% 48% 84% 56% CID 2011:53 (15 July) Talan et al

17. MRSA Strain Characteristics Were Initially Distinct Gorwitz, R. CDC, 2007

18. Distribution of PFGE types among MRSA isolates from nosocomial bloodstream infections,Grady Memorial Hospital, 2004 Historically community-acquired Seybold U, et al. Clin Infect Dis  2006;42:647-656

19. ABC Surveillance, 2008 *Cases per 100,000 population for ABCs areas^n=151 ˜n=20; could not be classified after chart review±1351 isolates were eligible for testing up receipt to CDC, 1005 have Inferred PFGE algorithm, 13 will require direct PFGE http://www.cdc.gov/abcs/reports-findings/survreports/mrsa08.html

20. Frequent Contact Crowding Defense Offense Cleanliness Antimicrobial Use Contaminated Surfaces and Shared Items Compromised Skin Factors that Facilitate Transmission

21. Preventing Transmission in the Community • Persons with skin infections should keep wounds covered, wash hands frequently (always after touching infected skin or changing dressings), dispose of used bandages in trash, avoid sharing personal items. • Uninfected persons can minimize risk of infection by keeping cuts and scrapes clean and covered, avoiding contact with other persons’ infected skin, washing hands frequently, avoiding sharing personal items. www.cdc.gov

22. Preventing Transmission in the Community • Exclusion of patients from school, work, sports activities, etc should be reserved for those that are unable to keep the infected skin covered with a clean, dry bandage and maintain good personal hygiene. • In general, it is not necessary to close schools to “disinfect” them when MRSA infections occur. • In ambulatory care settings, use standard precautions for all patients (hand hygiene before and after contact, barriers such as gloves, gowns as appropriate for contact with wound drainage and other body fluids). www.cdc.gov

23. Role of Pets • Greatest risk of Staph aureus/MRSA exposure in most humans is other humans • When household pet animals carry MRSA, likely acquired from a human • Transmission of MRSA from an infected or colonized pet to a human is possible, but likely accounts for a very small proportion of human infections • Reasonable to consider pet as a source if transmission continues in a household despite optimizing other control strategies • Little evidence that antimicrobial-based eradication therapy is effective in pets; however, colonization tends to be short-term* Barton et al 2006;Can J Infect Dis Med Microbiol

24. Healthcare Transmission Chain Housekeeper does not adequately disinfect the chair and cabinets HCW starts dialysis on Mr. Payne with finger of glove removed Mr. Payne develops fever and sepsis next day. Mr. Payne hospitalized with MRSA sepsis. Mr. Payne dies 8 weeks later. Outpatient dialysis patient is colonized with MRSA and not treated with precautions HCW does not perform hand hygiene

25. Role of Screening and Decolonization • Pre-operative screening • High risk screening • Universal screening • Decolonization of skin • Decolonization of nose

26. Preventing Healthcare Transmission: • Standard Precautions • Hand Hygiene • Contain body fluids • Transmission Based Precautions • Contact Precautions • Gown and gloves • Appropriate use of antibiotics

27. Environmental Decontamination • Adequate surface disinfection • Validation of cleaning efficacy • New technology

28. Validating cleaning by ATP

29. PreventingHealthcareTransmission:Hand Hygiene

30. Communication • Develop and use inter-facility reporting forms • Use the network of experts in your community • Get staff and medical staff engaged in reporting Each infection discussed = Identified prevention strategies Aim for Zero preventable infections… don’t be the Cream of the Crap!

31. Education • Patients and families • Standardized hand outs • Multi-media • Staff and Medical Staff • Inservices • Just in time • Safety Fairs • Make it fun, make it memorable • Yourself • Webinars • Internet • Peers

32. Present Actionable Data Code Purple, using hall beds and semi-privates Disinfectant wipe conversion

33. Prevention • Evaluate and implement best practice regularly • Engage staff…they are smart people! • Prevention doesn’t happen in an office!

34. In Closing…