Perspectives from Inside and Outside the Health Department

1. 4th Annual Betsy Lehman Center Patient Safety Conference December 4, 2007 Perspectives from Inside and Outside the Health Department Alfred DeMaria, Jr., M.D. Massachusetts Department of Public Health

3. 1940s – 1980s “Nosocomial” Organisms

4. Public Health Patient Safety Healthcare-Associated Infections “New” Organisms Shorter LOS NOW! Out-Patient Settings Surgicenters, etc. Rehabilitation LTCF Assisted Living Home Care

6. History of Infection Control 1847 - Semmelweiss – chlorinated lime handwashing to prevent puerperal sepsis 1867 - Lister – carbolic acid to prevent wound sepsis 1870-80s - Germ Theory – Pasteur, Koch; surgical asepsis 1930-40s - First antimicrobials 1951 - Gram-negative sepsis – Waisbren; emergence of penicillin-resistant S. aureus 1950s - Hospital-acquired staphylococcal infections; development of “infection control” techniques 1963 - Founding of Infectious Diseases Society of America (IDSA) 1960s - Appearance of infection control professionals 1968 - Use of antibiotics and resistant organisms in hospitals; emergence of MRSA 1970 - First International Conference on Nosocomial Infections, CDC, Atlanta; National Nosocomial Infections Surveillance (NNIS) System 1972 - Founding of the Association for Practitioners in Infection Control (APIC) 1974 - Study on the Efficacy of Nosocomial Infection Control Project (SENIC), CDC 1976 - Joint Commission standard for surveillance and control 1978 - CDC Hospital Infections Program 1980 - Founding of Society for Healthcare Epidemiology of America (SHEA); APIC Certification in Infection Control (CIC) 1987 - Universal Blood and Body Fluid Precautions 1990 - Body Substance Isolation 1993 - Hospital Infection Control Practices Advisory Committee (HICPAC) established 1996 - Standard Precautions 2001 - Hospital Infections Program becomes Division of Health Quality Promotion 2001 - Leapfrog Hospital Quality and Safety Survey 2003 - Surgical Care Improvement Project (SCIP), HospitalCompare, CMS 2004 - IHI 100,00 Lives Campaign 2005 - Patients First, MHA

8. MRSA: Why Now? • Increase in incidence • Change in the way health care delivered • Emergence of “community-onset” MRSA infection • Controversy about infection control procedures to address MRSA • VISA, VRSA

9. History of Methicillin-Resistant Staphylococcus aureus 1959 - Methicillin introduced 1960 - Methicillin-resistant S. aureus identified with mecA gene and altered PBP2a 1968 – First documented MRSA outbreak in U.S. at Boston City Hospital >1968 – Progressive increase in prevalence and reports of nosocomial outbreaks 1980-82 – Community-acquired outbreak in Detroit 1990-96 – “Community-acquired” strains in Australia, Canada 1998-99 – Community strain outbreaks in U.S 1996-2000 – VISA 2002 - VRSA

11. Finland, NEJM, 1955

12. History of Penicillin Resistance in Staphylococcus aureus Hospital-associated Community

14. Patients Acquire Resistant Organisms • From another colonized or infected individual • By selection of resistant organisms through antibiotic exposure • From the environment

16. S. aureus ColonizationNHANES Nasal Swab Survey 2001-2 S. aureus 32% MRSA 0.8% Kuehnert et al. unpublished

17. Prevalence of MRSA as cause of SSTI in Adult ED Patients –EMERGEncy ID Net,Moran GJ, et al, SAEM 2005 59% 7/13 (54%) 11/28 (39%) 3/20 (15%) 32/58 (55%) 43/58(74%) 24/47 (51%) 17/25 (68%) 25/42 (60%) 23/32 (72%) 18/30 (60%) 46/69 (67%) MSSA 17%

19. S. aureus Oxacillin Susceptibility Trendsp<0.0001

20. Proportion of Methicillin-Resistant Staphylococcus aureus in Massachusetts Hospitals (antibiograms)

21. Proportion of Methicillin-Resistant Staphylococcus aureus in Massachusetts Hospitals (antibiograms)

22. Proportion of Methicillin-Resistant Staphylococcus aureus in Massachusetts Hospitals (antibiograms)

23. MRSA Reported in MassachusettsUnder Active Surveillance, 2001-2005Characteristics of Age and Gender Mean/Median Age: 2001 = 70.6/74.4 2005 = 62.4/67.5 Male – 54% Female – 46%

24. Costs Associated with MRSA • Causes greater than 50% of hospital -acquired Staphylococcus aureus infections • Multivariate logistic regression analysis found MRSA infection to be an independent risk factor for mortality (OR, 3.0-4.2) (Conterno, 1998) • Higher mortality associated with MRSA (49-58%) than with MSSA (20-32%) bacteremia (Romero-Vivas, 1995) • Meta-analysis with pooling with a random-effects model, OR for mortality with MRSA versus MSSA bacteremia = 1.93 [95% CI: 1.54-2.42] (Cosgrove, 2003) • Cost attributable to a MRSA infection = $35,367 (Stone, 2002) • Cost of treating MRSA infections in U.S. = $3.2-4.2 billion (Pfizer, ISPOR)

26. 2003

27. Controversy Over Control of MRSA (and VRE) in Healthcare Facilities Strict Isolationists versus Traditionalists

28. Strict Isolationists • Screen all admissions at risk of exposure with surveillance cultures • Contact precautions until proven negative • Contact isolation for colonized and infected patients • Surveillance cultures

29. Secular Trends in Antimicrobial Resistance Among S. aureus Isolates Danish HospitalsDanMap 1998

30. Traditionalists • Standard precautions all the time for every patient • Monitor incidence and prevalence of colonization/infection in clinical cultures • Set levels of prevalence/incidence that trigger response • Hierarchy of response • Contact precautions for all infected/colonized

31. Impact of Isolation for Infection ControlStelfox, et al. JAMA 2003; 290: 1899-1905

32. Issues for Debate • Data from studies with multiple interventions • Cost/benefit • Heterogeneity of hospitals and problem (does one size fit all?) • Adverse impact of isolation

33. Education *** Emphasis on hand hygiene *** Antiseptic hand washes * Contact precautions and/or gloves *** Private rooms ** Segregation of cases ** Cohorting of patients * Cohorting of staff * Change in antimicrobial use ** Surveillance cultures of patients *** Surveillance cultures of staff Environmental cultures Extra cleaning and disinfection Dedicated equipment * Decolonization Ward closure to new patients MDRO Control Measures* - *** = Increasing Level of Recommendation/Evidence