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HEALTHCARE-ASSOCIATED MRSA Emerging Problems Clinical Patterns Strategies for Control

HEALTHCARE-ASSOCIATED MRSA Emerging Problems Clinical Patterns Strategies for Control. Ed Septimus, MD, FACP, FIDSA, FSHEA eseptimus@tmhs.org. Emerging Problems with S. aureus. Increasing proportion of healthcare-associated S. aureus infections due to MRSA.

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HEALTHCARE-ASSOCIATED MRSA Emerging Problems Clinical Patterns Strategies for Control

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  1. HEALTHCARE-ASSOCIATEDMRSAEmerging ProblemsClinical PatternsStrategies for Control Ed Septimus, MD, FACP, FIDSA, FSHEA eseptimus@tmhs.org

  2. Emerging Problems with S. aureus Increasing proportion of healthcare-associated S. aureus infections due to MRSA. Increasing prevalence of MRSA among community onset infections leading introduction into the healthcare system. Reports of S. aureus strains with reduced susceptibility to vancomycin (VISA) and VRSA ~30% of newly acquired MRSA carriers develop invasive disease which can be more severe

  3. How often do colonized patients lead to infection? • 19% of patients colonized with MRSA at admission develop an infection1 • For patients that acquire MRSA within the hospital, 25% develop an infection1 • 29% of MRSA positive patients became infected within 18 months2 • 3.95 MRSA infections estimated per 1000 discharges3 • 0.8 MRSA infections estimated per 1000 patient days4 1. Davis KA et.al. CID 2004;39:776-82 2. Huang & Platt, CID 2003;36:281 3. Kuehnert MJ et.al. EID 2005;11:868-72 4. Cooper BS et.al. Health Technol Assess. 2003;7(39):1-194

  4. Emerging Problems-continued Increasing resistance to mupirocin. Frequent failure of decolonization protocols. Decreased efficacy of vancomycin for the treatment of serious MRSA infections compared with an anti- staphylococcal penicillin for MSSA. Isolation of linezolid resistant isolates of MRSA and decreased susceptibility to daptomycin

  5. Hospitalization and Deaths Caused by MRSAUS 1999-2005Emerg Infect Dis 2007; 13:1840

  6. Hospitalization and Deaths Caused by MRSAUS 1999-2005Emerg Infect Dis 2007; 13:1840

  7. Incidence of Invasive CA-MRSA Infections and Deaths by AgeActive Bacterial Core surveillance (ABCS), 2005 Incidence per 100,000 persons Overall Incidence (all ages): Infections: 31.8 per 100,000 Deaths: 6.3 per 100,000 Klevens et al JAMA 2007;298:1763-71

  8. ID Rates • Invasive MRSA 31.8/100,000 people • Invasive pneumococcal disease 14.1/100,000 people • Invasive group A strep 3.6/100,000 people • Invasive meningococcal disease 0.35/100,000 people

  9. APIC National MRSA Inpatient SurveyAJIC 2007; 35:631

  10. Infections Due to Community- and Healthcare-Associated MRSA Prevalence of MRSA increasing in hospitals and in the community1 1. McDonald LC. Clin Infect Dis. 2006;42:S65-S71. 2. Naimi TS, et al. JAMA. 2003;290:2976-2984.

  11. 25 25 140 120 20 20 100 15 15 80 Patients (%) Patients (%) $1000 60 10 10 40 5 5 20 0 0 0 Mortality Mortality Mean Charges Substantial mortality and costs associated with surgical site infections caused by MRSA Adverse Outcomes Associated With MRSA Infection MRSA MSSA (n = 121) (n = 165) 25 140 b c a 120 20 100 15 80 $1000 Days 60 10 40 5 20 0 0 Mean Length of Stay Mean Charges a OR = 3.4 P = .003; b ME = 1.2, P = .11; c ME = 1.2 P = .03. OR = odds ratio; ME = multiplicative effect. Kaye K, et al. Emerg Infect Dis. 2004;10:1125-1128.

  12. Healthcare-Associated Community-Associated Most Invasive MRSA Infections Are Healthcare-Associated 86% 14% Klevens et al JAMA 2007;298:1763-71

  13. Classification of Invasive MRSA Infections ClassificationDefinition Health care-associated Cases with at least 1 of the following risk community-onset (HCA)factors: (1) presence of an invasive device on admit; (2) history of MRSA infection or colonization; (3) hx of surgery, hosp, dialysis, or residence of LTC in previous 12 months preceding culture Hospital-onset (HOI)Cases with positive culture result from a normally sterile site obtained >48 h after hospital admit. Cases may also have ≥1 of the community-onset risks Community-associated (CAI)Cases with no documented community-onset health care risk factor

  14. Invasive MRSAJAMA 2007; 298:1763

  15. Distinction Between CA-MRSAand HA-MRSA Is Blurring CA-MRSA strains are emerging in the healthcare setting, while HA-MRSA strains are moving out into the community Klevens RM, et al. Emerg Infect Dis. 2006;12:1991-1993.

  16. MRSA transmission between patients and employees depends on the frequency and duration of exposure to MRSA-positive patients and infection control measures employed Transmission of MRSA from colonized HCWs to their households was documented in 4 of 10 families investigated Carriage of MRSA among Hospital Employees: Prevalence, Duration, and Transmission to HouseholdsInfect Control Hosp Epidemiol 2004; 25:114

  17. Hospital or Acute care setting Home care Outpatient facility Long-term-care facility The Landscape of Healthcare-Associated (HCA) Infections • Healthcare system is evolving to an increased use of outpatient procedures and long-term care • Many long-term-care facilities now experience infection rates comparable to those in acute hospital settings • Outbreaks are common • High rates of colonization with resistant strains Nicolle LE. Clin Infect Dis. 2000;31:752-756.

  18. Epidemiology MRSA Reservoirs Humans are the natural reservoirs for S. aureus. 20-50 % of healthy adults are colonized with S. aureus, and 10-20% are persistent carriers. Colonization rates are highest among patients with type 1 diabetes, IV drug users, hemodialysis, dermatologic conditions, and AIDS. Colonized and infected patients are the major reservoir of MRSA.

  19. Where is the reservoir for MRSA? • ~10,000 participants in the US, 2001–2002 Natl. Health and Nutrition Examination Survey • 32.4% colonized with S. aureus = 89.4 million • 0.8% colonized with MRSA = 2.3 million 1 • 9.2% of 500 healthy children screened in 2004 were colonized 1. Creech et al. J Inf Dis 2006;193:169-71

  20. Role of Nasal Carriage inS. aureus InfectionsLancet Infect Dis 2005; 5:751

  21. Frequency of MRSA Colonization at Various Body Sites 13-25% 40% 30-39% Hill RLR et al. J Antimicrob Chemother 1988;22:377 Sanford MD et al. Clin Infect Dis 1994;19:1123

  22. Evaluation of a Strategy of Screening Multiple Anatomic Sites for MRSA at Admission to a Teaching HospitalInfect Control Hosp Epidemiol 2006; 27:181-184 Site% Positive Nares 73 Rectum 47 Axilla 25 Nares+Axilla 83 Nares+Rectum 91

  23. Epidemiology MRSA-continued MRSA has been isolated from environmental surfaces, and can be implicated in transmission Risk Factors-MRSA Hospitalization Greater than 65 years of age Invasive procedures Open wounds Certain underlying diseases (e.g. DM) Prior antibiotics

  24. MRSA/MSSA Risk after Levofloxacin and Ciprofloxacin Exposure Odds ratio Odds ratios from multivariable analysis Levofloxacin Ciprofloxacin P =0.005 P < 0.0001 Weber et al. Emerg Infect Dis. 2003;9:1415-1422.

  25. PREVENTION OF TRANSMISSION OF MRSA

  26. Reasons Infection Control Measures Have Failed to Control Spread of MRSA • Failure to perform active surveillance (iceberg effect) • Barrier precautions alone did not address reservoirs and modes of transmission of MRSA • Poor adherence to HCWs to barrier precautions and hand washing • Increasing importation of MRSA by patients admitted from extended-care facilities or to other acute care facilities and the community • Inadequate antimicrobial stewardship • Inadequate environmental cleaning

  27. How is the reservoir for MRSA identified? Clinical microbiology cultures capture “the tip of the iceberg” • 75-85% of the MRSA reservoir goes unidentified by clinical cultures alone1 • Colonized patients, not just infected patients, lead to transmission of MRSA2 1. Sources: Eveillard M et.al., J Hosp Infect 2005;59:254 & Salgado CD et.al., SHEA 2003 abstract 28, p.61 2. Bhalla A et.al. Infect Control Hosp Epidemiol 2004;25:164

  28. Role of the Environment: Colonized vs. Infected • Environmental contamination of patient rooms is the same whether the patient is colonized or infected (~ 70%) • Contaminated surfaces include patient’s gowns, floor, bed linens, blood pressure cuffs, overbed tables, etc. Boyce, ICHE 1997; 18:622 Reisner et al., ICHE 2000; 21:775

  29. Importance of the environment in MRSA acquisition: the case for hospital cleaningLancet Infect Dis online Oct 31, 2007

  30. Survival of MRSA/VRE in the Environment • Duration of survival of MRSA in dry conditions • Plastic charts = 11 days • Laminated tabletop = 12 days • Cloth curtains = 9 days • Environmental survival of VRE • 50% survival at 7 days on upholstery, furniture and wall coverings • VRE could be transferred easily by touching contaminated surfaces Huang et al., Infect Control Hosp Epidemiol 2006; 27:1267-69 Lankford et al., Am J Infect Control 2006; 34: 258-63

  31. Isolation Gowns • 65% of HCW’s contaminated their uniforms or gowns during routine care of patients with MRSA • > 25% of the time, HCW’s clean hands became recontaminated after contact with their contaminated clothing • Gowns prevented contamination of clothing underneath the gown Boyce, Infect Control Hosp Epidemiol 1997; 18:622. Boyce, SHEA 1998, Abstract #S74

  32. Risk of Acquiring Antibiotic-Resistant Bacteria From Prior Room OccupantsArch Intern Med 2006;166:1945 • Twenty-month retrospective cohort study of patients admitted to the ICU performing routine admission and weekly screening for MRSA and VRE • Among patients whose prior room occupant was MRSA positive, 3.9% acquired MRSA compared with 2.9% of patients whose prior room occupant was MRSA negative (OR 1.4; P=.04) • The environment overall was considered a contributor to overall transmission

  33. Percent MRSA Among All Nosocomial Infections 1975 to 1997, by Hospital Bed Size* Contact Precautions Body Substance Isolation Contact Isolation *Adapted from: National Nosocomial Infection Surveillance (NNIS) System

  34. Percent Handwashing Compliance among HCWsin 34 Observational Studies, 1981-2000 Median

  35. Infect Control Hosp Epidemiol 2006;27:245

  36. Hand Hygiene Does Work!

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