Transcript Unraveling the Mysteries

Prevention and Control of
Healthcare-Associated MethicillinResistant Staphylococcus aureus
John A. Jernigan
Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention
April 29, 2008
The findings and conclusions in this presentation/report are those of
the authors and do not necessarily represent the views of the Centers
for Disease Control and Prevention
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use.
Source: Hidron et al., abstract presentation, SHEA 2008
Most Invasive MRSA Infections Are
Healthcare-Associated
n=8,987
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In the US in 2005 there were:
– 94,360 invasive MRSA infections
– 18,650 associated deaths
14%
86%
Community-Associated
Healthcare-Associated
Source: ABCs Population-based surveillance System, Klevens et al. JAMA 2007
Why is the Emergence of MRSA as a
Healthcare Pathogen Important?
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Has emerged as one of the predominant pathogens in
healthcare-associated infections
Treatment options are limited and less effective
– higher morbidity and mortality
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High prevalence major influence on unfavorable antibiotic
prescribing, which contributes to further spread of resistance
– prevalent MRSA
more glycopeptide use
glycopeptide resistance (VRE VRSA)
linezolid/daptomycin use more resistance
more
more
Why is the Emergence of MRSA as a
Healthcare Pathogen Important?
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Adds to overall S. aureus infection burden
Represents a failure to contain transmission of drugresistant bacteria
– A marker for our ability to contain transmission of
important pathogens in the healthcare setting
– Learning how to successfully control of MRSA is likely to
have benefits that extend to other pathogens
The emergence of MRSA has been due to
transmission of relatively few clones, not de novo
selection
Hiramatsu, et al. Trends in Microbiology 2001;9:486
100%
80%
60%
A Few CA-MRSA Strains Cause Most
Community Outbreaks
Pneumonia (AL, AR, IL, MD, TX, WA)
Missouri
California
Athletes
Pennsylvania
Colorado
Mississippi
Texas
Prisoners
Georgia
Tennessee
Texas
Missouri
Children
California
USA300-114
Community
USA100
Hospital Strain
Hospital Strain
USA200
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
Key Prevention Strategies
Clinicians hold the solution!

Prevent infection
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Diagnose and treat infection
effectively

Use antimicrobials wisely
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Prevent transmission
Source: Burton et al., abstract presentation, SHEA 2008
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
Key Prevention Strategies
Clinicians hold the solution!

Prevent infection

Diagnose and treat infection
effectively

Use antimicrobials wisely

Prevent transmission
Preventing transmission is an
important part of MRSA control
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Entire healthcare-associated MRSA problem caused by
spread of a few clones
Preventing widespread colonization minimizes circulating
pool of resistance genes that can contribute to cycle of
increasing multi-drug resistance (e.g. VRSA is likely a
product of widespread colonization with VRE and MRSA)
Improving antibiograms helps ease pressure for broad
spectrum antibiotic use and preserves effectiveness of
preferred antimicrobial agents
Preventing colonization helps prevent infections
– Including those that might happen post-discharge (newly
colonized patients have up to 30% risk of infection in the
ensuing year)
Most Healthcare-Associated Invasive MRSA
Infections Have Their Onset Outside of the
Hospital
28%
14%
59%
Community-Associated
Healthcare-Associated (community-onset)
Healthcare-Associated (hospital-onset)
Source: ABCs Population-based surveillance System, Klevens et al. JAMA 2007
Regional Spheres of Influence Within
Spectrum of Inpatient Care
Nursing
Home 1
NH 2
Hospital A
Hospital B
Nursing
Home 4
Nursing
Home 3
Hospital c
Predicted Number of EMRSA-15 Outbreaks
During 1993-98, United Kingdom
900
800
700
600
500
30% Duration
400
300
200
30% transmission
100
30%both
20%
40%
60%
80%
100%
% of Facilities Implementing Intervention
Source: Austin JID 1999;179:883
How best to prevent MRSA
Transmission in Healthcare Settings?
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Controversial subject
– standard precautions versus standard
plus barrier (i.e. contact precautions)?
– Should contact precautions be used
only on those identified by clinical
cultures?
• Due to “iceberg effect”, many
colonized patients unrecognized base
on clinical cultures alone
• Should active surveillance be used to
identify carriers?
– If so, in what settings?
HICPAC Guidance On Management of
Multidrug-Resistant Organisms (MDROs) in
Healthcare Settings
First Tier: General Recommendations For All
Acute Care Settings
If endemic rates not decreasing, or
if first case of important organism
Second Tier: Intensified Interventions
HICPAC MDRO Guidance (acute care)
First Tier: General Recommendations For All
Acute Care Settings
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Administrative engagement
– Make MDRO prevention and control an organizational patient safety
priority
– Implement a multidisciplinary process to monitor and improve
healthcare personnel (HCP) adherence to recommended practices
– feedback on facility and patient-care unit trends in MDRO incidence
and adherence measure
Education and training of personnel
Judicious use of antimicrobial agents
Standard precautions for all patients
Contact Precautions for patients known to be infected or colonized
(masks not routinely recommended)
Monitoring of trends over time to determine whether additional
interventions are needed
HICPAC MDRO Guidance (acute care)
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Indications for moving to second tier
– First case or outbreak of an epidemiologically
important MDRO
– When endemic rates of a target MDRO are not
decreasing despite implementation of and correct
adherence to the first tier measures
HICPAC MDRO Guidance (acute care)
Second Tier: Intensified Interventions For
Acute Care Settings
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Active surveillance cultures from patients in populations at risk at the time of
admission to high-risk area, and at periodic intervals as needed to asses
transmission.
– Contact Precautions until surveillance culture known to be negative
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Additional recommendations for intensifying:
–
–
–
–
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administrative engagement/correction of systems failures
Education and training of personnel/adherence monitoring
Judicious use of antimicrobial agents
monitoring of trends
Cohorting of staff to the care of MDRO patients only
Enhanced environmental measures
Consult with experts on case-by-case basis regarding use of decolonization
therapy for patients or staff
If transmission continues despite full implementation of above, stop new
admissions to the unit.
MDRO and CDAD Module
Multidrug-Resistant Organism (MDRO) and
Clostridium difficile-Associated Disease (CDAD) Module
MDRO and CDAD Module
Organisms Monitored:
-Methicillin-Resistant Staphylococcus aureus (MRSA)
(option w/ Methicillin-Sensitive S. aureus (MSSA)
-Vancomycin-Resistant Enterococcus spp. (VRE)
-Multidrug-Resistant (MDR) Klebsiella spp.
-Multidrug-Resistant (MDR) Acinetobacter spp.
-Clostridium difficile-Associated Disease (CDAD)
Protocol available online at:
http://www.cdc.gov/ncidod/dhqp/nhsn_MDRO_CDAD.html
Goal of the
MDRO and CDAD Module

Provide a mechanism for healthcare facilities to
report and analyze data that will inform
infection control staff of the impact of targeted
prevention efforts
MDRO and CDAD Module
Reporting Requirements and Options Include:
Required:
-Infection Surveillance (not required for CDAD)
Optional:
-Proxy Infection Measures:
-Laboratory-Identified (LabID) Event
-Prevention Process Measures:
-Monitoring Adherence to Hand Hygiene
-Monitoring Adherence to Gown and Gloves Use
-Monitoring Adherence to Active Surveillance Testing
-Active Surveillance Testing (AST) Outcome Measures
NHSN MRSA Metrics
Metric
Description
Calculation
Comment
1
Nosocomial MRSA Infection Rate
# NHSN MRSA
infections/1000 pt-days
By selected patient-care location only
(i.e., MICU, SICU, etc.); uses NHSN
criteria to define infections
2
Incidence Rate of Hospital-Onset
MRSA Based on Clinical Cultures
# 1st MRSA specimens /1000
pt-days
3a
Incidence Rate of Hospital-Onset
MRSA Bloodstream Infections (BSI)
Based on Clinical Cultures
# MRSA BSI specimens
/1000 pt-days
Hospital-wide is easiest, can also restrict
to selected locations; evaluating same
locations as Metric 1 may be most useful;
uses positive culture data only
3b
Admission Prevalence MRSA BSI
Rate (community-onset infections)
# MRSA BSI specimens
/1000 admissions
4
Direct MRSA Acquisition
# new MRSA cultures /1000
pt-days
Requires data from active surveillance
testing (AST) program; selected locations
only
5
Adherence to Process Measures
Compliance Rate
Requires data from observational
assessment and/or from AST program;
selected locations only
6
Central Line-Associated Bloodstream
Infections (CLABSI) (all pathogens)
# CLABSI/1000 line days
By selected locations only; requires
following the Device-Associated
Module-CLABSI protocol
Opportunities for MRSA Prevention
Research
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Impact of focusing on high risk units
Use of topical antimicrobials/antiseptics for eradicating or suppressing S.
aureus colonization
– Chlorhexidine bathing of patients (targeted to colonized patients
versus high-risk groups)
– Use of topical antibioitics for decolonization (e.g. mupirocin)
Risk factors for healthcare-associated, community-onset (HACO) MRSA
Impact of hospital-based prevention programs on HACO
Use of mathematical modeling to understanding inter-facility transmission
dynamics and implications for prevention
Novel techniques for changing organization culture as a means to
improve adherence
Conclusions
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The burden of MRSA remains high in US healthcare settings
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Community-associated MRSA (CA-MRSA) infections are emerging
rapidly in many areas, but population-based estimates suggest that most
MRSA infections are healthcare-associated
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Epidemic strains of MRSA originally associated with the community have
emerged as important causes of hospital-acquired infections
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MRSA infections and transmission can be prevented, even in endemic
settings in the US
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Effective control programs must be multifaceted, and broad institutional
commitment, including measurement of impact, is required for successful
implementation
Acknowledgments
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Rachel Gorwitz
Kate Ellingson
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David Kleinbaum
Val Gebski
Jonathan Edwards
Pei-Jean Chang
Alexander Kallen
Scott Fridkin
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Monina Klevens
Jeff Hageman
Fred Tenover
Melissa Morrison
Teresa Horan
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Robert Muder
Rajiv Jain
The Active Bacterial Core
Surveillance
Investigators/Teams
Dawn Sievert
Deron Burton
Alicia Hidron
Dan Pollock

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