Transcript Efficacy of MRSA Prescreening and Eradication: New England

1st European S. aureus &
Surgical Site Infection
Round Table
MRSA Prescreening and Elimination:
New England Baptist Hospital
Experience
Vienna, Austria
March 5th
Maureen Spencer, M.Ed., RN, CIC
Infection Preventionist Consultant
Boston, MA
www.workingtowardzero.com
www.7sbundle.com
Move on and Improve
1st European S. aureus &
Surgical Site Infection
Round Table
New England Baptist Hospital
• 150-bed adult medical/surgical
hospital located in Mission Hill
area of Boston
• Orthopedic subspecialty
hospital Acute inpatient discharges:
• 75% Orthopedic
• 8% General Surgery
• 17% Medical
• Orthopedic Surgery ~
12,000/cases a year
• 4500 total joints
• 3500 spine cases
• 4000 general and outpatient
Anonymous Nasal Culture Study
February 2006
133 anonymous nares cultures after patient
anesthetized
Results:
38 – S. aureus
(29%)
*5 - MRSA
( 4%)
•all previously undiagnosed
*no precautions used in OR, PACU or
nursing units
*Cefazolin used for antibiotic prophylaxis
Screening Proposals

February 2006 – prepared three
screening proposals with costs
1) Traditional nasal cultures - 3 day results
$245,000.00
2) Purchase rapid PCR equipment
$337,338.00
3) Lease rapid PCR equipment
$259,990.00

March 2006 –Board approval of
equipment purchase
Implementation – 8 Months

March – October 2006
– Weekly meetings:
 surgical services, infection control, micro,
administration, & medical staff members
– July 2006 – letter to surgeons
– July 17, 2006 – initiated pilot on Spine Service
– August 2006 – letter to medical staff
– September 2006 – initiated universal pre-op
screening program for all inpatient surgery
Policy & Procedure

Protocol developed for all departments & units
affected
–
–
–
–
–
–
–
–
–
OR Scheduling
Patient Access
Prescreening Unit
Pre-surgical unit
Operating Room
PACU
Nursing Units
Microbiology Lab
Ancillary Departments: Housekeeping, Central Transport,
Radiology, etc.
Preadmission Preoperative
Screening Program Instituted

Nasal swabs during prescreening
process

Microbiology Laboratory PCR detects
presence of bacteria-specific DNA
– Cepheid GeneXpert

Topical decolonization protocol for
patients found to be carriers of S.
aureus or MRSA
Decolonization Protocol







Intranasal 2% mupirocin ointment
BID x 5 days
Pre-op shower with 2% chlorhexidine
daily x 5 days
Patients called by preadmission
testing to initiate treatment protocol
Repeat call to document compliance
MRSA carriers re-screened prior to
surgery
Contact precautions if 2nd MRSA
screen positive
Vancomycin for surgical prophylaxis
for patients with history of MRSA
carrier status
9
NEBH Program Budget
First year (2006) cost ~$400,000
~$100,000 for 2 full-time positions:
•Microbiologist & PASU Medical Technician
~$60,000 PCR rapid test equipment
~Lab cost for PCR ~$40.00/test
(compared to routine culture ~ $20.00)
~ 6,000 inpatient surgeries = $240,000
Intangible Benefits



S. aureus/MRSA prescreening & decolonization
program viewed as positive pro-active infection
control measure by staff, patients, family
members & media
Allows additional patient education on importance
of hand hygiene, prevention of SSI, infection
control measures in home to reduce transmission
of MRSA & S. aureus
Allows for adjustment of surgical prophylaxis to
Vancomycin for MRSA patients
12
Polymerase Chain Reaction (PCR) for Nasal
Screens – Lab Challenges
• Instructing nursing staff on
how to obtain nares specimen
with proper swabs
• Lab differentiation of the
colonized screens from routine
cultures.
• Molecular lab in a short time
frame with Cepheid’s
GeneXpert System
• Reporting system for positive
results to prescreening,
operating room, postanesthesia unit, infection
control
Easy workflow in less than 1 minute
3 Simple steps
1
2
Results in One Hour
14
3
Institutional Prescreening for Detection and Elimination of
Methicillin Resistant Staphylococcus aureus in Patients
Undergoing Elective Orthopaedic Surgery
Control Period
10/2005-6/2006
Study Period
6/2006-9/2007
5293
7019
MRSA Infection
10 (0.18%)
4 (0.06%)
0.0315
MSSA Infection
14 (0.26%)
9 (0.13%)
0.0937
Total SSIs
24 (0.45%)
13 (0.18%)
0.0093
N
p value
Kim DH, Spencer M, Davidson SM, et al. J Bone Joint Surg Am 2010;92:1820-1826
50% Reduction in MSSA SSI
60% Reduction in MRSA SSI
MRSA SSI Rate
MSSA SSI Rate
0.3
0.25
0.26%
0.2
0.18%
0.15
0.13%
0.1
0.06%
0.05
0
1
10/01/05-07/16/06
07/17/06-09/30/07
2
10/01/05-07/16/06
07/17/06-09/30/07
SSIs– Increased Risk with MRSA
1.21%
1.4
1.2
1
0.8
0.6
0.4
0.19%
0.2
0
Staph aureus
MRSA
• MRSA colonized patients had an increased risk of SSI
• Seven (7) Staph aureus infections in 2712 positives
• Seven (7) MRSA infections in the 576 positives
• Statistically significant difference
0.19%
1.21%
p=<.05
17
Pre-op MRSA and S. aureus Decolonization
• Results:
• Timeframe:
July 17, 2006 through September 2010
• Colonization:
20,065 patient screened
5,988 (23%)
1,027 ( 4%)
• Decolonization:
positive for Staph aureus
positive for MRSA
Repeat nasal screens on MRSA patients
revealed 77% elimination
18
Pre-op MRSA and S. aureus Infections
• Results: % MRSA and S. aureus SSI
Time Period
FY06
10/01/05-07/16/06*
Inpatient
Surgeries
# of Surgical
Infections
%MRSA/MSSA
5,293*
24*
0.45%*
*Historical Controls
FY07
07/17/06-09/30/07
7,019
13
0.18%
FY08
10/01/07-09/30/08
6,323
7
0.11%
FY09
10/01/08-09/30/09
6,364
11
0.17%
FY10
10/01/10-09/30/10
6,437
6
0.09%
19
Pre-op MRSA Infections
• Results: % MRSA SSI in Screened Patients
Inpatient
Surgeries
# MRSA
SSIs
MRSA%
#Infect/#MRSA
+
FY06
10/01/05-07/16/06
5,293
10 (NA)
0.19%
NA
FY07
07/17/06-09/30/07
7,019
3 (3+)
0.04%
3/309 (0.97%)
FY08
10/01/07-09/30/08
6,245
4 (2+)
0.06%
2/242 (0.83%)
FY09
10/01/08-09/30/09
6,336
6* (2+)
0.09%
2/234 (0.85%)
FY10
10/01/10-09/30/10
6,437
1 (1+)
0.01%
1/266 (0.37%)
Time Period
* 5 of the 6 available isolates sent for pulse field gel electrophoresis
None were related genetically
20
(historical controls)
Pre-op Staph aureus Infections
• Results: % S. aureus (MSSA) SSI in Screened Patients
Inpatient
Surgeries
# MSSA
SSIs
MSSA%
#Infect/#MSSA+
FY06
10/01/05-07/16/06
5,293
14 (NA)
0.26%
NA
FY07
07/17/06-09/30/07
7,019
3 (3+)
0.04%
3/1588
(0.19%)
FY08
10/01/07-09/30/08
6,245
3 (1+)
0.05%
1/ 1422
(0.07%)
FY09
10/01/08-09/30/09
6,336
5 (1+)
0.08%
3/1403
(0.21%)
FY10
10/01/10-09/30/10
6,437
6 (1+)
0.09%
1/1450
(0.06%)
Time Period
21
Other Studies Supporting MRSA
Screening and Decolonization
Mupirocin Resistance in UK
• In UK – Department of Health policy is active
MRSA surveillance and isolate positives
• 2011-2012 Retrospective review of 49.177
cases of MRSA + nasal screens
• Approximately 12.2% resistance and 29.7%
resistance to Neomycin
• Recommended treatment for resistant carriers
would be chlorhexidine/neomycin (Napseptin) or
for neomycin resistant strains use a
polyhexamethylene biguanide (Prontoderm)
• Paper presented at ECCMID 2012
Mupirocin Resistance
• Mupirocin resistance and methicillin-resistant Staphylococcus aureus
(MRSA). J Hosp Infect. 1997 Jan;35(1):1-8.
• Emergence of high-level mupirocin resistance in methicillin-resistant
Staphylococcus aureus isolated from Brazilian university hospitals.
Infect Control Hosp Epidemiol. 1996 Dec;17(12):813-6
• Emergence and spread of low-level mupirocin resistance in methicillinresistant Staphylococcus aureus isolated from a community hospital
in Japan. J Hosp Infect. 2001 Apr;47(4):294-300.
• Molecular fingerprinting of mupirocin-resistant methicillin-resistant
Staphylococcus aureus from a burn unit. Int J Infect Dis. 1998-1999
Winter;3(2):82-7
• The spread of a mupirocin-resistant/methicillin-resistant
Staphylococcus aureus clone in Kuwait hospitals. Acta Trop. 2001 Oct
22;80(2):155-61.
• The antimicrobial activity of mupirocin--an update on resistance. J
Hosp Infect 1991 Sep;19 Suppl B:19-25.
Conclusion:




Program for comprehensive prescreening/treatment of
S. aureus & MRSA prior to elective surgery is readily
established & well-received
Program allows early identification of colonized
patients, treatment, & adjustment of antibiotic
prophylaxis, early isolation & contact precautions for
MRSA
Associated with significant reduction in infections due
to S. aureus & MRSA
Rapid on demand screening with GeneXpert is a big
advantage to implement a decolonization program, and
a valuable investment as the system is scalable with an
extended menu of tests available
Thank You