PATIENTS

C DIFF

MRSA

Moving from Infection Controlto Infection Prevention:

A Journey through MRSA

Joan M. Ivaska, BS, MPH, CIC

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

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

Patient

Rehabilitation

Home Care

Surgery Center

HospitalLong Term Care

Dialysis

Physician Office

Staff/ Medical Staff

Visitors and Family

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

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

A Tale of Two Cows

Adapted from Daniel Saman, DrPH, MPH, CPH, HealthWatchUSA.com,2012.

Definitions

• CA-MRSA: Community-acquired MRSA• HA-MRSA: Healthcare-associated MRSA• Nosocomial: infection acquired while in the

hospital• SSTI: Skin and Soft Tissue Infection

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

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?

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

Outbreaks of MRSA in the Community

• Often first detected as clusters ofabscesses 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

MRSA Skin andSoft Tissue Infections

Comparison of Invasive Disease Incidence per 100,000 Population, 2008

• Neisseria meningitidis 0.3• Haemophilus influenzae 1.5• Group B Streptococcus 7.5• Streptococcus pneumoniae 14.5• MRSA 29.5

http://www.cdc.gov/abcs/reports-findings/surv-reports.html

Colonization Sites

Wertheim H, et al. Lancet Infect Dis, 2005, 5: 751-762

Infections

38%

58%

48%57%

56%

72%

40%

44%

53%

62%

84%

59%(98% USA300)

MRSA Was the Most Commonly Identified Cause of Purulent SSTIs Among Adult ED Patients

(EMERGEncy ID Net), 2004 to 2008

CID 2011:53 (15 July) Talan et al

MRSA Strain Characteristics Were Initially Distinct

MRSA in Healthcare

MRSA in the Community

Prevalent genotypes (U.S.) USA100, USA200

USA300, USA400

Antimicrobial resistance Multiple agents

Few agents

SCCmec (genetic element carrying mecA resistance gene)

Types I-III Types IV, V

PVL toxin gene Rare CommonGorwitz, R. CDC, 2007

Distribution of PFGE types among MRSA isolates from nosocomial bloodstream infections,

Grady Memorial Hospital, 2004

PFGE type

No. (%) of

nosocomial cases(n = 49)

USA300 10 (20)USA100 21 (43)USA500 18 (37)USA800 0 (0)

Seybold U, et al. Clin Infect Dis  2006;42:647-656

Historically community-acquired

ABC Surveillance, 2008MRSA Class

No. (Rate*)Cases^

No. (Rate*)Deaths˜

Inferred PFGE Type (N,%)Tot N±

Inferred PFGE Type (N,%)USA100±

Inferred PFGE Type (N,%)USA300±

HO 1276 (6.7) 304 (1.6) 247 177 (71.7)

48 (19.4)

HACO 3203 (16.8) 481 (2.5) 585 363 (62.1)

157 (26.8)

CA 929 (4.9) 91 (0.5) 151 46 (30.5) 103 (68.2)

*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

Factors that Facilitate Transmission

Cleanliness

Contaminated Surfacesand Shared Items

Frequent ContactCrowding

Compromised Skin

Antimicrobial Use

Preventing Transmissionin 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

Preventing Transmissionin 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

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

Healthcare Transmission Chain

Outpatient dialysis patient is colonizedwith MRSA and not

treated with precautions

Housekeeper does not adequatelydisinfect 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.

HCW does not performhand hygiene

Role of Screeningand Decolonization

• Pre-operative screening• High risk screening• Universal screening• Decolonization of skin• Decolonization of nose

Preventing Healthcare Transmission:

• Standard Precautions– Hand Hygiene– Contain body fluids

• Transmission Based Precautions– Contact Precautions

• Gown and gloves• Appropriate use of antibiotics

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

Validating cleaning by ATP

PreventingHealthcare

Transmission:Hand Hygiene

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!

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

Present Actionable Data

Code Purple, using hall beds and semi-privates

Disinfectant wipe conversion

Prevention

»Evaluate and implement best practice regularly

»Engage staff…they are smart people!

»Prevention doesn’t happen in an office!

In Closing…