mrsa in africa
DESCRIPTION
Infection control and MRSA. Comparison of European strategies and possible solutions for AfricaTRANSCRIPT
MRSA in Africa November 2012
Anderas Voss, MD, PhD 1
Andreas Voss iPrevent
UMCN & CWZ Nijmegen, The Netherlands
hFp://data.worldbank.org (access on 7-‐11-‐2012)
¤ One of the first cases reported in the conSnent was in S. Africa in 1978.
¤ In Sudan, MRSA was first reported in 1999
¤ Madagascar did not report cases of MRSA unSl the 21st century
¤ The prevalence in Africa ranged from 5% to 45%.
Thesis by Nirma D. Bustamante (2011)
South Afr J Epidemiol Infect 2011;26(4)(Part II):243-‐250
MRSA in Africa November 2012
Anderas Voss, MD, PhD 2
South Afr J Epidemiol Infect 2011;26(4)(Part II):243-‐250 Breurec et al. CMI 2011;17:160-‐65
Breurec et al. CMI 2011;17:160-‐65
HA-‐MRSA (Brazilian/Hungarian clone) (40%)
HA-‐MRSA (Belgium, Portugal, SWE) (28%) HA-‐ & CA-‐MRSA) (21%)
¤ E-‐MRSA ¤ HA-‐MRSA (HO-‐CA-‐MRSA, HO-‐LA-‐MRSA) ¤ CA-‐MRSA (CO-‐HA-‐MRSA, CO-‐LA-‐MRSA) ¤ LA-‐MRSA
The only type I am interested in: ¤ IDCWYCI-‐JTMHTFI-‐MRSA*
* I Don’t Care What You Call It – Just Tell Me How To Fix It – MRSA (ScoF Weese)
¤ The Netherlands as an example of how low prevalence countries can do it…
¤ “Search & destroy” strategy
MRSA in Africa November 2012
Anderas Voss, MD, PhD 3
¤ Search & Destroy (Control) strategy to avoid introducSon of MRSA into health-‐care senngs and reduce the chance of transmission: ² NaSonal MRSA guidelines (www.WIP.nl) ² NaSonal detecSon methods (NVMM) ² Use fast and reliable detecSon methods
¤ IsolaSon and screening of risk-‐paSents on admission
² at all Smes
² colonized and infected paSents
¤ DecolonizaSon of MRSA carriers
¤ Consequent acSons when transmissions occur
² screening of all paSents and HCWs at risk
² MRSA-‐posiSve HCWs not allowed to work
¤ Placement in isolaSon room
² with anteroom and negaSve pressure
¤ Gloves, gowns and face-‐masks
² for all entering the room
¤ Handhygiene
¤ AnSmcrobial stewardship
¤ IsolaSon and screening of risk-‐paSents on admission ² can’t determine paSents at risk ² only certain departments!
² not when too busy/weekends ² only infected paSents
¤ No decolonizaSon of MRSA carriers ¤ Consequent acSons when transmissions occur
² screening of all paSents but not HCWs à consequently MRSA-‐posiSve HCWs may conSnue to spread
MRSA in Africa November 2012
Anderas Voss, MD, PhD 4
0
10
20
30
40
50
60
70
80
IS (5
7)
NO
(522
)
SE (1
770)
DK
(978
)
NL
(140
1)
FI (6
79)
SI (3
10)
LV (1
38)
EE (1
23)
AT
(100
2)
CZ
(128
9)
BG
(137
)
PL (1
89)
DE
(991
)
LU (8
1)
HU
(857
)
BE
(917
)
ES (1
303)
FR (2
855)
RO
(79)
IL (4
58)
IT (1
119)
TR (8
27)
UK
(280
3)
HR
(329
)
IE (1
041)
GR
(541
)
CY
(54)
PT (8
36)
MT
(92)
199919991999200019991999200020042001200020002000200119991999200119992000200120022001199920031999200119991999200319992000
Country code (average number of isolates reported per year) & year of start surveillance#
% M
RSA
199920002001200220032004200520062007
*
*
*
*
*
EARSS report, October 2008
0
200400
600
8001000
1200
1400
16001800
2000
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2005 2006 2007 2008 2009
Counts of MRSA bacteraemia
Yea
r and
qua
rter
* DATA ARE PROVISIONAL NOT FOR WIDER CIRCULATIONCourtesy: A. Pearson (HPA, Sept 2009)
MRSA BSI episodes
MRSA bacteremia in Europe
Source: EARSS report
V. Jarlier et al. Arch Intern Med 2010
¤ IsolaSon IntervenSons ¤ PromoSon of Hand Hygiene ¤ IdenSficaSon of paSents with MRSA infecSons or colonizaSons
¤ Feedback ¤ Annual reports
MRSA in Africa November 2012
Anderas Voss, MD, PhD 5
IsolaSon IntervenSons ¤ Placement of paSents with MRSA infecSons or colonizaSons in single-‐bed rooms whenever possible
¤ Barrier precauSons for paSents with MRSA infecSons or colonizaSons such as: ² disposable gloves worn before and discarded arer paSent contact
² disposable aprons worn for extensive contacts (eg, bed making)
² small equipment (eg, stethoscope) dedicated to the paSent.
Should we ask universal precauSons ?
PromoSon of Hand Hygiene
¤ Hand washing with disinfectant soap arer contact with paSents with MRSA infecSons or colonizaSons before leaving the room
¤ An insStuSonal campaign for promoSng the use of alcohol-‐based hand-‐rub soluSons in place of hand washing ² launched in 2001 ² Training materials to the infecSon control teams (slide shows, 200 000 brochures, and 14 000 posters)
² formal leFers by the general director asking all administrators, heads of departments, and chief nurses to support the campaign.
IdenSficaSon of MRSA PaSents
¤ Passive surveillance through rouSne clinical specimens ¤ AcSve surveillance (screening) by culturing nares of
paSents with a high risk of MRSA colonizaSon, eg, intensive care unit (ICU) paSents and contacts of MRSA paSents
¤ Quick noSficaSon and flagging of new paSents with MRSA infecSons or colonizaSons by laboratories to medical teams
¤ IdenSficaSon of MRSA paSent rooms and charts (sScker) ¤ Informing units to which paSents with MRSA are
transferred.
Feedback
¤ Feedback to the local hospital community on the results (MRSA rates and progress in program implementaSon).
Annual report
¤ Each hospital reporSng to the central administraSon
² size of the infecSon control team
² implementaSon of the program
² organizaSon of audits (eg, on hand hygiene)
² feed-‐back
² progress of the iniSaSve has been annually presented during meeSngs of infecSon control teams and bacteriologists from all AP-‐HP hospitals,
¤ To a certainly level it may be the major components that count not the details: ² Screening ² IsolaSon (single room and glove and gowns) ² Hand hygiene ² CommunicaSon
MRSA in Africa November 2012
Anderas Voss, MD, PhD 6
² PrevenSon: verScal versus horizontal approach
HAI prevenSon
While important other factors count: ¤ Compliance with basic infecSon control measures
¤ Infrastructure of the hospital ¤ HCW-‐paSent raSo ¤ AnSbioSc use ¤ Emergence of CA-‐MRSA ¤ Farming (!) & food (?)
¤ Hand hygiene ¤ Gloves ¤ Gowns ¤ Masks ¤ Caps ¤ Single room ¤ CohorSng ¤ Info/feedback
¤ Flagging ¤ Environ. Cleaning ¤ Screening
² PaSents ² HCWs
¤ AnSbioSc Stewardship
¤ New strategies ² horizontal vs. verScal
Hands Gloves Gowns Mask Cap Isola>on Room
Single room Cohort
MRSA NL + + + + + + (+/-‐) outbreak
MRSA Africa
+ +/-‐ +/-‐ -‐ -‐ -‐ +/-‐ -‐
Screen pts
Screen HCWs
AB-‐steward
Dedicated HCW
Dedicated Equipme.
Info Feedb. Flags New
strat
MRSA NL + + + -‐ + + + +
MRSA Africa
+ +/-‐ + + + + + +