getting to zero despite ca mrsa
DESCRIPTION
3rd International Congress of Infection Control Association (Singapore)TRANSCRIPT
Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13
Andreas Voss, MD, PhD 1
Andreas Voss, MD, PhD Professor of InfecCon Control
RUNMC & CWZ Nijmegen, The Netherlands
¤ 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 (Sco^ Weese) CA-‐MRSA HA-‐MRSA LA-‐MRSA
CA
HA
LA
“Li^le brother” “Main problem” “Giant trouble”
CA-‐MRSA HA-‐MRSA LA-‐MRSA
MRSA bacteremia in Europe!
Source: EARSS report
Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13
Andreas Voss, MD, PhD 2
¤ Search & Destroy (Control) strategy to avoid introducCon of MRSA into health-‐care se#ngs and reduce the chance of transmission: ² NaConal MRSA guidelines (WIP) ² NaConal detecCon methods (NVMM) ² Use fast and reliable detecCon methods
¤ IsolaCon and screening of risk-‐paCents on admission
² at all Cmes
² colonized and infected paCents
¤ DecolonizaCon of MRSA carriers
¤ Consequent acCons when transmissions occur
² screening of all paCents and HCWs at risk
² MRSA-‐posiCve HCWs not allowed to work
¤ Placement in isolaCon room
² with anteroom and negaCve pressure
¤ Gloves, gowns and face-‐masks
² for all entering the room
¤ Handhygiene
¤ IsolaCon and screening of risk-‐paCents on admission ² can’t determine paCents at risk ² only certain departments!
² not when too busy/weekends ² only infected paCents
¤ No decolonizaCon of MRSA carriers ¤ Non-‐consequent acCons when transmissions occur
² screening of all paCents but not HCWs à consequently MRSA-‐posiCve HCWs may conCnue to spread
Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13
Andreas Voss, MD, PhD 3
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 CIRCULATION
BBC World news
Courtesy: A. Pearson (HPA, Sept 2009)
MRSA BSI episodes
V. Jarlier et al. Arch Intern Med 2010
¤ IsolaCon IntervenCons ¤ PromoCon of Hand Hygiene ¤ IdenCficaCon of paCents with MRSA infecCons or colonizaCons
¤ Feedback ¤ Annual reports
IsolaCon IntervenCons ¤ Placement of paCents with MRSA infecCons or colonizaCons in single-‐bed rooms whenever possible
¤ Barrier precauCons for paCents with MRSA infecCons or colonizaCons such as: ² disposable gloves worn before and discarded aier paCent contact
² disposable aprons worn for extensive contacts (eg, bed making)
² small equipment (eg, stethoscope) dedicated to the paCent.
Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13
Andreas Voss, MD, PhD 4
Should we ask universal precauCons ?
PromoCon of Hand Hygiene
¤ Hand washing with disinfectant soap aier contact with paCents with MRSA infecCons or colonizaCons before leaving the room
¤ An insCtuConal campaign for promoCng the use of alcohol-‐based hand-‐rub soluCons in place of hand washing ² launched in 2001 ² Training materials to the infecCon control teams (slide shows, 200 000 brochures, and 14 000 posters)
² formal le^ers by the general director asking all administrators, heads of departments, and chief nurses to support the campaign.
IdenCficaCon of MRSA PaCents
¤ Passive surveillance through rouCne clinical specimens ¤ AcCve surveillance (screening) by culturing nares of
paCents with a high risk of MRSA colonizaCon, eg, intensive care unit (ICU) paCents and contacts of MRSA paCents
¤ Quick noCficaCon and flagging of new paCents with MRSA infecCons or colonizaCons by laboratories to medical teams
¤ IdenCficaCon of MRSA paCent rooms and charts (sCcker) ¤ Informing units to which paCents with MRSA are
transferred.
Feedback
¤ Feedback to the local hospital community on the results (MRSA rates and progress in program implementaCon).
Annual report
¤ Each hospital reporCng to the central administraCon
² size of the infecCon control team
² implementaCon of the program
² organizaCon of audits (eg, on hand hygiene)
² feed-‐back
² progress of the iniCaCve has been annually presented during meeCngs of infecCon control teams and bacteriologists from all AP-‐HP hospitals,
What is CA-‐MRSA?
Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13
Andreas Voss, MD, PhD 5
¤ ProspecCve cohort study of MRSA infecCons idenCfied in 12 Minnesota laboratories in 2000
¤ 1100 MRSA infecCons ² 131 (12%): community-‐associated
² 937 (85%): health care-‐associated
¤ Epidemiological definiCon
Naimi et al. JAMA 2003; 290: 2976-84
CA-/HA-MRSA: Age Distribution!
Naimi et al. JAMA 2003; 290: 2976-84
No underlying condiCons as risk factor
Naimi et al. JAMA 2003; 290: 2976-84
CA-/HA-MRSA: Underlying conditions!
Predominantly skin and soi Cssue infecCons
CA-/HA-MRSA: Infection type!
Naimi et al. JAMA 2003; 290: 2976-84
SCll suscepCble to most other classes of anCbioCcs
CA-/HA-MRSA: Susceptibility!
Naimi et al. JAMA 2003; 290: 2976-84
Enriched with SCCmec IV, PVL and other exotoxins
Naimi et al. JAMA 2003; 290: 2976-84
Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13
Andreas Voss, MD, PhD 6
CA-‐ strains geneCcally unrelated to HA-‐MRSA
CA-/HA-MRSA: Clonal spread!
¤ Aboriginals ¤ NaCve Americans (indians, eskimos) ¤ Jails ¤ Saunas ¤ Sport teams ¤ Homosexual men ¤ Military recruits ¤ Day Care Centers
King et al Ann Intern Med 2006;144:309-‐317
" SSTI caused by CO-‐MRSA in a non-‐outbreak seFng (Atlanta, Q3+4 2003)
" 384 persons with documented CA-‐SSTI due to S. aureus
King et al Ann Intern Med 2006;144:309-‐317
nearly ¾ MRSA
nearly 90% US 300/400*
* 99% (155 of 157) of the typed CA-‐MRSA isolates were USA 300
¤ Aboriginals ¤ NaCve Americans (indians, eskimos) ¤ Jails ¤ Saunas ¤ Sport teams ¤ Homosexual men ¤ Military recruits ¤ Day Care Centers ¤ Animal lovers ?
Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13
Andreas Voss, MD, PhD 7
First
cases
• 2004: 23%
• 2006: 50%
• 2010: >70%
Wulf et al. Eurosurveillance 2008;13
Only ris
k-‐factor
: a HCW
living on
the gro
unds of
a pig fa
rm
Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13
Andreas Voss, MD, PhD 8
46 7734 41 54 67 97 104 100
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Each person only included once, unless a new subtype is found R. Skov 2009
020406080
100120140160180200220240
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Import HA HACO CA
R. Skov 2009 71% of the MRSA cases in Copenhagen area were community-onset MRSA (CO-MRSA)
Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13
Andreas Voss, MD, PhD 9
... lines between categories may be “graying,” with community-‐associated strains encroaching on hospitals, and health-‐care associated strains
entering the community. Stranden et al. InfecCon 2009;37:44
v 36.4% of 11 CA-‐MRSA and 43.9% of 66 HA-‐MRSA harbored SCCmec type IV/IVA. v Type IV/IVA has become the most common SCCmec type in inpaCents of a Swiss university hospital. v SCCmec type IV/IVA is present in both CA-‐MRSA and HA-‐MRSA limiCng its use as a marker for CA-‐MRSA.
¤ we have all kind of SSCmec-‐types in the hospital (including IV and V)
¤ we have healthcare outbreaks of ST398-‐MRSA and CA-‐MRSA strains
¤ we have HA-‐MRSA strains in the community, in pets and in livestock animals
¤ MRSA -‐ it’s not graying, it is gray! CA-‐MRSA HA-‐MRSA LA-‐MRSA
CA-‐MRSA HA-‐MRSA LA-‐MRSA Just-‐MRSA Is this sCll a possiblity?
Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13
Andreas Voss, MD, PhD 10
¤ We know the risk factors for HA-‐MRSA ² foreign admission/dialysis, adopCon, known outbreaks, (nursing homes)
¤ We know the risk factors for LA-‐MRSA ² pig-‐ and calf-‐farming (poultry) ² (but this may change)
¤ We know some of the risk factors for CA-‐MRSA ² but can’t use them for S&D
¤ Consequent decolonizaCon of all MRSA carriers (especially outside the hospitals) is of upmost importance ! ² works with HA-‐MRSA
² should work with CA-‐MRSA
² trouble LA-‐MRSA
020406080
100120140160180200220240
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
No.
of i
sola
tes
Import HA HACO CA
R. Skov 2009 71% of the MRSA cases in Copenhagen area were community-onset MRSA (CO-MRSA)
The Danish curbed this outbreak by ”destroying” the community sources
¤ To a certainly level it may be the major components that count not the details: ² Good epidemiology ² Screening ² IsolaCon (single room and glove and gowns) ² Hand hygiene ² CommunicaCon ² DecolonizaCon
While important other factors count:
¤ Compliance with basic infecCon control measures in all (healthcare) se#ngs
¤ Infrastructure of healthcare se#ngs
¤ HCW-‐paCent/client raCo
¤ AnCbioCc use
¤ Farming (!) & food (?)
Ge#ng to zero in midst of CA-‐MRSA 28-‐02-‐13
Andreas Voss, MD, PhD 11
June 25-‐28, 2013 Geneva Switzerland
www.icpic2013.com