Surprising Victories Against Old Foes: New Hope for Prevention and Control of Healthcare-Associated MRSA Infections

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Surprising Victories Against Old Foes New Hope
for Prevention and Control of Healthcare-Associate
d MRSA Infections

• John A. Jernigan, MD, MS
• Division of Healthcare Quality Promotion
• Centers for Disease Control and Prevention
• Atlanta, Georgia

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What is the Preventable Fraction of Healthcare
Associated Infections?
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What is the Preventable Fraction of Healthcare
Associated Infections?

• SENIC study results
• others

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What is the Preventable Fraction of Healthcare
Associated Infections?

• Some may have interpreted these data to mean that
  most healthcare associated infections are
  inevitable
• What impact has this had on the Psychology of
  prevention?
• How has this impacted how infection control
  programs operate?

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Eliminating catheter-related bloodstream
infections in the intensive care unit
Berenholtz, S et al. Critical Care Medicine.
32(10)2014-2020, October 2004.
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Maybe the Preventable Fraction is Much Larger
than we Thought?

• Healthcare Epidemiologists have been afraid of
  using the E word (elimination) with regard to
  healthcare-associated infections, but recent
  successes suggest that perhaps we should have
  been using it more.

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Are such goals appropriate for the problem of
antimicrobial resistance, with MRSA as a starting
point?
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Emerging Prevalence of Methicillin-Resistance
Among S. aureus in U.S. Intensive Care Units
National Nosocomial Infections Surveillance
(NNIS) System
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Rationale for Efforts to Prevent and Control
Resistant Gram-positive Bacteria

• Emerging as dominant pathogens in
  healthcare-associated infections
• for example
• Between 1992-2002, among infections following
  CABG, cholecystectomy, colectomy, and total hip
  replacement, S. aureus 16.6 -30.9
• S. aureus infections attributable to MRSA
  increased from 9.2 to 49.3
• Treatment options are limited and less effective,
  may result in higher morbidity and mortality
• Gonzalez Clin Infect Dis 1999291171
• Lucas Clin Infect Dis 1998261127
• Abramson ICHE 1999 20408-411
• Cheng et al J Hospital Infect 19881291-101
• Stosor et al. Arch Intern Med 1998 158522-527

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Summary of Unadjusted Results of Studies
Comparing Mortality of MRSA and MSSA Bacteremia
Cosgrove et al. Clinical Infectious Diseases
20033653-59
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Rationale for Efforts to Prevent and Control
Resistant Gram-positive Bacteria

• Prevalence of resistance leads to unfavorable
  antibiotic prescribing, and leads to more
  resistance
• prevalent MRSA more glycopeptide use
  more glycopeptide resistance

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MRSA infections add to the total S. aureus
infection rate

• Stamm Am J Infect Control 19932170
• Boyce J Infect Dis 1993148763
• Chaix JAMA 1999 2821745-1751
• Jernigan ICHE 199516686
• Harbarth J Hosp Infect 20004643
• Therefore, preventing MRSA infections should
  result in decreased S. aureus infection rates

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Okay, so MRSA and antimicrobial resistance in
general are important problems, but they are
different from bloodstream infections. Its okay
to set bold goals for preventing bloodstream
infections, but we could never hope to be so
successful against MRSA infection! Could we?
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Emerging Prevalence of Methicillin-Resistance
Among S. aureus in U.S. Intensive Care Units
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Emerging Prevalence of Methicillin-Resistance
Among S. aureus in U.S. Intensive Care Units
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Methicillin-resistant Staphylococcus aureus in
Europe, 19992002Tiemersma et. al. Emerg Infect
Dis 2004101627-34
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Methicillin-resistant Staphylococcus aureus in
Europe, 19992002Tiemersma et. al. Emerg Infect
Dis 2004101627-34
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Can the experience in other countries be
reproduced here?
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Overall Rates Pre-intervention 1.48
infections/1,000 pt days Post-intervention
0.68 infections/1,000 pt days
54 reduction, p.04
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Overall Rates Pre-intervention 3.82
infections/1,000 pt days Post-intervention
1.62 infections/1,000 pt days
58 reduction, plt.01
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Huang, S. IDSA 2005
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There are a growing number of studies suggesting
that US healthcare facilities can successfully
prevent MRSA infections
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• A regional collaborative approach may be a good
  way to approach the MRSA problem
• Sharing of MRSA-carriers between facilities
• Success at the community level may be more
  readily accepted as generalizable
• Need to agree on common system for measuring
  outcome, but there is room for alternative
  approaches to prevention. One size may not fit
  all.
• Successes can be shared and spread across the
  community

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Summary

• We (healthcare epidemiologists) may have badly
  underestimated the preventable fraction of
  healthcare-associated infections
• Regional/community collaboratives have been
  effective in achieving major reductions in
  healthcare-associated infections
• MRSA is an important patient safety issue that
  needs addressing.

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Summary (continued)

• MRSA infections can be prevented, even in endemic
  settings
• Regional collaboration on MRSA prevention may
  have particular advantages.
• Successful MRSA prevention across a region would
  represent a major advance for infection control,
  and would have implications for control of other
  antimicrobial resistant infections