Controlling the Spread of MRSA

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Controlling the Spread of MRSA

• WPHA/WALHDAB
• Annual Conference
• May 23, 2007

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Controlling the Spread of MRSATopics

• History
• Characteristics
• Staphylococcal organisms
• HA MRSA
• CA MRSA
• Control strategies
• Healthcare settings
• Community settings

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Controlling the Spread of MRSA

• Abbreviations
• MRSA methicillin resistant Staphylococcus
  aureus
• HA healthcare associated
• CA community associated
• ARO antibiotic resistant organisms
• Definitions
• Colonization organism is on or in the body but
  not causing disease
• Infection organism is present and causing signs
  and symptoms of disease

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History
1928
Serendipitous discovery of penicillin
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History

• 1942
• Antibiotics touted as the magic bullet

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History

• 1950s PRSA
• 1959 methicillin introduced
• 1961 MRSA appears in UK
• 1968 outbreaks of staph in US nurseries

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History
"At the dawn of a new millennium, humanity is
faced with another crisis. Formerly curable
diseases...are now arrayed in the increasingly
impenetrable armor of antimicrobial
resistance." --Director-General, WHO-- 2000
Margaret Chan
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Characteristics

• Gram positive cocci

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Characteristics

• Reservoirs
• Skin
• Nares
• Axilla
• Pharynx
• Perineum
• Contaminated surfaces, items

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Characteristics

• Causes minor infections such as pimples, boils,
  other skin conditions
• Impetigo
• Major infections include bacteremia, cellulitis,
  pneumonia, osteomylitis
• Scalded skin syndrome in newborns

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Characteristics

• Food poisoning
• Toxic shock syndrome
• Major cause of hospital acquired infections

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Characteristics

• Why focus on MRSA?
• Increased morbidity, mortality, cost
• More prevalent than other resistant organisms
• Threat of vancomycin resistance (VISA, VRSA)
• New community strains

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WI Guidelines for AROPremises

• MRSA is spread by direct and indirect contact.
• Both colonized and infected persons are sources
  of transmission.
• Colonized persons are not always identified.
• Most persons with histories of MRSA are either
  permanently or intermittently colonized.

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WI Guidelines for AROPremises
The most common way resistant organisms are
spread in health care settings is from patient to
patient via the hands of health care workers.
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WI Guidelines for ARO

• Administrative measures
• Prudent use of antibiotics
• Decolonization
• Surveillance
• Infection control

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WI Guidelines for AROAdministrative Measures

• Administration representative on infection
  control committee
• Monitor hand hygiene/std precautions
• Infection prevention
• Limit use of indwelling devices
• Vaccines
• Implement major IC Practice Guidelines

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WI Guidelines for AROSurveillance

• Determine prevalence
• Identify reservoirs
• Monitor rates of transmission

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WI Guidelines for AROSurveillance

• All acute care organizations should
• Use clinical culture data to monitor trends in
  proportions of ARO
• Maintain line lists of known infected and
  colonized patients and isolate appropriately

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WI Guidelines for AROSurveillance

• New CDC isolation guidelines require that MRSA
  rates must be decreasing in each health care
  organization

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WI Guidelines for AROSurveillance

• Identify unknown reservoirs by using screening
  cultures on high risk patients
• Elderly
• Chronically ill
• Previously colonized
• Long term care residents
• Isolate colonized and infected sources
  standard PLUS contact precautions

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Reservoir for the Spread of Antibiotic Resistant
Pathogens
clinical infections
colonized (asymptomatic) patients
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WI Guidelines for ARODecolonization

• Not recommended as a routine component of control
• Eradication not long-term
• Increased mupirocin resistance
• Optimum methods not established
• Decision to treat
• If individual would benefit clinically
• If ongoing transmission would be reduced
• Decision to treat HCW based on epidemiologic
  evidence

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WI Guidelines for AROInfection Control

• Standard precautions
• All patients
• Contact with blood, body fluids, mucous
  membranes, non-intact skin
• Proper handling of laundry
• Disposal of infectious waste
• Hand hygiene alcohol hand sanitizer

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WI Guidelines for AROInfection Control

• Contact precautions
• Private room or co-habitate
• Gowns/glove upon entry to room
• Limit patient movement outside room
• Clean and disinfect all items before removing
  from room

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WI Guidelines for AROInfection Control

• Contact precautions (cont)
• Patients should wash hands before leaving room
  and have clean gown/clothing
• Includes patients with uncontrolled body
  secretions, wound drainage

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HA MRSA Summary

• The proportion of S. aureus clinical isolates
  that are MRSA should be decreasing in acute care
  settings
• Strategies
• Active surveillance cultures
• Strict adherence to contact precautions and hand
  hygiene

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CA MRSA

• Emerged in 1990s
• Distinct from HA MRSA
• Epidemiologically
• Clinically
• Genetically

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Comparison of HA-MRSA and CA-MRSA
SCC Staphylococcal cassette chromosome PVL
Panton Valentine leukocidin
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CA and HA MRSA Prevalence in Three StatesActive
Bacterial Core Surveillance System, CDC 2001-02
_ HA MRSA _ CA MRSA
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12
9
80
88
91
Minnesota
Georgia
Maryland
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CA MRSA

• Prevalence lt 1 of the US population is
  colonized
• Outbreaks have occurred in
• Prisons
• Sports teams
• Military recruits
• MSM
• IV drug users

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CA MRSA

• Risk factors for community transmission
• Crowding
• Close contact
• Compromised skin
• Contaminated surfaces, items
• Cleanliness (lack of)

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EMERGEncy ID Net Study

• Bacterial isolates from purulent skin/soft tissue
  (SST) infections in 11 US emergency departments
  during August 2004
• S. aureus was isolated from 320/422 (76) of
  patients with SST infections
• 59 were MRSA
• 97 were USA300 strain
• NEJM 2006355666-74

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EMERGEncy ID Net Study

• SCCmec type IV and PVL toxin gene detected in 98
  of MRSA isolates
• Among MRSA isolates
• 95 susceptible to clindamycin
• 6 susceptible to erythromycin
• 60 susceptible to fluoroquinolones
• 100 susceptible to rifampin and TMP/SMX
• 92 susceptible to tetracycline

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EMERGEncy ID Net Study

• Potential indicators of CA MRSA infection vs.
  other bacteria
• Antibiotic in past month
• Abscess
• Reported spider bite
• History of MRSA infection
• Close contact with someone having similar
  infection

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EMERGEncy ID Net Study

• Antibiotic therapy was not concordant with
  results of susceptibility testing in 100 of 175
  patients who received antibiotics (57)
• Conclusions
• MRSA most common identifiable cause of SST
  infections
• When antibiotics indicated, clinicians should
  consider obtaining cultures and modifying empiric
  therapy to cover MRSA

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Wisconsin Prevalence
MRSA Outpatient Clinical Isolates 2004
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CA MRSA

• Healthcare associated transmission
• Postpartum women at Columbia University Hospital
• Post-op infections in orthopedic patients at
  Grady Memorial, Atlanta
• Newborn nurseries in Chicago and Los Angeles

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CA MRSA

• Three Main Factors

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CA MRSA

• 1. CA MRSA is the leading cause of skin and soft
  tissue infections in adults
• Culture purulent material
• Consider coverage for MRSA in empiric antibiotic
  therapy

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CA MRSA

• 2. CA MRSA spreads more readily in the community
  than HA MRSA
• Look for infections in household contacts when
  treating patients
• Give instructions to patients on how to reduce
  transmission in the household
• Suspicion of CA MRSA increased in members of
  sports teams, day care attendees, inmates,
  military personnel

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CA MRSA

• 3. CA MRSA can spread in the health care setting
• Place persons with suspected CA MRSA in contact
  precautions in both outpatient and inpatient
  settings. Index of suspicion increased for
• Pustules with necrotic center
• Larger than usual pustules that expand rapidly
• Pustules present in other household contacts

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Management of CA MRSAClinician information

• Localized infections TMP/SMX, clindamycin
• Serious, systemic infections vancomycin,
  linezolid
• Provide patient education on wound care, hand
  washing, and hygiene
• Instruct outpatients to return if symptoms do not
  resolve

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Management of CA MRSAPatient education

• Wash hands
• Consider use of gloves when doing wound care
• Cover wounds
• Dispose of heavily soiled dressings in sealed
  plastic bags
• Shower before close contact with others
• Do not share personal items
• Disinfect contaminated surfaces

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Prevention of Transmission in Community Settings
Increased awareness among health care providers
Early detection and appropriate treatment
Screen high risk groups Monitor close contacts
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Prevention of Transmission in Community Settings

• Hand hygiene
• Personal hygiene/covering skin lesions
• Cleaning shared equipment
• Processing laundry properly

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CA MRSA

• Messages for public
• Most infections are mild skin infections
• Infections are treatable
• Risk of infection can be reduced by keeping skin
  clean and healthy

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Keep skin clean
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Keep skin intact
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MRSA

• Link to
• Guidelines for Management of Patients with ARO
• CA MRSA Guidelines
• CA MRSA Patient Pamphlet
• http//dhfs.wisconsin.gov/communicable/
• Communicable/HlthProvider.htm

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Gwen Borlaug, CIC, MPHDivision of Public
Health1 West Wilson Street Room 318Madison, WI
53701608-267-7711borlagm_at_dhfs.state.wi.us