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Prevention and Control of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus

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Title: Prevention and Control of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus


1
Prevention and Control of Healthcare-Associated
Methicillin-Resistant Staphylococcus aureus
  • John A. Jernigan
  • Division of Healthcare Quality Promotion
  • Centers for Disease Control and Prevention
  • April 29, 2008

The findings and conclusions in this
presentation/report are those of the authors and
do not necessarily represent the views of the
Centers for Disease Control and Prevention
2
  • Continuing Education Credits DISCLAIMERIn
    compliance with continuing education
    requirements, all presenters must disclose any
    financial or other relationships with the
    manufacturers of commercial products, suppliers
    of commercial services, or commercial supporters
    as well as any use of unlabeled product(s) or
    product(s) under investigational use. CDC, our
    planners, and the presenters for this seminar do
    not have financial or other relationships with
    the manufacturers of commercial products,
    suppliers of commercial services, or commercial
    supporters. This presentation does not involve
    the unlabeled use of a product or product under
    investigational use.

3
Source Hidron et al., abstract presentation,
SHEA 2008
4
Most Invasive MRSA Infections Are
Healthcare-Associated
n8,987
  • In the US in 2005 there were
  • 94,360 invasive MRSA infections
  • 18,650 associated deaths

14
86
Source ABCs Population-based surveillance
System, Klevens et al. JAMA 2007
5
Why is the Emergence of MRSA as a Healthcare
Pathogen Important?
  • Has emerged as one of the predominant pathogens
    in healthcare-associated infections
  • Treatment options are limited and less effective
  • higher morbidity and mortality
  • High prevalence major influence on unfavorable
    antibiotic prescribing, which contributes to
    further spread of resistance
  • prevalent MRSA more glycopeptide use
    more glycopeptide resistance (VRE
    VRSA) more linezolid/daptomycin
    use more resistance

6
Why is the Emergence of MRSA as a Healthcare
Pathogen Important?
  • Adds to overall S. aureus infection burden
  • Represents a failure to contain transmission of
    drug-resistant bacteria
  • A marker for our ability to contain transmission
    of important pathogens in the healthcare setting
  • Learning how to successfully control of MRSA is
    likely to have benefits that extend to other
    pathogens

7
The emergence of MRSA has been due to
transmission of relatively few clones, not de
novo selection
Hiramatsu, et al. Trends in Microbiology
20019486
8
A Few CA-MRSA Strains Cause Most Community
Outbreaks
100
80
60
100
80
60
Pneumonia (AL, AR, IL, MD, TX, WA)
Pneumonia (AL, AR, IL, MD, TX, WA)
Missouri
Missouri
California
California
Athletes
Athletes
Pennsylvania
Pennsylvania
Colorado
Colorado
Mississippi
Mississippi
Texas
Texas
Prisoners
Prisoners
Georgia
Georgia
Tennessee
Tennessee
Texas
Texas
Children
Children
Missouri
Missouri
California
California
USA300-114
USA300-114
Community
Community
USA100
USA100
Hospital Strain
Hospital Strain
Hospital Strain
Hospital Strain
USA200
USA200
9
Key Prevention Strategies
  • Prevent infection
  • Diagnose and treat infection effectively
  • Use antimicrobials wisely
  • Prevent transmission

Clinicians hold the solution!
10
Source Burton et al., abstract presentation,
SHEA 2008
11
Key Prevention Strategies
  • Prevent infection
  • Diagnose and treat infection effectively
  • Use antimicrobials wisely
  • Prevent transmission

Clinicians hold the solution!
12
Preventing transmission is an important part of
MRSA control
  • Entire healthcare-associated MRSA problem caused
    by spread of a few clones
  • Preventing widespread colonization minimizes
    circulating pool of resistance genes that can
    contribute to cycle of increasing multi-drug
    resistance (e.g. VRSA is likely a product of
    widespread colonization with VRE and MRSA)
  • Improving antibiograms helps ease pressure for
    broad spectrum antibiotic use and preserves
    effectiveness of preferred antimicrobial agents
  • Preventing colonization helps prevent infections
  • Including those that might happen post-discharge
    (newly colonized patients have up to 30 risk of
    infection in the ensuing year)

13
Most Healthcare-Associated Invasive MRSA
Infections Have Their Onset Outside of the
Hospital
28
59
14
Source ABCs Population-based surveillance
System, Klevens et al. JAMA 2007
14
Regional Spheres of Influence Within Spectrum of
Inpatient Care
Nursing Home 1
NH 2
Hospital A
Nursing Home 3
Hospital B
Nursing Home 4
Hospital c
15
Predicted Number of EMRSA-15 Outbreaks During
1993-98, United Kingdom
EMRSA-15 outbreaks 1993-1998
30 Duration
30 transmission
30both
of Facilities Implementing Intervention
Source Austin JID 1999179883
16
How best to prevent MRSA Transmission in
Healthcare Settings?
  • Controversial subject
  • standard precautions versus standard plus barrier
    (i.e. contact precautions)?
  • Should contact precautions be used only on those
    identified by clinical cultures?
  • Due to iceberg effect, many colonized patients
    unrecognized base on clinical cultures alone
  • Should active surveillance be used to identify
    carriers?
  • If so, in what settings?

17
HICPAC Guidance On Management of
Multidrug-Resistant Organisms (MDROs) in
Healthcare Settings
First Tier General Recommendations For All Acute
Care Settings
If endemic rates not decreasing, or if first case
of important organism
Second Tier Intensified Interventions
18
HICPAC MDRO Guidance (acute care)First Tier
General Recommendations For All Acute Care
Settings
  • Administrative engagement
  • Make MDRO prevention and control an
    organizational patient safety priority
  • Implement a multidisciplinary process to monitor
    and improve healthcare personnel (HCP) adherence
    to recommended practices
  • feedback on facility and patient-care unit trends
    in MDRO incidence and adherence measure
  • Education and training of personnel
  • Judicious use of antimicrobial agents
  • Standard precautions for all patients
  • Contact Precautions for patients known to be
    infected or colonized (masks not routinely
    recommended)
  • Monitoring of trends over time to determine
    whether additional interventions are needed

19
HICPAC MDRO Guidance (acute care)
  • Indications for moving to second tier
  • First case or outbreak of an epidemiologically
    important MDRO
  • When endemic rates of a target MDRO are not
    decreasing despite implementation of and correct
    adherence to the first tier measures

20
HICPAC MDRO Guidance (acute care)Second Tier
Intensified Interventions For Acute Care Settings
  • Active surveillance cultures from patients in
    populations at risk at the time of admission to
    high-risk area, and at periodic intervals as
    needed to asses transmission.
  • Contact Precautions until surveillance culture
    known to be negative
  • Additional recommendations for intensifying
  • administrative engagement/correction of systems
    failures
  • Education and training of personnel/adherence
    monitoring
  • Judicious use of antimicrobial agents
  • monitoring of trends
  • Cohorting of staff to the care of MDRO patients
    only
  • Enhanced environmental measures
  • Consult with experts on case-by-case basis
    regarding use of decolonization therapy for
    patients or staff
  • If transmission continues despite full
    implementation of above, stop new admissions to
    the unit.

21
MDRO and CDAD Module
Multidrug-Resistant Organism (MDRO)
and Clostridium difficile-Associated Disease
(CDAD) Module
22
MDRO and CDAD Module
  • Organisms Monitored
  • Methicillin-Resistant Staphylococcus aureus
    (MRSA)
  • (option w/ Methicillin-Sensitive S. aureus
    (MSSA)
  • Vancomycin-Resistant Enterococcus spp. (VRE)
  • Multidrug-Resistant (MDR) Klebsiella spp.
  • Multidrug-Resistant (MDR) Acinetobacter spp.
  • Clostridium difficile-Associated Disease (CDAD)

Protocol available online at http//www.cdc.gov/n
cidod/dhqp/nhsn_MDRO_CDAD.html
23
Goal of the MDRO and CDAD Module
  • Provide a mechanism for healthcare facilities to
    report and analyze data that will inform
    infection control staff of the impact of targeted
    prevention efforts

24
MDRO and CDAD Module
  • Reporting Requirements and Options Include
  • Required
  • Infection Surveillance (not required for CDAD)
  • Optional
  • Proxy Infection Measures
  • Laboratory-Identified (LabID) Event
  • Prevention Process Measures
  • Monitoring Adherence to Hand Hygiene
  • Monitoring Adherence to Gown and Gloves Use
  • Monitoring Adherence to Active Surveillance
    Testing
  • Active Surveillance Testing (AST) Outcome Measures

25
NHSN MRSA Metrics
Metric Description Calculation Comment
1 Nosocomial MRSA Infection Rate NHSN MRSA infections/1000 pt-days By selected patient-care location only (i.e., MICU, SICU, etc.) uses NHSN criteria to define infections
2 Incidence Rate of Hospital-Onset MRSA Based on Clinical Cultures 1st MRSA specimens /1000 pt-days Hospital-wide is easiest, can also restrict to selected locations evaluating same locations as Metric 1 may be most useful uses positive culture data only
3a Incidence Rate of Hospital-Onset MRSA Bloodstream Infections (BSI) Based on Clinical Cultures MRSA BSI specimens /1000 pt-days Hospital-wide is easiest, can also restrict to selected locations evaluating same locations as Metric 1 may be most useful uses positive culture data only
3b Admission Prevalence MRSA BSI Rate (community-onset infections) MRSA BSI specimens /1000 admissions Hospital-wide is easiest, can also restrict to selected locations evaluating same locations as Metric 1 may be most useful uses positive culture data only
4 Direct MRSA Acquisition new MRSA cultures /1000 pt-days Requires data from active surveillance testing (AST) program selected locations only
5 Adherence to Process Measures Compliance Rate Requires data from observational assessment and/or from AST program selected locations only
6 Central Line-Associated Bloodstream Infections (CLABSI) (all pathogens) CLABSI/1000 line days By selected locations only requires following the Device-Associated Module-CLABSI protocol
26
Opportunities for MRSA Prevention Research
  • Impact of focusing on high risk units
  • Use of topical antimicrobials/antiseptics for
    eradicating or suppressing S. aureus colonization
  • Chlorhexidine bathing of patients (targeted to
    colonized patients versus high-risk groups)
  • Use of topical antibioitics for decolonization
    (e.g. mupirocin)
  • Risk factors for healthcare-associated,
    community-onset (HACO) MRSA
  • Impact of hospital-based prevention programs on
    HACO
  • Use of mathematical modeling to understanding
    inter-facility transmission dynamics and
    implications for prevention
  • Novel techniques for changing organization
    culture as a means to improve adherence

27
Conclusions
  • The burden of MRSA remains high in US healthcare
    settings
  • Community-associated MRSA (CA-MRSA) infections
    are emerging rapidly in many areas, but
    population-based estimates suggest that most MRSA
    infections are healthcare-associated
  • Epidemic strains of MRSA originally associated
    with the community have emerged as important
    causes of hospital-acquired infections
  • MRSA infections and transmission can be
    prevented, even in endemic settings in the US
  • Effective control programs must be multifaceted,
    and broad institutional commitment, including
    measurement of impact, is required for successful
    implementation

28
Acknowledgments
  • Rachel Gorwitz
  • Kate Ellingson
  • David Kleinbaum
  • Val Gebski
  • Jonathan Edwards
  • Pei-Jean Chang
  • Alexander Kallen
  • Scott Fridkin
  • Monina Klevens
  • Jeff Hageman
  • Fred Tenover
  • Melissa Morrison
  • Teresa Horan
  • Robert Muder
  • Rajiv Jain
  • The Active Bacterial Core Surveillance
    Investigators/Teams
  • Dawn Sievert
  • Deron Burton
  • Alicia Hidron
  • Dan Pollock

29
  • Continuing Education guidelines require that the
    attendance of all who participate in COCA
    Conference Calls be properly documented. ALL
    Continuing Education credits (CME, CNE, CEU and
    CHES) for COCA Conference Calls are issued online
    through the CDC Training Continuing Education
    Online system http//www2a.cdc.gov/TCEOnline/.
  •  
  • Those who participate in the COCA Conference
    Calls and who wish to receive CE credit and will
    complete the online evaluation by April 26, 2008
    will use the course code EC1265. Those who wish
    to receive CE credit and will complete the online
    evaluation between April 27, 2008 and March 27,
    2009 will use course code WD1265. CE certificates
    can be printed immediately upon completion of
    your online evaluation. A cumulative transcript
    of all CDC/ATSDR CEs obtained through the CDC
    Training Continuing Education Online System
    will be maintained for each user.

30
  • CME CDC is accredited by the Accreditation
    Council for Continuing Medical Education (ACCME)
    to provide continuing medical education for
    physicians. CDC designates this educational
    activity for a maximum of 1 Category 1 credit
    toward the AMA Physician's Recognition Award.
    Physicians should only claim credit commensurate
    with the extent of their participation in the
    activity.
  • CNE This activity for 1.0 contact hours is
    provided by CDC, which is accredited as a
    provider of continuing education in nursing by
    the American Nurses Credentialing Center's
    Commission on Accreditations.
  • CEU CDC has been reviewed and approved as an
    authorized provider by the International
    Association for Continuing Education and Training
    (IACET), 8405 Greensboro Drive, Suite 800,
    McLean, VA 22102. CDC has awarded 0.1 CEU to
    participants who successfully complete this
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  • CHEC CDC is a designated provider of continuing
    education contact hours (CECH) in health
    education by the National Commission for Health
    Education Credentialing, Inc. This program is a
    designated event for the CHES to receive 1
    Category I Contact Hour(s) in health education.
    CDC provider number GA0082.
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