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REALM project update MRSA and KPC January 26, 2011

REALM project update MRSA and KPC January 26, 2011. Michael Lin, MD MPH on behalf of REALM co-investigators. Outline. MRSA surveillance a. Overview and main results b. Contact precautions analysis c. NICU analysis KPC surveillance and future directions. Aim.

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REALM project update MRSA and KPC January 26, 2011

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  1. REALM project updateMRSA and KPCJanuary 26, 2011 Michael Lin, MD MPH on behalf of REALM co-investigators

  2. Outline • MRSA surveillance a. Overview and main results b. Contact precautions analysis c. NICU analysis • KPC surveillance and future directions REALM update

  3. Aim • Evaluation of 2007 mandate for MRSA active surveillance among all Illinois hospital ICU and “high risk” patients. • Is the prevalence of MRSA colonization decreasing after the initiation of state-wide active surveillance? REALM update

  4. Design 3 year project involving all hospitals in city of Chicago with ≥ 10 ICU beds • Serial point prevalence survey of MRSA colonization in ICUs (6 times over 3 years) • All ICUs (neonatal, pediatric, and adult) • City of Chicago hospitals – chosen for feasibility and to limit selection bias • Peds/adults – swabbed in nose and groin; neonates – nose and umbilicus • All cultures processed in central laboratory REALM update

  5. Design (cont.) • All 26 eligible hospitals in Chicago participating • Timeline: • 1st survey: 2008 (2nd half) • 6th survey: 2011 (1st half) • We tracked the prevalence (%) of • MRSA colonization • CA-MRSA vs. HA-MRSA genotype • Mupirocin resistance REALM update

  6. Hospital locations within Chicago REALM update

  7. Results • Through 5 surveys*, total patients: • Neonates: 1,328 • Pediatric: 409 • Adult: 2,545 * Survey 5 almost complete. All data involving survey 5 are preliminary. REALM update

  8. Trend, P = 0.04

  9. Trend, P = 0.41

  10. Trend, P = 0.33

  11. Mupirocin resistance Surveys 1-5 combined REALM update

  12. MRSA trend summary • Adult ICU MRSA colonization rate may be decreasing over time! • No change for PICU or NICU • CA-MRSA rates stable • No significant mupirocin resistance REALM update

  13. Kallen AJ, JAMA 2010

  14. Outline • MRSA surveillance a. Overview and main results b. Contact precautions analysis c. NICU analysis • KPC surveillance and future directions REALM update

  15. Contact Precautions analysis • Question – of the patients that are found by our point prevalence survey to be MRSA+, what percent of the patients are in contact precautions? • Data from surveys 1-2 • Presented at 5th SHEA/IDSA/CDC Decennial International Conference on Healthcare-Associated Infections in Atlanta, 2010 REALM update

  16. Methods • Reported by hospital • Heterogeneous practice Admission Surveillance Study patient timeline Point Prevalence Surveillance • Obtained by study, standardized • Variable timing • Contact Precautions assessed

  17. Admission screen results Hospitals had obtained admission screening cultures for 95% for adults 98% for neonates MRSA admission prevalence (hospital report) 9.3% for adults 1.3% for neonates REALM update

  18. Point prevalence survey results Median ICU day for point prevalence survey: Adults: ICU day 4 Neonates: ICU day 17 MRSA prevalence (point prevalence survey): 12.4% of adults (Hospital-reported admission rate, 9.3%) 5.3% of neonates (Hospital-reported admission rate, 1.3%) REALM update

  19. Contact Precautions results Contact Precautions for any reason: 26% of adults 5% of neonates Of patients with hospital-reported admission cultures MRSA +: 87% of adults in Contact Precautions 86% of neonates in Contact Precautions REALM update

  20. Contact Precautions results Of patients with point prevalence survey cultures MRSA +, Contact Precautions rate: 52% (65 / 125) of adults 39% (11 / 28) of neonates REALM update

  21. Possible reasons for Contact Precautions deficit 1. Inadequate MRSA surveillance test sensitivity 2. Lag time for admission surveillance results 3. Lag time for initiating Contact Precautions after surveillance results known 4. On-going nosocomial MRSA acquisition REALM update

  22. Possible reasons for Contact Precautions deficit 1. Inadequate MRSA surveillance test sensitivity 2. Lag time for admission surveillance results 3. Lag time for initiating Contact Precautions after surveillance results known 4. On-going nosocomial MRSA acquisition REALM update

  23. Contact Precautions Summary Point prevalence surveys identified a greater proportion of MRSA-colonized ICU patients compared to routine mandated admission screening. At a given point in time, about half of MRSA-colonized ICU patients were not in Contact Precautions, despite on-going active surveillance at admission. REALM update

  24. Contact Precautions Conclusion • Possibilities for improvement: • Increasing test sensitivity (more body sites, enrichment methods) • Periodic surveillance to detect acquisition (especially among neonates) • We do not know if current 50% level of Contact Precautions is sufficient to reduce MRSA transmission and infection REALM update

  25. Outline • MRSA surveillance a. Overview and main results b. Contact precautions analysis c. NICU analysis • KPC surveillance and future directions REALM update

  26. Outline • MRSA surveillance a. Overview and interim results b. Contact precautions analysis c. NICU analysis • KPC surveillance and future directions REALM update

  27. Neonatal ICU:MRSA epidemiology • How does neonatal ICU MRSA colonization differ from that of adult ICU patients? • Data from surveys 1-4 • Presented at IDSA 2010 REALM update

  28. Neonatal MRSA+ distribution

  29. Adult MRSA+ distribution

  30. NeonatalICU Adult ICU

  31. NeonatalICU Median MRSA+ Median MRSA+ Adult ICU

  32. NICU Summary • MRSA colonization is common among neonatal ICU patients • For neonates, MRSA is uncommon early in ICU stay; rather, colonization appears days or weeks after admission • If active surveillance is performed among neonates, it should be performed serially rather than only upon admission

  33. Outline • MRSA surveillance a. Overview and main results b. Contact precautions analysis c. NICU analysis • KPC surveillance and future directions REALM update

  34. KPC – emerging threat • Klebsiella pneumoniaecarbapenemase – usually found in Klebsiellaspp., but can also be transmitted to other bacteria(E. coli, Pseudomonas). • Carbapenems (imipenem) often last resort for treatment • KPCs: no reliable antibiotic therapy, making some infections impossible treat. REALM update

  35. KPC PPS - Rationale • First KPC isolated in Chicago ~ 2008 • Increasing prevalence of KPC colonization and infection • Nursing home / LTACH epicenters • Survey of Chicago hospitals – 65% in 2010 have isolated KPC • Goal: • Determine prevalence of KPC colonization among ICU patients in Chicago REALM update

  36. Design • Surveys 5 and 6 (July 2010 – June 2011) • Voluntary hospital participation • Adult ICUs (optional for NICU/PICU) • Initial design: • Groin swab + urine culture (if urine bag present) • Modified design: rectal culture • Lab – phenotypic screen for carbapenemase resistance; confirmation using in-house PCR for blaKPC REALM update

  37. Results Survey 5: 25 eligible hospitals ─ 1 remaining = 24 hospitals 6 hospitals: groin/urine culture only 2 hospitals: groin culture only 18 hospitals: rectal cultures Patients: 459 adults (and 67 NICU/PICU) REALM update

  38. KPC results • Overall KPC prevalence in adult ICUs: 17 / 459= 4% REALM update

  39. KPC future directions • Identify the extent of problem • LTACH surveillance • Nursing home surveillance? • REALM survey 6 – KPC survey #2 • Extending REALM for KPCs? • Identify best practices to control KPCs • Chlorhexidine bathing? Environmental cleaning? • Improve communication between facilities REALM update

  40. Thank you! Co-investigators Rosie D. Lyles, Karen Lolans, Mary K. Hayden, Alexander J. Kallen, Stephen G. Weber, Robert A. Weinstein, and William E. Trick CDC John Jernigan, Scott Fridkin Illinois Department of Public Health Craig Conover Cook County department of public health Sue Gerber Hospital epidemiologists and infection preventionists at all 26 hospitals REALM update

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