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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.

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prevention and control of healthcare associated methicillin resistant staphylococcus aureus

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

slide2
Continuing Education Credits DISCLAIMER:In 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.
most invasive mrsa infections are healthcare associated

Healthcare-Associated

Community-Associated

Most Invasive MRSA Infections Are Healthcare-Associated
  • In the US in 2005 there were:
    • 94,360 invasive MRSA infections
    • 18,650 associated deaths

n=8,987

14%

86%

Source: ABCs Population-based surveillance System, Klevens et al. JAMA 2007

why is the emergence of mrsa as a healthcare pathogen important
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
why is the emergence of mrsa as a healthcare pathogen important6
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
slide7

The emergence of MRSA has been due to transmission of relatively few clones, not de novo selection

Hiramatsu, et al. Trends in Microbiology 2001;9:486

slide8

100%

100%

100%

100%

80%

80%

80%

80%

60%

60%

60%

60%

Pneumonia (AL, AR, IL, MD, TX, WA)

Pneumonia (AL, AR, IL, MD, TX, WA)

Pneumonia (AL, AR, IL, MD, TX, WA)

Pneumonia (AL, AR, IL, MD, TX, WA)

Missouri

Missouri

Missouri

Missouri

California

California

California

California

Athletes

Athletes

Athletes

Athletes

Pennsylvania

Pennsylvania

Pennsylvania

Pennsylvania

Colorado

Colorado

Colorado

Colorado

Mississippi

Mississippi

Mississippi

Mississippi

Texas

Texas

Texas

Texas

Prisoners

Prisoners

Prisoners

Prisoners

Georgia

Georgia

Georgia

Georgia

Tennessee

Tennessee

Tennessee

Tennessee

Texas

Texas

Texas

Texas

Children

Children

Children

Children

Missouri

Missouri

Missouri

Missouri

California

California

California

California

USA300-114

USA300-114

USA300-114

USA300-114

Community

Community

Community

Community

USA100

USA100

USA100

USA100

Hospital Strain

Hospital Strain

Hospital Strain

Hospital Strain

Hospital Strain

Hospital Strain

Hospital Strain

Hospital Strain

USA200

USA200

USA200

USA200

A Few CA-MRSA Strains Cause Most Community Outbreaks

100%

100%

80%

80%

60%

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

key prevention strategies

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Key Prevention Strategies
  • Prevent infection
  • Diagnose and treat infection effectively
  • Use antimicrobials wisely
  • Prevent transmission

Clinicians hold the solution!

key prevention strategies11

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Key Prevention Strategies
  • Prevent infection
  • Diagnose and treat infection effectively
  • Use antimicrobials wisely
  • Prevent transmission

Clinicians hold the solution!

preventing transmission is an important part of mrsa control
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)
most healthcare associated invasive mrsa infections have their onset outside of the hospital

Healthcare-Associated (community-onset)

Healthcare-Associated (hospital-onset)

Community-Associated

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

slide14

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

slide15

900

800

700

600

500

400

300

200

100

20%

40%

60%

80%

100%

Predicted Number of EMRSA-15 Outbreaks

During 1993-98, United Kingdom

EMRSA-15 outbreaks 1993-1998

30% Duration

30% transmission

30%both

% of Facilities Implementing Intervention

Source: Austin JID 1999;179:883

how best to prevent mrsa transmission in healthcare settings
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?
hicpac guidance on management of multidrug resistant organisms mdros in healthcare settings
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

hicpac mdro guidance acute care first tier general recommendations for all acute care settings
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
hicpac mdro guidance acute care
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
hicpac mdro guidance acute care second tier intensified interventions for acute care settings
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.
mdro and cdad module
MDRO and CDAD Module

Multidrug-Resistant Organism (MDRO) and

Clostridium difficile-Associated Disease (CDAD) Module

mdro and cdad module22
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/ncidod/dhqp/nhsn_MDRO_CDAD.html

goal of the mdro and cdad module
Provide a mechanism for healthcare facilities to reportand analyze data that will inform infection control staff of the impact of targeted prevention effortsGoal of the MDRO and CDAD Module
mdro and cdad module24
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
opportunities for mrsa prevention research
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
conclusions
Conclusions
  • The burden of MRSAremains 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
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

Acknowledgments
slide29
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 May 28, 2008 will use the course code EC1265. Those who wish to receive CE credit and will complete the online evaluation between May 29, 2008 and April 29, 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 CE’s obtained through the CDC Training & Continuing Education Online System will be maintained for each user.
slide30
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 program.

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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