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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

REALM project updateMRSA and KPCJanuary 26, 2011

Michael Lin, MD MPH

on behalf of REALM co-investigators

outline
Outline
  • MRSA surveillance

a. Overview and main results

b. Contact precautions analysis

c. NICU analysis

  • KPC surveillance and future directions

REALM update

slide3
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

design
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

design cont
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

results
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

mupirocin resistance
Mupirocin resistance

Surveys 1-5 combined

REALM update

mrsa trend summary
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

outline1
Outline
  • MRSA surveillance

a. Overview and main results

b. Contact precautions analysis

c. NICU analysis

  • KPC surveillance and future directions

REALM update

contact precautions analysis
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

methods
Methods
  • Reported by hospital
  • Heterogeneous practice

Admission Surveillance

Study patient timeline

Point Prevalence Surveillance

  • Obtained by study, standardized
  • Variable timing
  • Contact Precautions assessed
admission screen results
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

point prevalence survey results
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

contact precautions results
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

contact precautions results1
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

possible reasons for contact precautions deficit
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

possible reasons for contact precautions deficit1
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

contact precautions summary
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

contact precautions conclusion
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

outline2
Outline
  • MRSA surveillance

a. Overview and main results

b. Contact precautions analysis

c. NICU analysis

  • KPC surveillance and future directions

REALM update

outline3
Outline
  • MRSA surveillance

a. Overview and interim results

b. Contact precautions analysis

c. NICU analysis

  • KPC surveillance and future directions

REALM update

neonatal icu mrsa epidemiology
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

slide30

NeonatalICU

Adult ICU

slide31

NeonatalICU

Median MRSA+

Median MRSA+

Adult ICU

nicu summary
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
outline4
Outline
  • MRSA surveillance

a. Overview and main results

b. Contact precautions analysis

c. NICU analysis

  • KPC surveillance and future directions

REALM update

kpc emerging threat
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

kpc pps rationale
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

design1
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

results1
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

kpc results
KPC results
  • Overall KPC prevalence in adult ICUs:

17 / 459= 4%

REALM update

kpc future directions
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

thank you
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