MRSA Prevention Strategies for Healthcare and Community Settings

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MRSA Prevention Strategies for Healthcare and
Community Settings

• Pam Webb, RN, CIC
• Infection Control Coordinator
• Benefis Healthcare

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Objectives

• At the end of this session you will be able to
• Describe what MRSA is and how it is spread from
  person to person
• Explain the difference between healthcare
  associated MRSA and community acquired MRSA
• Describe the impact of MRSA in healthcare and
  community settings
• Identify measures to prevent the spread of MRSA
  in the healthcare or community setting

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What is Staphylococcus aureus?

• Staph
• MSSA (methicillin susceptible Staph aureus)
• Bacteria commonly carried on the skin or in the
  nose of healthy people
• 25 30 colonized with Staph
• Major cause of
• Invasive systemic infections
• Skin and soft tissue infections

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What is MRSA?

• Type of Staph aureus that is resistant to an
  antibiotic class called beta-lactams (includes
  methicillin, oxacillin, penicillin, amoxicillin)
• Resistant Staph emerged in 1961
• First associated with hospitals
• Widespread use of antibiotics results in
  resistance

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What is MRSA?

• Commonly found on human skin, nose, perineal and
  rectal areas of the body
• Can cause serious infections
• Spread primarily via contact with contaminated
  hands, skin or fomites
• Antibiotic resistance limits treatment options
  for infections

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Factors Promoting Resistance

• Antibiotic selective pressure
• Prolonged antibiotic courses
• Inadequate dose of antibiotic
• Protected sites/foreign bodies
• Hospitalized patients with weakened immune
  systems
• Inadequate infection prevention and control
  practices

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Whats the difference between HA-MRSA and CA-MRSA?
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HA-MRSA vs. CA-MRSA

• Community Associated
• No recent healthcare exposure
• Contact sports, military recruits, prisoners, IV
  drug users
• PVL toxin gene common
• Susceptible to more antibiotics than HA- MRSA

• Healthcare Associated
• Recent healthcare exposure
• 59 community onset disease
• PVL toxin gene rare
• Resistant to more antibiotics than CA-MRSA

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HA-MRSA vs. CA-MRSAAntibiotic Susceptibilities
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CA-MRSA

• Environmental Conditions
• Living in crowded or unsanitary conditions
• Close contact with someone known to be infected
  or colonized with MRSA
• Contact with a colonized pet
• High incidence of MRSA in the community

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What types of infections does MRSA cause?
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Sites of MRSA InfectionsHealth Care vs.
Community
Median age 68 years 4 were PVL-positive
Median age 23 years 77 were PVL-positive
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CA-MRSA Predominantly Causes Skin Disease
Disease Syndrome () Skin/soft tissue
(SSTI) 1,266 (77) Wound (Traumatic) 157
(10) Urinary Tract Infection 64
(4) Sinusitis 61 (4) Bacteremia 43
(3) Pneumonia 31 (2)
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CA-MRSA Skin and Soft Tissue Infections

• Skin and soft tissue infections can be of many
  types
• Most common presentations are soft tissue
  infections such as boils, abscesses, furuncles,
  carbuncles etc.

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Dont be too quick to blame spiders for those
spider bite wounds!

• Misdiagnosis of MRSA infections as spider bites
  has been occurring throughout the United States
• This misdiagnosis impedes the proper treatment of
  the infection and facilitates the spread of the
  infection.

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What is the impact of MRSA?
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Implications for Antimicrobial Resistance

• Limited treatment options, treatment failure
• Increased morbidity and mortality
• MRSA are transmissible
• Increased healthcare costs
• Decreased patient satisfaction
• Can negatively impact quality of life

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Impact of MRSA
PHC4 Research Brief MRSA in Pennsylvania
Hospitals Issue 10 August 2006
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Burden of Disease

• Nationally 59 of SSTIs in ERs attributed to
  MRSA
• Varied geographically from 15-74
• Recent APIC study estimated 1.2 million
  infections in hospitalized patients per year 10
  times previous estimate
• Total prevalence of 46/1000 patients either
  infected or colonized
• Last estimate was 3.9/1000
• Two-thirds of MRSA patients were found on medical
  floors
• 77 admitted to hospital already colonized or
  infected

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Burden of DiseaseTrends in MRSA for Montana
Based on results from state-wide antimicrobial
susceptibility testing survey of laboratories
conducted by Montana DPHHS 1 Preliminary
analysis of 2006 data For more information,
contact the Montana Antibiotic Resistance
Awareness Program at [phone]
(www.mara.mt.gov)
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U.S. Federal and State Policy Actions

• 5 states discussing legislation of MRSA
  eradication program, including Active
  Surveillance IL, NJ, NY, PA and MD SHEA/APIC
  in opposition
• Legislation passed May 25th in Minnesota
• CMS Deficit Reduction Act (DRA) proposals for
  non-reimbursement of certain HAIs starting Oct
  08
• Catheter-associated UTIs - Vascular catheter HAIs
• Staph aureus septicemia - Vent Associated
  Pneumonias
• MRSA infections -Surgical site infections
• Clostridium difficile associated disease
• SELECTING 6 CONDITIONS FOR IMPLEMENTATION OCT 08

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Reporting MRSA Infections in Montana

• Individual cases of MRSA are not specifically
  reportable conditions in Montana.
• Some states require selective reporting of only
  invasive infections
• Some states are considering legislation to
  require reporting of all MRSA infections
  (Tennessee, Texas)
• Clusters of 4 or more culture confirmed MRSA
  infections within a common setting/venue within a
  month long period are reportable
• http//arm.sos.mt.gov/37137-28771.htm

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How can MRSA transmission be prevented?
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Modes of transmission

• Primarily person-to-person via hands
• Environmental Contact w/ contaminated items

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Infection Control- Healthcare Setting
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Active Surveillance (ASC)

• Colonization usually precedes infection
• Purpose of ASC is to find unrecognized MRSA
  reservoirs to prevent spread
• Nares (culture or PCR test) most common site
• Groin, perineum, rectal, open wounds (culture)

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Colonization vs. Infection

• Colonization
• No signs and symptoms
• Sites differ
• CA-MRSA groin, axilla, vagina, rectum
• HA-MRSA nares and invasive device sites

• Infection
• Clinical signs and symptoms, e.g., skin wound
• Usually requires medical intervention

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Reservoir for the Spread of Antibiotic Resistant
Pathogens
clinical infections
colonized (asymptomatic)
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BHC Active Surveillance

• Identify surveillance groups based on facility
  risk assessment
• Traditional groups new clinical cultures, admit
  from nursing home, readmit with previous history
  of infection or colonization
• Additional groups Critical Care Total Joint
  Surgery

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Active Surveillance- Communication

• Flag chart for readmission so that contact
  isolation can be implemented immediately
• Keep a patient/resident line listing
• Communicate MRSA status to receiving facility

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Contact Isolation

• Patient/Resident Placement
• Private room preferable
• If need to cohort avoid placing MRSA patient or
  resident with roommate who
• Has open wound, nonintact skin, surgical
  incision, ostomy
• Has trach, or uncontrolled respiratory secretions
• Has invasive devices such Foley catheter, JP
  tubes. chest tubes
• Is on a ventilator
• Is culture positive for another multi-drug
  resistant organism such as VRE (Vancomycin
  resistant Enterococcus)
• Is incontinent of urine or feces or has drainage
  from a site that cant be contained

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Decolonization Strategies

• Not necessary for every case of MRSA colonization
  (ex. chronic colonization)
• Used for control of outbreak situation
• Decolonization regimens may include
• Mupirocin ointment to nares bid x 5 days
• Oral antibiotics
• Chlorhexidine showers

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Decolonization _at_ BHC

• Mupirocin ointment to nares bid x 5 days for
  positive nares PCR
• Repeat nares screen (culture) at least 24 hours
  after last dose
• Goal is to discontinue isolation though
  decolonization might be transient
• DC isolation when nares and clinical culture
  negative nares negative consider whether
  patient has non-intact skin before discontinuing
  isolation

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Interim Guidelines for the Control and
Prevention ofMethicillin-Resistant
Staphylococcus aureus (MRSA) Skin and Soft Tissue
Infectionsin Non-Healthcare SettingsAugust,
2007
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CA-MRSA GuidelinesPrevention - Four Simple Steps

• Hand hygiene
• Keep wounds clean and covered
• Dont share personal items
• Clean environmental surfaces regularly

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Hand Hygiene
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Example of an EPA Registered Disinfectant

• LYSOL ? Brand ICTM Ready to Use Disinfectant
  Cleaner
• Kills 99.9 of bacteria in 30 seconds on hard
  nonporous surfaces
• Meets the requirements of the OSHA Bloodborne
  Pathogens Standard
• Effective against Tuberculosis (TB), Poliovirus,
  and
• Human Immunodeficiency Virus Type 1 (HIV-1)
  (Aids-Virus)
• Contains no bleach, phenol, alcohol, or harsh
  abrasives
• EPA Registration No. 675-55

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Mixing Bleach Solutions for Disinfection

• For routine disinfection of non-porous surfaces
• 1100 dilution of household chlorine bleach
  (5.25)
• 2 ½ tablespoons of bleach in a gallon of water
• Open bottles of bleach lose effectiveness after
  30 days change bleach every 30 days for accurate
  concentrations.
• Chlorine solutions are most effective if mixed on
  a daily basis.
• Leave on surface for 5-10 minutes to achieve
  maximum disinfection
• ALWAYS make sure surface/item is compatible with
  bleach
• NEVER use bleach to clean a persons skin

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Dealing with Skin Infections in the Community

• Prevent Transmission
• The 4 Steps!
• Evaluate and Refer

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Evaluate and Refer

• Any unusual skin lesion or draining wound is
  potentially infectious to others and should be
  evaluated by a health care provider.
• Encourage persons with skin and soft tissue
  infections to see their health care provider
  promptly for evaluation and treatment.

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Use Antibiotics Appropriately

• If you have a virus, dont demand antibiotics
  they wont work!
• The presence of yellow/green mucus does not mean
  the infection is bacterial
• If antibiotics are prescribed, take as directed
  and finish them
• Dont save or share antibiotics

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Where can you get more information?
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Centers for Disease Control and
Prevention http//www.cdc.gov/ncidod/dhqp/ar_mrsa_
ca.html
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Montana Antimicrobial Resistance
Awareness www.mara.mt.gov
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Montana Antibiotic Resistance Awareness Program
Antibiotic Resistance Awareness Program MT
DPHHS- Communicable Disease Control and
Prevention BureauCogswell Building, RM
C-2161400 Broadway PO Box 202951Helena, MT
59620Phone [phone]Fax (406)
444-0272Email hhsmara_at_mt.gov or
www.mara.mt.gov
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Resources

• www.apic.org
• MRSA webinars
• Guide to the Elimination of Methicillin-Resistant
  Staphylococcus aureus (MRSA) Transmission in
  Hospital Settings, March 2007
• Dispelling the Myths The True Costs of
  Healthcare-Associated Infections, February 2007
• www.cdc.gov
• Management of Multidrug-Resistant Organisms in
• Healthcare Settings, 2006
• Living with MRSA booklet and handouts
• www.doh.wa.gov/Topics/Antibiotics/MRSA.htm

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Resources

• www.ihi.org/IHI/Programs/Campaign
• Getting Started Kit Reduce Methicillin-Resistant
  Staphylococcus aureus Infection How to Guide
• www.dphhs.mt.gov/PHSD/MARA/documents/MT-DPHHSMRSAG
  uidelinesFINAL090507.pdf
• Muto, C., Jernigan, J., Ostrowsky, B., Richet,
  H., Jarvis, W., Boyce, J., Farr, B., SHEA
  Guideline for Preventing Nosocomial Transmission
  of Multidrug-Resistant Strains of Staphylococcus
  aureus and Enterococcus, Infection Control and
  Hospital Epidemiology, May 2003

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Questions?

• Pam Webb, IC Coordinator, Benefis Health System
• 406.455.4292
• webbpama_at_benefis.org
• Bonnie Barnard, Epidemiologist, MTDPHHS
• 406.444.0274
• bbarnard_at_mt.gov