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

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Source Hidron et al., abstract presentation,
SHEA 2008
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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

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The emergence of MRSA has been due to
transmission of relatively few clones, not de
novo selection
Hiramatsu, et al. Trends in Microbiology
20019486
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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
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Key Prevention Strategies

• Prevent infection
• Diagnose and treat infection effectively
• Use antimicrobials wisely
• Prevent transmission

Clinicians hold the solution!
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Source Burton et al., abstract presentation,
SHEA 2008
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Key Prevention Strategies

• Prevent infection
• Diagnose and treat infection effectively
• Use antimicrobials wisely
• Prevent transmission

Clinicians hold the solution!
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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)

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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
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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
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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?

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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
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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

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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

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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.

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MDRO and CDAD Module
Multidrug-Resistant Organism (MDRO)
and Clostridium difficile-Associated Disease
(CDAD) Module
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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
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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

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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

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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
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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

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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

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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

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