MRSA Prescreening and MRSA Prescreening and Eradication: Eradication: New England Baptist New England Baptist Hospital Experience Hospital Experience David H. Kim, MD David H. Kim, MD Director of Medical Education Director of Medical Education New England Baptist Hospital New England Baptist Hospital Boston, MA Boston, MA
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MRSA Prescreening and Eradication: New England Baptist Hospital Experience
MRSA Prescreening and Eradication: New England Baptist Hospital Experience. David H. Kim, MD Director of Medical Education New England Baptist Hospital Boston, MA. New England Baptist Hospital. 150-bed adult medical/surgical hospital located in Mission Hill area of Boston - PowerPoint PPT Presentation
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MRSA Prescreening and MRSA Prescreening and Eradication:Eradication:New England Baptist New England Baptist Hospital ExperienceHospital Experience
David H. Kim, MDDavid H. Kim, MDDirector of Medical EducationDirector of Medical EducationNew England Baptist HospitalNew England Baptist HospitalBoston, MABoston, MA
New EnglandBaptist Hospital 150-bed adult
medical/surgical hospital located in Mission Hill area of Boston
Orthopaedic subspecialty hospital & “Center of Excellence”– Acute inpatient discharges:
75% Orthopedic 8% General Surgery 17% Medical
Orthopaedic Surgery ~ 10,000/cases a year
Total Inpatient Volume Massachusetts MarketOrthopaedic Surgery
Most important Most important pathogen in SSIpathogen in SSI
Most SSI caused by Most SSI caused by strains carried by strains carried by patient into hospitalpatient into hospital
Anterior nares main Anterior nares main nicheniche
Nasal carriage of Nasal carriage of S. S. aureusaureus is risk factor is risk factor for SSI for SSI [Kluytmans et al, [Kluytmans et al, Clin Microbiol Rev 1997]Clin Microbiol Rev 1997]
MRSA vs. MSSAMRSA vs. MSSA
Infection associated with higher Infection associated with higher mortalitymortality [Melzer et al, Clin Infect Dis 2003][Melzer et al, Clin Infect Dis 2003]
Survive in dry conditions & on Survive in dry conditions & on inanimate surfaces up to 20 days inanimate surfaces up to 20 days [Clarke et al, Ir Med J 2001][Clarke et al, Ir Med J 2001]
Prevalence increasingPrevalence increasing
History of MRSAHistory of MRSA
Resistance to PCN within 1 yrResistance to PCN within 1 yr– By 1950’s, 3/4 of By 1950’s, 3/4 of S. aureusS. aureus strains PCN- strains PCN-
1959—methicillin (11959—methicillin (1stst antistaph PCN) antistaph PCN) introducedintroduced– 11stst MRSA strain within 2yrs MRSA strain within 2yrs– 60% of clinical 60% of clinical S. aureusS. aureus strains isolated strains isolated
from ICU’s are MRSAfrom ICU’s are MRSA
LinezolidLinezolid
Introduced in 2000 for MRSAIntroduced in 2000 for MRSA
–Resistant strain reported within 1 yearResistant strain reported within 1 year[Tsiodras et al, Lancet 2001][Tsiodras et al, Lancet 2001]
Daptomycin
Introduced in 2003 for MRSA
• Resistant strain reported within 2 yearsResistant strain reported within 2 years[Mangili et al, Clin Infect Dis 2005][Mangili et al, Clin Infect Dis 2005]
Vancomycin Vancomycin ResistanceResistance Recognized after almost 40 yrsRecognized after almost 40 yrs
– 11stst glycopeptide-intermediate glycopeptide-intermediate S. aureusS. aureus (GISA) isolated in Japan in 1996 (GISA) isolated in Japan in 1996 [Hiramatsu et al, J Antimicrob Chemother 1997]
High level resistance appeared in High level resistance appeared in Detroit in 2002Detroit in 2002– vanAvanA gene complex acquired from VRE gene complex acquired from VRE
[Centers for Disease Control and Prevention, MMWR [Centers for Disease Control and Prevention, MMWR Morb Mortal Wkly Rep 2002]Morb Mortal Wkly Rep 2002]
22ndnd strain in Philadelphia strain in Philadelphia 33rdrd strain in New York strain in New York
MIC CreepMIC Creep
Increases in vancomycin MIC in both MRSA Increases in vancomycin MIC in both MRSA & MSSA over time & MSSA over time [Rhee et al, Clin Infect Dis 2005][Rhee et al, Clin Infect Dis 2005]
Largest study of >6000 Largest study of >6000 S. aureusS. aureus isolates isolates over 5 yrs in California university hospitalover 5 yrs in California university hospital– Drift towards reduced susceptibilityDrift towards reduced susceptibility ing percentage of isolates with MIC ≥ 1.0 ing percentage of isolates with MIC ≥ 1.0
μμg/mLg/mL 19.9% in 200019.9% in 2000 70.4% in 200470.4% in 2004 [Wang et al, J Clin Microbiol 2006][Wang et al, J Clin Microbiol 2006]
MIC CreepMIC Creep
’’d vancomycin failure rate in d vancomycin failure rate in MRSA infections in setting of MRSA infections in setting of ’d ’d MICsMICs– [Sakoulas et al, J Clin Microbiol 2005][Sakoulas et al, J Clin Microbiol 2005]
Surgical Site Infection Surgical Site Infection (SSI)(SSI) Increased costsIncreased costs
– Median hospital stay Median hospital stay increased 2 wksincreased 2 wks
[Whitehouse et al, Infect Control Hosp Epidemiol 2002]
SSI CostsSSI Costs
CapitationCapitation– DRGs do not cover DRGs do not cover
cost of treating cost of treating nosocomial nosocomial infection infection (considered (considered “preventable”)“preventable”)
Risk of SSI Increased Risk of SSI Increased in Nasal Carriersin Nasal Carriers Nasal carriage only independent risk Nasal carriage only independent risk
factor for factor for S. aureusS. aureus SSI in orthopaedic SSI in orthopaedic implant surgeryimplant surgery– Kalmeijer et al, Infect Control Hosp Epidemiol 2000Kalmeijer et al, Infect Control Hosp Epidemiol 2000
SSI rate 2-9x higher in carriersSSI rate 2-9x higher in carriers– Kluytmans et al, Clin Microbiol Rev 1997Kluytmans et al, Clin Microbiol Rev 1997– Perl et al, Ann Pharmacother 1998Perl et al, Ann Pharmacother 1998– Wenzel et al, J Hosp Infect 1995 Wenzel et al, J Hosp Infect 1995
In In S. aureusS. aureus SSI, SSI, S.aureusS.aureus isolates from isolates from wound match nares 85% of time wound match nares 85% of time – Perl et al, N Engl J Med 2002Perl et al, N Engl J Med 2002
Risk of MRSA Nasal Risk of MRSA Nasal CarriageCarriage
Case-control study of 308 Case-control study of 308 vascular surgery pts (nasal vascular surgery pts (nasal swabs)swabs)– 11.4% MSSA carriers11.4% MSSA carriers– 4.2% MRSA carriers4.2% MRSA carriers
2.9% on admission2.9% on admission 1.3% acquired in hospital1.3% acquired in hospital
Transfer from another dept or Transfer from another dept or facility risk factors for MRSA facility risk factors for MRSA carriagecarriage
MRSA infection rateMRSA infection rate– 30.8% in MRSA carriers30.8% in MRSA carriers– 0.68% in noncarriers0.68% in noncarriers
[Morange-Saussier et al, Ann Vasc Surg 2006]
Environmental Environmental ReservoirsReservoirs
MRSA infected/colonized pts MRSA infected/colonized pts contaminate rooms, contribute to contaminate rooms, contribute to endemic MRSAendemic MRSA
Prospective study of 25 MRSA ptsProspective study of 25 MRSA pts Sampling of isolation roomsSampling of isolation rooms
– 53.6% of surface samples positive53.6% of surface samples positive– 28% of air samples28% of air samples– 40.6% of settle plates40.6% of settle plates
Isolates identical or closely related Isolates identical or closely related in 70% of patientsin 70% of patients
Kluytmans et al, Infect Control Hosp Kluytmans et al, Infect Control Hosp Epidemiol 1996; Tacconelli et al, Clin Epidemiol 1996; Tacconelli et al, Clin Infect Dis 2003 (Infect Dis 2003 (dialysisdialysis))
– Cimochowski et al, Ann Thorac Surg Cimochowski et al, Ann Thorac Surg 2001; Kluytmans et al, Infect Control 2001; Kluytmans et al, Infect Control Hosp Epidemiol 1996 (Hosp Epidemiol 1996 (CardiovascCardiovasc))
– Gernaat-van der Sluis et al, Acta Gernaat-van der Sluis et al, Acta Orthop Scand 1998 (Orthop Scand 1998 (orthoortho))
– Perl et al, N Engl J Med 2002 (Perl et al, N Engl J Med 2002 (mixedmixed))
Mupirocin and the Risk Mupirocin and the Risk of of S. Aureus S. Aureus (MARS) (MARS) StudyStudy
University of IowaUniversity of Iowa Prospective randomized double-blind placebo-Prospective randomized double-blind placebo-
– Elective cardiothoracic, general, oncologic, gyn, neuro surgeryElective cardiothoracic, general, oncologic, gyn, neuro surgery Rate of Rate of S. aureus S. aureus SSI (primary endpoint)SSI (primary endpoint)
– 2.3% in mupirocin pts2.3% in mupirocin pts– 2.4% in placebo pts2.4% in placebo pts
No reduction in rate of S. aureus SSINo reduction in rate of S. aureus SSI– Among nasal carriers, risk of nosocomial Among nasal carriers, risk of nosocomial S. aureus S. aureus infection infection
decreased by half (7.7% to 4.0%)decreased by half (7.7% to 4.0%)
[Perl et al, N Engl J Med 2002]
MARS StudyMARS Study
Mupirocin nasal swab for up to 5 daysMupirocin nasal swab for up to 5 days Chlorhexidine shower for cardiothoracic Chlorhexidine shower for cardiothoracic
pts night before & morning of surgerypts night before & morning of surgery Power analysisPower analysis
– 4046 pts to detect 50% 4046 pts to detect 50% in in S. aureus S. aureus SSI SSI (estimated reduction of 2.8% (57 pts) to (estimated reduction of 2.8% (57 pts) to 1.4% (28 pts) with 85% power1.4% (28 pts) with 85% power
4030 enrolled, 3551 completed study4030 enrolled, 3551 completed study– 82.6% received at least 3 mupirocin doses 82.6% received at least 3 mupirocin doses
[Perl et al, N Engl J Med 2002]
MARS Study Infection MARS Study Infection RatesRates
Risk of Risk of S. aureus S. aureus infection among nasal carriers cut in halfinfection among nasal carriers cut in half S. aureus S. aureus SSI 4.5x higher in carriers receiving placeboSSI 4.5x higher in carriers receiving placebo 84.6% isolates from SSI pts identical between wound & nares84.6% isolates from SSI pts identical between wound & nares 39 different strains among 77 patients39 different strains among 77 patients Mupirocin resistance in 6/1021 (0.6%) isolates over 4 yrsMupirocin resistance in 6/1021 (0.6%) isolates over 4 yrs
Effect of Universal Effect of Universal Screening: University of Screening: University of Geneva HospitalGeneva Hospital [Harbarth et al, JAMA [Harbarth et al, JAMA
2008]2008] Prospective interventional cohort with crossoverProspective interventional cohort with crossover 21,754 pts (multiple surgical subspecialty wards)21,754 pts (multiple surgical subspecialty wards) Rapid screening + standard infection control Rapid screening + standard infection control
measures vs. standard measures alonemeasures vs. standard measures alone MRSA Screening before or on admission by PCRMRSA Screening before or on admission by PCR Standard infection control for MRSA carriersStandard infection control for MRSA carriers
– Contact isolationContact isolation– Gown, mask, glovesGown, mask, gloves– Adjusted perioperative abxAdjusted perioperative abx– Mupirocin & chlorhexidine x 5 daysMupirocin & chlorhexidine x 5 days
Universal rapid MRSA admission screening did Universal rapid MRSA admission screening did not reduce nosocomial MRSA infectionnot reduce nosocomial MRSA infection
Incidence of MRSA Incidence of MRSA Infections Infections [Harbarth et al, JAMA 2008][Harbarth et al, JAMA 2008]
Harbarth et al: ResultsHarbarth et al: Results 94% (10,193/10,844) screened94% (10,193/10,844) screened
– 21,754 pts--70% power to detect reduction in MRSA infection 21,754 pts--70% power to detect reduction in MRSA infection rate from 0.9% to 0.6%rate from 0.9% to 0.6%
5.1% (515 pts) MRSA-positive5.1% (515 pts) MRSA-positive No difference in MRSA SSI rateNo difference in MRSA SSI rate
– 0.99% (76 pts) without screening0.99% (76 pts) without screening– 1.14% (93 pts) with screening1.14% (93 pts) with screening
57% (53/93 pts) with nosocomial MRSA infection 57% (53/93 pts) with nosocomial MRSA infection during screening period were MRSA-free on during screening period were MRSA-free on admissionadmission– 31% of MRSA carriers identified after surgery31% of MRSA carriers identified after surgery– 43% of MRSA carriers identified before surgery rec’d 43% of MRSA carriers identified before surgery rec’d
None of MRSA carriers detected during None of MRSA carriers detected during outpatient preop visits developed outpatient preop visits developed MRSA infectionMRSA infection– all received decolonization treatment & all received decolonization treatment &
appropriate antibiotic prophylaxisappropriate antibiotic prophylaxis 57% of infections hospital-acquired57% of infections hospital-acquired
Preoperative Preoperative DecolonizationDecolonization University of PittsburghUniversity of Pittsburgh Prospective Prospective
observational studyobservational study Total joint arthroplastyTotal joint arthroplasty 1966 patients1966 patients
– 636 screened (nasal)636 screened (nasal) 26% positive for S. 26% positive for S.
Problem with Problem with Historical ControlsHistorical Controls
University of Amsterdam, The NetherlandsUniversity of Amsterdam, The Netherlands Prospective double-blind, placebo-controlledProspective double-blind, placebo-controlled 614 pts614 pts
– Elective ortho surgery with implants (hip, knee, Elective ortho surgery with implants (hip, knee, spine)spine)
No reduction in SSI rateNo reduction in SSI rate (primary outcome) (primary outcome)– Rate of endogenous Rate of endogenous S. aureus S. aureus infection 5x lowerinfection 5x lower
[Kalmeijer et al, Clin Infect Dis 2002][Kalmeijer et al, Clin Infect Dis 2002]
SSI RateSSI Rate
Spontaneous disappearance of deep Spontaneous disappearance of deep infections (SSI surveillance effect?)infections (SSI surveillance effect?)– Implications for use of historical controlsImplications for use of historical controls
[Kalmeijer et al, Clin Infect Dis 2002][Kalmeijer et al, Clin Infect Dis 2002]
Program for comprehensive prescreening/treatment of S. aureus & MRSA prior to elective surgery is readily established & well-received
Program allows early identification of colonized patients, treatment, & adjustment of antibiotic prophylaxis, early isolation & contact precautions for MRSA
Associated with significant reduction in infections due to S. aureus & MRSA
MRSA colonized patients continue to have higher rate of SSI
death/2500 pts; save $102/ptdeath/2500 pts; save $102/pt
[Young and Winston, Infect Control Hosp Epidemiol 2006][Young and Winston, Infect Control Hosp Epidemiol 2006]
Cost-effectivenessCost-effectiveness
Budget impact model of rapid testing & Budget impact model of rapid testing & decolonizationdecolonization– 7,181,484 elective surgeries in US (2003)7,181,484 elective surgeries in US (2003)– Rapid test cost $25/ptRapid test cost $25/pt
[Noskin et al, Infect Control Hosp Epidemiol 2008]Noskin et al, Infect Control Hosp Epidemiol 2008]
Intangible BenefitsIntangible Benefits
NEBH S. aureus/MRSA prescreening & eradication program viewed very favorably as positive pro-active infection control measure by staff, patients, family members & media
Allows additional patient education on importance of hand hygiene, prevention of SSI, & infection control measures in home to reduce transmission of MRSA & S. aureus
ConcernsConcerns
NEBH Screening Results
7/17/06 to 9/30/07– 7019 patients screened
1588 (22.6%) S. aureus positive 309 ( 4.4%) MRSA positive
Repeat nasal screens of MRSA carriers reveal 78% eradication rate
Prevalence of carriers increasing
Time Period Inpatient surgeries Surgical Infections Infec. Rate
FY06 10/01/05-07/16/06 5293 24 0.46%
FY0707/17/06-09/30/07 7019 13 0.18%
FY0810/01/07-06/30/08 4770 4 0.08%
New England Baptist Hospital
MRSA/MSSA Infection Rates
ConclusionsConclusions
Targeted active surveillance usefulTargeted active surveillance useful– In outbreaksIn outbreaks– In high-risk populations, e.g. ICU’sIn high-risk populations, e.g. ICU’s
Efficacy of universal surveillance & Efficacy of universal surveillance & eradication remains unproveneradication remains unproven– Depends on regional variations in Depends on regional variations in
MRSA/MSSA epidemiologyMRSA/MSSA epidemiology– Depends on hospital surveillance dataDepends on hospital surveillance data