Prevention and Control of Healthcare-Associated Methicillin- Resistant Staphylococcus aureus John A. Jernigan Division of Healthcare Quality Promotion.

Prevention and Control of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus

John A. JerniganDivision of Healthcare Quality Promotion

Centers for Disease Control and PreventionApril 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

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Source: Hidron et al., abstract presentation, SHEA 2008

Most Invasive MRSA Infections Are Healthcare-Associated

Healthcare-Associated

Community-Associated

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

14% 86%

n=8,987

In the US in 2005 there were:– 94,360 invasive MRSA infections– 18,650 associated deaths

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 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

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

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

selection

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A Few CA-MRSA Strains Cause Most Community Outbreaks

Key Prevention Strategies

Prevent infection Diagnose and treat infection

effectively

Use antimicrobials wisely

Prevent transmission

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Clinicians hold the solution!

Source: Burton et al., abstract presentation, SHEA 2008

Key Prevention Strategies

Prevent infection Diagnose and treat infection

effectively

Use antimicrobials wisely

Prevent transmission

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Clinicians hold the solution!

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)

Community-Associated

14% 59%

28%

Healthcare-Associated (hospital-onset)

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

Regional Spheres of Influence Within Spectrum of Inpatient Care

Hospital A

Hospital B

Nursing Home 1

Nursing Home 4

NH 2

Nursing Home 3

Hospital c

Predicted Number of EMRSA-15 Outbreaks During 1993-98, United Kingdom

Source: Austin JID 1999;179:883

30% transmission

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600

500

400

300

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100

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100%80%60%40%20%

30% Duration

30%bothEM

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199

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9 98

% of Facilities Implementing Intervention

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

First Tier: General Recommendations For All Acute

Care Settings

Second Tier: Intensified Interventions

If endemic rates not decreasing, orif first case of important organism

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)

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

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

Multidrug-Resistant Organism (MDRO) andClostridium difficile-Associated Disease (CDAD)

Module

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 report and analyze data that will inform infection control staff of the impact of targeted prevention efforts

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

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 only3a Incidence Rate of Hospital-Onset

MRSA Bloodstream Infections (BSI) Based on Clinical Cultures

# MRSA BSI specimens /1000 pt-days

3b Admission Prevalence MRSA BSI Rate (community-onset infections)

# MRSA BSI specimens /1000 admissions

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

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

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

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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