Presentation on theme: "John A. Jernigan Division of Healthcare Quality Promotion"— Presentation transcript:
1Prevention and Control of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus John A. JerniganDivision of Healthcare Quality PromotionCenters for Disease Control and PreventionApril 29, 2008The 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
2Continuing Education Credits DISCLAIMER: In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. CDC, our planners, and the presenters for this seminar do not have financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. This presentation does not involve the unlabeled use of a product or product under investigational use.
3Source: Hidron et al., abstract presentation, SHEA 2008
4Most Invasive MRSA Infections Are Healthcare-Associated In the US in 2005 there were:94,360 invasive MRSA infections18,650 associated deaths14%86%Healthcare-AssociatedCommunity-AssociatedSource: ABCs Population-based surveillance System, Klevens et al. JAMA 2007
5Why is the Emergence of MRSA as a Healthcare Pathogen Important? Has emerged as one of the predominant pathogens in healthcare-associated infectionsTreatment options are limited and less effectivehigher morbidity and mortalityHigh prevalence major influence on unfavorable antibiotic prescribing, which contributes to further spread of resistanceprevalent MRSA more glycopeptide use more glycopeptide resistance (VRE VRSA) more linezolid/daptomycin use more resistance
6Why is the Emergence of MRSA as a Healthcare Pathogen Important? Adds to overall S. aureus infection burdenRepresents a failure to contain transmission of drug-resistant bacteriaA marker for our ability to contain transmission of important pathogens in the healthcare settingLearning how to successfully control of MRSA is likely to have benefits that extend to other pathogens
7The emergence of MRSA has been due to transmission of relatively few clones, not de novo selection Hiramatsu, et al. Trends in Microbiology 2001;9:486
8A Few CA-MRSA Strains Cause Most Community Outbreaks 100%80%60%AthletesPrisonersChildrenHospital StrainMissouriCaliforniaTexasPennsylvaniaMississippiColoradoGeorgiaTennesseeUSAUSA100USA200CommunityPneumonia (AL, AR, IL, MD, TX, WA)100%80%60%AthletesPrisonersChildrenHospital StrainMissouriCaliforniaTexasPennsylvaniaMississippiColoradoGeorgiaTennesseeUSAUSA100USA200CommunityPneumonia (AL, AR, IL, MD, TX, WA)100%80%60%AthletesPrisonersChildrenHospital StrainMissouriCaliforniaTexasPennsylvaniaMississippiColoradoGeorgiaTennesseeUSAUSA100USA200CommunityPneumonia (AL, AR, IL, MD, TX, WA)100%80%60%AthletesPrisonersChildrenHospital StrainMissouriCaliforniaTexasPennsylvaniaMississippiColoradoGeorgiaTennesseeUSAUSA100USA200CommunityPneumonia (AL, AR, IL, MD, TX, WA)A Few CA-MRSA Strains Cause Most Community Outbreaks60%60%80%80%100%100%Pneumonia (AL, AR, IL, MD, TX, WA)Pneumonia (AL, AR, IL, MD, TX, WA)MissouriMissouriCaliforniaCaliforniaAthletesAthletesPennsylvaniaPennsylvaniaColoradoColoradoMississippiMississippiTexasTexasPrisonersPrisonersGeorgiaGeorgiaTennesseeTennesseeTexasTexasMissouriMissouriChildrenChildrenCaliforniaCaliforniaUSAUSACommunityCommunityUSA100USA100Hospital StrainHospital StrainUSA200USA200Hospital StrainHospital Strain
9Key Prevention Strategies Campaign to Prevent Antimicrobial Resistance in Healthcare SettingsKey Prevention StrategiesPrevent infectionDiagnose and treat infection effectivelyUse antimicrobials wiselyPrevent transmissionThese 4 strategies – preventing infection, diagnosing and treating infection effectively, using antimicrobials wisely, and preventing transmission - form the framework for CDC’s Campaign to Prevent Antimicrobial Resistance.Clinicians and their patient care partners hold the solution to integrating these strategies into daily practice and optimizing the care and safety of all patients.Clinicians hold the solution!
10Source: Burton et al., abstract presentation, SHEA 2008
11Key Prevention Strategies Campaign to Prevent Antimicrobial Resistance in Healthcare SettingsKey Prevention StrategiesPrevent infectionDiagnose and treat infection effectivelyUse antimicrobials wiselyPrevent transmissionThese 4 strategies – preventing infection, diagnosing and treating infection effectively, using antimicrobials wisely, and preventing transmission - form the framework for CDC’s Campaign to Prevent Antimicrobial Resistance.Clinicians and their patient care partners hold the solution to integrating these strategies into daily practice and optimizing the care and safety of all patients.Clinicians hold the solution!
12Preventing transmission is an important part of MRSA control Entire healthcare-associated MRSA problem caused by spread of a few clonesPreventing 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 agentsPreventing colonization helps prevent infectionsIncluding those that might happen post-discharge (newly colonized patients have up to 30% risk of infection in the ensuing year)
13Most Healthcare-Associated Invasive MRSA Infections Have Their Onset Outside of the Hospital 28%14%59%Community-AssociatedHealthcare-Associated (community-onset)Healthcare-Associated (hospital-onset)Source: ABCs Population-based surveillance System, Klevens et al. JAMA 2007
14Regional Spheres of Influence Within Spectrum of Inpatient Care Nursing Home 1NH 2Hospital ANursing Home 3Hospital BNursing Home 4Hospital c
15Predicted Number of EMRSA-15 Outbreaks During , United Kingdom900700600500400300200100800100%80%60%40%20%EMRSA-15 outbreaks30% Duration30% transmission30%both% of Facilities Implementing InterventionSource: Austin JID 1999;179:883
16How best to prevent MRSA Transmission in Healthcare Settings? Controversial subjectstandard 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 aloneShould active surveillance be used to identify carriers?If so, in what settings?
17HICPAC Guidance On Management of Multidrug-Resistant Organisms (MDROs) in Healthcare Settings First Tier: General Recommendations For All Acute Care SettingsIf endemic rates not decreasing, orif first case of important organismSecond Tier: Intensified Interventions
18HICPAC MDRO Guidance (acute care) First Tier: General Recommendations For All Acute Care Settings Administrative engagementMake MDRO prevention and control an organizational patient safety priorityImplement a multidisciplinary process to monitor and improve healthcare personnel (HCP) adherence to recommended practicesfeedback on facility and patient-care unit trends in MDRO incidence and adherence measureEducation and training of personnelJudicious use of antimicrobial agentsStandard precautions for all patientsContact 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
19HICPAC MDRO Guidance (acute care) Indications for moving to second tierFirst case or outbreak of an epidemiologically important MDROWhen endemic rates of a target MDRO are not decreasing despite implementation of and correct adherence to the first tier measures
20HICPAC 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 negativeAdditional recommendations for intensifying:administrative engagement/correction of systems failuresEducation and training of personnel/adherence monitoringJudicious use of antimicrobial agentsmonitoring of trendsCohorting of staff to the care of MDRO patients onlyEnhanced environmental measuresConsult with experts on case-by-case basis regarding use of decolonization therapy for patients or staffIf transmission continues despite full implementation of above, stop new admissions to the unit.
21MDRO and CDAD Module Multidrug-Resistant Organism (MDRO) and Clostridium difficile-Associated Disease (CDAD) Module
22Protocol available online at: MDRO and CDAD ModuleOrganisms 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:
23Goal 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
24MDRO and CDAD Module Reporting Requirements and Options Include: Required:Infection Surveillance (not required for CDAD)Optional:Proxy Infection Measures:Laboratory-Identified (LabID) EventPrevention Process Measures:Monitoring Adherence to Hand HygieneMonitoring Adherence to Gown and Gloves UseMonitoring Adherence to Active Surveillance TestingActive Surveillance Testing (AST) Outcome Measures
25NHSN MRSA Metrics Metric Description Calculation Comment 1 Nosocomial MRSA Infection Rate# NHSN MRSA infections/1000 pt-daysBy selected patient-care location only (i.e., MICU, SICU, etc.); uses NHSN criteria to define infections2Incidence Rate of Hospital-Onset MRSA Based on Clinical Cultures# 1st MRSA specimens /1000 pt-daysHospital-wide is easiest, can also restrict to selected locations; evaluating same locations as Metric 1 may be most useful; uses positive culture data only3aIncidence Rate of Hospital-Onset MRSA Bloodstream Infections (BSI) Based on Clinical Cultures# MRSA BSI specimens /1000 pt-days3bAdmission Prevalence MRSA BSI Rate (community-onset infections)# MRSA BSI specimens /1000 admissions4Direct MRSA Acquisition# new MRSA cultures /1000 pt-daysRequires data from active surveillance testing (AST) program; selected locations only5Adherence to Process MeasuresCompliance RateRequires data from observational assessment and/or from AST program; selected locations only6Central Line-Associated Bloodstream Infections (CLABSI) (all pathogens)# CLABSI/1000 line daysBy selected locations only; requires following the Device-Associated Module-CLABSI protocol
26Opportunities for MRSA Prevention Research Impact of focusing on high risk unitsUse of topical antimicrobials/antiseptics for eradicating or suppressing S. aureus colonizationChlorhexidine 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) MRSAImpact of hospital-based prevention programs on HACOUse of mathematical modeling to understanding inter-facility transmission dynamics and implications for preventionNovel techniques for changing organization culture as a means to improve adherence
27Conclusions 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-associatedEpidemic strains of MRSA originally associated with the community have emerged as important causes of hospital-acquired infectionsMRSA infections and transmission can be prevented, even in endemic settings in the USEffective control programs must be multifaceted, and broad institutional commitment, including measurement of impact, is required for successful implementation
28Acknowledgments Rachel Gorwitz Kate Ellingson Monina Klevens David KleinbaumVal GebskiJonathan EdwardsPei-Jean ChangAlexander KallenScott FridkinMonina KlevensJeff HagemanFred TenoverMelissa MorrisonTeresa HoranRobert MuderRajiv JainThe Active Bacterial Core Surveillance Investigators/TeamsDawn SievertDeron BurtonAlicia HidronDan Pollock
29Continuing Education guidelines require that the attendance of all who participate in COCA Conference Calls be properly documented. ALL Continuing Education credits (CME, CNE, CEU and CHES) for COCA Conference Calls are issued online through the CDC Training & Continuing Education Online systemThose who participate in the COCA Conference Calls and who wish to receive CE credit and will complete the online evaluation by April 26, 2008 will use the course code EC1265. Those who wish to receive CE credit and will complete the online evaluation between April 27, 2008 and March 27, 2009 will use course code WD1265. CE certificates can be printed immediately upon completion of your online evaluation. A cumulative transcript of all CDC/ATSDR CE’s obtained through the CDC Training & Continuing Education Online System will be maintained for each user.
30CME: CDC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. CDC designates this educational activity for a maximum of 1 Category 1 credit toward the AMA Physician's Recognition Award. Physicians should only claim credit commensurate with the extent of their participation in the activity.CNE: This activity for 1.0 contact hours is provided by CDC, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditations.CEU: CDC has been reviewed and approved as an authorized provider by the International Association for Continuing Education and Training (IACET), 8405 Greensboro Drive, Suite 800, McLean, VA CDC has awarded 0.1 CEU to participants who successfully complete this program.CHEC: CDC is a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event for the CHES to receive 1 Category I Contact Hour(s) in health education. CDC provider number GA0082.