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

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

Most Invasive MRSA Infections Are Healthcare-Associated In the US in 2005 there were: 94,360 invasive MRSA infections 18,650 associated deaths 14% 86% Healthcare-Associated Community-Associated Source: ABCs Population-based surveillance System, Klevens et al. JAMA 2007

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

The 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

A Few CA-MRSA Strains Cause Most Community Outbreaks 100% 80% 60% Athletes Prisoners Children Hospital Strain Missouri California Texas Pennsylvania Mississippi Colorado Georgia Tennessee USA300-114 USA100 USA200 Community Pneumonia (AL, AR, IL, MD, TX, WA) 100% 80% 60% Athletes Prisoners Children Hospital Strain Missouri California Texas Pennsylvania Mississippi Colorado Georgia Tennessee USA300-114 USA100 USA200 Community Pneumonia (AL, AR, IL, MD, TX, WA) 100% 80% 60% Athletes Prisoners Children Hospital Strain Missouri California Texas Pennsylvania Mississippi Colorado Georgia Tennessee USA300-114 USA100 USA200 Community Pneumonia (AL, AR, IL, MD, TX, WA) 100% 80% 60% Athletes Prisoners Children Hospital Strain Missouri California Texas Pennsylvania Mississippi Colorado Georgia Tennessee USA300-114 USA100 USA200 Community Pneumonia (AL, AR, IL, MD, TX, WA) A Few CA-MRSA Strains Cause Most Community Outbreaks 60% 60% 80% 80% 100% 100% 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 Missouri Missouri Children Children California California USA300-114 USA300-114 Community Community USA100 USA100 Hospital Strain Hospital Strain USA200 USA200 Hospital Strain Hospital Strain

Key Prevention Strategies Campaign to Prevent Antimicrobial Resistance in Healthcare Settings Key Prevention Strategies Prevent infection Diagnose and treat infection effectively Use antimicrobials wisely Prevent transmission These 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!

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

Key Prevention Strategies Campaign to Prevent Antimicrobial Resistance in Healthcare Settings Key Prevention Strategies Prevent infection Diagnose and treat infection effectively Use antimicrobials wisely Prevent transmission These 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!

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 28% 14% 59% Community-Associated Healthcare-Associated (community-onset) Healthcare-Associated (hospital-onset) Source: ABCs Population-based surveillance System, Klevens et al. JAMA 2007

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

Predicted Number of EMRSA-15 Outbreaks During 1993-98, United Kingdom 900 700 600 500 400 300 200 100 800 100% 80% 60% 40% 20% EMRSA-15 outbreaks 1993-1998 30% Duration 30% transmission 30%both % of Facilities Implementing Intervention Source: Austin JID 1999;179:883

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 If endemic rates not decreasing, or if first case of important organism Second Tier: Intensified Interventions

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) and Clostridium difficile-Associated Disease (CDAD) Module

Protocol available online at: 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 only 3a 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 Monina Klevens 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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