1 st European S. aureus & Surgical Site Infection Round Table MRSA Prescreening and Elimination: New England Baptist Hospital Experience Vienna, Austria March 5th Vienna, Austria March 5th Move on and Improve Maureen Spencer, M.Ed., RN, CIC Infection Preventionist Consultant Boston, MA Maureen Spencer, M.Ed., RN, CIC Infection Preventionist Consultant Boston, MA

New England Baptist Hospital 150-bed adult medical/surgical hospital located in Mission Hill area of Boston Orthopedic subspecialty hospital Acute inpatient discharges: 75% Orthopedic 8% General Surgery 17% Medical Orthopedic Surgery ~ 12,000/cases a year 4500 total joints 3500 spine cases 4000 general and outpatient

February anonymous nares cultures after patient anesthetized Results: 38 – S. aureus (29%) *5 - MRSA ( 4%) all previously undiagnosed *no precautions used in OR, PACU or nursing units *Cefazolin used for antibiotic prophylaxis Anonymous Nasal Culture Study

Screening Proposals February 2006 – prepared three screening proposals with costs 1) Traditional nasal cultures - 3 day results $245, )Purchase rapid PCR equipment $337, )Lease rapid PCR equipment $259, March 2006 –Board approval of equipment purchase

March – October 2006 –Weekly meetings: surgical services, infection control, micro, administration, & medical staff members –July 2006 – letter to surgeons –July 17, 2006 – initiated pilot on Spine Service –August 2006 – letter to medical staff –September 2006 – initiated universal pre-op screening program for all inpatient surgery Implementation – 8 Months

Policy & Procedure Protocol developed for all departments & units affected –OR Scheduling –Patient Access –Prescreening Unit –Pre-surgical unit –Operating Room –PACU –Nursing Units –Microbiology Lab –Ancillary Departments: Housekeeping, Central Transport, Radiology, etc.

Preadmission Preoperative Screening Program Instituted Nasal swabs during prescreening process Microbiology Laboratory PCR detects presence of bacteria-specific DNA –Cepheid GeneXpert Topical decolonization protocol for patients found to be carriers of S. aureus or MRSA

Decolonization Protocol Intranasal 2% mupirocin ointment BID x 5 days Pre-op shower with 2% chlorhexidine daily x 5 days Patients called by preadmission testing to initiate treatment protocol Repeat call to document compliance MRSA carriers re-screened prior to surgery Contact precautions if 2nd MRSA screen positive Vancomycin for surgical prophylaxis for patients with history of MRSA carrier status

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First year (2006) cost ~$400,000 ~$100,000 for 2 full-time positions: Microbiologist & PASU Medical Technician ~$60,000 PCR rapid test equipment ~Lab cost for PCR ~$40.00/test (compared to routine culture ~ $20.00) ~ 6,000 inpatient surgeries = $240,000 NEBH Program Budget

Intangible Benefits S. aureus/MRSA prescreening & decolonization program viewed 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 Allows for adjustment of surgical prophylaxis to Vancomycin for MRSA patients

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Polymerase Chain Reaction (PCR) for Nasal Screens – Lab Challenges Instructing nursing staff on how to obtain nares specimen with proper swabs Lab differentiation of the colonized screens from routine cultures. Molecular lab in a short time frame with Cepheid’s GeneXpert System Reporting system for positive results to prescreening, operating room, post- anesthesia unit, infection control

14 3 Simple steps Easy workflow in less than 1 minute Results in One Hour

Institutional Prescreening for Detection and Elimination of Methicillin Resistant Staphylococcus aureus in Patients Undergoing Elective Orthopaedic Surgery Kim DH, Spencer M, Davidson SM, et al. J Bone Joint Surg Am 2010;92: Control Period 10/2005-6/2006 Study Period 6/2006-9/2007 p value N MRSA Infection10 (0.18%)4 (0.06%) MSSA Infection14 (0.26%)9 (0.13%) Total SSIs24 (0.45%)13 (0.18%)0.0093

0. 18 % % 0.26% 0.13 % 50% Reduction in MSSA SSI 60% Reduction in MRSA SSI MRSA SSI RateMSSA SSI Rate 10/01/05-07/16/0607/17/06-09/30/0710/01/05-07/16/0607/17/06-09/30/07

17 SSIs– Increased Risk with MRSA MRSA colonized patients had an increased risk of SSI Seven (7) Staph aureus infections in 2712 positives 0.19% Seven (7) MRSA infections in the 576 positives 1.21% Statistically significant difference p=< % 1.21%

Pre-op MRSA and S. aureus Decolonization Results: Timeframe:July 17, 2006 through September 2010 Colonization:20,065 patient screened 5,988 (23%) positive for Staph aureus 1,027 ( 4%) positive for MRSA Decolonization:Repeat nasal screens on MRSA patients revealed 77% elimination 18

Pre-op MRSA and S. aureus Infections Results: % MRSA and S. aureus SSI 19 Time Period Inpatient Surgeries # of Surgical Infections %MRSA/MSSA FY06 10/01/05-07/16/06* 5,293*24*0.45%* FY07 07/17/06-09/30/07 7, % FY08 10/01/07-09/30/08 6, % FY09 10/01/08-09/30/09 6, % FY10 10/01/10-09/30/10 6, % *Historical Controls

Pre-op MRSA Infections Results: % MRSA SSI in Screened Patients 20 Time Period Inpatient Surgeries # MRSA SSIs MRSA% #Infect/#MRSA + FY06 10/01/05-07/16/06 5,29310 (NA)0.19% NA (historical controls) FY07 07/17/06-09/30/07 7,0193 (3+)0.04%3/309 (0.97%) FY08 10/01/07-09/30/08 6,2454 (2+)0.06%2/242 (0.83%) FY09 10/01/08-09/30/09 6,3366* (2+)0.09%2/234 (0.85%) FY10 10/01/10-09/30/10 6,4371 (1+)0.01%1/266 (0.37%) * 5 of the 6 available isolates sent for pulse field gel electrophoresis None were related genetically

Pre-op Staph aureus Infections Results: % S. aureus (MSSA) SSI in Screened Patients 21 Time Period Inpatient Surgeries # MSSA SSIs MSSA%#Infect/#MSSA+ FY06 10/01/05-07/16/06 5,29314 (NA)0.26%NA FY07 07/17/06-09/30/07 7,0193 (3+)0.04% 3/1588 (0.19%) FY08 10/01/07-09/30/08 6,2453 (1+)0.05% 1/ 1422 (0.07%) FY09 10/01/08-09/30/09 6,3365 (1+)0.08% 3/1403 (0.21%) FY10 10/01/10-09/30/10 6,4376 (1+)0.09% 1/1450 (0.06%)

Other Studies Supporting MRSA Screening and Decolonization

Mupirocin Resistance in UK In UK – Department of Health policy is active MRSA surveillance and isolate positives Retrospective review of cases of MRSA + nasal screens Approximately 12.2% resistance and 29.7% resistance to Neomycin Recommended treatment for resistant carriers would be chlorhexidine/neomycin (Napseptin) or for neomycin resistant strains use a polyhexamethylene biguanide (Prontoderm) Paper presented at ECCMID 2012

Mupirocin Resistance Mupirocin resistance and methicillin-resistant Staphylococcus aureus (MRSA). J Hosp Infect Jan;35(1):1-8. Emergence of high-level mupirocin resistance in methicillin-resistant Staphylococcus aureus isolated from Brazilian university hospitals. Infect Control Hosp Epidemiol Dec;17(12):813-6 Emergence and spread of low-level mupirocin resistance in methicillin- resistant Staphylococcus aureus isolated from a community hospital in Japan. J Hosp Infect Apr;47(4): Molecular fingerprinting of mupirocin-resistant methicillin-resistant Staphylococcus aureus from a burn unit. Int J Infect Dis Winter;3(2):82-7 The spread of a mupirocin-resistant/methicillin-resistant Staphylococcus aureus clone in Kuwait hospitals. Acta Trop Oct 22;80(2): The antimicrobial activity of mupirocin--an update on resistance. J Hosp Infect 1991 Sep;19 Suppl B:19-25.

Conclusion: 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 Rapid on demand screening with GeneXpert is a big advantage to implement a decolonization program, and a valuable investment as the system is scalable with an extended menu of tests available

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