1. The Alarming Rise of CA-MRSA at UMass-Memorial Medical Center David M. Bebinger, M.D. Assistant Professor Division of Infectious Diseases UMass-Memorial Medical Center July 30, 2007

2. MRSA Epidemiology Study Participants   David M. Bebinger, MD   Richard T. Ellison III, MD   Ranjan Chowdhry, MD   Rose Erlichman, RN, BSN, CIC

5. MRSA Trends at UMMC

6. Study Objective To identify demographic features associated with acquisition of CA-MRSA as compared to acquisition of healthcare- associated (HCA) or nosocomially acquired (Noso) MRSA.

7. Methods  A retrospective record review of patients identified previously by the infection control department as being newly diagnosed with an infection or colonization with MRSA between October 1, 2003 and September 30, 2006.   All cases were evaluated by infection control practitioners and categorized as CA, HCA, or Noso.  Of 2920 patients meeting this inclusion criteria 879 were chosen for chart review

8. Total Number of New MRSA Cases TotalCAHCANoso 2003-466993378198 2004-5986278456252 2005-61265557468240 Total29209281302690

9. Information recorded from electronic record review:  Age  Sex  Race  Zip code  Culture site  Healthcare site  Amount of exposure to the UMass system Methods

10. Average Age of Patient by Year *includes neonatal infections CAHCA*NosoTotal 2003-442.066.658.055.5 2004-534.357.955.949.4 2005-635.360.156.250.5 Total37.261.556.7 P<0.0001

11. Average Age of Patient by Year

12. Percentage of Male Patients CAHCANosoTotal 2003-447525650.7 2004-552516154.7 2005-656555956.7 TOTAL51.752.758.7

13. Percentage of Caucasian Patients CAHCANoso 2003-476/8483/9082/86 2004-561/7384/9075/88 2005-672/7776/8481/85 Total73/8385/9383/91 % of total/Adjusted for unlisted race P<0.003

14. Ethnicity

15. MRSA Epidemiology Study Percentage of Cultures Obtained From Inpatient and Emergency Department By Year Inpatient Total Inpatient CA Inpatient HCA ED Total 2003-47558689 2004-564485910 2005-657225916

16. Total #CAHCANoso 2003-467.74334.4 2004-5804920 2005-6864924 Percentage of Cultures labeled “Wound”

18. Patients With Bacteremia by Year CAHCANosoTotal 2003-49121435 2004-5711422 2005-6511420

19. Healthcare exposure: >15 days exposed to UMass System CAHCANoso 2003-416.158.166.7 2004-595563 2005-675157

20. Healthcare exposure: >15 days exposed to UMass System

21. Healthcare exposure: <6 days exposed to UMass System CAHCANoso 2003-458205 2004-572246 2005-677196 ALL67216 P<0.001 P<0.025

22. Healthcare exposure: <6 days exposed to UMass System

23. 2005-6 Antibiogram Data ErythroLevoClindaTMP/ SMX Tetra- cyclin CA576829994 HCA636479892 Noso2263310096 All547559994 Indicates percentage of isolates sensitive to given agent

24. 2005-6 Antibiogram Data

25. A Caveat to Clindamycin Data  “Our lab does not correctly test for resistance to clindamycin. In order to do this properly you have to perform a D-test.”  Most Mec IV isolates are D-test negative Jennifer Daly, MD

26. The incidence of CA-MRSA at UMMMC now consistently exceeds the incidence of HCA-MRSA and Noso-MRSA. CA-MRSA patients are younger, more ethnically diverse, and are primarily presenting with skin and soft tissue infections. MRSA should now be considered a possible pathogen in ALL patients with possible S. aureus infections The decreasing level of prior contact with our healthcare system suggests that the strain is established in our community. Conclusions

27. Ramifications Current infection control practices are unlikely to contain the continued spread of MRSA – which will have major implications in both the overall approach to the management of patients with MRSA, as well as strategies to prevent healthcare associated illnesses such as surgical site infections Mec IV, USA 300 and USA 400 strains may have a fitness advantage above their ability to survive in the presence of beta-lactam antibiotics