1. REALM project update MRSA and KPC January 26, 2011 Michael Lin, MD MPH on behalf of REALM co-investigators

2. REALM update Outline 1.MRSA surveillance a. Overview and main results b. Contact precautions analysis c. NICU analysis 2.KPC surveillance and future directions

3. REALM update Aim Evaluation of 2007 mandate for MRSA active surveillance among all Illinois hospital ICU and “high risk” patients. –Is the prevalence of MRSA colonization decreasing after the initiation of state-wide active surveillance?

4. REALM update Design 3 year project involving all hospitals in city of Chicago with ≥ 10 ICU beds –Serial point prevalence survey of MRSA colonization in ICUs (6 times over 3 years) –All ICUs (neonatal, pediatric, and adult) –City of Chicago hospitals – chosen for feasibility and to limit selection bias –Peds/adults – swabbed in nose and groin; neonates – nose and umbilicus –All cultures processed in central laboratory

5. REALM update Design (cont.) All 26 eligible hospitals in Chicago participating Timeline: –1 st survey: 2008 (2 nd half) –6 th survey: 2011 (1 st half) We tracked the prevalence (%) of 1.MRSA colonization 2.CA-MRSA vs. HA-MRSA genotype 3.Mupirocin resistance

6. REALM update Hospital locations within Chicago

7. REALM update Results Through 5 surveys*, total patients: –Neonates: 1,328 –Pediatric: 409 –Adult: 2,545 * Survey 5 almost complete. All data involving survey 5 are preliminary.

8. Trend, P = 0.04

9. Trend, P = 0.41

10. Trend, P = 0.33

11. REALM update Mupirocin resistance Surveys 1-5 combined No resistance Low resistance High resistance Adult ICU 93% (261/281)5% (14/281)2% (6/281) Pediatric ICU 90% (17/19)5% (1/19) Neonatal ICU 100% (62/62)––

12. MRSA trend summary Adult ICU MRSA colonization rate may be decreasing over time! –No change for PICU or NICU CA-MRSA rates stable No significant mupirocin resistance REALM update

13. Kallen AJ, JAMA 2010

14. REALM update Outline 1.MRSA surveillance a. Overview and main results b. Contact precautions analysis c. NICU analysis 2.KPC surveillance and future directions

15. REALM update Contact Precautions analysis Question – of the patients that are found by our point prevalence survey to be MRSA+, what percent of the patients are in contact precautions? –Data from surveys 1-2 –Presented at 5 th SHEA/IDSA/CDC Decennial International Conference on Healthcare- Associated Infections in Atlanta, 2010

16. Methods Admission Surveillance Point Prevalence Surveillance Reported by hospital Heterogeneous practice Obtained by study, standardized Variable timing Contact Precautions assessed Study patient timeline

17. REALM update Admission screen results Hospitals had obtained admission screening cultures for –95% for adults –98% for neonates MRSA admission prevalence (hospital report) –9.3% for adults –1.3% for neonates

18. REALM update Point prevalence survey results Median ICU day for point prevalence survey: –Adults: ICU day 4 –Neonates: ICU day 17 MRSA prevalence (point prevalence survey): –12.4% of adults (Hospital-reported admission rate, 9.3%) –5.3% of neonates (Hospital-reported admission rate, 1.3%)

19. REALM update Contact Precautions results Contact Precautions for any reason: –26% of adults –5% of neonates Of patients with hospital-reported admission cultures MRSA +: –87% of adults in Contact Precautions –86% of neonates in Contact Precautions

20. REALM update Contact Precautions results Of patients with point prevalence survey cultures MRSA +, Contact Precautions rate: 52% (65 / 125) of adults 39% (11 / 28) of neonates

21. REALM update Possible reasons for Contact Precautions deficit 1. Inadequate MRSA surveillance test sensitivity 2. Lag time for admission surveillance results 3. Lag time for initiating Contact Precautions after surveillance results known 4. On-going nosocomial MRSA acquisition

22. REALM update Possible reasons for Contact Precautions deficit 1. Inadequate MRSA surveillance test sensitivity 2. Lag time for admission surveillance results 3. Lag time for initiating Contact Precautions after surveillance results known 4. On-going nosocomial MRSA acquisition

23. REALM update Contact Precautions Summary Point prevalence surveys identified a greater proportion of MRSA-colonized ICU patients compared to routine mandated admission screening. At a given point in time, about half of MRSA-colonized ICU patients were not in Contact Precautions, despite on-going active surveillance at admission.

24. REALM update Contact Precautions Conclusion Possibilities for improvement: –Increasing test sensitivity (more body sites, enrichment methods) –Periodic surveillance to detect acquisition (especially among neonates) We do not know if current 50% level of Contact Precautions is sufficient to reduce MRSA transmission and infection

25. REALM update Outline 1.MRSA surveillance a. Overview and main results b. Contact precautions analysis c. NICU analysis 2.KPC surveillance and future directions

26. REALM update Outline 1.MRSA surveillance a. Overview and interim results b. Contact precautions analysis c. NICU analysis 2.KPC surveillance and future directions

27. REALM update Neonatal ICU: MRSA epidemiology How does neonatal ICU MRSA colonization differ from that of adult ICU patients? Data from surveys 1-4 Presented at IDSA 2010

28. Neonatal MRSA+ distribution

29. Adult MRSA+ distribution

30. Neonatal ICU Adult ICU

31. Neonatal ICU Adult ICU Median MRSA+

32. NICU Summary MRSA colonization is common among neonatal ICU patients For neonates, MRSA is uncommon early in ICU stay; rather, colonization appears days or weeks after admission If active surveillance is performed among neonates, it should be performed serially rather than only upon admission

33. REALM update Outline 1.MRSA surveillance a. Overview and main results b. Contact precautions analysis c. NICU analysis 2.KPC surveillance and future directions

34. KPC – emerging threat Klebsiella pneumoniae carbapenemase – usually found in Klebsiella spp., but can also be transmitted to other bacteria (E. coli, Pseudomonas). Carbapenems (imipenem) often last resort for treatment KPCs: no reliable antibiotic therapy, making some infections impossible treat. REALM update

35. KPC PPS - Rationale First KPC isolated in Chicago ~ 2008 Increasing prevalence of KPC colonization and infection –Nursing home / LTACH epicenters –Survey of Chicago hospitals – 65% in 2010 have isolated KPC Goal: –Determine prevalence of KPC colonization among ICU patients in Chicago

36. REALM update Design Surveys 5 and 6 (July 2010 – June 2011) Voluntary hospital participation Adult ICUs (optional for NICU/PICU) Initial design: –Groin swab + urine culture (if urine bag present) Modified design: rectal culture Lab – phenotypic screen for carbapenemase resistance; confirmation using in-house PCR for bla KPC

37. REALM update Results Survey 5: 25 eligible hospitals ─ 1 remaining = 24 hospitals 6 hospitals: groin/urine culture only 2 hospitals: groin culture only 18 hospitals: rectal cultures Patients: 459 adults (and 67 NICU/PICU)

38. KPC results Overall KPC prevalence in adult ICUs: 17 / 459= 4% REALM update

39. KPC future directions Identify the extent of problem –LTACH surveillance –Nursing home surveillance? –REALM survey 6 – KPC survey #2 –Extending REALM for KPCs? Identify best practices to control KPCs –Chlorhexidine bathing? Environmental cleaning? Improve communication between facilities

40. REALM update Thank you! Co-investigators –Rosie D. Lyles, Karen Lolans, Mary K. Hayden, Alexander J. Kallen, Stephen G. Weber, Robert A. Weinstein, and William E. Trick CDC –John Jernigan, Scott Fridkin Illinois Department of Public Health –Craig Conover Cook County department of public health –Sue Gerber Hospital epidemiologists and infection preventionists at all 26 hospitals