1. MRSA
Moving from Infection Control to Infection Prevention: A Journey through MRSA
PATIENTS
C DIFF
Joan M. Ivaska, BS, MPH, CIC

2. Objectives
Participants will understand the differences between infection control and infection prevention.
Understand the epidemiology of MRSA
Understand risk factors for MRSA
Review current MRSA management trends
Discuss MRSA prevention
and control strategies

3. Cardo et al. Infection Control and Hospital Epidemiology , Vol. 31, No
Cardo et al. Infection Control and Hospital Epidemiology , Vol. 31, No. 11 (November 2010), pp

4. Patient Visitors and Family Staff/ Medical Staff Rehabilitation
Home Care
Surgery Center
Hospital
Long Term Care
Dialysis
Physician Office

5. What is the role of Infection Prevention and Epidemiology?
Epidemiology is the cornerstone of public health
Inform policy decisions and evidence-based medicine
Identify risk factors for disease
Target prevention strategies
Infection control addresses factors related to the spread of infections within the health-care setting (whether patient-to-patient, from patients to staff and from staff to patients, or among-staff)
Interruption of outbreaks
When we are not proactive in doing the right thing,
we invite others to define the right thing for us
Wikipedia, September 2011

6. What is the difference between control and prevention?
to exercise restraining or directing influence over
to have power over
to reduce the incidence or severity of especially to innocuous levels
Prevent:
to be in readiness for
to act ahead of
To keep from happening or existing

7. A Tale of Two Cows
At a recent healthcare innovations summit, Atul Gawande used the United States’ robust data-driven agricultural industry as a model that healthcare should emulate and commented that we even know the number of cows in every county. It is hard to imagine how cows have anything to do with healthcare acquired infections.  The former are gentle creatures that mankind has benefited from for ages, and the latter is an unrelenting plague causing significant death and disability in untold numbers.   It is estimated that these infections affect one-in-twenty hospitalized patients, but besides estimates and projections there is little hard evidence, just scant data from handpicked references or reports in the literature.  
However, having data on the strength of the enemy is essential in any armed engagement and the question must be asked, if we have a map that shows the number of cows in each county in America, why don’t we have a map that shows the rates of deadly superbugs such as MRSA or for that matter all of the major bacteria that cause healthcare acquired infections (HAIs)?  
We are not experts in agriculture, and thus, cannot know the complexities of ranching. However, we have seen what is going on in medicine and can only guess what may have taken place in generating the data for the cow density map.     
If medicine were run like agriculture we would have a map for MRSA, but if agriculture were run like medicine the following may have taken place in the derivation of the cow map.  Please indulge in the following absurdity:
First there was intense disagreement on what a cow is.  Not everyone used the same definition.  Some farmers defined cows as black-haired mammals with at least four white spots, while others defined them as four-legged mammals with three black spots. Confusion certainly prevailed.  Some farmers asked whether cows in ponds are counted the same as cows eating grass.   It was then decided to only count cows standing in streams.  Called Cow Stream Infestations (CSIs) or cowteremia, this classification provided data that some praised and all could agree upon.  But the CSIs occurred so infrequently that meaningful comparison between farms could not be made.  
And who was going to pay for the farmhands to count the cows?  After all, counting them would not change the number of cows on the farm and it was ultimately viewed as wasted effort.  In addition, the time that farmhands spent counting could be used to do other things.   
So as not to burden the farm, initially counting was done on the basis of farm income tax returns showing the number of cows sold.  But only about half of the cows were tabulated because of software limitations. It was then decided to have the farmhands count the cows in the field.
Because of the difficulties in counting individual cows, some states thought it would be easier to just count cow herds. However, no one could agree on how many cows constituted a herd.  A definition that was finally agreed upon was that a herd was a group of cows that was more than the usual number on a farm.  No one could agree on what a “usual number” was and thus few herds or cows were actually reported.     
One state counted two cow herds that year; a true landmark for cow counting!  Other states reported no cow herds whatsoever.  It was later found that many cows were not counted that first year due to a low number of farmhands, as scores were fired because of financial cutbacks.  In addition, no one was verifying if the counting was being done properly.      
Of course, farms with less than 25 acres weren’t required to count cows, as their cow population was deemed negligible.        Another problem was the cows drifting onto farms from other counties.  Fences were proposed to prevent this.  But these were deemed too expensive.  The great fence conspiracy then started.  Two farms were found that had put up poor fences. One of these farms was not even in the United States.  These two examples were used to argue that fences did not always work, and thus, no conclusions or recommendations for intervention could be made to address the wandering cow problem.  
After years of discussion, meetings, research and legal action, it occurred to a few farmers that counting was important.    It became clear that counting cows was vital to the financial success of farms, overall cow health, fence maintenance, and ordering the correct amount of feed and supplies.   The cow map was finally able to be made.
The 2007 beef cow density map is 100% authentic, as the United States Department of Agriculture Census of Agriculture collects data on all farmers and ranchers every five years. Participation in the Census is required by law. The map displays beef cow inventory per cropland acre by county across all counties in the United States.  No such system exists in healthcare facilities for the reporting of HAIs.  It is this absurdity that bound us to act – the knowledge that our farmers are required to report on the number of cows they have while the vast majority of our hospitals, the places we trust with our lives, do not report when a patient leaves worse off because of a methicillin resistant Staphyloccus aureus (MRSA) hospital acquired infection.     
Adapted from Daniel Saman, DrPH, MPH, CPH, HealthWatchUSA.com,2012.

8. Definitions CA-MRSA: Community-acquired MRSA
HA-MRSA: Healthcare-associated MRSA
Nosocomial: infection acquired while in the hospital
SSTI: Skin and Soft Tissue Infection

9. Staphylococcus aureus
common cause of infection in the community
Lives on skin, in nose, in soil, water, dead plant material
Causes colonization or infection
Methicillin-resistant Staphylococcus aureus (MRSA):
Increasingly important cause of healthcare-associated infections since 1970s
In 1990s, emerged as cause of infection in the community

10. Antibiotic resistance in S. aureus
Penicillin, 1950
Methicillin (= all β-lactam antibiotics), 1961
Tetracycline, Co-trimoxazol, rifampin, clindamycin, macrolides, quinolones
Vancomycin, intermediate-R, 2000
Vancomycin, high-level-R, 2002
Linezolid, Daptomycin?

11. MRSA in Healthcare Historical Risk Factors
Prolonged hospitalization
Prolonged antimicrobial use
Stay in an intensive care or burn unit
Exposure to a colonized/infected person
Residence in a nursing home
Age >65
Common infections include surgical wound infections, urinary tract infections, bloodstream infections, and pneumonia

12. Outbreaks of MRSA in the Community
Often first detected as clusters of
abscesses or “spider bites”
Various settings
Sports participants
Inmates in correctional facilities
Military recruits
Daycare attendees
Native Americans / Alaskan Natives
Men who have sex with men
Tattoo recipients
Hurricane evacuees in shelters

13. Soft Tissue Infections
MRSA Skin and
Soft Tissue Infections

14. Comparison of Invasive Disease Incidence per 100,000 Population, 2008
Neisseria meningitidis 0.3
Haemophilus influenzae 1.5
Group B Streptococcus 7.5
Streptococcus pneumoniae
MRSA

15. Colonization Sites Infections
Wertheim H, et al. Lancet Infect Dis, 2005, 5:

16. MRSA Was the Most Commonly Identified Cause of Purulent SSTIs Among Adult ED Patients
(EMERGEncy ID Net), 2004 to 2008
59%
(98% USA300)
38%
40%
44%
53%
72%
58%
62%
57%
48%
84%
56%
CID 2011:53 (15 July) Talan et al

17. MRSA Strain Characteristics Were Initially Distinct
MRSA in Healthcare
MRSA in the Community
Prevalent genotypes (U.S.)
USA100, USA200
USA300, USA400
Antimicrobial resistance
Multiple agents
Few agents
SCCmec (genetic element carrying mecA resistance gene)
Types I-III
Types IV, V
PVL toxin gene
Rare
Common
Gorwitz, R. CDC, 2007

18. Distribution of PFGE types among MRSA isolates from nosocomial bloodstream infections, Grady Memorial Hospital, 2004
PFGE type
No. (%) of nosocomial cases (n = 49)
USA300
10 (20)
USA100
21 (43)
USA500
18 (37)
USA800
0 (0)
Historically community-acquired
Seybold U, et al. Clin Infect Dis  2006;42:

19. ABC Surveillance, 2008 MRSA Class No. (Rate*) Cases^
No. (Rate*) Deaths˜
Inferred PFGE Type (N,%) Tot N±
Inferred PFGE Type (N,%) USA100±
Inferred PFGE Type (N,%) USA300± HO
1276 (6.7)
304 (1.6)
247
177 (71.7)
48 (19.4)
HACO
3203 (16.8)
481 (2.5)
585
363 (62.1)
157 (26.8) CA
929 (4.9)
91 (0.5)
151
46 (30.5)
103 (68.2)
*Cases per 100,000 population for ABCs areas ^n=151 ˜n=20; could not be classified after chart review ±1351 isolates were eligible for testing up receipt to CDC, 1005 have Inferred PFGE algorithm, 13 will require direct PFGE

20. Factors that Facilitate Transmission
Crowding
Defense
Offense
Frequent Contact
Antimicrobial Use
Compromised Skin
Contaminated Surfaces
and Shared Items
Cleanliness

21. Preventing Transmission
in the Community
Persons with skin infections should keep wounds covered, wash hands frequently (always after touching infected skin or changing dressings), dispose of used bandages in trash, avoid sharing personal items.
Uninfected persons can minimize risk of infection by keeping cuts and scrapes clean and covered, avoiding contact with other persons’ infected skin, washing hands frequently, avoiding sharing personal items.

22. Preventing Transmission
in the Community
Exclusion of patients from school, work, sports activities, etc should be reserved for those that are unable to keep the infected skin covered with a clean, dry bandage and maintain good personal hygiene.
In general, it is not necessary to close schools to “disinfect” them when MRSA infections occur.
In ambulatory care settings, use standard precautions for all patients (hand hygiene before and after contact, barriers such as gloves, gowns as appropriate for contact with wound drainage and other body fluids).

23. Role of Pets
Greatest risk of Staph aureus/MRSA exposure in most humans is other humans
When household pet animals carry MRSA, likely acquired from a human
Transmission of MRSA from an infected or colonized pet to a human is possible, but likely accounts for a very small proportion of human infections
Reasonable to consider pet as a source if transmission continues in a household despite optimizing other control strategies
Little evidence that antimicrobial-based eradication therapy is effective in pets; however, colonization tends to be short-term*
Barton et al 2006;Can J Infect Dis Med Microbiol

24. Healthcare Transmission Chain
Housekeeper does not adequately
disinfect the chair and cabinets
HCW starts dialysis on Mr. Payne with finger of glove removed
Mr. Payne develops fever and sepsis next day. Mr. Payne hospitalized with MRSA sepsis.
Mr. Payne dies 8 weeks later.
Outpatient dialysis patient is colonized
with MRSA and not treated with precautions
HCW does not perform
hand hygiene

25. Role of Screening and Decolonization Pre-operative screening
High risk screening
Universal screening
Decolonization of skin
Decolonization of nose

26. Preventing Healthcare Transmission:
Standard Precautions
Hand Hygiene
Contain body fluids
Transmission Based Precautions
Contact Precautions
Gown and gloves
Appropriate use of antibiotics

27. Environmental Decontamination
Adequate surface disinfection
Validation of cleaning efficacy
New technology

28. Validating cleaning by ATP

29. Preventing Healthcare Transmission: Hand Hygiene

30. Communication Develop and use inter-facility reporting forms
Use the network of experts in your community
Get staff and medical staff engaged in reporting
Each infection discussed = Identified prevention strategies
Aim for Zero preventable infections…
don’t be the Cream of the Crap!

31. Education Patients and families Staff and Medical Staff Yourself
Standardized hand outs
Multi-media
Staff and Medical Staff
Inservices
Just in time
Safety Fairs
Make it fun, make it memorable
Yourself
Webinars
Internet
Peers

32. Present Actionable Data
Code Purple, using hall beds and semi-privates
Disinfectant wipe conversion

33. Prevention Evaluate and implement best practice regularly
Engage staff…they are smart people!
Prevention doesn’t happen in an office!

34. In Closing…