1. Community-acquired methicillin-resistant Staph. aureus (CA-MRSA): Amarillo experience Infectious Disease Epidemiology Work Group Texas Department of State Health Services January 4, 2008 J Rush Pierce Jr, MD, MPH Public Health Authority, Amarillo Bi-City-County Health District Associate Professor, Dept of Internal Medicine, TTUHSC Todd E. Bell, MD Assistant Professor, Department of Internal Medicine, TTUHSC

2. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 2 Amarillo, Texas MSA 2006 estimated population = 236,113 Three hospitals Health Department serves citizens in two counties 69% White, 22% Hispanic, 6% African American

3. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 3 Community Acquired MRSA in Amarillo

4. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 4 Origin of local CA-MRSA Advisory Committee Passive surveillance and reports from practitioners noted marked rise in CA-MRSA in 2004 Requests to Health Dept from schools, LTCF’s and hospitals for recommendations MRSA Advisory Committee appointed April, 2005 and recommended investigation of 2004 cases

5. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 5 Strategy of Community Investigation of CA-MRSA 1. Get list of MRSA isolates from hospital labs 2. Review hospital and outpatient records to exclude hospital-associated MRSA 3. Call remainder  Exclude hospital-associated MRSA  Inquire about risk factors and other items  Get risk factors on another household member who did not have CA-MRSA

6. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 6 Amarillo CA-MRSA Investigation – Exclusion criteria Any hospitalization in the year before the culture Any surgery during in the year before the culture Any dialysis in the year before the culture Any stay in a long-term care facility in the year before the culture Presence of any of the following at the time of culture: tracheotomy, gastrostomy, urinary catheter, intravenous catheter

7. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 7 Amarillo CA-MRSA Investigation - Results Over 1100 ED and outpatient charts reviewed; 299 met criteria for CA-MRSA At least 2 phone calls and mail request 35 no contact info, 3 dead, 8 declined survey, 110 not reached and did not respond to mail request = 143 included in investigation (48% response rate) Of 143 included, 10 (7%) had exclusion criteria after interview

8. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 8 Amarillo CA-MRSA Investigation - gender

9. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 9 Amarillo CA-MRSA Investigation - ethnicity

10. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 10 DemographicscasesProportion, cases Proportion, Potter/Randall counties p Age (n=132) 0-19 20-64 65+ 25 96 11 0.19 0.73 0.08 0.29 0.59 0.12 0.009 0.001 NS Race/Ethnicity (n=120) Black Hispanic White 6 14 100 0.05 0.12 0.83 0.06 0.22 0.69 NS 0.001 NS

11. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 11 Amarillo CA-MRSA Investigation - age

12. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 12 Amarillo CA-MRSA Investigation – location of infection

13. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 13 Mistaken for spider bite by either patient or physician

14. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 14 MRSA Infections by month of diagnosis

15. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 15 CA-MRSA Antibiotic Resistance

16. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 16 MRSA – Antibiotic treatment

17. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 17 CA-MRSA – time to healing

18. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 18 CA-MRSA – exposure

19. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 19 CA-MRSA – Are you familiar?

20. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 20 CA-MRSA Investigation Conclusions CA-MRSA is common –est. incidence in 2004 = 106/100,000 population Involves all ages, all ethnic groups and all areas of District Frequently mistaken for spider bites Most commonly skin and soft tissue infection Some increase seen in summer Almost always sensitive to rifampin, TCN, TMP- SMX, genta, vanc – 90% sens to clinda Patients commonly (1/3) had contact with someone else that had MRSA Most (3/4) patients not familiar with it

21. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 21 MRSA related public health activities in Amarillo Continued voluntary reporting Public and HCW education Interventions developed for responding to reported clusters Population based surveillance cultures by TTUHSC investigator Meetings with school nurses and other groups to review TDSHS guidelines Continued MRSA Advisory Group activities

22. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 22 MRSA Advisory Committee: hospital sharing of data Surgical site infection rate for elective total knees 3x national average – not hospital or surgeon specific Community deaths  2006 = 14  2007 = 17 Surveillance cultures to ICU (by one hospital) 12% positive; but less than 2% nosocomial transmission with out special isolation

23. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 23 MRSA Advisory Committee: Isolation Guidelines in hospitals Gown and glove for all hospital personnel entering room if patient in contact isolation Gown and glove for visitors patients with MRSA

24. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 24 MRSA Advisory Committee: surveillance guidelines for hospitals Contact isolation for patients admitted who have had positive MRSA culture in previous six months Surveillance cultures for all patients undergoing elective total knee replacement Recommend public health data base

25. CA MRSA: Amarillo Experience. Preliminary data. Not for publication 25 Other recommendations of MRSA Advisory Committee Evidence based pre-operative decontamination regimen Recommendation for single dose of pre- operative vancomycin, clindamycin, or linezolid for patients colonized with MRSA