MRSA surveillance and optional strategies for elective surgeries Dianne M Kendall M.D. Medical Laboratory Director St Joseph’s Medical Center Brainerd, MN

Tell me and I’ll forget. Show me, and I may not remember. Involve me, and I’ll understand.

Objectives Review concepts of MRSA surveillance projects Review optional approaches for elective surgical patients

Surveillance The monitoring of behavior, activities or other changing information, usually of people and often in a surreptitious (clandestine, undercover, covert) manner. What behavior/activities are we monitoring with MRSA surveillance? How is it covert? What do we do with the information gathered? What is the goal of this surveillance program?

MRSA surveillance MONITOR the effectiveness of your isolation/contact precautions/infection control practices of known MRSA patients to PREVENT spread to adjacent patients in the facility via HEALTHCARE WORKERS or HEALTHCARE ENVIRONMENT Surveillance annual report: We had 5% of inpatients identified with MRSA. Patients adjacent to these admitted patients had a 0% transmission rate of MRSA. Contact precautions instituted within 2 hours of discovery of MRSA in 85% of cases. Hand hygiene audit revealed 77% of nurses used appropriate hand hygiene at work, and 42% of physicians used appropriate hand hygiene (random sampling by blinded observation of Units 7a, 2d, ED and Resp Therapy). 100% rooms cleaned properly at discharge.

MN State Statute 144.585 Section 15 [144.585] Methicillin-Resistant Staphylococcus aureus control programs In order to improve the prevention of hospital-associated infections due to MRSA, every hospital shall establish an MRSA control program that meets MDH MRSA recommendations as published Jan 15, 2008. In developing MRSA recommendations, the Department of Health shall consider the following infection control practices:

Cont.. 1. identification of MRSA-colonized patients in all intensive care units, or other at risk patients identified by the hospital; 2. isolation of identified MRSA-colonized or MRSA-infected patients in an appropriate manner; 3. adherence to hand hygiene requirements, AND 4. monitor trends in the incidence of MRSA in the hospital over time and modify interventions if MRSA infection rates do not decrease. MDH to review MRSA recommendations annually and revise as necessary.

MRSA Background MRSA: methacillin resistant Staphylococcus aureus 30% of humans colonized by S. aureus at any point and time, usually anterior nares Other sites hands, skin (intact and non-intact), throat, urine, perineum, stool MRSA discovered in 60’s and has increased since that time

MRSA vs MSSA MRSA colonized more likely to have MRSA infection compared to MSSA colonized pts with MSSA infections MRSA easier to transmit between patients and caregivers compared to MSSA transmission Hospital acquired versus community acquired Different strains, Comm. Acq.(CA) more virulent

Infection prevention and control strategies Standard Precautions Any blood, body fluid, secretion, excretion, non-intact skin and mucous membranes contain transmissible infectious agents Hand hygiene, gloves When exposure anticipated, gown, mask, eye protection or face shield Transmission-Based Precautions: Contact precautions (MRSA) Direct and indirect contact Droplet precautions Airborne precautions

Specific IP/IC strategies Private patient room or cohort strategy Private room patient rooms/isolation may have higher anxiety and depression, less interaction with healthcare providers, have shorter direct examination times, are less likely to have vital signs recorded, fewer physician progress notes, more likely to complain and more likely to experience an adverse event (as compared to non-isolation patients)

Personal protective equipment Before entering room, wear gloves and gown. Gloves to prevent contaminating hands with MRSA from patient (direct) or patient environment (indirect) Glove use positively associated with hand hygiene compliance Gown use with glove use associated with increased compliance with all precautions Compared to periodic/procedure based use when contact is anticipated type system.

Hand Hygiene If you care for MRSA patient, is there MRSA on you? MRSA found on 65% of uniforms and gowns or healthcare workers caring for MRSA patients 42% of healthcare workers who ONLY had contact with patient environment had MRSA on their gloves 13% - 29% of healthcare workers’ hands were contaminated with same organism present on the outside of their gloves How compliant are we with hand hygiene? Not great with figures ranging between 5-81%, average 40%

What about visitors? Instruction on basic precautions including hand hygiene, to reduce the risk of transmission Visitors are not required to follow glove and gown recommendations UNLESS participating in direct care of patient Institution specific policies

Environment MRSA can live on a surface for 1-56 days Up to 25% of patients with MRSA found to have objects in environment (over-bed table, door handle, etc.) contaminated with MRSA Proper facility cleaning EQUIPMENT: dedicated patient only equipment including stethoscope, blood pressure cuff, tourniquet, computer, etc… or thorough cleaning between patients How would you accomplish this in peri-operative setting?

Screening Optional Population Individual If low risk hospital, then select high risk patients ICU, long term care residents/skilled nursing facilities, history recent hospitalization, dialysis, correctional facilities with recent antibiotic use, chronic skin wounds, elderly If high risk hospital, screen all admits Screen these and identify those colonized ACTIVE SURVEILLANCE CULTURES Place in contact precautions Monitor other patients to make sure no transmission to neighbors; monitoring compliance with IC/IP practices Individual Consider patient risk factors, history, procedure, etc.. Screen patient prior to procedure Attempt to decolonize prior to procedure Optional

Why screen populations? ICU patients more prone to infections and MRSA infections Many receiving antibiotics and have indwelling invasive medical devices ICU patient colonized with MRSA 4X likely to get MRSA bacteremia compared to MSSA colonized patient Prevent spread of MRSA to vulnerable patient population.

Why screen individual? Identify with intent to decolonize prior to procedure. Prevent surgical site infections Cardiothoracic surgery Orthopedic surgery with implants Elective surgeries Adherence to SSI prevention measures such as proper selection, timing and administration and discontinuation of antibiotics; skin preparation practices, etc… probably have bigger impact than screening and decolonizing patients See www.ihi.org for more information If SSI rates do not decrease with SSI prevention measures, consider screening for MRSA and decolonizing strategy.

What about screening healthcare workers? BAD IDEA Although healthcare workers can become colonized with MRSA, HCW are rarely the cause of MRSA outbreaks in acute care settings. Transmission of MRSA from HCW (as primary source of MRSA) to patient is thought to be rare Unless epidemiological evidence of HCW linked to epidemic, screening NOT recommended HCW may have transient carriage Disruption to staff routine, stigmatization, decolonization and furloughed, etc.. Don’t screen Healthcare Workers

How to decolonize for individual model of MRSA screening? Several protocols in literature. Most involve mupurocin ointment alone in combination with antimicrobial body washes How effective are decolonization efforts and how long do they last? Several studies: Initial success 90% After 90 days: 54-61% Multiple colonized sites: 6% What about resistance to mupurocin? It is reported and increasing in frequency

Other strategies to reduce MRSA Antibiotic stewardship About 50% of antibiotic usage is inappropriate Use narrow spectrum agent rather than broad Do not use abx for viral infections Clinically unnecessary doses and extended duration of treatment Education and Training of Healthcare workers Education, accountability, feedback with administrative support and participation of organization leadership with champions Be a good role model for your co-workers

Apply these principles to Perioperative setting How will you put some patients into “virtual isolation” ? More space around them Last case of the day? Have them wait in room, not OR How will you segregate equipment? Special stethoscopes? How will make sure hand hygiene is optimized? Where does hand sanitizer get placed? Sinks? How will you comply with gown portion of contact precautions in open room with multiple patients? Do you need extra soiled hamper by bedside? How to clean environment after patient taken to surgery or returned to room post surgery from recovery? How much environment would be impacted compared to patient room?

Summary MRSA Surveillance will usually identified small group of patients needing contact precautions, with intent to prevent infection to other patients by optimizing infection control and infection prevention practices Optional individuals could be screened for MRSA with attempts to decolonize Perioperative environment presents with unique challenges in complying with the usual contact precautions