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

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

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. 1101-1105

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

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

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 www.merriam-webster.com/dictionary

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.

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

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

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?

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

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

Soft Tissue Infections MRSA Skin and Soft Tissue Infections

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 14.5 MRSA 29.5 http://www.cdc.gov/abcs/reports-findings/surv-reports.html

Colonization Sites Infections Wertheim H, et al. Lancet Infect Dis, 2005, 5: 751-762

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

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

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;42:647-656

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 http://www.cdc.gov/abcs/reports-findings/survreports/mrsa08.html

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

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. www.cdc.gov

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). www.cdc.gov

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

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

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

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

Environmental Decontamination Adequate surface disinfection Validation of cleaning efficacy New technology

Validating cleaning by ATP

Preventing Healthcare Transmission: Hand Hygiene

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!

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

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

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

In Closing…