1. David Tucker Honorary Treasurer Infection Prevention Society

2. Introduction Back ground to the problem Drivers for change Impact of the improvement programme Impact of screening

3. MRSA Background Methicillin Semisynthetic antibiotic introduced in 1959 for penicillin-resistant S. aureus isolates Resistance identified first in UK in 1961 MecA gene encodes penicillin-binding protein MRSA First coined after outbreak in Boston City Hospital in 1968 Thought to be purely nosocomial until 1998, US differentiated CA-MRSA from HA-MRSA

4. MRSA Background Incidence USA Large increases in HA-MRSA (1999-2005) Hospitalisations: 127,036 to 278,203 - ↑ 119% Septicaemias: 31,044 to 56,248 – ↑ 80% Europe Vast country differences in MRSA vs MSSA (2002) Greece 49% > Spain 24% > Norway 0.2% Though proportions slowing, >25% in 1/3 countries (2009), highest in Mediterranean region

5. Epidemiology of MRSA Nearly always (in UK) hospital or healthcare associated MRSA is usually brought into hospital by patient carriers Colonisation precedes infection Organisms are usually transferred via staff hands Colonisation may last months/years Patients re-admitted or transferred to another institution are sources for new cross-colonisation/infection This 'revolving door' has made national and international control difficult Mulligan ME et al, Am J Med 1993; 94: 313-328. Boyce JM et al. Infect Control Hosp Epidemiol 1994;15(2):105-15. Combined Working Party Report. J Hosp Infect 1998;39:253-290.

6. Community-associated infection Human + Bacteria ( commensals, potential or obligate pathogens ) = Disease Healthcare-associated infection ET tube Human + Bacteria ( commensals, potential or obligate pathogens ) + Catheter = Disease Knife ANTIBIOTICS MRSA - HAIs

7. % MRSA in blood 1999-2001 EARSS 2002

8. MRSA Background Incidence UK Political drive Pressure to “measure” HCAI Identified as ‘superbug’ Winning Ways, 2003 Intensified control measures Saving Lives Campaign, 2005 ‘ Tools to support HCAI improvement … form an essential plan to implement best practice, guidance and the latest IPC policies’. Newspaper Attention

9. MRSA: A growing UK problem Proportion of S. aureus blood isolates that were MRSA rose from ~2% in 1992 to ~40% in 2003 1 In 1997-2005 85% of SSIs in national surveillance (England) had organisms cultured and 26% of these were MRSA 2 Almost twice those caused by any other pathogen 1. National Audit Office. Improving patient care by reducing the risk of hospital acquired infection: A progress report. 14th July 2004. 2. Surveillance of Surgical Site Infection in England October 1997 – September 2005. Heralth Protection Agency, London 2006..

10. Percentage of Staph aureus bacteraemia isolates that were MRSA England & Wales 1990-2004 http://www.hpa.org.uk/infections/topics/staphylo/lab_data_staphyl.htm % Methicillin resistant

11. Number of MRSA bacteraemia isolates reported to the HPA England & Wales 1990-2004 http://www.hpa.org.uk/infections/topics/staphylo/lab_data_staphyl.htm

12. MRSA infection Usually hospital- or healthcare-associated infection (HCAI) BELIEFS MRSA infection is one of the inevitable consequences of modern medicine, even with good practice vs MRSA infection is the result of poor clinical practice and is intolerable

13. Serious hospital SA infections usually MRSA & are associated with poor outcomes Compared with MSSA MRSA infections have increased risk of: mortality (x2) (1,2), morbidity (2,3), prolonged hospitalization (3), increased healthcare costs and hospital resource utilization (2,4) ‏ (Controlled for other factors) ‏ Cosgrove SE et al. Clin Infect Dis 2003;36:36:53–9. Engemann JJ et al. Clin Infect Dis. 2003;36:592-598. Stevens DL et al. Clin Inf Dis 2002;34:1481-90. Li Z et al. Pharmacotherapy 2001;21(3):263-74.

14. National Audit Office (2004) Improving patient care by reducing the risk of hospital acquired infection: A progress report Implementation has been patchy. Progress is dependent on changing staff behaviour, but change constrained by limited progress in mandatory surveillance & lack of evidence for the impact of different intervention strategies.

15. Mandatory reporting of MRSA Bacteraemia rates Required to submit MRSA bacteraemia cases from April 2001 Quarterly reports published from 2002 Results for individual Trusts are published on the web & there are summaries in CDR April 2001 – March 2002 CDR Weekly Volume 12 No 25, 20 June 2002. April 2002 – March 2003. CDR Weekly Volume 13 No 25, 19 June 2003. April 2001 – March 2004. CDR Weekly Volume 14 No 29, 15 July 2004

16. In general, MRSA bacteraemia did not decrease during 2001-4 And Guy’s & St Thomas’ Trust (GSTT) had the worst rates in London and the second worst in England

17. MRSA Background Incidence UK STH Highest rate of any London teaching hospital

18. Epidemiology of MRSA bacteraemia at GSTT MRSA bacteraemias occurred in all specialities (except Paeds/Obs & Gyn) But were highest in ITU/Renal/HaemOnc 40% were associated with IV devices 30% were in patients in ITU or HDU 50% in or had been in ITU/HDU Cases elsewhere often associated with IV devices

19. Intervention programme targeting MRSA & other HCAIs Began in October 2003 with a series of high impact interventions: Education and communication Hand hygiene MRSA screening MRSA care pathway – 2006 guidelines Screening targeted to high risk areas including Acute Medicine Intravascular device management Environmental decontamination RCA Feedback on individual bacteraemia cases Tackling MRSA infection at GSTT was made a Trust priority

20. Control of Hospital Infection – rationale for screening If we know the epidemiology of MRSA (or any other HCAI) ‏ it should be possible to intervene and control it

21. Recommendation SHEA (2003) WIP (2005) Working Party UK (2006) CDC (2006) Hand hygieneY Contact precautionsY EducationND System to identify patients with MRSA /Feedback ND Cohorting ND Active surveillance testing Y Environmental Decontamination Antimicrobial Stewardship Decolonization therapy MRSA – Control Recommendations IA, strongly recommended, strongly supported by evidence IB, strongly recommended supported by evidence; Dutch Working party (WIP) Approach recommended for implementation II Suggested implementation, supported by suggestive studies or S Recommended in specific populations only; ND, not discussed (adapted from Calfee et al Infect Hosp Epi 2008; 29:S62-80)

22. Improvement programme: Trust-wide engagement Need accepted without significant dissent Compliance monitored through performance review MRSA employed as a surrogate for HCAIs

23. Reductions in MRSA infections Since the introduction of the programme, MRSA bacteraemias have fallen 85% from average of 42 per quarter in 2003 (0.47 per 1000 OBDs) to an average of 4 per quarter in 2009/10 (<0.10 per 1000 OBDs)

24. Average 42 per quarter Av quarterly rate 0.47 Average 6 per quarter Av quarterly rate 0.10 Corporate infection control programme

25. Reductions in MRSA infections During this period the numbers of patients acquiring MRSA fell (based on clinical specimens), while the number admitted with MRSA rose In 2003, for every patient admitted with MRSA there was 1 clinical acquisition By end 2007, 5 patients were admitted with MRSA for every acquisition

26. Corporate infection control programme MRSA Introductions & Acquisitions

27. MRSA screening extension Re-launch of Trust improvement programme and Saving Lives July 2007 2007 Lord Darzi’s “Our Healthier Nation” recommended screening of admissions April 2008 GSTT introduced screening of all in-patient admissions either at PAC or on admission Compliance monitored and fed back weekly and monthly - PRM April 2009 adapted to include DH requirement for day cases, but continued with all other admissions

28. Adm. screen Extended targeted screen Extended Adm. screen

29. Calculated savings associated with the reduction in MRSA infection rates to 2009 We estimate that this represents a minimal annual saving (cf 2003) of approximately: 528 all MRSA infections 288 wound infections 152 bacteraemias 4,000 bed days £2m of hospital costs Some 30 deaths.

30. MRSA The European picture Country (2009)BSI / 100,000 bed days Netherlands0.2 Croatia5.7 UK8.7 Italy9.9 Ireland10.6 Malta14.7 Portugal28.3

31. Conclusions Without knowing the scale of the problem it is not possible to strategically target resources, therefore some form of screening is necessary Managing transmission in the acute setting may have impacted on reducing cases admitted from the community Effectiveness – discharge screening? Targeted surveillance effectively impacted on rates; is the gain from extension to include all admissions justifiable and sustainable? Cost - £15 per screen for culture – 77,000 screens in 2009!!!!!!

32. The future? Transmission is still occurring – why? Within the current financial climate there will be Pressure on isolation facilities Pressure on beds Pressure on staffing Most clinicians will not see either MRSA bacteraemia or MRSA infection – how can we ensure continued engagement and focus