1. Household MRSA Colonization, Transmission, and Infection: A Multidisciplinary Approach Presented by Manuel Bramble Principal Investigator: Dr. Ebbing Lautenbach Co-Principal Investigators: Dr. Joshua Metlay and Dr. Jeffrey Weiser

2. Background

3. What is MRSA?  MRSA stands for Methicillin- Resistant Staphylococcus aureus (“staph aureus” for short)  Even though the bacteria is referred to as methicillin-resistant, it is resistant to many antibiotics, which makes it particularly hard to treat

4. Who cares?  The percentage of S. aureus isolates that are methicillin-resistant rose from 22% in 1995 to 57% in 2001 (Boucher et al., 2008)  MRSA now accounts for over 60% of S. aureus isolates in United States ICUs (Boucher et al., 2008)  MRSA infections cause around 19,000 American patient deaths annually (Boucher et al., 2008)  In 2003, the associated incremental cost of staphylococcal disease was $14.5 billion, and 60% of the infections were caused by MRSA (Kluytmans et al., 2009)

5. Colonization vs. Infection  Colonization- when the bacteria are present in the body without causing illness. The most common sites for MRSA colonization are in warm, moist places, such as the nostrils, groin, and armpits.  Infection- indicated by the presence of clinical symptoms such as fever, redness, pain, and swelling. Infection occurs most often in wounds or other open skin.

6. Healthcare Associated (HA-MRSA) vs. Community Associated (CA-MRSA) There are two different types of MRSA, and they differ based on where they are most prevalent.  HA-MRSA is found in healthcare settings such as hospitals or long-term care facilities  CA-MRSA is found in the community, outside of health care facilities (includes the home)

7. How is MRSA spread? Most of what we know about MRSA is from the hospital environment. Much less is known about transmission in the home. However, some mechanisms have been suggested: 1. Direct contact with infected or colonized host -human-to-human contact 2. Contaminated intermediate surfaces -hand towels -faucets -tub/shower 3. Airborne fluid droplets

8. Pets’/Animals’ Roles in MRSA Transmission  In several studies, it has been found that farm owners, veterinary clinicians, and pet owners are at greater risk for MRSA infection  In particular, there have been documented MRSA transmission to humans from:  Dogs  Cats  Horses  Pigs  It is often noted that animals, especially pets, can serve as “reservoirs of infection”

9. The Study

10. Two Approaches 1.The first phase of the study is a prospective cohort study. During this phase, all household members enrolled in the study will undergo regular sampling for MRSA colonization over time. 2.The second phase is a randomized control trial. The purpose of this phase is to compare the effectiveness of two decolonization interventions.

11. Main Goals of the Study: 1) To identify the reasons that some people are more likely than others to have MRSA on their skin and how MRSA may spread from person to person 2) To identify possible strategies to prevent MRSA spread and infection 3) To determine how MRSA colonization is affected by co-existing S. pneumoniae colonization

12. Recruitment Patients are to be enrolled at four hospitals:  Hospital of the University of Pennsylvania (HUP),  Penn Presbyterian Medical Center (PPMC)  Children’s Hospital of Philadelphia (CHOP)  Penn State Hershey Medical Center (HMC) All adults and children receiving care in the emergency departments (EDs) for newly diagnosed skin or soft tissue infection (SSTI) will be approached for the study. Enrollment will be completed upon medical confirmation of MRSA as the cause of infection.

13. What is required of study subjects? All members of each enrolled household will: 1.Undergo sampling for MRSA and S. pneumoniae colonization at enrollment 2.Receive one initial home visit to receive swab supplies and one additional home visit for S. pneumoniae sampling at 3 month follow-up 3.Undergo regular self-collected sampling for MRSA colonization over the entire 6-month period of follow-up. 4.Participate in bi-monthly telephone interviews about lifestyle behaviors Each household member will be compensated $5 per swab.

14. My Contributions

15. The Brochure  The Brochure is designed to ensure that everyone being approached about the study is fully aware of what being a part of the study entails. The information they receive will allow them to make a well- informed decision before they sign the consent form.  I wrote and designed the brochure (with guidance from Pam Tolomeo, the Project Manager, and Dr. Lautenbach, the Principal Investigator)

16. Data Collection Forms  During the initial and follow-up visits, data collection forms will be filled out in order to record information concerning the study.  I went through all of the data collection forms and edited them. This helped to ensure that the data collection forms were: -legible/understandable -practical -relevant to the study -in concordance with the grant

17. Narrative Review  Dr. Lautenbach will be submitting a new grant that will investigate the role of pets in MRSA transmission within the household.  I reviewed all of the available medical literature on this topic, and I am in the process of will be provide critical background information for this grant.  The literature review is also being written up as a narrative review on the topic of the role of pets in MRSA household transmission. This work will be submitted as a scientific manuscript with me as lead author.

18. What I’ve Learned  Process of proposing, organizing, and maintaining a study  Informed consent  Data entry  Recruitment  Writing and publishing one’s research  MRSA

19. Acknowledgements  Dr. Ebbing Lautenbach  Dr. Joshua Metlay  Pam Tolomeo  Joanne  Shanta  SUMR scholars and staff  LDI  CHERP  Provost’s Diversity Fund  AHRQ

20. References Boucher, H. W. and G. R. Corey (2008). "Epidemiology of methicillin-resistant Staphylococcus aureus." Clin Infect Dis 46 Suppl 5: S344-9 Kluytmans, J. and M. Struelens (2009). "Meticillin resistant Staphylococcus aureus in the hospital." BMJ 338: b364.

21. Thanks for listening!