1st European S. aureus & Surgical Site InfectionRound Table

11stst European European S. S. aureusaureus & Surgical & Surgical Site InfectionSite InfectionRound TableRound Table

MRSA Prescreening and Elimination:New England Baptist Hospital Experience

MRSA Prescreening and Elimination:New England Baptist Hospital Experience

Vienna, Austria

March 5th

Vienna, Austria

March 5th

Move on and ImproveMove on and Improve

Maureen Spencer, M.Ed., RN, CICInfection Preventionist ConsultantBoston, MA

www.workingtowardzero.comwww.7sbundle.com

Maureen Spencer, M.Ed., RN, CICInfection Preventionist ConsultantBoston, MA

www.workingtowardzero.comwww.7sbundle.com

New England Baptist Hospital

• 150-bed adult medical/surgical hospital located in Mission Hill area of Boston

• Orthopedic subspecialty hospital Acute inpatient discharges:

• 75% Orthopedic• 8% General Surgery• 17% Medical

• Orthopedic Surgery ~ 12,000/cases a year• 4500 total joints• 3500 spine cases• 4000 general and outpatient

February 2006

133 anonymous nares cultures after patient anesthetized

Results:

38 – S. aureus (29%)

*5 - MRSA ( 4%)

•all previously undiagnosed

*no precautions used in OR, PACU or nursing units

*Cefazolin used for antibiotic prophylaxis

Anonymous Nasal Culture Study

Screening Proposals February 2006 – prepared three

screening proposals with costs1) Traditional nasal cultures - 3 day results

$245,000.00 2) Purchase rapid PCR equipment

$337,338.00 3) Lease rapid PCR equipment

$259,990.00 March 2006 –Board approval of

equipment purchase

March – October 2006– Weekly meetings:

surgical services, infection control, micro, administration, & medical staff members

– July 2006 – letter to surgeons – July 17, 2006 – initiated pilot on Spine

Service– August 2006 – letter to medical staff – September 2006 – initiated universal pre-

op screening program for all inpatient surgery

Implementation – 8 Months

Policy & Procedure

Protocol developed for all departments & units affected– OR Scheduling– Patient Access– Prescreening Unit – Pre-surgical unit – Operating Room– PACU– Nursing Units– Microbiology Lab– Ancillary Departments: Housekeeping, Central

Transport, Radiology, etc.

Preadmission Preoperative Screening Program Instituted

Nasal swabs during prescreening process

Microbiology Laboratory PCR detects presence of bacteria-specific DNA– Cepheid GeneXpert

Topical decolonization protocol for patients found to be carriers of S. aureus or MRSA

Decolonization Protocol

Intranasal 2% mupirocin ointment BID x 5 days

Pre-op shower with 2% chlorhexidine daily x 5 days

Patients called by preadmission testing to initiate treatment protocol

Repeat call to document compliance

MRSA carriers re-screened prior to surgery

Contact precautions if 2nd MRSA screen positive

Vancomycin for surgical prophylaxis for patients with history of MRSA carrier status

9

First year (2006) cost ~$400,000

~$100,000 for 2 full-time positions:

•Microbiologist & PASU Medical Technician

~$60,000 PCR rapid test equipment

~Lab cost for PCR ~$40.00/test

(compared to routine culture ~ $20.00)

~ 6,000 inpatient surgeries = $240,000

NEBH Program Budget

Intangible Benefits

S. aureus/MRSA prescreening & decolonization program viewed as positive pro-active infection control measure by staff, patients, family members & media

Allows additional patient education on importance of hand hygiene, prevention of SSI, infection control measures in home to reduce transmission of MRSA & S. aureus

Allows for adjustment of surgical prophylaxis to Vancomycin for MRSA patients

12

Polymerase Chain Reaction (PCR) for Nasal Screens – Lab Challenges

• Instructing nursing staff on how to obtain nares specimen with proper swabs

• Lab differentiation of the colonized screens from routine cultures.

• Molecular lab in a short time frame with Cepheid’s GeneXpert System

• Reporting system for positive results to prescreening, operating room, post-anesthesia unit, infection control

14

3 Simple steps

Easy workflow in less than 1 minute

11 22 33

Results in One Hour

Institutional Prescreening for Detection and Elimination of Methicillin Resistant Staphylococcus aureus in Patients Undergoing Elective Orthopaedic

Surgery

Kim DH, Spencer M, Davidson SM, et al. J Bone Joint Surg Am 2010;92:1820-1826

Control Period10/2005-6/2006

Study Period6/2006-9/2007 p value

N 5293 7019

MRSA Infection

10 (0.18%) 4 (0.06%) 0.0315

MSSA Infection 14 (0.26%) 9 (0.13%) 0.0937

Total SSIs 24 (0.45%) 13 (0.18%) 0.0093

0

0.05

0.1

0.15

0.2

0.25

0.3

1 2

0.18%

0.06%

0.26%

0.13%

50% Reduction in MSSA SSI

60% Reduction in MRSA SSI

MRSA SSI Rate MSSA SSI Rate

10/01/05-07/16/06 07/17/06-09/30/07 10/01/05-07/16/06 07/17/06-09/30/07

17

SSIs– Increased Risk with MRSA

• MRSA colonized patients had an increased risk of SSI

• Seven (7) Staph aureus infections in 2712 positives 0.19%• Seven (7) MRSA infections in the 576 positives 1.21%• Statistically significant difference p=<.05

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Staph aureus MRSA

0.19%

1.21%

Pre-op MRSA and S. aureus Decolonization

• Results:

• Timeframe: July 17, 2006 through September 2010

• Colonization: 20,065 patient screened

5,988 (23%) positive for Staph aureus 1,027 ( 4%) positive for MRSA

• Decolonization: Repeat nasal screens on MRSA patients revealed 77% elimination

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Pre-op MRSA and S. aureus Infections

• Results: % MRSA and S. aureus SSI

19

Time PeriodInpatient Surgerie

s

# of Surgical Infections

%MRSA/MSSA

FY0610/01/05-07/16/06* 5,293* 24* 0.45%*

FY0707/17/06-09/30/07 7,019 13 0.18%

FY08 10/01/07-09/30/08 6,323 7 0.11%

FY09 10/01/08-09/30/09 6,364 11 0.17%

FY1010/01/10-09/30/10 6,437 6 0.09%

*Historical Controls

Pre-op MRSA Infections

• Results: % MRSA SSI in Screened Patients

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Time Period

Inpatient

Surgeries

# MRSA SSIs

MRSA%#Infect/#MRSA+

FY0610/01/05-07/16/06 5,293 10 (NA) 0.19%

NA(historical controls)

FY0707/17/06-09/30/07

7,019 3 (3+) 0.04%3/309 (0.97%)

FY08 10/01/07-09/30/08

6,245 4 (2+) 0.06%2/242 (0.83%)

FY09 10/01/08-09/30/09

6,336 6* (2+) 0.09%2/234

(0.85%)

FY1010/01/10-09/30/10

6,437 1 (1+) 0.01%1/266

(0.37%)* 5 of the 6 available isolates sent for pulse field gel electrophoresis None were related genetically

Pre-op Staph aureus Infections

• Results: % S. aureus (MSSA) SSI in Screened Patients

21

Time PeriodInpatient Surgerie

s

# MSSA SSIs

MSSA%#Infect/#MSSA+

FY0610/01/05-07/16/06 5,293 14 (NA) 0.26% NA

FY0707/17/06-09/30/07 7,019 3 (3+) 0.04%

3/1588 (0.19%)

FY08 10/01/07-09/30/08 6,245 3 (1+) 0.05%

1/ 1422 (0.07%)

FY09 10/01/08-09/30/09 6,336 5 (1+) 0.08%

3/1403 (0.21%)

FY1010/01/10-09/30/10 6,437 6 (1+) 0.09%

1/1450 (0.06%)

Other Studies Supporting MRSA Screening and Decolonization

Mupirocin Resistance in UK

• In UK – Department of Health policy is active MRSA surveillance and isolate positives

• 2011-2012 Retrospective review of 49.177 cases of MRSA + nasal screens

• Approximately 12.2% resistance and 29.7% resistance to Neomycin

• Recommended treatment for resistant carriers would be chlorhexidine/neomycin (Napseptin) or for neomycin resistant strains use a polyhexamethylene biguanide (Prontoderm)

• Paper presented at ECCMID 2012

Mupirocin Resistance• Mupirocin resistance and methicillin-resistant Staphylococcus

aureus (MRSA). J Hosp Infect. 1997 Jan;35(1):1-8.• Emergence of high-level mupirocin resistance in methicillin-

resistant Staphylococcus aureus isolated from Brazilian university hospitals. Infect Control Hosp Epidemiol. 1996 Dec;17(12):813-6

• Emergence and spread of low-level mupirocin resistance in methicillin-resistant Staphylococcus aureus isolated from a community hospital in Japan. J Hosp Infect. 2001 Apr;47(4):294-300.

• Molecular fingerprinting of mupirocin-resistant methicillin-resistant Staphylococcus aureus from a burn unit. Int J Infect Dis. 1998-1999 Winter;3(2):82-7

• The spread of a mupirocin-resistant/methicillin-resistant Staphylococcus aureus clone in Kuwait hospitals. Acta Trop. 2001 Oct 22;80(2):155-61.

• The antimicrobial activity of mupirocin--an update on resistance. J Hosp Infect 1991 Sep;19 Suppl B:19-25.

Conclusion:

Program for comprehensive prescreening/treatment of S. aureus & MRSA prior to elective surgery is readily established & well-received

Program allows early identification of colonized patients, treatment, & adjustment of antibiotic prophylaxis, early isolation & contact precautions for MRSA

Associated with significant reduction in infections due to S. aureus & MRSA

Rapid on demand screening with GeneXpert is a big advantage to implement a decolonization program, and a valuable investment as the system is scalable with an extended menu of tests available

Thank You