moving from infection control to infection prevention: a journey through mrsa
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PATIENTS
C DIFF
MRSA
Moving from Infection Controlto Infection Prevention:
A Journey through MRSA
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. 11 (November 2010), pp. 1101-1105
Patient
Rehabilitation
Home Care
Surgery Center
HospitalLong Term Care
Dialysis
Physician Office
Staff/ Medical Staff
Visitors and Family
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?
• Control:– 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
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
• 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 ofabscesses 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
MRSA Skin andSoft 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
Wertheim H, et al. Lancet Infect Dis, 2005, 5: 751-762
Infections
38%
58%
48%57%
56%
72%
40%
44%
53%
62%
84%
59%(98% USA300)
MRSA Was the Most Commonly Identified Cause of Purulent SSTIs Among Adult ED Patients
(EMERGEncy ID Net), 2004 to 2008
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 CommonGorwitz, 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)
Seybold U, et al. Clin Infect Dis 2006;42:647-656
Historically community-acquired
ABC Surveillance, 2008MRSA 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
Cleanliness
Contaminated Surfacesand Shared Items
Frequent ContactCrowding
Compromised Skin
Antimicrobial Use
Preventing Transmissionin 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 Transmissionin 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
Outpatient dialysis patient is colonizedwith MRSA and not
treated with precautions
Housekeeper does not adequatelydisinfect 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.
HCW does not performhand hygiene
Role of Screeningand 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
PreventingHealthcare
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
– 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…
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