Detection and control of MRSA in healthcare facilities

E. Tacconelli

Dept. Infectious Diseases

Catholic University, Rome, Italy

• EARS-Net (198 laboratories in 22 EU countries up to 2009): the number of bloodstream infections caused by S. aureus increased by 34%. However, the proportion of meticillin resistant isolates decreased.

1. Lack of awareness

Non-medical specialists

Junior doctors

Subspecialties of ID / CM

2. High level evidence not always available

3. Local implementation of international protocols not always possible

Road map

1. MRSA+ pt at hospitalisation

2. MRSA+ pt before surgery

3. MRSA+ pt during hospitalisation

4. MRSA+ pt at hospital discharge

5. MRSA+ pt in ambulatory setting

Tackling resistance of HA-MRSA

Prevention of

resistance

development

Antimicrobial

stewardship

1 - Pathogen

2 - Patient

Prevention of

infection

Screening

Surgical

prophylaxis

Decolonization

Prevention of

intrahospital

spreading

Patient

Isolation

Cohort

Contact prec.

Hand hygiene

HCW

Education

Individual

protection

Environment

3 – Hospital

Tackling resistance of MDR resistant bacteria

2 - Patient

Prevention of

infection

Screening

Surgical

prophylaxis

Decolonization

Colonisation precedes the infection

MRSA infections develop in 11% to 33% of colonized patients

Nasal carriage of MRSA increases risk of MRSA infections by 4 fold

Mest, Anesth Analg, 1994; Jernigan, ICHE, 1995; Sadfar, Am J Med 2008

Guidelines SHEA, 2003

CID / CAMS, 2004

HIS, ICNA, British Society of Antimicrobial Chemotherapy, 2006

Hospital-acquired MRSA

Center for Diseases Control and Prevention, 2007

MDR-bacteria

British Society of Infection Control, 2008 Prophylaxis and treatment update Community-acquired MRSA

Consensus ESCMID-ISC 2010

ECDC guidance document 2011 (under revision)

Harbarth, CMI 2010; Tacconelli CMI 2010; Garau CMI 2010

Paterson, JCM, 2010

Universal versus targeted screening

Multivariables risk factors screenings

Haley, J Clin Microbiol, 2007

Universal versus targeted screening

Collins, JHI 2011

Scotland challenges the UK..

Targeted vs Universal

Collins, JHI 2011

Scotland challenges the UK.. Targeted vs Universal

MRSA detection rates did not increase despite an exponential increase in lab workload

1-month period: 7 cases missed using targeted S&D approach. Detection of these additional pts: lab costs £20,000 / 4200 neg screens

Screening strategy based upon clinical risk is more pragmatic and more cost-effective than the universal programme

Scotland challenges the UK..

Targeted vs Universal

Type of test for MRSA screening

PCR-based vs chromogenic-based

Tacconelli, Lancet Infectious Diseases 2009

MRSA Decolonisation

Cookson et al., CMI 2010 ESCMID-ISC, Expert Consensus 2010

Protocols

MRSA

2% mupirocin ointment intranasally alone or:

2% chlorhexidine or octenidine dihydrocholride washes or 7% povidone-iodine or 2% triclosan and

oral rifampin and/or doxycycline or trimethoprim-sulfamethoxazole

oral vancomycin (250 mg q6h, 2002)

arbekacin inhalation + trimethoprim-sulfamethoxazole (800 mg/160 mg, twice daily)

tea tree topical preparation

Paediatric (3-step-protocol): mupirocin + oral rifampin (20 mg/Kg/die) + fusidic acid (50 mg/kg/die) + chlorhexidine for washing x 5 days; teicoplanin for (10 mg/kg 12 h x 3 doses then once daily for 9 days) for persistent carriage (2007)

Gentian violet

Duration of therapy: 5-7 days

Gilpin, J hosp infect 2010

Isolation and

decolonisation

Decolonisation of

inpatients

Ammerlaan et al., JAC 2011

Ammerlaan et al., JAC in press

Decolonisation: who, where, how and when

Implementation of GL increases treatment success

60% of MRSA carriers were successfully decolonised

after the first eradication

Risk factors for decolonisation failure: CPD, throat-

perineum carriage, and carriage among household

contacts (uncomplicated); throat carriage and

dependence in activities of daily living (complicated)

Ammerlaan et al., JAC in press

First trial on mupirocin efficacy

Ammerlaan HS, JAC 2011

Current evidence, further supported by the first trial on mupirocin

efficacy, suggests that a decolonization protocol including local and

oral antibiotic therapy and decolonization of household contacts of

complicated MRSA carriers, combined with the introduction of

national guidelines endorsing decolonization, is highly efficacious in

populations with a low endemic level of MRSA.

However, the measures required to control MRSA in hospitals,

including decolonization protocols, where MRSA is highly endemic

may be different from those required in other institutions.

Tacconelli & Johnson JAC 2011

Isolation and decolonisation

Decolonisation of household

Bocher, CMI 2009

Manian, CID, 2003

Lee, CID 2011

Risk factors for MRSA persistent colonisation

Low level mupirocin resistance and genotypic chlorexidine resistance

Tackling resistance of HA-MRSA

Prevention of

intrahospital

spreading

Patient

Isolation

Cohort

Contact prec.

Hand hygiene

HCW

Education

Individual

protection

Environment

3 – Hospital

BMJ, 2004

No well designed studies exist that allow

the role of isolation measures alone to be

assessed.

None the less, there is evidence that

concerted efforts that include isolation can

reduce MRSA even in endemic settings.

Current isolation measures recommended

in national guidelines should continue to

be applied until further research

establishes otherwise.

Monthly Incidence of Colonization or Infection

with MRSA or VRE among Patients in ICUs

The mean ICU-level incidence of MRSA/VRE colonization/infection

per 1000 pts-days at risk, adjusted for baseline incidence, did not differ

significantly between the intervention and control ICUs (40.4±3.3 vs 35.6±3.7; P

= 0.35).

• Most of the evidence for HCW screening comes

from outbreak reports where the outbreak was

brought to an end following the introduction of

staff screening as part of a suite of infection

control measures

• Further research is required before a

recommendation could be made to introduce

routine MRSA screening of HCWs

Hawkins, J hosp infect 2011

Wilson, Crit Care Med 2011

Enhanced cleaning of the near-patient environment and hospital pathogens

from the bed area and staff hands

Datta, Arch Intern Med 2011

Enhanced cleaning

and risk of acquiring MRSA and VRE from prior room occupant

Tekerekoglu, AJIC 2011

Mobile phones

how many risks..

Bray, CMI 2011

Mobile phones how many risks..

Tackling resistance of MDR resistant bacteria

Prevention of

resistance

development

Antimicrobial

stewardship

1 - Pathogen

Tacconelli, Journal of Antimicrobial Chemotherapy (2008) 61, 26–38

Systematic review

Gram-positive bacteria: MRSA

Tacconelli, Antimicr Agents Chemoth, 2009

Risk of MRSA and/or VRE

new acquisition

after antibiotic therapy

in hospitalized patients

MRSA+ pt before surgery

Isolation and decolonisation

High risk patients: surgery

Bode et al., NEJM 2010

MRSA bundle

Surgery patients

1. MRSA nasal screening

upon admission

2. Contact isolation

3. Handhygiene

4. Antimicrobial

stewardship

5. Outcome measures

Awad, ICHE, 2009

MRSA+ pt during hospitalisation

Rymzhanova, ICHE, 2009

“Real life”

1. MRSA+ pt at hospitalisation

Target screening of high risk patients

Universal sreening if MR > 35% on blood cultures

Contact precaution

Decoloniization if LOS > 7 days

In case of failure: pharingeal screening

2. MRSA+ pt before surgery

Decolonization for S aureus!

3. MRSA+ pt during hospitalisation

Periodic screening of high risk patients

4. MRSA+ pt at hospital discharge

Decolonization + household dec. – envirom. If needed

Health economic evaluation of prevention of MRSA infections or

-colonisations at hospitals: A systematic review (2004-2009)

829 economic publication reviewed 8 economic studies analysed

Limited quality

The break even point of cost-effective prevention and control measurements for MRSA cannot be finally clarified

There is a need for additional cost-benefit analyses

Korczak, GMS HTA 2010

Cost-effectiveness studies and MRSA

23 papers

costing studies to establish the

excess cost of MRSA infection or an

estimate of the national burden (n = 7)

economic evaluations comparing the

costs and benefits of an intervention

with the pre-existing service (n = 15)

All evaluated screening in hospital

with one exception (cleaning)

Gould, CMI 2010

Major pitfalls of cost analyses for reducing MRSA

No studies on IC measures

Majority of interventions were 7–8 years old

Different countries with different health care systems and cost structures USA (9)

UK (5)

Germany (3)

One southern European country (Spain)

Lack of generalizability

Single hospital study

Specific population

ICU

Emergency population

High risk patients

Surgery patients

Gould, CMI 2010

Olchanski, ICHE 2011

Cost effectiveness

universal vs targeted screening

PCR-based vs chromogenic media

Universal screening

Admission prevalence 7.5%

PCR screening (94.6% / 96.6%)

Strategy Active surveillance + decolonisation

Vs

Active surveillance

No screening

Outcomes HAI MRSA infections

Deaths avoided

Nelson, CMI 2010

Special setting

Cardiac surgery

Lee, Am J Manag Care 2010

Special setting

Orthopedic surgery

Lee, ICHE 2010

High risk setting: ICU

Nyman, Am J Infect Control 2011

Hospital admission Medium MRSA prevalence (5%):

Targeted screening with

chromogenic media is cost-

effective versus PCR-based

screening

High MRSA prevalence (15%):

PCR-based targeted screening

is cost-effective versus

chromogenic-media

Cardiac and orthopedic surgery / ICU:

Universal screening with PCR is

cost-effective versus chromogenic

media

Implications for

practice

Cost-effectiveness is only one of a number of criteria that should be employed in determining whether interventions are made available.

Issues of equity, needs, priorities and so on should also form part of the decision-making process.

Consider whether the cost-effective interventions would address major sources of the MRSA disease burden in your country and determine whether the cost-effective interventions would be feasible given existing institutions and experiences with implementation in their countries.

Implications for practice

Could the risk of MRSA hospital acquisition

have been reduced?

Preoperative screening: POSITIVE for S. aureus

Decolonisation NO early PJI NO long LOS NO UTI NO antibiotic therapy

Preoperative screening: NEGATIVE

No decolonisation early PJI long LOS HIGH RISK PATIENT !!!! Screening at hospital admission: positive for MRSA!!! No endocarditis……