methicillin resistant staphylococcus aureus (mrsa) in the nordic countries petter elstrøm advisor...
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Methicillin resistant Staphylococcus aureus (MRSA)
in the Nordic countries
Petter ElstrømAdvisor
Norwegian Institute of Public Health
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Objective
Prevent establishment of MRSA in hospitals
• Increased rate of MRSA enforce changes in empiric treatment of S. aureus-infections
• Changes in antibiotic-guidelines will lead to more resistant bacteria and increase the cost
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Historical overview • Penicillin G introdused in 1941• Penicillin resistant (-lactamase prod.) S.aureus isolated
in 1942• Meticillin introdused in 1959 as the first -lactamase resistant penicillin• Meticillin resistant S.aureus first described in 1961• In late sixties MRSA was identified as a nosokomial
pathogen • In late nineties reduced sensitivity against Vancomycin
(VISA) was reported • Vancomycin resistant S.aureus (VRSA) isolated in 2002
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First ”MRSA-wave”• Meticillin resistant first described in 1961• Worldwide spread of a single arcaic clone
Second “MRSA-wave”• Outbreaks in hospitals• 5 dominant clones
Third “MRSA-wave”• CA-MRSA• Evolution of ”old” clones• Continually new MRSA-strains discovered
Historical overview
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CA-MRSA
• Both epidemiological and microbiological definition
• Increased incidence among people outside hospitals• Young people with no known risk factors for MRSA
• Differ genetically from strains inside hospitals– SCCmec IV, PVL
• Less resistant• Mainly skin- and soft tissue infections Occasionally
severe infections (necrotizing pneumonia)
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Changed epidemiology
• Earlier:– Imported cases
– Related to hospital admission or employment
• Now:– Most domestic cases
– Increasing rate of cases not related to hospitals
– Often no known risk factors for MRSA
– Outbreaks in nursing homes
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MRSA in western Europe
Source: www.earss.rivm.nl
Proportion of invasive isolates resistant to methicillin 2003
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MRSA in England og Wales
0
5
10
15
20
25
30
35
40
45
50
Proportion (%) of MRSA i blood culture, 1989-2002
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MRSA in the Nordic countries
*Estimated for 2005
Source: http://www.srga.org/SSAC/doc/2005/SSAC_MRSAreport_2004.pdf
0
5
10
15
20
25
30
Year
Inc
ide
nc
e (
No
/10
0.0
00
) Sweden
Finland
Denmark
Norway
Iceland
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MRSA in DenmarkDistribution by place of transmission
0
50
100
150
200
250
300
1999 2000 2001 2002 2003 2004
No
. of c
ases
CO-MRSA
HA-MRSA
Imported
Source: Robert Skov, State serum institute, Sept. 2005
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MRSA i Danmark
0
5
10
15
20
25
30
35
40
45
<1 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 >81
Age group
No
. of
ca
se
s
CA-MRSA
HA-MRSA
Distribution by age group, 2003
Source: Robert Skov, State serum institute, Sept. 2005
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MRSA in Sweden
Community
Hospital
Primary care
Home for the elderly
Abroad (communityand hospital)
Unknown
S
2003 2004
Source: Otto Cars, Smittskyddsinstitutet, sept. 2005
Distribution by place of transmission
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MRSA in NorwayNo. of cases, 1995 – 15.nov. 2005
0
50
100
150
200
250
300
350
400
450
500
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
No
. of
ca
se
s
Infection Colonization
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0
2
4
6
8
10
12
14
16
18
20
No
. pe
r 1
00
00
0 2004
15. nov. 05
MRSA in NorwayProportion by county, 2004 - 2005
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MRSA in NorwayDistribution by place of transmission
0
20
40
60
80
100
120
140
160
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
No
. o
f ca
ses
Domestic
Imported
Unknown
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Hospitalized:
MRSA in NorwayDistribution by place of infection onset
0
20
40
60
80
100
120
140
160
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
No
. o
f ca
ses
Yes
No
Unknown
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Reported outbreaks in health care institutions
0
1
2
3
4
5
6
7
2002 2003 2004 2005
Sykehus Sykehjem
MRSA in Norway
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2003: 2 hospitals, 3 nursing homes
2004: 2 hospitals, 4 nursing homes
2005: 8 nursing homes
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Challenges
• Increasing incidence of MRSA• Changing epidemiology• Bacterial evolution• Laboratorial methods are not optimal• Lack in knowledge• Differs in national and regional guidelines• Compliance of infection control measures are
not optimal
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Actions
• Coordinate the guidelines in the Nordic countries • Discuss and coordinate advices and guidelines in
Norway• Better survey through genotyping of all isolates• Continue rational use of antibiotics• Science
• High quality in hygiene and other infection control measures