preventing mrsa transmission in the icu what have we learnt? · 2019. 11. 18. · skin folds plus...
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Preventing MRSA transmission in the ICUPreventing MRSA transmission in the ICU
What have we learnt?What have we learnt?
Jonathan EdgeworthConsultant Microbiologist Infection and Immunology Unit
Brief overview of local & UK MRSA epidemiology
Describe intervention programme on an ICU
Analysis of a highly invasive MRSA strain
Some science
AcknowledgementsDuncan Wyncoll (Consultant Intensivist) Ben Cooper (HPA)Rahul Batra (Clinical Fellow) Steve Bentley (Sanger Institute)Smriti Pathak (PhD student) Matt Holden (Sanger Institute)
2003 - Top (bottom) of the table…….
Mandatory reporting
*
Declining national rates of MRSA
Government Targets, PMDU, CQC
Board-to-floor accountability, DIPC,assurance framework
Investment, performance management, mandatory training, audits
Raised profile of IPC, clinical championschange in culture and behaviour
So how has this been achieved?
Recommendation SHEA (2003) WIP (2005) Working Party
UK (2006) CDC (2006)
Hand hygiene Y
Contact precautions Y
Education ND ND
System to identify patients with MRSA /Feedback
ND
Cohorting ND ND
Active surveillance testing Y
Environmental Decontamination
Antimicrobial Stewardship
Decolonization therapy
IA, strongly recommended, strongly supported by evidence IB, strongly recommended supported by evidence; Dutch Working party (WIP) Approach recommended for implementation
II Suggested implementation, supported by suggestive studies orS Recommended in specific populations only; ND, not discussed
(adapted from Calfee et al Infect Hosp Epi 2008; 29:S62-80)
MRSA – Control Recommendations for ICU
What evidence is there in the literature?
PubMed search “MRSA control and ICU” (March 17th)531 references (1980-present)201 reviewed (2007-present)
2Controlled study
6Time series analysis
10Surveys / reviews
13Observationalbefore / after
2Cleaning
1Cohorting
3Rapid diagnostics
3AST + isolation
8AST + decolonisation
6 studies from the UK……
*AST = active surveillance testing
An ICU intervention programme
Two 15-bed general ICUs5 side rooms
In 2002….Daily microbiology consults and infection control nurse visitEducation and hand hygiene auditsAlcohol gel at every bed-side
MRSA screening on admission and every Monday (nose, axilla, perineum)
Admitted – MRSA isolated from admission screen or any clinical sample in first 48 hoursAcquired – MRSA isolated from sample taken after first screen and 48 hours on the ICU
No cohorting or use of side rooms for MRSANo decolonisation strategy
0
5
10
15
20
J F M A M J J A S O N D J F M A M J J A S O N D
2002 2003
Admitted Acquired Bacteremia
A B
High level MRSA transmission in intensive care
A = education, audits and hand hygieneB = isolation and cohorting
0
2
4
6
8
10
12
14
16
18
J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J
2002 2003 2004N
umbe
r
TW Non-TW
0
2
4
6
810
12
14
16
18
J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J
2002 2003 2004
Num
ber
TW Non-TW
Admissions
Acquisitions
TW MRSAResistant to: Pen, Ery, Meth, Cip, Neo, Gent, Tet (T), Trim (W)Susceptible to: Vanc, Rif, Fus, Lzd
Emergence of a new highly resistant MRSA strain Emergence of a new highly resistant MRSA strain ““TWTW””
Holden MTG et al J Bact 2010:192; 888-92
φSaTW - 127 kbSimilar to region in S. epidermidis RP62aAminoglycoside resistanceNovel LPxTG adhesin (homologous to sesI)
TW ST239
Harris S et al Science (2010) 327; 469-474.
TW MRSA – imported from Thailand?
MRSA Positive Patients:• 1% CHX to nostrils, tracheostomy
sites 4x daily• 1% CHX powder to groin, axillae,
skin folds plus 4% CHX whole body wash daily
MRSA Negative Patients:• 1% CHX to nostrils, tracheostomy
sites 2x daily• 1% CHX powder to groin, axillae,
skin folds daily• 2% Triclosan body wash daily
Source control
Colonisation avoidance
Implementation of a chlorhexidine based antiseptic protocol
ADMISSION Confirmed MRSA +ve
KnownMRSA +ve
Unknown
0
2
4
6
8
10
12
14
16
18
J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D
2002 2003 2004
Num
ber
TW Non-TW
C
C = Chlorhexidine-based decolonisation strategy
Control of endemic transmission and termination ofthe TW MRSA outbreak
A
Edgeworth J et al Clin Infect Dis (2007) 44;493-501
B
Guy’s & St Thomas’ antimicrobial resistance and transmission database (GSTAR)5.2 million data points from 4,570 patients (2002 to 2006)517 patients admitted with MRSA / 347 patients acquired MRSA>70% MRSA isolates saved
Age, sex, specialty, dates of admission, discharge/death, starting and stopping of: ventilation, antibiotics and haemofiltration, dates of insertion and removal of vascular catheters, Admission & daily APACHE II scores, daily therapeutic intervention scores, collection and results of all microbiology specimens, daily bed placement, staffing levels.
Barnett AG et al Am J Epidemiol 2009:170;1186-1194
Which interventions were associated with a reduction inMRSA transmission?
Interventions:A Educational/Hand hygiene campaign, B Isolation and cohorting, C Antiseptic protocol
Interrupted Time Series analysis of MRSA Transmission
Endemic MRSA TW MRSA
Interventions Incidence Rate Ratio (95% CI) Prob. ≠ 1 Incidence Rate
Ratio (95% CI) Prob. ≠ 1
Education 0.91 (0.53, 1.58) 15 1.12 (0.63, 2.01) 17
Cohorting 1.12 (0.60, 2.09) 18 0.71 (0.18, 2.88) 25
Antiseptics 0.30 (0.19, 0.47) 100 3.85 (0.80, 18.59) 83
Change in trend following Education
1.00 (1.00, 1.00) 4 0.93 (0.85, 1.02) 75
Change in trend following Cohorting
1.00 (1.00, 1.00) 4 0.99 (0.92, 1.06) 15
Change in trend following Antiseptics
1.00 (1.00, 1.00) 4 0.96 (0.88, 1.05) 57
Step change
Trend change
*
* The columns headed “Prob ≠ 1” give estimated probabilities for an effect associated with each parameter. Low values indicate little evidence for an effect and values close to 100 indicate increasingly strong evidence
Batra R, et al Clin Infect Dis 2010 50;210-217.
Step change reduction in endemic TW MRSA transmissionafter introduction of the antiseptic protocol
MRSA Strains Before antiseptic protocol
After antiseptic protocol p value
TW Strainn 82 28Screen sites 28(34)* 11(39) 0.31Respiratory tract 52(63) 15(53) 0.18Skin breaches 45(55) 16(57) 0.42
Endemic Strainsn 480 274Screen sites 359(75) 140(52) <0.001Respiratory tract 261(54) 97(36) <0.001Skin breaches 145(30) 59(22) 0.005
Antiseptic Protocol Reduced Endemic Strain But Not TW Site Colonisation
*n(%) of patients with MRSA isolated at that site at any time during their stay on ICU
MRSA TYPE qacA/B carriagen (%)
TW (n=21)* 21 (100%)
Endemic strains (n=21)* 1 (5%)
qacA/B Carriage
* Representative isolates from cluster acquisitions in the year prior to introduction of the antiseptic protocol
qacA/B are plasmid born multi-component efflux pumps found in 10-20% UK, 65% EU 80% South American and 55% of Asian MRSA strainsPiddock Clin Microbiol Rev 2006; 19: 382-402
MRSA TYPE Triclosan MBC(ug/ml)
Chlorhexidine MBC(ug/ml)
TW (n=5) 25 78±4
Endemic Strains (n=5)* 25 26±8
Increased Chlorhexidine MBCs of TW MRSA
* qacA/B PCR negative
OutcomePopulation and interventionSetting
Acquisitions 21 v 11 Incidence (%) 2.48 v 1.49(p=0.048)
845 v 736 admMRSA 93 (11%) v (69) 9.4%9m AST + contact precautions9m add CHX + mupirocin
Ridenour (2007)Before – after16 bed ICU
Before: 193 (16%) MRSA positive After: 45 (3.1%) adm and 47 (3.4%) acqStep reduction
1232 v 1421 adm. 24m clinical cultures & contact precautions24m AST +CHX baths/nasal treatment
Gould et al (2007)Before - after16 bed ICU
Acquisitions 67 v 45 Incidence (%) 5.04 v 3.44 (p=0.046)
2670 v 2650 admMRSA prevalence 1.6-6.3%6m soap/water v 6m CHX all patients
Climo et al (2009)Before - after6 ICUs
Other studies: Thompson et al J Hosp Infect 2009:71;314-319Raineri et al J Hosp Infect 2007:67;308-315Sandri et al Infect Control Hosp Epidemiol 2006:27;185-187
Studies reporting on the use of chlorhexidine
Summary
Factor contributing to declining UK MRSA transmission have not been clearly defined
Decolonisation/universal antiseptic use may have an important role
MRSA strains carrying qacA/B are resistant to a chlorhexidine based antiseptic protocol
MRSA strains differ in their virulence and response to infectioncontrol interventions in ICU
Intercontinental transmission of a highly invasive, highly antiseptic and antibiotic resistance variant of MRSA (ST239-TW)