Infection control and MRSA. Comparison of European strategies and possible solutions for Africa

1. MRSA
in
Africa
November
2012
Andreas
Voss
iPrevent
UMCN
&
CWZ
Nijmegen,
The
Netherlands
¤ One
of
the
first
cases
reported
in
the
conSnent
was
in
S.
Africa
in
1978.
¤ In
Sudan,
MRSA
was
first
reported
in
1999
¤ Madagascar
did
not
report
cases
of
MRSA
unSl
the
21st
century
¤ The
prevalence
in
Africa
ranged
from
5%
to
45%.
hFp://data.worldbank.org
(access
on
7-­‐11-­‐2012)
Thesis
by
Nirma
D.
Bustamante
(2011)
South
Afr
J
Epidemiol
Infect
2011;26(4)(Part
II):243-­‐250
Anderas
Voss,
MD,
PhD
1

2. MRSA
in
Africa
November
2012
South
Afr
J
Epidemiol
Infect
2011;26(4)(Part
II):243-­‐250
Breurec
et
al.
CMI
2011;17:160-­‐65
HA-­‐MRSA
(Belgium,
Portugal,
SWE)
(28%)
HA-­‐
&
CA-­‐MRSA)
(21%)
HA-­‐MRSA
(Brazilian/Hungarian
clone)
(40%)
Breurec
et
al.
CMI
2011;17:160-­‐65
¤ E-­‐MRSA
¤
The
Netherlands
as
an
example
of
how
low
¤ HA-­‐MRSA
(HO-­‐CA-­‐MRSA,
HO-­‐LA-­‐MRSA)
prevalence
countries
can
do
it…
¤ CA-­‐MRSA
(CO-­‐HA-­‐MRSA,
CO-­‐LA-­‐MRSA)
¤ LA-­‐MRSA
¤
“Search
&
destroy”
strategy
The
only
type
I
am
interested
in:
¤ IDCWYCI-­‐JTMHTFI-­‐MRSA*
*
I
Don’t
Care
What
You
Call
It
–
Just
Tell
Me
How
To
Fix
It
–
MRSA
(ScoF
Weese)
Anderas
Voss,
MD,
PhD
2

3. MRSA
in
Africa
November
2012
¤ IsolaSon
and
screening
of
risk-­‐paSents
on
admission
¤ Search
&
Destroy
(Control)
strategy
to
avoid
² at
all
Smes
introducSon
of
MRSA
into
health-­‐care
senngs
² colonized
and
infected
paSents
and
reduce
the
chance
of
transmission:
¤ DecolonizaSon
of
MRSA
carriers
² NaSonal
MRSA
guidelines
(www.WIP.nl)
¤ Consequent
acSons
when
transmissions
occur
² NaSonal
detecSon
methods
(NVMM)
² screening
of
all
paSents
and
HCWs
at
risk
² Use
fast
and
reliable
detecSon
methods
² MRSA-­‐posiSve
HCWs
not
allowed
to
work
¤ IsolaSon
and
screening
of
risk-­‐paSents
on
admission
¤ Placement
in
isolaSon
room
² can’t
determine
paSents
at
risk
² with
anteroom
and
negaSve
pressure
² only
certain
departments!
² not
when
too
busy/weekends
¤ Gloves,
gowns
and
face-­‐masks
² only
infected
paSents
² for
all
entering
the
room
¤ No
decolonizaSon
of
MRSA
carriers
¤ Consequent
acSons
when
transmissions
occur
¤ Handhygiene
² screening
of
all
paSents
but
not
HCWs
à
consequently
¤ AnSmcrobial
stewardship
MRSA-­‐posiSve
HCWs
may
conSnue
to
spread
Anderas
Voss,
MD,
PhD
3

4. MRSA
in
Africa
November
2012
80
1999
2000 MRSA
BSI
70 2001
2002
episodes
2003
60 2004 2000
2005
2006 1800
50
Year and quarter
2007 1600
*
% MRSA
* 1400
40
1200
30 1000
800
*
20 * 600
400
10
*
200
0
0
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
NL (1401)
LV (138)
CZ (1289)
LU (81)
IL (458)
IS (57)
NO (522)
SE (1770)
DK (978)
FI (679)
SI (310)
EE (123)
AT (1002)
PL (189)
DE (991)
HU (857)
ES (1303)
FR (2855)
RO (79)
UK (2803)
HR (329)
GR (541)
CY (54)
IE (1041)
BG (137)
BE (917)
IT (1119)
TR (827)
MT (92)
PT (836)
2005 2006 2007 2008 2009
1999 1999 1999 2000 1999 1999 2000 2004 2001 2000 2000 2000 2001 1999 1999 2001 1999 2000 2001 2002 2001 1999 2003 1999 2001 1999 1999 2003 1999 2000
Counts of MRSA bacteraemia
Country code (average number of isolates reported per year) & year of start surveillance# Courtesy: A. Pearson (HPA, Sept 2009)
EARSS report, October 2008 * DATA ARE PROVISIONAL NOT FOR WIDER CIRCULATION
MRSA
bacteremia
in
Europe
Source: EARSS report
¤ IsolaSon
IntervenSons
¤ PromoSon
of
Hand
Hygiene
¤ IdenSficaSon
of
paSents
with
MRSA
infecSons
or
colonizaSons
¤ Feedback
¤ Annual
reports
V.
Jarlier
et
al.
Arch
Intern
Med
2010
Anderas
Voss,
MD,
PhD
4

5. MRSA
in
Africa
November
2012
IsolaSon
IntervenSons
¤ Placement
of
paSents
with
MRSA
infecSons
or
colonizaSons
in
single-­‐bed
rooms
whenever
possible
¤ Barrier
precauSons
for
paSents
with
MRSA
infecSons
or
colonizaSons
such
as:
² disposable
gloves
worn
before
and
discarded
arer
paSent
contact
² disposable
aprons
worn
for
extensive
contacts
(eg,
bed
making)
² small
equipment
(eg,
stethoscope)
dedicated
to
the
paSent.
Should
we
ask
universal
precauSons
?
PromoSon
of
Hand
Hygiene
IdenSficaSon
of
MRSA
PaSents
¤ Hand
washing
with
disinfectant
soap
arer
contact
with
¤ Passive
surveillance
through
rouSne
clinical
specimens
paSents
with
MRSA
infecSons
or
colonizaSons
before
leaving
the
room
¤ AcSve
surveillance
(screening)
by
culturing
nares
of
paSents
with
a
high
risk
of
MRSA
colonizaSon,
eg,
intensive
¤ An
insStuSonal
campaign
for
promoSng
the
use
of
alcohol-­‐ care
unit
(ICU)
paSents
and
contacts
of
MRSA
paSents
based
hand-­‐rub
soluSons
in
place
of
hand
washing
¤ Quick
noSficaSon
and
flagging
of
new
paSents
with
MRSA
² launched
in
2001
infecSons
or
colonizaSons
by
laboratories
to
medical
teams
² Training
materials
to
the
infecSon
control
teams
(slide
shows,
¤ IdenSficaSon
of
MRSA
paSent
rooms
and
charts
(sScker)
200
000
brochures,
and
14
000
posters)
² formal
leFers
by
the
general
director
asking
all
administrators,
¤ Informing
units
to
which
paSents
with
MRSA
are
heads
of
departments,
and
chief
nurses
to
support
the
transferred.
campaign.
Feedback
¤ To
a
certainly
level
it
may
be
the
major
¤ Feedback
to
the
local
hospital
community
on
the
results
(MRSA
rates
and
progress
in
program
implementaSon).
components
that
count
not
the
details:
² Screening
Annual
report
² IsolaSon
(single
room
and
glove
and
gowns)
¤ Each
hospital
reporSng
to
the
central
administraSon
² Hand
hygiene
² size
of
the
infecSon
control
team
² CommunicaSon
² implementaSon
of
the
program
² organizaSon
of
audits
(eg,
on
hand
hygiene)
² feed-­‐back
² progress
of
the
iniSaSve
has
been
annually
presented
during
meeSngs
of
infecSon
control
teams
and
bacteriologists
from
all
AP-­‐HP
hospitals,
Anderas
Voss,
MD,
PhD
5

6. MRSA
in
Africa
November
2012
²
PrevenSon:
verScal
versus
horizontal
approach
While
important
other
factors
count:
¤ Compliance
with
basic
infecSon
control
measures
¤ Infrastructure
of
the
hospital
HAI
prevenSon
¤ HCW-­‐paSent
raSo
¤ AnSbioSc
use
¤ Emergence
of
CA-­‐MRSA
¤ Farming
(!)
&
food
(?)
¤
Hand
hygiene
¤
Flagging
¤
Gloves
¤
Environ.
Cleaning
¤
Gowns
¤
Screening
¤
Masks
² PaSents
²
HCWs
¤
Caps
¤
AnSbioSc
¤
Single
room
Stewardship
¤
CohorSng
¤
New
strategies
¤
Info/feedback
² horizontal
vs.
verScal
Isola>o Single
Hands
Gloves
Gowns
Mask
Cap
Cohort
n
Room
room
MRSA
NL
+
+
+
+
+
+
(+/-­‐)
outbreak
MRSA
+
Africa
+/-­‐
+/-­‐
-­‐
-­‐
-­‐
+/-­‐
-­‐
Screen
Screen
AB-­‐ Dedicated
Dedicated
Info
New
HCW
Equipme.
Flags
pts
HCWs
steward
Feedb.
strat
MRSA
NL
+
+
+
-­‐
+
+
+
+
MRSA
+
Africa
+/-­‐
+
+
+
+
+
+
Anderas
Voss,
MD,
PhD
6