Ali Rabaan - saudi aramco medical services
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  • NICE SIR
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    THANKS MASALAAM
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  • Faire le lien entre biothreat et méthodes moléculaires pour introduire le bénéfice de la sample prep intégrée ds GX
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  • Includes reagents for the detection of MRSA as well as quality controls.
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Ali Rabaan - saudi aramco medical services Ali Rabaan - saudi aramco medical services Presentation Transcript

  • Molecular Detection of MRSA and its Impact on Infection Control Dr. Ali Rabaan, M.Med.Sci, PhD. Head of Molecular Microbiology Laboratory Saudi Aramco Medical Services Organization
  • Outlines
    • History of MRSA and Antibiotics.
    • Why We Worried About It.
    • Prevalence.
    • Transmission.
    • Factors Enhance the Emergence and Transmission.
    • Impact of Molecular Testing on Infection Control.
    • Molecular Testing of MRSA.
  • Staphylococcus aureus
    • Gram positive cocci.
    • Arranged in a grape-like structure.
    Lowy. N Engl J Med . 1998;339:520-532 .
  •  
  • Why We Are Worried
    • Greater morbidity and mortality.
    • Hospitalization and supportive care.
    • Increased use of:
      • Laboratory and diagnostic tests.
      • Infection control procedures.
      • Housekeeping procedures.
      • More expensive antimicrobials
      • (Very limited choices).
      • Length of hospital stay (9 days).
    • Rubinstein and Zhanel. Lancet Infect Dis 2007.
    • Lynch and Zhanel. Sem Resp Crit Care Med 2005.
  • www.thelancet.com Vol 367 Month xx, 2006
  • Prevalence of MRSA in Saudi Arabia
    • Prevalence is unknown, and varies geographically.
    • In Jeddah, the prevalence increased from 2% in 1988 to 33% in 1998 (T. Madni et al, 2001).
    • Another study in Jeddah, MRSA comprised 7.5%/year of all S. aureus (T. Austin et al, 1994).
    • In Riyadh, the prevalence ranged from 12 to 49.4% in six major hospitals (Baddour et al, 2006).
  • Prevalence of MRSA infection in Saudi Aramco
    • A study conducted from 1999 to 2003 (J. Al-Tawfiq, 2006).
    • A total of 5162 S. aureus isolates.
    • MRSA constitutes 6% (308) of all isolates.
    • Currently ~15%.
  • Who Gets MRSA Anyone can get MRSA!
  •  
  • MRSA Colonization sites
    • Nose/throat.
    • Axilla.
    • Groin.
    • Wounds.
    • IV access sites.
    • Urinary catheter exit sites.
  • Transmission
    • Direct person to person contact.
    • Sharing of towels or personal hygiene items.
    • Athletic equipment.
    • Clothes.
    • Drug use equipment.
    • Contact sports.
    • Food-borne.
  • Factors that Facilitate Transmission Contaminated Surfaces and Shared Items Cleanliness Crowding Compromised Skin Antimicrobial Use Defense Offense Frequent Contact
  • Practice of HCW Hospital of Saint Raphael, New Haven, CT http://www.handhygiene.org/
  •  
    • A male infant suffering Pierre Robin syndrome. He was intubated and mechanically ventilated 4 days after birth. Because of respiratory insufficiency. A suspected respiratory tract infection (amoxicillin/clavulanic acid).
    • Became bacteraemic after 3 days (amoxicillin and cefotaxime).
    • Blood culture grew methicillin-susceptible S. aureus (MSSA) (flucloxacillin).
    • He seemed to recover, but amoxicillin/clavulanic acid was reinstated for 10 more days on day 32 after the respiratory tract infection had recurred.
  • MRSA screening Options
    • Microbiology culture.
    • Molecular Testing.
  • Microbiology Culture
    • Gold standard: sensitive but slow.
    • 48 hr broth enrichment.
    • Dedicated skilled lab personnel.
    • Confirm identification and resistance
    • patterns of multiple colonies.
    • Restricted to lab opening hours.
    • Report final results in 48 - 120 hours (5 days). Good solution if it is not urgent (e.g. elective surgery/planned hospital stay).
  • Why Utilize Molecular Testing
  • infection control and hospital epidemiology April 2010, vol. 31, no. 4
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  • PAGE | Conventional PCR/ 1 st generation rt-PCR
    • Test-to-result time theoretically rapid  5h
    • Labor-intensive
    • Dedicated skilled personnel
    • Several separated lab rooms
    • Batch-testing required for cost-efficiency
    • Average time-to-report 36 h (24-72)
    Raw Sample Prep 2 - 4 hours PCR Amplification 1.5 - 2.5 hours Fluorescence Detection 1 - 2 hours
  • Molecular testing
    • Cepheid GeneXpert ® MRSA.
    • Continuous and individual patient random access.
    • Fully automated.
    • All testing processes - sample preparation, real-time PCR amplification and detection - are performed in a closed single testing cartridge.
    • Individual patient results in 56 minutes.
    • Very easy to implement.
    • Can be performed “near-patient”.
  • Handling 56 minutes maximum
  • In House MRSA Validation Study
    • Analytical sensitivity (lower limit of detection) is 80 CFU/swab.
    • Analytical specificity showed No cross-reactivity with other microorganisms and it cab be detected in mixed population.
    • Comparative study included 51 clinical and volunteer samples. All results are correlated with Microbiology results.
  • Why we introduce GeneXpert MRSA in Saudi Aramco
    • To reduce the turn around time (TAT) of MRSA result.
    • To release the results within 120 minutes and our target is at least 90%.
  • Monitoring of Rapid MRSA Molecular assay results in Saudi Aramco
    • A total of 1071 samples processed from October 15, 2008 to April 19, 2009. MRSA comprised (64) 6.4%
    • Analysis of data obtain from laboratory information system (LIS) showed the following:
    • A total of 250 specimens were processed from Jan to Feb, 2009.
    • Nursing department 21% delay.
    • Lab triage section 17% delay.
    • From receiving to resulting 77% delay.
    • From ordering to resulting 77% delay.
    • Samples processed by techs 44-100% delay.
  • Time allocation for MRSA Sample Processing
    • 1. Nursing department =10 minutes.
    • 2. Lab triage section =10 minutes.
    • 3. Molecular or Microbiology lab =100 minutes.
  • Monitoring of Rapid MRSA Molecular assay in Saudi Aramco Month # of specimens % results within 2 hours % of results beyond 2 hours Jan-Feb 09 250 23 77 March 09 195 53 47 April 09 161 75 25 May 09 164 69 31
  • Limitations of the assay
    • Increasingly, several reports about presence of SCC WITHOUT mecA
    • MRSA SCCmec True positive
    • S. aureus False positive
    orfX mecA orfX SCC orfX mecA
  •  
  • Old versus New Kit Old kit % old kit New Kit % New Kit Negative 552 78 453 71 Positive 134 19 50 8 Error 11 1.5 17 2.7 Invalid 2 0.3 61 9.6 No result 7 1 6 1 Total 706 634
  • Limitations
    • Mutations or polymorphisms in primer or probe binding regions may affect detection of new or unknown MRSA variants resulting in a false negative result.
    • Blood or mucus or both have been shown to cause inhibition in 4.2% of nasal swab specimens.
    • A positive test result does not necessarily indicate the presence of viable organism.
    • Therapeutic success or failure cannot be assessed using this test because DNA might persist following antimicrobial therapy.
    orfX mecA
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  • Summary
    • MRSA is a global health problem.
    • MRSA is transmitted easily between patients and HCWs and vice versa.
    • Rapid molecular assay helps very effectively in infection control.
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    • Thank you