MRSA In The Community Epidemiology and Treatment
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MRSA In The Community Epidemiology and Treatment MRSA In The Community Epidemiology and Treatment Presentation Transcript

  • Methicillin ResistantStaphylococcus aureus (MRSA) in the Community:Epidemiology and Management Rachel Gorwitz, MD, MPH Division of Healthcare Quality PromotionCenters for Disease Control and Prevention
  • Staphylococcus aureus Staphylococcus aureus: common cause of infection in the community Methicillin-resistant Staphylococcus aureus (MRSA): – Increasingly important cause of healthcare- associated infections since 1970s – In 1990s, emerged as cause of infection in the community
  • MRSA Strain Characteristics Were Initially Distinct MRSA in MRSA in the Healthcare CommunityPrevalent genotypes (U.S.) USA100, USA300, USA200 USA400Antimicrobial resistance Multiple Few agents agentsSCCmec (genetic element Types I-III Types IV, Vcarrying mecA resistancegene)PVL toxin gene Rare Common
  • Dice (Opt:0.50%) (Tol 1.3%-1.3%) (H>0.0% S>0.0%) [0.0%-100.0%] Pfsma National Database of MRSA Pulsed-Field Types Pfsma (Highlighted PFTs: historically community-associated) PFT MLST SCCmec pvl 100 50 60 70 80 90 USA300 .IVa 8 2001005114 USA300 IV8 POS .POS NE USA700 .IVa 72 USA700 IV72 2001005078 NEG .NEG NE USA100 .I I 5 2000018626 USA100 I I5 NEG .NEG NE USA800 .I V 5 2001035045 USA800 IV5 NEG NEG NE USA400 .IVa 1 99045065 USA400 IV 1 POS . USA500 .I V 8 95009938 USA500 IV, I I 8 NEG .NEG NE USA1000 .IV 59 USA1000IV59 94042318 NEG/POSNE USA900 . 15 USA900 MSSA 96023760 15 / 13 1.NEG USA600 .I I 45 USA600 I .I 99034758 . NEG USA200 .I I 36 USA200 I I36 96028758 NEG . PO USA1100 .IVa 30 USA1100IV30 AA0097 POS NE USA1200 . 2004711282 USA1200MSSA POSMcDougal et al J Clin Micro 2003;41:5113-5120
  • A Single Pulsed-Field Type (USA300) has Accounted for Most Community-Associated MRSA Infections in the U.S. 100% 80% 60% Pneumonia (AL, AR, IL, MD, TX, WA) Missouri California Pennsylvania Athletes Colorado Mississippi Texas Georgia Prisoners Tennessee Texas Missouri Children California USA300-114 Community USA100 Hospital Strain USA200 Hospital Strain
  • Community-Associated MRSA:CDC Population-Based Surveillance Definition MRSA culture in outpatient setting or 1st 48 hours of hospitalization AND patient lacks risk factors for healthcare-associated MRSA: – Hospitalization – Surgery – Long-term care – Dialysis – Indwelling devices – History of MRSA
  • Outbreaks of MRSA in the Community Often first detected as clusters of abscesses or “spider bites” Various settings – Sports participants – Inmates in correctional facilities – Military recruits – Daycare attendees – Native Americans / Alaskan Natives – Men who have sex with men – Tattoo recipients – Hurricane evacuees in shelters
  • Factors that Facilitate Transmission Crowding
  • Factors that Facilitate Transmission Crowding Frequent Contact
  • Factors that Facilitate Transmission Crowding Frequent ContactCompromised Skin
  • Factors that Facilitate Transmission Crowding Frequent Contact Contaminated SurfacesCompromised Skin and Shared Items
  • Factors that Facilitate Transmission Crowding Frequent Contact Contaminated SurfacesCompromised Skin and Shared Items Cleanliness
  • Factors that Facilitate Transmission Crowding Frequent Contact Antimicrobial Use Contaminated SurfacesCompromised Skin and Shared Items Cleanliness
  • 2004/2005 ABCs MRSA Surveillance Areas Minnesota New York Oregon Connecticut California Colorado Maryland Tennessee GeorgiaTotal Population: ~ 16.3 million
  • CA-MRSA Infections are Mainly Skin Infections Disease Syndrome (%) Skin/soft tissue 1,266 (77%) Wound (Traumatic) 157 (10%) Urinary Tract Infection 64 (4%) Sinusitis 61 (4%) Bacteremia 43 (3%) Pneumonia 31 (2%)Fridkin et al NEJM 2005;352:1436-44
  • CA-MRSA Incidence Varies by Age and Race Atlanta, 2001-2002 Baltimore, 2002 26 per 100,000 18 per 100,000Incidence, Casesper 100,00080 Black 80 Black70 White 70 White60 6050 5040 4030 3020 2010 10 0 0 <2 2-18 19-64 >64 <2 2-18 19-64 >64 Age Group (yr) Age Group (yr) •Fridkin et al NEJM 2005;352:1436-44
  • Most Invasive MRSA Infections Are Healthcare-Associated 14% 86% Community-Associated Healthcare-AssociatedKlevens et al JAMA 2007;298:1763-71
  • Incidence of Invasive CA-MRSA Infections and Deaths by Age Active Bacterial Core surveillance (ABCS), 2005 Incidence per Infections Deaths 100,000 persons 10 Overall Incidence (all ages): 8 Infections: 4.6 per 100,000 Deaths: 0.5 per 100,000 6 4 2 0 <1 1 2-4 5-17 18-34 35-49 50-64 >64 Age in yearsKlevens et al JAMA 2007;298:1763-71
  • S. aureus-Associated Skin and Soft Tissue Infections in Ambulatory Care  11.6 million ambulatory care visits per year in 2001-03 for skin infections typical of S. aureus  Increase in hospital outpatient and ED visits (2001-03 versus 1992-94)McCaig et al Emerg Infect Dis 2006;12:1715-1723
  • MRSA Was the Most Commonly Identified Cause of Purulent SSTIs Among Adult ED Patients (EMERGEncy ID Net), August 2004 54% 39% 15% 59% (97% USA300) 55% 74% 51% 68% 60% 60% 72% 67%Moran et al NEJM 2006;355:666-674
  • S. aureus Nasal Colonization National Health and Nutrition Examination Survey 2001-02 50 45 S. aureus: 32.4% = 89.4 M people 40 35 Prevalence (%) 30 Male 25 Female 20 15 MRSA: 0.8% = 2.3 M people 10 5 0 1--5 6--11 12--19 20--29 30--39 40--49 50--59 60--69 70+ Age (years)MRSA colonization associated with age >= 60 years & being female
  • Clindamycin Resistance Among MRSA Isolates,Texas Children’s Hospital, Houston Texas,2001-2004 20 n=181 % Clindamycin Resistant 15 10 n=163 n=915 n=1192 5 n=198 n=551 0 Year 1 Year 2 Year 3 Community Onset, Healthcare-associated MRSA Community-associated MRSA Source: Hulten et al. PIDJ 2006;25:349-53, and Kaplan et al. Clin Infect Dis 2005;40:1785-91
  • Emerging Multi-Drug Resistance in USA300?  Clusters of USA300 isolates with multiple resistance to erythromycin, clindamycin, tetracycline, ciprofloxacin, and mupirocin1  Resistance to ≤ one class of antibiotics other than beta-lactams is still the most common resistance pattern in MRSA USA300  TMP/SMX resistance rare in MRSA USA3001Diep et al Lancet 2006. Han et al J Clin Micro 2007.
  • Distribution of PFGE types among MRSA isolates from nosocomial bloodstream infections Grady Memorial Hospital, 2004 No. (%) of nosocomial PFGE cases type (n = 49) USA300 10 (20) USA100 21 (43) USA500 18 (37) USA800 0 (0)Seybold U, et al. Clin Infect Dis 2006;42:647-656
  • Strategies for Clinical Management of MRSA in the Communityhttp:www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html
  • Clinical Considerations - Evaluation MRSA belongs in the differential diagnosis of skin and soft tissue infections (SSTI’s) compatible with S. aureus infection:  Abscesses, pustular lesions, “boils”  “Spider bites”  Cellulitis?
  • Clinical Considerations - Evaluation MRSA should also be considered in differential diagnosis of severe disease compatible with S. aureus infection: – Osteomyelitis – Empyema – Necrotizing pneumonia – Septic arthritis – Endocarditis – Sepsis syndrome – Necrotizing fasciitis – Purpura fulminans
  • Management of Skin Infections in the Era of CA-MRSA I&D should be routine for purulent skin lesions
  • Management of Skin Infections in the Era of CA-MRSA I&D should be routine for purulent skin lesions Obtain material for culture
  • Management of Skin Infections in the Era of CA-MRSA I&D should be routine for purulent skin lesions Obtain material for culture No data to suggest molecular typing or toxin-testing should guide management
  • Management of Skin Infections in the Era of CA-MRSA I&D should be routine for purulent skin lesions Obtain material for culture No data to suggest molecular typing or toxin-testing should guide management Empiric antimicrobial therapy may be needed
  • Management of Skin Infections in the Era of CA-MRSA I&D should be routine for purulent skin lesions Obtain material for culture No data to suggest molecular typing or toxin-testing should guide management Empiric antimicrobial therapy may be needed Alternative agents have +’s and –’s: More data needed to identify optimal strategies
  • 80%Percentage CA-MRSA Management of Skin Infections 70% 60% 50% 40% 30% 20% 10% 0% in the Era of CA-MRSA Center Center Center Center Total A B C D  I&D should be routine for purulent skin lesions  Obtain material for culture  No data to suggest molecular typing or toxin- testing should guide management  Empiric antimicrobial therapy may be needed  Alternative agents have +’s and –’s: More data needed to identify optimal strategies  Use local data for treatment
  • Management of Skin Infections in the Era of CA-MRSA I&D should be routine for purulent skin lesions Obtain material for culture No data to suggest molecular typing or toxin-testing should guide management Empiric antimicrobial therapy may be needed Alternative agents have +’s and –’s: More data needed to identify optimal strategies Use local data for treatment Patient education is critical!
  • Management of Skin Infections in the Era of CA-MRSA I&D should be routine for purulent skin lesions Obtain material for culture No data to suggest molecular typing or toxin-testing should guide management Empiric antimicrobial therapy may be needed Alternative agents have +’s and –’s: More data needed to identify optimal strategies Use local data for treatment Patient education is critical! Maintain adequate follow-up
  • Clinical Considerations - Management Antimicrobial Selection (SSTIs) Alternative agents (More data needed to establish effectiveness!): – Clindamycin – Potential for inducible resistance, Relatively higher risk of C. difficile associated disease? – TMP/SMX – Group A strep isolates commonly resistant – Tetracyclines – Not recommended for <8yo – Rifampin – Not as a single agent – Linezolid – Expensive, Potential for resistance with inappropriate use
  • Clinical Considerations - Management Antimicrobial Selection (SSTIs) Not optimal for MRSA (High prevalence of resistance or potential for rapid development of resistance): – Macrolides – Fluoroquinolones
  • D-zone test for Inducible Clindamycin Resistance E CC-Perform on erythromycin-resistant, clindamycin-susceptible S. aureus isolates-Clinical implications unclear, but treatment failures haveoccurred-Does not require pre-treatment or co-treatment witherythromycin in vivo
  • Management of Severe / Invasive Infections  Vancomycin remains a 1st-line therapy for severe infections possibly caused by MRSA  Other IV agents may be appropriate Consult an infectious disease specialist.  Final therapy decisions should be based on results of culture and susceptibility testing  Severe community-acquired pneumonia: Vancomycin or linezolid if MRSA is a consideration**IDSA/ATS Guidelines for treatment of CAP in adults: Mandell etal. CID 2007;44:S27-72
  • Screening and Decolonization In general, colonization cultures of infected or exposed persons in community settings are not recommended. (May have a role in public health investigations). Decolonization regimens: – May have a role in preventing recurrent infections (more data needed to establish efficacy and optimal regimens for use in community settings). – After treating active infections and reinforcing hygiene and appropriate wound care, consider consultation with an infectious disease specialist regarding use of decolonization when there are recurrent infections in an individual patient or members of a household.
  • Preventing Transmission  Persons with skin infections should keep wounds covered, wash hands frequently (always after touching infected skin or changing dressings), dispose of used bandages in trash, avoid sharing personal items.  Uninfected persons can minimize risk of infection by keeping cuts and scrapes clean and covered, avoiding contact with other persons’ infected skin, washing hands frequently, avoiding sharing personal items.www.cdc.gov
  • Preventing Transmission Exclusion of patients from school, work, sports activities, etc should be reserved for those that are unable to keep the infected skin covered with a clean, dry bandage and maintain good personal hygiene. In general, it is not necessary to close schools to “disinfect” them when MRSA infections occur. In ambulatory care settings, use standard precautions for all patients (hand hygiene before and after contact, barriers such as gloves, gowns as appropriate for contact with wound drainage and other body fluids).www.cdc.gov
  • Role of Pets  Greatest risk of Staph aureus / MRSA exposure in most humans is other humans  When household pet animals carry MRSA, likely acquired from a human  Transmission of MRSA from an infected or colonized pet to a human is possible, but likely accounts for a very small proportion of human infections  Reasonable to consider pet as a source if transmission continues in a household despite optimizing other control strategies  Little evidence that antimicrobial-based eradication therapy is effective in pets; however, colonization tends to be short-term*Barton et al 2006;Can J Infect Dis Med Microbiol
  • Conclusions New strains of MRSA have emerged in the community, with implications for management of skin infections and other staphylococcal infections. Incision and drainage remains a primary therapy for purulent skin infections. Oral treatment options are available for patients with skin infections that require ancillary antibiotic therapy. Patient education on proper wound care is a critical component of case management for patients with skin infections. Strategies focusing on increased awareness, early detection and appropriate management, enhanced hygiene, and maintenance of a clean environment have been successful in controlling clusters / outbreaks of infection.
  • DHQP Posters and Patient Tear Sheet http://www.cdc.gov/mrsa
  • CA-MRSA Working Group Meeting Participants, July 2004Gordon L. Archer Gregory Moran CDCCarol L. Baker Olga Nuno Daniel B. Jernigan*Elizabeth Bancroft John H. Powers John Jernigan*Henry F. Chambers L. Barth Reller Jay C. ButlerRobert S. Daum Nalini Singh Denise CardoJeffrey S. Duchin Marcus Zervos Roberta CareyMonica Farley Craig Zinderman Rachel GorwitzJames Hadler Jeffrey C. HagemanJim Jorgensen Thomas HennessySheldon K. Kaplan James M. HughesNewton E. Kendig Jean PatelKathleen Harriman Fred TenoverFranklin D. Lowy J. Todd WeberRuth LynfieldJ. Kathryn MacDonald *Meeting Co-ChairLoren Miller
  • Questions? DHQP Inquiries hip@cdc.gov