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Periop conference   mrsa and mssa - sep 11 2010
 

Periop conference mrsa and mssa - sep 11 2010

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  • We conducted another anonymous surveillance culture study in Feb 2006 – 133 spine patients noses were cultured in the OR 29% grew out Staph aureus and 4% were positive for MRSA – which was undiagnosed and therefore surgical prophylaxis with Vancomycin was not administered and no precautions were used in the OR, PACU or nursing units. These patients may also Have been discharged to a rehab facility with no flagging for precautions.

Periop conference   mrsa and mssa - sep 11 2010 Periop conference mrsa and mssa - sep 11 2010 Presentation Transcript

  • Maureen Spencer, RN,M.Ed., CIC Infection Control Manager New England Baptist Hospital Boston, Ma. Email: [email_address] 617 754-5332 www.workingtowardzero.com
  • What is Staphylococcus aureus ?
    • Staphylococcus aureus , "staph," are bacteria commonly carried on the skin or in the nose of healthy people.
    • They are gram positive (purple colored) cocci in clusters on gram stain
  • Overview of Antibiotic Resistance
    • Unnecessary antibiotic use. excessive and unnecessary antibiotic use.
    • Antibiotics in food and water. Antibiotics in livestock find their way into municipal water systems when the runoff from feedlots contaminates streams and groundwater.
    • Germ mutation. Antibiotics don't destroy every germ they target. Germs learn to resist others and mutate much more quickly than new drugs can be produced.
    • Transfer Factors – survival of the fittest – quantum communication
  • Past 60 years – Resistance
    • 50-70’s Staph aureus developed Penicillin resistance (blocking enzyme called penicillinase)
    • 70’s Pencillinase resistant antibiotics (methicillin, oxacillin)
    • Early 1980’s – first cases of MRSA - Methicillin-Resistant Staphylococcus aureus in US
    • Early 1990’s Vancomycin Resistant Enterococci (VRE)
    • Early 2000’s CA-MRSA (USA300)
    • Now - V.I.S.A. & V.R.S.A.
    • Vancomycin intermediate and Vanco resistant strains
  • What is MRSA?
    • MRSA is the term used for a subgroup of bacteria of the Staphylococcus aureus species that are resistant to the usual antibiotics used in the treatment of infections
    • Not just resistant to Methicillin - often have resistance to many antibiotics traditionally used against S.aureus .
  • How Does it Get Resistant?
    • Presence of the mec gene in the bacteria.
    • This alters the site at which methicillin binds to kill the organism.
    • Hence, methicillin and other antibiotics are not able to effectively bind to the bacteria.
  • Penicillin Binding Protein 2a
    • MRSA carry a unique protein called PBP 2a (penicillin-binding protein) on the cell membrane that plays a key role in helping to defend against antibiotics.
    • Sspecific components of the bacterial cell wall interact with PBP 2a to form a chemical barricade.
    • New antibiotics will deactivate the protein so they succumb to the antibiotic.
  • CA-MRSA and HA-MRSA
    • CA-MRSA Community-acquired Methicillin resistant Staph aureus
      • Unique microbiologic and genetic properties compared with HA-MRSA may allow the community strains to spread more easily or cause more skin disease
    • HA-MRSA Healthcare-acquired Methicillin resistant Staph aureus
    • Many hospitals now seeing CA-MRSA in healthcare associated infections
  • Differences in Strains
    • HA-MRSA
      • Pulse field gel electrophoresis (PFGE) USA 100, 200 & 500
      • Less mobile
      • Panton valentine leucocidin (PVL) gene rare
      • More resistant to antibiotics
    • CA-MRSA
      • Pulse field gel electrophoresis (PFGE) USA 300, 400, 1000 &1100
      • More mobile
      • PVL gene more common
      • Less resistant to abx
      • Clindamycin resistance developing in USA 300 strains
  • Community-acquired (CA)-MRSA
    • Susceptible to Clindamycin, Tetracyclines, and Bactrim
    • Genotypes of CA-MRSA
      • most common in US is clonal cluster ST-8 classified by the CDC as "USA 300."
    • CA-MRSA has a novel methicillin-resistance cassette element: type SCC mec IV, which has not been found in HA-MRSA isolates
    • CA-MRSA is more likely to encode for the Panton-Valentine leukocidin (PVL) toxin
      • virulence factor associated with severe necrotizing pneumonia and skin and soft-tissue infections.
  • Severe CA-MRSA – Not PVL
    • Most scientists believed the cause of severe CA-MRSA infection was Panton-Valentine leukocidin (PVL) toxin released by the organism
    • However, a study indicating that PVL does not play a major role in CA- MRSA infections was published in 2006
    • Question: what does????
    • Reference: J Voyich et al. Is Panton-Valentine leukocidin the major virulence determinant in community-associated methicillin-resistant Staphylococcus aureus disease? The Journal of Infectious Diseases 194(12), 2006
  • Phenol Soluble Modulin Protein
    • Newly described proteins in CA-MRSA
      • members of the phenol-soluble modulin (PSM) protein family
    • CA-MRSA strains attract and then destroy protective human white blood cells
      • eliminates immune defense mechanisms
      • production of the protein was typically higher in CA-MRSA strains
        • Release Panton Valentine Leukocidin virulence toxin to destroy tissue
    • Identification of novel cytolytic peptides as key virulence determinants of community-associated MRSA. Wang, Otto et al. Nature Medicine 2007 Nov 11 epub.
  • Vancomycin Resistance
    • In 1996, the first clinical isolate - Japan
    • In June 2002, Vancomycin Resistant Staph aureus (VRSA) isolated from a intravenous catheter site
      • Michigan resident aged 40 years with diabetes, peripheral vascular disease, and chronic renal failure
      • It contained the Van A resistance gene – from VRE
    • vanA in this VRSA - acquired through exchange of genetic material from the vancomycin-resistant enterococcus also isolated from the swab culture
    • MMWR July 5, 2002 / 51(26);565-567
  • New, lethal MRSA strain emerges……
    • A new strain of methicillin-resistant Staphylococcus aureus (MRSA) is emerging
    • Researchers with Henry Ford Hospital say the USA600 strain is partially immune to vancomycin
    • Half of the USA600-infected patients in the study died within a month, a death rate five times that of those infected with known MRSA strains. (Ordinarily, 11 percent of patients infected with MRSA die within 30 days)
    • Factor may be age - those with the strain were, on average, 64 years old, as compared with 52 years old for other MRSA-infected people.
    • Source: Presentation at the Infectious Diseases Society of America, October 29, 2009
  • Populations at Risk for CA-MRSA
    • CA-MRSA do not have the usual risk factors associated with nosocomial MRSA.
    • Populations at greater risk include:
      • children and day care centers
      • persons in correctional facilities
      • military personnel
      • native populations
      • gay men
      • HIV-infected persons
      • Sports: football, basketball, baseball,
      • wrestlers, fencing, soccer
      • injection drug users
      • homeless
  • Pets can carry MRSA
    • German woman - multiple deep abscesses
      • Strain of drug-resistant MRSA
      • Cured after the family's cat was tested and treated.
    • Husband and two children carriers of MRSA
    • Treated and tested negative, she still was infected
    • Three apparently healthy cats screened
    • One tested positive for MRSA
    • 4 weeks after the cat was treated with antibiotics, the woman was also free of MRSA
    • "We conclude that pets should be considered as possible household reservoirs of MRSA that can cause infection or reinfection in humans ” .
    • Source: March 13 2007, New England Journal of Medicine
  • MRSA Skin/Soft Tissue
    • NEJM – August 17, 2006
    • Emergency departments in 11 university-affiliated August 2004
    • Researchers enrolled adult patients with acute, purulent skin and soft-tissue infections
    • MRSA found to be the most common causative agent
    • S. aureus was isolated from 320 of 422 patients (76%) with skin and soft-tissue infections, with the prevalence of MRSA being 59% overall.
    • MRSA coverage when antimicrobial therapy is needed for the treatment of skin and soft-tissue infections
  • Risk Factors for Acquiring HA-MRSA
    • Break in natural skin barrier:
      • Surgery – especially implants
      • Bedsores
    • Invasive devices and procedures
      • Intravenous catheters
      • Urinary catheters
      • Intubation
    • Overuse of antibiotics
    • Patients with co-morbidities
      • obesity, diabetes, steroids
  • Hospital Equipment
      • Contaminated shared equipment
      • Contaminated hands of healthcare workers – especially if presence of contact dermatitis and other skin conditions
      • Contaminated environment
  • Staph aureus Colonization
    • Colonization: Staph bacteria are present on or in the body without causing illness.
    • Approximately 25 to 30% of the population is colonized in the nose with sensitive Staph aureus at a given time
      • NEBH is finding 23% are colonized
  • MRSA Colonization
    • ~2-10% general population colonized with MRSA
      • NEBH is finding 5% are colonized
    • ~0.9%-13.2% healthcare workers are colonized with MRSA
    • Higher rates in prison (~10%), among drug users, day care centers, professional sports teams and high schools
    • Once colonized for more than three months, it becomes much more difficult to clear
  • Rate of MRSA and MSSA in Surgeons and Residents
    • Schwarzkopf, et al: MRSA and MSSA in nares of physicians at the Hospital for Joint Diseases in New York.
      • Ran Schwarzkopf, Richelle C. Takemoto, Igor Immerman, James D. Slover, and Joseph A. Bosco Prevalence of Staphylococcus aureus Colonization in Orthopaedic Surgeons and Their Patients: A Prospective Cohort Controlled Study J Bone Joint Surg Am. 2010;92:1815-1819
    • 74 surgeons and 61 residents screened
      • Surgeons: MRSA 2.7% and MSSA 23.3%
      • Residents: MRSA 0% and MSSA 59%
      • Control Group of Patients: MRSA 2.17% and MSSA 35.7%
      • Previous studies - 3% of MRSA outbreaks are caused by asymptomatic colonized health-care workers.
      • Vonberg RP, Stamm-Balderjahn S, Hansen S, Zuschneid I, Ruden H, Behnke M, Gastmeier P. How often do asymptomatic healthcare workers cause methicillin-resistant Staphylococcus aureus outbreaks? A systematic evaluation. Infect Control Hosp Epidemiol. 2006;27:1123-7
  • Higher Rate of Infection if Colonized
    • Colonized patients have a 30-60% risk of infection following colonization.
    • Host factors influence the onset of infection.
      • Immunosuppression, steroids, diabetes, invasive devices and procedures, surgery, skin breakdown, pneumonia, obesity, hematoma, etc.
    • Reference: Graham P, Lin S, Larson E (2006). "A U.S. population-based survey of Staphylococcus aureus colonization". Ann Intern Med 144 (5): 318-25.
  • Antimicrobial Agents for Treating MRSA
    • Systemic/PO Topical Decolonization
    • Vancomycin Chlorhexidine body was
    • Clindamycin 2% Mupirocin ointment
    • Bactrim (Bactroban)
    • Rifampin po
    • Zyvox (Linezolid)IV or po
    • Daptomycin
  • New Antibiotics for MRSA
    • ETX1153 ( e-Therapeutics plc) found to be highly potent against the most common epidemic strain of MRSA in the UK ( EMRSA-16) and effective against V.I.S.A. strains
    • Platensimycin (Merck) blocks the enzymes that produce fatty acids - essential for the construction of the membranes of bacteria – still under investigation
    • Daptomycin (Cubist) can be used in combination regimens when infection with a gram-negative or anaerobic organism is either suspected or confirmed. This drug's action is rapidly bactericidal.
    • Linezolid (Zyvox) is active against gram-positive organisms, such as VRE and MRSA
  • MRSA Transmission
    • MRSA is transmitted by:
      • Direct Contact with body fluids, skin, secretions, excretions – during patient care and procedures, during sports, in close quarters
      • Indirect contact by contaminated inanimate objects – such as BP cuffs, oximeter sensors, thermometers, environment, contaminated hands, stethoscopes, otoscopes, commodes, bedside curtains, towels, locker rooms, prisons, toys in daycare
  • Outbreaks in Sports Teams
    • An outbreak of methicillin resistant Staphylococcus aureus infection in a rugby football team. British Journal of Sports Medicine, Vol 32, Issue 2 153-154, 1998
    • Methicillin-Resistant Staphylococcus aureus in a High School Wrestling Team and the Surrounding Community Arch Intern Med. 1998;158:895-899.
    • Cutaneous Community-acquired Methicillin-resistant Staphylococcus aureus Infection in Participants of Athletic Activities. Southern Medical Journal. 98(6):596-602, June 2005.
    • National Athletic Trainers' Association, Inc.Outbreak of Community-Acquired Methicillin-Resistant Staphylococcus aureus Skin Infections Among a Collegiate Football Team. J Athl Train. 2006; 41(2): 141 – 145.
  • CA-MRSA in Sports Teams
    • Washington Redskins
    • Toronto Blue Jays
    • San Francisco Giants
    • Celtics Basketball
    • Miami Dolphins
    • Dutch Soccer Team
    • Many high school football teams
  • Sources for Transmission
    • Hands number one!
    • Close contact sports
    • Cuts, abrasions and bruises – wound care
    • Bandages, soiled towels
    • Locker rooms, Jacuzzi, hot tub
    • Benches, chairs, exercise equipment
    • Sharing items: towels, razors, drinks, weights, bikes, etc.
  • Prevention: Wash and Sanitize Alcohol Foam, Liquid and Hand Wipes At NEBH all patients admitted receive package of alcohol wipes In each patient room, outside rooms, cafeteria and other areas Wash hands often – before eating, before leaving work, after contamination, after bathroom
  • MRSA Patient Rooms
    • Brigham and Women ’ s Hospital - environmental contamination and the accompanying relative odds of infection acquisition.
    • Newly-admitted patients housed in a room in which the most recent occupant was MRSA-positive or VRE-positive, “ significantly increased the odds of acquisition ” for a MRSA-related or VRE-related infection.
    • MRSA room
      • 3.9 percent of new patients acquired an infection.
    • VRE room
      • 4.5 percent acquired a VRE infection.
    • Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med. 2006 Oct 9;166(18):1945-51.
  • MRSA contamination in precaution rooms
    • Ref: Boyce, Infec Cont Hosp Epid 1977
    • 70% of rooms had environmental contamination when the patient was colonized or infected
    • 42% of nurses’ gloves cultured were contaminated after touching environmental surfaces WITHOUT touching the patient!
    • Ref: Boyce, et. Al. SHEA 1998 Abstract
    • Results: 14 (40%) of 35 HCWs gowns were culture + for MRSA on exiting room. Clothing underneath was negative. 11 (69%) of 16 HCWs wearing freshly laundered lab coats had detectable contamination. 3 of 11 developed positive hand cx after touching the coat.
      • Institutional Prescreening for Detection and Eradication of Methicillin-Resistant Staphylococcus aureus in Patients Undergoing Elective Orthopaedic Surgery J Bone Joint Surg Am. 2010;92:1820-1826
      • David H. Kim, Maureen Spencer, Susan M. Davidson, Ling Li, Jeremy D. Shaw, Diane Gulczynski, David J. Hunter, Juli F. Martha, Gerald B. Miley, Stephen J. Parazin, Pamela Dejoie, and John C. Richmond
  • February 2006 Anonymous Nares Cultures
    • 133 patients
    • Obtained nasal cultures
    • Purpose: to determine pre-op
    • MRSA and MSSA colonization
    • Results:
    • 38 – Staph aureus (29%)
    • *5 - MRSA ( 4%)
    • *all undiagnosed and no precautions used in OR or postop nursing unit
  • Decolonization Treatment Protocol
      • 5-day application of intranasal 2% mupirocin - applied twice daily - for MRSA and Staph aureus positive patients.
      • Daily body wash with chlorhexidine
      • MRSA Patients - Vancomycin surgical prophylaxis
  • What were the outcomes?
  • MRSA/MSSA Eradication Results
      • From July 17, 2006 through July 2010
      • 25,025 patients screened
        • 5770 (23%) positive for Staph aureus
        • 1027 ( 4%) positive for MRSA
        • Repeat nasal screens on MRSA patients
        • revealed 78% eradication
    • Time Period Inpatient surgeries # Surgical Infections % MRSA/MSSA
    • FY06
    • 10/01/05-07/16/06 5293* 24 0.45%
    • FY07
    • 07/17/06-09/30/07 7019 6 0.08%
    • FY08
    • 10/01/07-09/30/08 6323 7 0.11%
    • FY09
    • 10/01/08-09/30/09 6364 11 0.17%
    • FY10
    • 10/01/10-07/31/10 5397 5 0.09%
    • *historical controls
    % MRSA and Staph aureus SSI
  • In Conclusion
    • MRSA is increasing in the community and in hospitals
    • Overuse of antibiotics has created some of the problem
    • Resistance among the species is a factor in resistance
    • Close quarters, equipment, environments and contaminated hands are sources for transmission
    • Limited antibiotics available to treat MRSA
    • Pre-surgical screening program is an effective method of detection for treatment and precautions