The document discusses strategies for controlling methicillin-resistant Staphylococcus aureus (MRSA) in healthcare settings. It describes the ideal "search and destroy" strategy of isolating and screening high-risk patients, decolonizing MRSA carriers, and taking consistent action when transmissions occur. However, it notes many healthcare facilities do not fully implement this strategy due to difficulties identifying at-risk patients and constraints like staffing issues. The document advocates for universal precautions like isolating MRSA-positive patients, promoting hand hygiene, and providing feedback to help facilities improve and reduce MRSA rates.

1. Ge#ng
to
zero
in
midst
of
CA-­‐MRSA
28-­‐02-­‐13
Andreas
Voss,
MD,
PhD
Professor
of
InfecCon
Control
RUNMC
&
CWZ
Nijmegen,
The
Netherlands
¤ E-­‐MRSA
¤ HA-­‐MRSA
(HO-­‐CA-­‐MRSA,
HO-­‐LA-­‐MRSA)
LA
¤ CA-­‐MRSA
(CO-­‐HA-­‐MRSA,
CO-­‐LA-­‐MRSA)
HA
¤ LA-­‐MRSA
CA
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
(Sco^
Weese)
CA-­‐MRSA
HA-­‐MRSA
LA-­‐MRSA
“Li^le
brother”
“Main
problem”
“Giant
trouble”
MRSA bacteremia in Europe!
CA-­‐MRSA
HA-­‐MRSA
LA-­‐MRSA
Source: EARSS report
Andreas
Voss,
MD,
PhD
1

2. Ge#ng
to
zero
in
midst
of
CA-­‐MRSA
28-­‐02-­‐13
¤ Search
&
Destroy
(Control)
strategy
to
avoid
introducCon
of
MRSA
into
health-­‐care
se#ngs
and
reduce
the
chance
of
transmission:
² NaConal
MRSA
guidelines
(WIP)
² NaConal
detecCon
methods
(NVMM)
² Use
fast
and
reliable
detecCon
methods
¤ IsolaCon
and
screening
of
risk-­‐paCents
on
admission
² at
all
Cmes
¤ Placement
in
isolaCon
room
² colonized
and
infected
paCents
² with
anteroom
and
negaCve
pressure
¤ DecolonizaCon
of
MRSA
carriers
¤ Gloves,
gowns
and
face-­‐masks
¤ Consequent
acCons
when
transmissions
occur
² for
all
entering
the
room
² screening
of
all
paCents
and
HCWs
at
risk
² MRSA-­‐posiCve
HCWs
not
allowed
to
work
¤ Handhygiene
¤ IsolaCon
and
screening
of
risk-­‐paCents
on
admission
² can’t
determine
paCents
at
risk
² only
certain
departments!
² not
when
too
busy/weekends
² only
infected
paCents
¤ No
decolonizaCon
of
MRSA
carriers
¤ Non-­‐consequent
acCons
when
transmissions
occur
² screening
of
all
paCents
but
not
HCWs
à
consequently
MRSA-­‐posiCve
HCWs
may
conCnue
to
spread
Andreas
Voss,
MD,
PhD
2

3. Ge#ng
to
zero
in
midst
of
CA-­‐MRSA
28-­‐02-­‐13
MRSA
BSI
episodes
2000
1800
Year and quarter
1600
1400
BBC
World
news
1200
1000
800
600
400
200
0
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2005 2006 2007 2008 2009
Counts of MRSA bacteraemia
Courtesy: A.DATA ARE(HPA, Sept 2009) FOR WIDER CIRCULATION
* Pearson PROVISIONAL NOT
V.
Jarlier
et
al.
Arch
Intern
Med
2010
IsolaCon
IntervenCons
¤ IsolaCon
IntervenCons
¤ Placement
of
paCents
with
MRSA
infecCons
or
¤ PromoCon
of
Hand
Hygiene
colonizaCons
in
single-­‐bed
rooms
whenever
possible
¤ Barrier
precauCons
for
paCents
with
MRSA
infecCons
¤ IdenCficaCon
of
paCents
with
MRSA
or
colonizaCons
such
as:
infecCons
or
colonizaCons
² disposable
gloves
worn
before
and
discarded
aier
paCent
¤ Feedback
contact
² disposable
aprons
worn
for
extensive
contacts
(eg,
bed
¤ Annual
reports
making)
² small
equipment
(eg,
stethoscope)
dedicated
to
the
paCent.
Andreas
Voss,
MD,
PhD
3

4. Ge#ng
to
zero
in
midst
of
CA-­‐MRSA
28-­‐02-­‐13
PromoCon
of
Hand
Hygiene
¤ Hand
washing
with
disinfectant
soap
aier
contact
with
paCents
with
MRSA
infecCons
or
colonizaCons
before
leaving
the
room
¤ An
insCtuConal
campaign
for
promoCng
the
use
of
alcohol-­‐
based
hand-­‐rub
soluCons
in
place
of
hand
washing
² launched
in
2001
² Training
materials
to
the
infecCon
control
teams
(slide
shows,
200
000
brochures,
and
14
000
posters)
² formal
le^ers
by
the
general
director
asking
all
administrators,
heads
of
departments,
and
chief
nurses
to
support
the
campaign.
Should
we
ask
universal
precauCons
?
IdenCficaCon
of
MRSA
PaCents
Feedback
¤ Feedback
to
the
local
hospital
community
on
the
results
(MRSA
¤ Passive
surveillance
through
rouCne
clinical
specimens
rates
and
progress
in
program
implementaCon).
¤ AcCve
surveillance
(screening)
by
culturing
nares
of
paCents
with
a
high
risk
of
MRSA
colonizaCon,
eg,
intensive
Annual
report
care
unit
(ICU)
paCents
and
contacts
of
MRSA
paCents
¤ Each
hospital
reporCng
to
the
central
administraCon
¤ Quick
noCficaCon
and
flagging
of
new
paCents
with
MRSA
² size
of
the
infecCon
control
team
infecCons
or
colonizaCons
by
laboratories
to
medical
teams
² implementaCon
of
the
program
¤ IdenCficaCon
of
MRSA
paCent
rooms
and
charts
(sCcker)
² organizaCon
of
audits
(eg,
on
hand
hygiene)
¤ Informing
units
to
which
paCents
with
MRSA
are
transferred.
² feed-­‐back
² progress
of
the
iniCaCve
has
been
annually
presented
during
meeCngs
of
infecCon
control
teams
and
bacteriologists
from
all
AP-­‐HP
hospitals,
What
is
CA-­‐MRSA?
Andreas
Voss,
MD,
PhD
4

5. Ge#ng
to
zero
in
midst
of
CA-­‐MRSA
28-­‐02-­‐13
CA-/HA-MRSA: Age Distribution!
¤ ProspecCve
cohort
study
of
MRSA
infecCons
idenCfied
in
12
Minnesota
laboratories
in
2000
¤ 1100
MRSA
infecCons
² 131
(12%):
community-­‐associated
² 937
(85%):
health
care-­‐associated
¤ Epidemiological
definiCon
Naimi et al. JAMA
2003; 290: 2976-84
Naimi et al. JAMA 2003; 290: 2976-84
CA-/HA-MRSA: Underlying conditions! CA-/HA-MRSA: Infection type!
Predominantly
skin
and
soi
Cssue
infecCons
No
underlying
condiCons
as
risk
factor
Naimi et al. JAMA 2003; 290: 2976-84 Naimi et al. JAMA 2003; 290: 2976-84
CA-/HA-MRSA: Susceptibility!
Enriched
with
SCCmec
IV,
PVL
and
other
exotoxins
SCll
suscepCble
to
most
other
classes
of
anCbioCcs
Naimi et al. JAMA 2003; 290: 2976-84 Naimi et al. JAMA 2003; 290: 2976-84
Andreas
Voss,
MD,
PhD
5

6. Ge#ng
to
zero
in
midst
of
CA-­‐MRSA
28-­‐02-­‐13
CA-/HA-MRSA: Clonal spread!
¤ Aboriginals
¤ NaCve
Americans
(indians,
eskimos)
¤ Jails
¤ Saunas
¤ Sport
teams
¤ Homosexual
men
¤ Military
recruits
¤ Day
Care
Centers
CA-­‐
strains
geneCcally
unrelated
to
HA-­‐MRSA
" SSTI
caused
by
CO-­‐MRSA
in
a
non-­‐outbreak
seFng
(Atlanta,
Q3+4
2003)
" 384
persons
with
documented
CA-­‐SSTI
due
to
S.
aureus
King
et
al
Ann
Intern
Med
2006;144:309-­‐317
¤ Aboriginals
¤ NaCve
Americans
(indians,
eskimos)
¤ Jails
nearly
¾
¤ Saunas
MRSA
¤ Sport
teams
¤ Homosexual
men
nearly
90%
¤ Military
recruits
US
300/400*
¤ Day
Care
Centers
*
99%
(155
of
157)
of
the
typed
CA-­‐MRSA
isolates
were
USA
300
¤ Animal
lovers
?
King
et
al
Ann
Intern
Med
2006;144:309-­‐317
Andreas
Voss,
MD,
PhD
6

7. Ge#ng
to
zero
in
midst
of
CA-­‐MRSA
28-­‐02-­‐13
st
Fir es
cas
• 2004:
23%
• 2006:
50%
• 2010:
>70%
m
far
a
pig
ds
of
un
gro
the
on
ing
W
liv
HC
:
a
to r
-­‐ fac
ly
risk
On
Wulf
et
al.
Eurosurveillance
2008;13
Andreas
Voss,
MD,
PhD
7

8. Ge#ng
to
zero
in
midst
of
CA-­‐MRSA
28-­‐02-­‐13
900 851 854 Import HA HACO CA
Each
person
only
included
once,
800 unless
a
new
subtype
is
found
240
R.
Skov
2009
705 220 71% of the MRSA cases in Copenhagen area
R.
Skov
2009
700 659 were community-onset MRSA (CO-MRSA)
200
600 547 180
No. of isolates
500 160
No. of isolates
400
140
120
300
229 100
200 80
77 97 104 100 60
100 46 54 67
34 41
40
0
20
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
0
19
19
19
19
19
19
20
20
20
20
20
20
20
20
20
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Andreas
Voss,
MD,
PhD
8

9. Ge#ng
to
zero
in
midst
of
CA-­‐MRSA
28-­‐02-­‐13
v
36.4%
of
11
CA-­‐MRSA
and
43.9%
of
66
HA-­‐MRSA
harbored
SCCmec
type
IV/IVA.
v
Type
IV/IVA
has
become
the
most
common
SCCmec
type
in
...
lines
between
categories
may
be
“graying,”
with
inpaCents
of
a
Swiss
university
hospital.
community-­‐associated
strains
encroaching
on
v
SCCmec
type
IV/IVA
is
present
in
both
CA-­‐MRSA
and
HA-­‐MRSA
hospitals,
and
health-­‐care
associated
strains
limiCng
its
use
as
a
marker
for
CA-­‐MRSA.
entering
the
community.
Stranden
et
al.
InfecCon
2009;37:44
¤
we
have
all
kind
of
SSCmec-­‐types
in
the
hospital
(including
IV
and
V)
¤
we
have
healthcare
outbreaks
of
ST398-­‐MRSA
and
CA-­‐MRSA
strains
¤
we
have
HA-­‐MRSA
strains
in
the
community,
in
pets
and
in
livestock
animals
¤
MRSA
-­‐
it’s
not
graying,
it
is
gray!
CA-­‐MRSA
HA-­‐MRSA
LA-­‐MRSA
CA-­‐MRSA
HA-­‐MRSA
LA-­‐MRSA
Just-­‐MRSA
Is
this
sCll
a
possiblity?
Andreas
Voss,
MD,
PhD
9

10. Ge#ng
to
zero
in
midst
of
CA-­‐MRSA
28-­‐02-­‐13
¤
We
know
the
risk
factors
for
HA-­‐MRSA
²
foreign
admission/dialysis,
adopCon,
known
outbreaks,
(nursing
homes)
¤
We
know
the
risk
factors
for
LA-­‐MRSA
²
pig-­‐
and
calf-­‐farming
(poultry)
²
(but
this
may
change)
¤
We
know
some
of
the
risk
factors
for
CA-­‐MRSA
²
but
can’t
use
them
for
S&D
Import HA HACO CA
¤
Consequent
decolonizaCon
of
all
MRSA
240
R.
Skov
2009
71% of the MRSA cases in Copenhagen area
220
carriers
(especially
outside
the
hospitals)
is
of
200
were community-onset MRSA (CO-MRSA)
The
Danish
curbed
this
outbreak
by
upmost
importance
!
180 ”destroying”
the
community
sources
160
No. of isolates
²
works
with
HA-­‐MRSA
140
120
²
should
work
with
CA-­‐MRSA
100
80
²
trouble
LA-­‐MRSA
60
40
20
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
¤
To
a
certainly
level
it
may
be
the
major
components
that
count
not
the
details:
While
important
other
factors
count:
¤
Compliance
with
basic
infecCon
control
²
Good
epidemiology
measures
in
all
(healthcare)
se#ngs
²
Screening
¤
Infrastructure
of
healthcare
se#ngs
²
IsolaCon
(single
room
and
glove
and
gowns)
²
Hand
hygiene
¤
HCW-­‐paCent/client
raCo
²
CommunicaCon
¤
AnCbioCc
use
²
DecolonizaCon
¤
Farming
(!)
&
food
(?)
Andreas
Voss,
MD,
PhD
10

11. Ge#ng
to
zero
in
midst
of
CA-­‐MRSA
28-­‐02-­‐13
June
25-­‐28,
2013
Geneva
Switzerland
www.icpic2013.com
Andreas
Voss,
MD,
PhD
11