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MRSA in the Netherlands
The document discusses different types of methicillin-resistant Staphylococcus aureus (MRSA) including community-associated MRSA (CA-MRSA), healthcare-associated MRSA (HA-MRSA), and livestock-associated MRSA (LA-MRSA). It notes that CA-MRSA strains are genetically unrelated to HA-MRSA strains and are enriched with genes like SCCmec IV and PVL toxin. The document also discusses transmission of MRSA between livestock animals like pigs and humans with occupational exposure, finding increased risk of MRSA carriage in those with direct contact to live animals. Overall, the document examines epidemiological characteristics and transmission dynamics of different MRSA strains, especially the emergence of LA-MR
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MRSA in the Netherlands
- 1. MRSA in the NL 01-‐03-‐13 ¤ E-‐MRSA ¤ HA-‐MRSA (HO-‐CA-‐MRSA, HO-‐LA-‐MRSA) ¤ CA-‐MRSA (CO-‐HA-‐MRSA, CO-‐LA-‐MRSA) ¤ LA-‐MRSA 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 (ScoR Weese) LA HA CA CA-‐MRSA HA-‐MRSA LA-‐MRSA CA-‐MRSA HA-‐MRSA LA-‐MRSA “LiRle brother” “Main problem” “Giant trouble” Andreas Voss, MD, PhD 1
- 2. MRSA in the NL 01-‐03-‐13 CA-/HA-MRSA: Age Distribution! ¤ ProspecXve cohort study of MRSA infecXons idenXfied in 12 Minnesota laboratories in 2000 ¤ 1100 MRSA infecXons ² 131 (12%): community-‐associated ² 937 (85%): health care-‐associated ¤ Epidemiological definiXon 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 soc Xssue infecXons No underlying condiXons as risk factor Naimi et al. JAMA 2003; 290: 2976-84 Naimi et al. JAMA 2003; 290: 2976-84 Andreas Voss, MD, PhD 2
- 3. MRSA in the NL 01-‐03-‐13 CA-/HA-MRSA: Susceptibility! Enriched with SCCmec IV, PVL and other exotoxins SXll suscepXble to most other classes of anXbioXcs Naimi et al. JAMA 2003; 290: 2976-84 Naimi et al. JAMA 2003; 290: 2976-84 CA-/HA-MRSA: Clonal spread! ¤ Aboriginals ¤ NaXve Americans (indians, eskimos) ¤ Jails ¤ Saunas ¤ Sport teams ¤ Homosexual men ¤ Military recruits ¤ Day Care Centers CA-‐ strains geneXcally unrelated to HA-‐MRSA " SSTI caused by CO-‐MRSA in a non-‐outbreak se;ng (Atlanta, Q3+4 2003) " 384 persons with documented CA-‐SSTI due to S. aureus King et al Ann Intern Med 2006;144:309-‐317 Andreas Voss, MD, PhD 3
- 4. MRSA in the NL 01-‐03-‐13 ¤ Aboriginals ¤ NaXve 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 st Fir es cas • 2004: 23% • 2006: 50% • 2010: >70% Andreas Voss, MD, PhD 4
- 5. MRSA in the NL 01-‐03-‐13 • 50 farms/232 individuals – 50 farmers, 13 employees • Three large pig slaughterhouses were studied in 2008 using – 169 household members human and environmental samples. • Intensive pig contact (29%), • The overall prevalence of nasal MRSA carriage in employees medium contact (12%), of pig slaughterhouses was 5.6% person living on farm (2%) MRSA • Working with live pigs was the single most important factor for being MRSA positive (OR 38.2, P0.0001). • Higher risk with sows and finishing • Exact transmission routes from animals to humans remain to pigs be elucidated. Van Cleef et al. Epidemiol Infect 2010 doi:10.1017/S09502688100000245 P39 van Cleef et al. NVMM 2008 ¤ 15.9% of humans in contact with calves were MRSA+ ² 33% of the farmers (direct contact) ² 8% of the family members Graveland et al. PLOSone 2010; 5:e10990 Graveland et al. • 40 Dutch broiler flocks, in six slaughterhouses and 466 personnel • 26 (5.6%) employees were positive • Risk was significantly higher for personnel having contact with live animals – especially hanging broilers on slaughterline (20.0%) vs all other (1.9%). • Conventional electric stunning = higher risk of MRSA carriage than CO2 stunning (9.7% vs. 2.0%). • From 40 Dutch slaughter flocks - 35.0% were positive. • Of the 119 MRSA isolates, predominantly livestock-associated MRSA ST398 was found, although 27.7% belonged to ST9 (spa type t1430). Mulders et al. Epidemiol Infect 2010 doi: 10.1017/S095026881000000075 Andreas Voss, MD, PhD 5
- 6. MRSA in the NL 01-‐03-‐13 ¤ Randomly selected adults (n=583) from 3 Dutch municipaliXes in high pig-‐desity regions ¤ Of the 534 persons without livestock-‐contact, one was posiXve for MRSA (0.2%). ¤ Of the 49 persons who did indicate to be working at or living on a livestock farm, 13 were posiXve for MRSA (26.5%). All spa-‐types belonged to CC398. Use of anXmicrobials in food animal producXon à ¤ LA-‐MRSA has a high prevalence in people with direct contact with animals. At this moment it has not spread from the farms into the resistant m.o.’s and resistance genes can spread from community. animals to humans Kluytmans JA Clin Microbiol Infect 2010;16:11 Buy two … 11.9% … get millions for free ! Kluytmans JA Clin Microbiol Infect 2010;16:11 180 160 930% increase of which 81% 140 (108/132) was due to ST398 120 ST398 unexpected 100 ST398 Other MRSA unexpected 80 other MRSA 60 40 20 0 2002 2003 2004 2005 2006 2007 2008 Frequency of newly idenXfied MRSA posiXve individuals increased from 16/ year between 2002-‐2006 to 148/year between 2006-‐2008 Andreas Voss, MD, PhD 6
- 7. MRSA in the NL 01-‐03-‐13 ¤ More cases that need precauXons and isolaXon ¤ More HCWs complaining about extra work ¤ Problems of isolaXon ¤ “Destroy” part of SD not possible with permanent source ¤ What to do with MRSA+ HCWs? Nosocomial transmission of ST398 MRSA is 72% less likely Wassenberg et al. Clin Microbiol Infect 2010 Wulf et al. Eurosurveillance 2008;13 Andreas Voss, MD, PhD 7
- 8. MRSA in the NL 01-‐03-‐13 ¤ EsXmated “lower virulence than HA-‐MRSA” ¤ Many cases of skin and soc-‐Xssue infecXons acer direct inoculaXon (pig bite or injuries during work) ¤ Case of endocardiXs Ekkelenkamp et al. Ned Tijdschr Geneesk 2006;150:2442-‐7 ¤ Case of osteomyeliXs Van Rijn et al. P1951 ¤ Severe wound infecXons Declercq et al. Infec_on 2008 (epubl.) ¤ InfecXon acer total hip replacement ¤ … cases to common to publish Andreas Voss, MD, PhD 8
- 9. MRSA in the NL 01-‐03-‐13 MRSA bacteremia in Europe! Source: EARSS report ¤ Search Destroy (Control) strategy to avoid introducXon of MRSA into health-‐care setngs and reduce the chance of transmission: ² NaXonal MRSA guidelines (WIP) ² NaXonal detecXon methods (NVMM) ² Use fast and reliable detecXon methods ¤ IsolaXon and screening of risk-‐paXents on admission ² at all Xmes ¤ Placement in isolaXon room ² colonized and infected paXents ² with anteroom and negaXve pressure ¤ DecolonizaXon of MRSA carriers ¤ Gloves, gowns and face-‐masks ¤ Consequent acXons when transmissions occur ² for all entering the room ² screening of all paXents and HCWs at risk ² MRSA-‐posiXve HCWs not allowed to work ¤ Handhygiene Andreas Voss, MD, PhD 9
- 10. MRSA in the NL 01-‐03-‐13 ¤ IsolaXon and screening of risk-‐paXents on admission ² can’t determine paXents at risk ² only certain departments! ² not when too busy/weekends ² only infected paXents ¤ No decolonizaXon of MRSA carriers ¤ Non-‐consequent acXons when transmissions occur ² screening of all paXents but not HCWs à consequently MRSA-‐posiXve HCWs may conXnue to spread 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 Andreas Voss, MD, PhD 10
- 11. MRSA in the NL 01-‐03-‐13 IsolaXon IntervenXons ¤ IsolaXon IntervenXons ¤ Placement of paXents with MRSA infecXons or ¤ PromoXon of Hand Hygiene colonizaXons in single-‐bed rooms whenever possible ¤ Barrier precauXons for paXents with MRSA infecXons ¤ IdenXficaXon of paXents with MRSA or colonizaXons such as: infecXons or colonizaXons ² disposable gloves worn before and discarded acer paXent ¤ Feedback contact ² disposable aprons worn for extensive contacts (eg, bed ¤ Annual reports making) ² small equipment (eg, stethoscope) dedicated to the paXent. PromoXon of Hand Hygiene ¤ Hand washing with disinfectant soap acer contact with paXents with MRSA infecXons or colonizaXons before leaving the room ¤ An insXtuXonal campaign for promoXng the use of alcohol-‐ based hand-‐rub soluXons in place of hand washing ² launched in 2001 ² Training materials to the infecXon control teams (slide shows, 200 000 brochures, and 14 000 posters) ² formal leRers by the general director asking all administrators, heads of departments, and chief nurses to support the campaign. Should we ask universal precauXons ? IdenXficaXon of MRSA PaXents Feedback ¤ Feedback to the local hospital community on the results (MRSA ¤ Passive surveillance through rouXne clinical specimens rates and progress in program implementaXon). ¤ AcXve surveillance (screening) by culturing nares of paXents with a high risk of MRSA colonizaXon, eg, intensive Annual report care unit (ICU) paXents and contacts of MRSA paXents ¤ Each hospital reporXng to the central administraXon ¤ Quick noXficaXon and flagging of new paXents with MRSA ² size of the infecXon control team infecXons or colonizaXons by laboratories to medical teams ² implementaXon of the program ¤ IdenXficaXon of MRSA paXent rooms and charts (sXcker) ² organizaXon of audits (eg, on hand hygiene) ¤ Informing units to which paXents with MRSA are transferred. ² feed-‐back ² progress of the iniXaXve has been annually presented during meeXngs of infecXon control teams and bacteriologists from all AP-‐HP hospitals, Andreas Voss, MD, PhD 11
- 12. MRSA in the NL 01-‐03-‐13 900 851 854 Each person only included once, 800 unless a new subtype is found 705 R. Skov 2009 700 659 600 547 No. of isolates 500 400 300 229 200 77 97 104 100 100 46 54 67 34 41 0 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 Import HA HACO CA 240 R. Skov 2009 220 71% of the MRSA cases in Copenhagen area were community-onset MRSA (CO-MRSA) 200 180 160 No. of isolates 140 120 100 80 60 ... lines between categories may be “graying,” with 40 community-‐associated strains encroaching on 20 hospitals, and health-‐care associated strains 0 entering the community. 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 ¤ 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 v 36.4% of 11 CA-‐MRSA and 43.9% of 66 HA-‐MRSA harbored SCCmec type IV/IVA. ¤ we have HA-‐MRSA strains in the community, in v Type IV/IVA has become the most common SCCmec type in pets and in livestock animals inpaXents of a Swiss university hospital. v SCCmec type IV/IVA is present in both CA-‐MRSA and HA-‐MRSA limiXng its use as a marker for CA-‐MRSA. ¤ MRSA -‐ it’s not graying, it is gray! Stranden et al. InfecXon 2009;37:44 Andreas Voss, MD, PhD 12
- 13. MRSA in the NL 01-‐03-‐13 CA-‐MRSA HA-‐MRSA LA-‐MRSA CA-‐MRSA HA-‐MRSA LA-‐MRSA Just-‐MRSA ¤ We know the risk factors for HA-‐MRSA ² foreign admission/dialysis, adopXon, 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 SD Import HA HACO CA ¤ Consequent decolonizaXon 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 Andreas Voss, MD, PhD 13
- 14. MRSA in the NL 01-‐03-‐13 ¤ To a certainly level it may be the major components that count not the details: While important other factors count: ¤ Compliance with basic infecXon control ² Good epidemiology measures in all (healthcare) setngs ² Screening ¤ Infrastructure of healthcare setngs ² IsolaXon (single room and glove and gowns) ² Hand hygiene ¤ HCW-‐paXent/client raXo ² CommunicaXon ¤ AnXbioXc use ² DecolonizaXon ¤ Farming (!) food (?) ¤ PDF of b/w slides (6 per page) at: hRp://www.slideshare.net/iPrevent/ June 25-‐28, 2013 Geneva Switzerland www.icpic2013.com “We appreciate you “Before you criXsize someone you should walk a reading ciXng ARIC and welcome mile in their shoes … your manuscripts” … that way, if he gets angry, he'll be a mile away, and you have their shoes ” hRp://www.aricjournal.com/ Homer Simpson “SlideShare iPrevent” Andreas Voss, MD, PhD 14