Professional Documents
Culture Documents
Eli N. Perencevich, MD MS May 15, 2012 Director, CADRE Iowa City VA HCS Professor, University of Iowa
Overview
Definitions Overview of the VHA MRSA Initiative
Evidence for prediction-targeted screens Regional control Novel strains and detection issues
Controlling MDROs
(1) Horizontal programs that broadly attempt to reduce infections from all pathogens - Hand-hygiene - CLABSI Bundles (2) Vertical programs target single pathogens - Screening and isolation - Can include decolonization
FOR MORE INFO...
Wenzel RP, Edmond MB.. Int J Infect Dis. Oct 2010;14 Suppl 4:S35.
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Importance of MRSA
2x mortality vs MSSA1 94,000 invasive cases/year2
19,000 excess deaths2
VA MRSA Initiative
VA Pittsburgh (pilot study) 17 beta-site medical centers (2006) Bundle:
(1) admission, in-hospital transfer and discharge active- surveillance swabs for MRSA (2) contact precautions for patients known or found to be MRSA carriers (3) efforts targeting improved hand-hygiene and (4) efforts encouraging culture change ***Support for site-level MRSA Coordinator
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Components of VA Bundle
One vertical intervention:
Swabs and contact precautions
This suggests that VA is better prepared than in 2007 to deal with new emergent pathogens
Two models of hospital-MRSA transmission: (1) All benefits attributable to hand-hygiene (2) All benefits due to contact precautions
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Contact precautions and hand hygiene led to: 1-4% of declines in ICUs 3-6% in non-ICUs Neither transmission prevention component of the bundle could explain more than 50% of the reduction in infections
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Editorial
Systematic analysis of MRSA bundle and challenges conventional wisdom that MRSA control only comes via screening Models assumed the VA was one aggregate entity, as they didnt have individual hospital-level data
Individual VAs might have higher transmission rates and/or lower admission prevalence = larger benefits attributable to contact precautions or hand hygiene
Editorial
Systematic analysis of MRSA bundle and challenges conventional wisdom that MRSA control only comes via screening Models assumed the VA was one aggregate entity, as they didnt have individual hospital-level data
Individual VAs might have higher transmission rates and/or lower admission prevalence = larger benefits attributable to contact precautions or hand hygiene
FOR MORE INFO... Lee AS et al. Clin Infect Dis 2011:52 (Jun 15): 1422-1430
FOR MORE INFO... Lee AS et al. Clin Infect Dis 2011:52 (Jun 15): 1422-1430
Richter SS et al. 50th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), September 13, 2010, Boston, MA (abstract E-820)
Richter SS et al. 50th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), September 13, 2010, Boston, MA (abstract E-820)
Hogs 2004
Rank State Value ($1000) % US total
1.
2. 3. 4. 5. 6. 7. 8. 9. 10.
Iowa
North Carolina Minnesota Illinois Nebraska Indiana Missouri Oklahoma Ohio Kansas
3,801,018
2,078,800 1,724,512 1,027,628 761,953 738,470 623,260 615,411 402,719 379,048
26.49%
14.49% 12.02% 7.16% 5.31% 5.15% 4.34% 4.29% 2.81% 2.64%
30% NT in 20072
FOR MORE INFO...
1. Van Loo I et al. Emerg Infect Dis 2007;13(12):1834-1839 2. Huijsdens XW Euro Surveill 2009 Sep 24;14(38)
49% (147/299) swine were MRSA+ 45% (9/20) of workers were MRSA
All at facility A
Undetected by current PCR Widespread in Scotland, England and Denmark 54% (13/24) of the bovine isolates I doubt this could happen here
FOR MORE INFO... Garcia-Alvarez L et al. Lancet Infect Dis 2011, Published online June 3, 2011
Other Organisms
Acinetobacter NDM-1 (US Military Hospital Afghanistan) KPCs (1st emerged in North Carolina) ESBLs C. difficile
FOR MORE INFO... Kumarasamy K et al. Lancet ID 11 August 2010 MMWR June 10, 2011 Yigit H, et al Antimicrob Agents Chemother 2001;45:1151-61.
Acinetobacter
Gram-negative coccobacillus Was often viewed as a colonizer HAS ARRIVED as a nosocomial pathogen Acinetobacter baumannii is the most common
Reference
Clinical Setting
Cases
Attributable Mortality
36.5% 7.8%
22.7%
40 CR- Infections
96 MDR-Infections 48 MDR-BSI
25-30%
8.4% 21.8%
14.8%
Playford (2007)
66 CR-Infections or Colonization
20%
NHSN: impenem-resistance
Bacteria CLABSI VAP CAUTI Pooled (% (% (% (% imipenem imipenem imipenem imipenem resistant) resistant) resistant) resistant)
Pseudomonas
Klebsiella Acinetobacter
23.0%
10.8 29.2
25.1%
10.1 25.6
26.4%
3.6 36.8
25.3%
MDR-Acinetobacter in LTACs
180-bed, hospital-afilliated LTAC1 147 patient point prevalence survey (12/05) 28% AB+ (41 patients)
Sensitivity by site 22% peri-rectal, 68% sputum, 22% wound
Effectiveness of PPE
88% 90% 100%
81
2%
19%
2.6%
85%
1. Morgan D, et al, Infect Control Hosp Epidemiol July 2010; 31(7):716-21. 2. Snyder G, et al, Infect Control Hosp Epidemiol July 2008; 29(7):584-589
50% 60%
70%
80% 90%
11%
7% 4%
6%
4% 2.% 0
5%
3% 2% 0
4%
3% 1% 0
3%
2% 1% 0
2%
2% 1% 0
1%
1% 1% 0
100% 0 0
50%
60%
70%
80%
90%
100%
Environment Equipment
Patient A
Nosocomial Transmission
Patient B
Healthcare Workers
Environmental Sampling
Percent of rooms with positive environmental cultures for organism known to be colonizing patient (PFGE)
78% Acinetobacter 35% VRE 28% MRSA 22% P. aeruginosa 15% KPC
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Results
50 Rooms
48% (24/50) of rooms
Identification of A. Baumannii
478 Samples
10%
16%
4%
3% 6%
9%
4%
Cohort (139 35% vs. 73% patients examined by patients, 31 CP) attending physicians Matched cohort (50 hours) 5.3 vs. 10.9 contacts HCWs 22% less contact time overall
Klein et al 1989
Goldszer et al 2002 Stelfox et al 2003 Morgan et al 2012
Pediatric ICU
Ward awaiting Nursing Home Ward 4 hospitals
Conclusion
MRSA Initiative has been a success Given rise of novel strains in MRSA and also increased burden of Gram-negatives and C. difficile, horizontal interventions may become the dominant strategy for control Environmental cleaning increasingly important The downsides of screening are costs and clinical impact of isolating patients