Download (MRSA) in the Nordic countries

Methicillin resistant
Staphylococcus aureus (MRSA)
in the Nordic countries
Petter Elstrøm
Advisor
Norwegian Institute of Public Health
Objective
Prevent establishment of MRSA in hospitals
• Increased rate of MRSA enforce changes in
empiric treatment of S. aureus-infections
• Changes in antibiotic-guidelines will lead to
more resistant bacteria and increase the cost
Historical overview
• Penicillin G introdused in 1941
• Penicillin resistant (-lactamase prod.) S.aureus isolated
in 1942
• Meticillin introdused in 1959 as the first -lactamase
resistant penicillin
• Meticillin resistant S.aureus first described in 1961
• In late sixties MRSA was identified as a nosokomial
pathogen
• In late nineties reduced sensitivity against Vancomycin
(VISA) was reported
• Vancomycin resistant S.aureus (VRSA) isolated in 2002
Historical overview
First ”MRSA-wave”
• Meticillin resistant first described in 1961
• Worldwide spread of a single arcaic clone
Second “MRSA-wave”
• Outbreaks in hospitals
• 5 dominant clones
Third “MRSA-wave”
• CA-MRSA
• Evolution of ”old” clones
• Continually new MRSA-strains discovered
CA-MRSA
• Both epidemiological and microbiological definition
• Increased incidence among people outside hospitals
• Young people with no known risk factors for MRSA
• Differ genetically from strains inside hospitals
– SCCmec IV, PVL
• Less resistant
• Mainly skin- and soft tissue infections
Occasionally severe infections (necrotizing pneumonia)
Changed epidemiology
• Earlier:
– Imported cases
– Related to hospital admission or employment
• Now:
–
–
–
–
Most domestic cases
Increasing rate of cases not related to hospitals
Often no known risk factors for MRSA
Outbreaks in nursing homes
MRSA in western Europe
Proportion of invasive isolates resistant to methicillin 2003
Source: www.earss.rivm.nl
MRSA in England og Wales
Proportion (%) of MRSA i blood culture, 1989-2002
50
45
40
35
30
25
20
15
10
5
20
02
20
01
20
00
19
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
90
19
89
0
MRSA in the Nordic countries
Sweden
Finland
25
Denmark
20
Norway
Iceland
15
10
5
*
05
20
04
20
03
20
02
20
01
20
00
20
99
19
98
19
97
0
19
Incidence (No/100.000)
30
*Estimated for 2005
Year
Source: http://www.srga.org/SSAC/doc/2005/SSAC_MRSAreport_2004.pdf
MRSA in Denmark
Distribution by place of transmission
300
No. of cases
250
CO-MRSA
HA-MRSA
Imported
200
150
100
50
0
1999
2000
2001
2002
2003
Source: Robert Skov, State serum institute, Sept. 2005
2004
MRSA i Danmark
Distribution by age group, 2003
45
40
No. of cases
35
CA-MRSA
HA-MRSA
30
25
20
15
10
5
0
<1
1-10
11-20
21-30
31-40
41-50
51-60
61-70
Age group
Source: Robert Skov, State serum institute, Sept. 2005
71-80
>81
MRSA in Sweden
Distribution by place of transmission
2003
Community
2004
Hospital
Primary care
S
Home for the elderly
Abroad (community
and hospital)
Unknown
Source: Otto Cars, Smittskyddsinstitutet, sept. 2005
MRSA in Norway
No. of cases, 1995 – 15.nov. 2005
500
450
400
Infection
Colonization
No. of cases
350
300
250
200
150
100
50
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Au ers
st hus
-A
Bu gd
sk er
Fi eru
nn d
m
H ar
ed k
M
ør Ho ma
e
og rda rk
R lan
om d
N
or No sda
d- rd l
Tr la
øn nd
d
O ela
pp g
la
nd
So
O
gn Ro sl
og ga o
l
Sø Fj and
r-T ord
rø an
n e
Te del
le ag
m
ar
T
Ve ro k
st ms
-A
g
Ve der
st
f
Ø old
st
fo
ld
Ak
No. per 100 000
20
MRSA in Norway
18
Proportion by county, 2004 - 2005
16
14
12
2004
15. nov. 05
10
8
6
4
2
0
MRSA in Norway
160
Distribution by place of transmission
Domestic
140
Imported
Unknown
No. of cases
120
100
80
60
40
20
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
MRSA in Norway
160
Distribution by place of infection onset
140
Hospitalized:
Yes
120
No. of cases
No
Unknown
100
80
60
40
20
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
MRSA in Norway
Reported outbreaks in health care institutions
7
6
5
4
3
2
1
0
2002
2003
Sykehus
2004
Sykehjem
2005
2003: 2 hospitals, 3 nursing homes
2004: 2 hospitals, 4 nursing homes
2005: 8 nursing homes
Challenges
•
•
•
•
•
•
•
Increasing incidence of MRSA
Changing epidemiology
Bacterial evolution
Laboratorial methods are not optimal
Lack in knowledge
Differs in national and regional guidelines
Compliance of infection control measures are
not optimal
Actions
• Coordinate the guidelines in the Nordic countries
• Discuss and coordinate advices and guidelines in
Norway
• Better survey through genotyping of all isolates
• Continue rational use of antibiotics
• Science
• High quality in hygiene and other infection control
measures