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HEALTHCARE-ASSOCIATED
MRSA
Emerging Problems
Clinical Patterns
Strategies for Control
Ed Septimus, MD, FACP, FIDSA, FSHEA
[email protected]
Emerging Problems with S. aureus
•
•
•
•
Increasing proportion of healthcare-associated S.
aureus infections due to MRSA.
Increasing prevalence of MRSA among
community onset infections leading introduction into the
healthcare system.
Reports of S. aureus strains with reduced susceptibility
to vancomycin (VISA) and VRSA
~30% of newly acquired MRSA carriers develop
invasive disease which can be more severe
How often do colonized patients lead to
infection?
• 19% of patients colonized
with MRSA at admission
develop an infection1
• For patients that acquire
MRSA within the hospital,
25% develop an infection1
• 29% of MRSA positive
patients became infected
within 18 months2
• 3.95 MRSA infections
estimated per 1000
discharges3
• 0.8 MRSA infections
estimated per 1000 patient
4
days
1. Davis KA et.al. CID 2004;39:776-82
2. Huang & Platt, CID 2003;36:281
3. Kuehnert MJ et.al. EID 2005;11:868-72
4. Cooper BS et.al. Health Technol Assess. 2003;7(39):1-194
Emerging Problemscontinued
•Increasing resistance to mupirocin.
•Frequent failure of decolonization
protocols.
•Decreased efficacy of vancomycin for the
treatment of serious MRSA infections
compared with an anti- staphylococcal
penicillin for MSSA.
•Isolation of linezolid resistant isolates of
MRSA and decreased susceptibility to daptomycin
Hospitalization and Deaths Caused by MRSA
US 1999-2005
Emerg Infect Dis 2007; 13:1840
Hospitalization and Deaths Caused by MRSA
US 1999-2005
Emerg Infect Dis 2007; 13:1840
Incidence of Invasive CA-MRSA Infections and Deaths by
Age
Active Bacterial Core surveillance (ABCS), 2005
Incidence per
100,000 persons
10
Infections
Deaths
Overall Incidence (all ages):
Infections: 31.8 per 100,000
Deaths: 6.3 per 100,000
8
6
4
2
0
<1
1
2-4
5-17
18-34
Age in years
Klevens et al JAMA 2007;298:1763-71
35-49
50-64
>64
ID Rates
• Invasive MRSA
31.8/100,000 people
• Invasive pneumococcal disease
14.1/100,000 people
• Invasive group A strep
• Invasive meningococcal disease
3.6/100,000 people
0.35/100,000 people
APIC National MRSA Inpatient Survey
AJIC 2007; 35:631
Infections Due to Community- and
Healthcare-Associated MRSA
Prevalence of MRSA
increasing in hospitals
and in the community1
Infections associated
with CA-MRSA (n = 131)2
Other 8%
Urinary tract 1%
Bloodstream 4%
Respiratory tract 6%
Methicillin-resistant S aureus
Otitis media/externa7%
Resistant isolates (%)
100
Nosocomial infection
75
Community-acquired infection
Skin/Soft tissue 75%
Infections associated
with HA-MRSA (n = 937)2
50
Other 12%
25
Urinary tract 20%
Skin/Soft tissue 37%
0
1970
1980 1990
Year
2000
Bloodstream 9%
Otitis media/externa 1%
Respiratory tract 22%
1. McDonald LC. Clin Infect Dis. 2006;42:S65-S71. 2. Naimi TS, et al. JAMA. 2003;290:2976-2984.
Substantial mortality and costs associated
with surgical site infections caused by MRSA
Adverse Outcomes Associated
With MRSA Infection
25
MRSA
MSSA
(n = 121)
(n = 165)
25
140
b
a
120
20
c
20
15
$1000
15
Days
Patients (%)
100
10
10
80
60
40
5
5
20
0
0
Mortality
a
0
Mean Length of Stay
OR = 3.4 P = .003; b ME = 1.2, P = .11; c ME = 1.2 P = .03.
OR = odds ratio; ME = multiplicative effect.
Kaye K, et al. Emerg Infect Dis. 2004;10:1125-1128.
Mean Charges
Most Invasive MRSA Infections Are HealthcareAssociated
14%
86%
Community-Associated
Healthcare-Associated
Klevens et al JAMA 2007;298:1763-71
Classification of Invasive MRSA
Infections
Classification
Definition
Health care-associated
community-onset (HCA)
Cases with at least 1 of the following risk
factors: (1) presence of an invasive device on admit;
(2) history of MRSA infection or colonization; (3) hx
of surgery, hosp, dialysis, or residence of LTC in
previous 12 months preceding culture
Hospital-onset (HOI)
Cases with positive culture result from a normally sterile
site obtained >48 h after hospital admit. Cases
may also have ≥1 of the community-onset risks
Community-associated (CAI)
Cases with no documented community-onset
health care risk factor
Invasive MRSA
JAMA 2007; 298:1763
70
60
50
percent
40
30
20
10
0
HCA
HOI
CAI
Distinction Between CA-MRSA
and HA-MRSA Is Blurring
CA-MRSA strains are emerging in the healthcare setting, while
HA-MRSA strains are moving out into the community
Klevens RM, et al. Emerg Infect Dis. 2006;12:1991-1993.
Carriage of MRSA among Hospital Employees:
Prevalence, Duration, and Transmission to
Households
Infect Control Hosp Epidemiol 2004; 25:114
• MRSA transmission between
patients and employees
depends on the frequency
and duration of exposure to
MRSA-positive patients and
infection control measures
employed
• Transmission of MRSA from
colonized HCWs to their
households was
documented in 4 of 10
families investigated
The Landscape of
Healthcare-Associated (HCA) Infections
• Healthcare system is evolving to an increased use of outpatient procedures and
long-term care
Hospital or
Acute care setting
Home care
Outpatient facility
Long-term-care facility
• Many long-term-care facilities now experience infection rates comparable to those
in acute hospital settings
•
Outbreaks are common
•
High rates of colonization with resistant strains
Nicolle LE. Clin Infect Dis. 2000;31:752-756.
Epidemiology MRSA
Reservoirs
1. Humans are the natural reservoirs for S. aureus. 20-50
% of healthy adults are colonized with S. aureus, and
10-20% are persistent carriers. Colonization rates are
highest among patients with type 1 diabetes, IV drug
users, hemodialysis, dermatologic conditions, and
AIDS.
2. Colonized and infected patients are the major
reservoir of MRSA.
Where is the reservoir for MRSA?
1
• ~10,000 participants in the US, 2001–2002 Natl.
Health and Nutrition Examination Survey
•
32.4% colonized with S. aureus = 89.4 million
•
0.8% colonized with MRSA
=
2.3 million
• 9.2% of 500 healthy children screened in 2004 were
colonized
1. Creech et al. J Inf Dis 2006;193:169-71
Role of Nasal Carriage in
S. aureus Infections
Lancet Infect Dis 2005; 5:751
Frequency of MRSA Colonization
at Various Body Sites
13-25%
40%
30-39%
Hill RLR et al. J Antimicrob Chemother 1988;22:377
Sanford MD et al. Clin Infect Dis 1994;19:1123
Evaluation of a Strategy of Screening Multiple
Anatomic Sites for MRSA at Admission to a
Teaching Hospital
Infect Control Hosp Epidemiol 2006; 27:181-184
Site
% Positive
Nares
Rectum
Axilla
Nares+Axilla
Nares+Rectum
73
47
25
83
91
Epidemiology MRSA-continued
3. MRSA has been isolated from environmental surfaces,
and can be implicated in transmission
Risk Factors-MRSA
1. Hospitalization
2. Greater than 65 years of age
3. Invasive procedures
4. Open wounds
5. Certain underlying diseases (e.g. DM)
6. Prior antibiotics
Odds ratios from multivariable analysis
MRSA/MSSA Risk after Levofloxacin and Ciprofloxacin
Exposure
Odds ratio
3.5
3
2.5
MRSA
MSSA
2
1.5
1
0.5
0
Levofloxacin
Ciprofloxacin
P < 0.0001
P =0.005
Weber et al. Emerg Infect Dis. 2003;9:1415-1422.
PREVENTION OF
TRANSMISSION OF MRSA
Reasons Infection Control Measures Have
Failed to Control Spread of MRSA
• Failure to perform active surveillance (iceberg effect)
• Barrier precautions alone did not address reservoirs
•
•
•
•
and modes of transmission of MRSA
Poor adherence to HCWs to barrier precautions and
hand washing
Increasing importation of MRSA by patients admitted
from extended-care facilities or to other acute care
facilities and the community
Inadequate antimicrobial stewardship
Inadequate environmental cleaning
How is the reservoir for MRSA identified?
Clinical microbiology cultures
capture “the tip of the iceberg”
 75-85% of the MRSA
reservoir goes
unidentified by clinical
cultures alone1
 Colonized patients, not
just infected patients,
lead to transmission of
MRSA2
1. Sources: Eveillard M et.al., J Hosp Infect 2005;59:254 & Salgado CD et.al., SHEA 2003 abstract 28,
p.61
2. Bhalla A et.al. Infect Control Hosp Epidemiol 2004;25:164
Role of the Environment: Colonized vs.
Infected
• Environmental contamination of patient
rooms is the same whether the patient is
colonized or infected (~ 70%)
• Contaminated surfaces include patient’s
gowns, floor, bed linens, blood pressure
cuffs, overbed tables, etc.
Boyce, ICHE 1997; 18:622
Reisner et al., ICHE 2000; 21:775
ENVIRONMENTAL SITES POSITIVE
FOR MRSA
Bed Linen
Patient Gown
Overbed Table
BP Cuff
Side Rails
Bath Door Handle
IV Pump Button
Room Door Handle
0
20
40
60
80
Percent of Surfaces Positive
Boyce JM et al. Infect Control Hosp Epidemiol 1997;18:622
100
Importance of the environment in MRSA acquisition: the case for
hospital cleaning
Lancet Infect Dis online Oct 31, 2007
Survival of MRSA/VRE in the Environment
• Duration of survival of MRSA in dry conditions
• Plastic charts = 11 days
• Laminated tabletop = 12 days
• Cloth curtains = 9 days
• Environmental survival of VRE
• 50% survival at 7 days on upholstery, furniture
and wall coverings
• VRE could be transferred easily by touching
contaminated surfaces
Huang et al., Infect Control Hosp Epidemiol 2006; 27:1267-69
Lankford et al., Am J Infect Control 2006; 34: 258-63
Isolation Gowns
• 65% of HCW’s contaminated their uniforms or gowns
during routine care of patients with MRSA
• > 25% of the time, HCW’s clean hands became
recontaminated after contact with their contaminated
clothing
• Gowns prevented contamination of clothing underneath
the gown
Boyce, Infect Control Hosp Epidemiol 1997; 18:622.
Boyce, SHEA 1998, Abstract #S74
Risk of Acquiring Antibiotic-Resistant Bacteria From
Prior Room Occupants
Arch Intern Med 2006;166:1945
• Twenty-month retrospective cohort study of patients
•
•
admitted to the ICU performing routine admission and
weekly screening for MRSA and VRE
Among patients whose prior room occupant was
MRSA positive, 3.9% acquired MRSA compared with
2.9% of patients whose prior room occupant was
MRSA negative (OR 1.4; P=.04)
The environment overall was considered a
contributor to overall transmission
Percent MRSA Among All Nosocomial Infections
1975 to 1997, by Hospital Bed Size*
% MRSA
<200 beds
200-499 beds
40
>500 beds
Contact Precautions
35
Body Substance Isolation
30
25
20
15
Contact Isolation
10
5
95
93
91
89
87
85
83
81
79
77
75
0
*Adapted from: National Nosocomial Infection Surveillance (NNIS) System
Year
Percent Handwashing Compliance among HCWs
in 34 Observational Studies, 1981-2000
70
60
Median
50
40
30
20
33
31
29
27
25
23
21
19
17
15
13
11
9
7
5
3
10
0
1
Percent Compliance
90
80
Infect Control Hosp Epidemiol 2006;27:245
Hand Hygiene Does Work!
Year Author
SETTING Comparison
RESULTS
1982 Maki
ICU
(US)
crossover
 Nosocomial
1984 Massanari ICU
(US)
crossover
2000 Pittet
GROUP
infection
Teaching
observational
hospital,
Switzerland
 Nosocomial
infection
 Nosocomial
infection
 MRSA
rates
Decreased MRSA in Association With Improved
Handwashing
 Acute and Long Term Care Hospital in Illinois
 Hospital-wide introduction of wall mounted alcohol-
based “sinkless” hand rub plus educational session
 MRSA rate decrease from 0.9 isolates/1000 patient
days to 0.6 isolates/1000 pt days (p=0.002)
Vernon MO, et al. IDSA 2001, abstract 249
Adherence to Recommended
Barrier Precautions and Handwashing
Among HCWs Caring for MRSA Patients
• Observational survey conducted in a teaching
•
•
hospital in Canada
488 observations
Adherence to MRSA precautions
• Gloves worn to enter room
• Gown worn when entering room
• Hand hygiene after glove/gown removal
• All measures adhered to
Afif W et al. Am J Infect Control 2002;30:430
65%
65%
35%
28%
Percent of S. aureus Blood Isolates Resistant to
Antimicrobials in Denmark, 1960-1995
Source: DANMAP Report, 1997
Dutch Approach to Controlling MRSA
• In the Netherlands, a national guideline was developed by a
Dutch Working Party on Infection Control, and was adopted
nation-wide in 1988.
• Aggressive, “search & destroy” strategy
– Private room for MRSA patients
– use of masks, cap, gloves and gown for entering room
– Pre-emptive Isolation & screening cultures of patients
transferred from other countries with endemic MRSA
– if MRSA case found, screening cultures of patients/HCWs
– Colonized patients and HCWs are treated with mupirocin
• Restrict use of broad-spectrum antibiotics
• Prevalence of MRSA has remained < 1% in the Netherlands
despite multiple importations from other countries
Verhoef J et al. Eur J Clin Microbiol Infect Dis 1999;18:461
Efficacy of Contact Precautions in
Preventing Transmission of MRSA
• Outbreak investigation that included weekly
cultures of patients, cultures of personnel,
molecular typing of isolates, and decolonization
of some patients
• Rate of MRSA transmissions/day:
– from patients not in Contact Precautions
– from patients in Contact Precautions
– relative risk of transmission = 15.6
= 0.14
= 0.009
• Transmission was reduced 16-fold by Contact
Precautions
Jernigan JA et al. Am J Epidemiol 1996;143:496
Intensified Efforts to Control Resistant Pathogens in
a Hospital with Endemic MRSA and VRE
• University hospital found that current control
measures proved ineffective in controlling endemic
MRSA and VRE
• Implemented intensified control measures
– weekly screening of high-risk patients in adult and
pediatric ICUs and intermediate care units
– anterior nares (and wound if present) cultured for MRSA
– perirectal cultures obtained for VRE
– Cultures on selective media by Infection Control lab
– colonized/infected patients placed on Contact Precautions
Karchmer TB et al. Annual SHEA meeting, 2003, abstr. 257
Incidence of Colonization Since Initiation of Active
Surveillance
Percentage per 100 pts at risk
8%
T im e fra m e = 4 /2 3 /0 2 - 1 2 /1 7 /0 2
7%
6%
5%
4%
3%
2%
1%
0%
1
2
3
4
5
6
4-w eek intervals
M RS A
7
8
VR E
Chi-sq for Trend : MRSA p = 0.003, VRE p < 0.0001
9
MRSA Screening Program
in an SICU, Hospital of Saint Raphael
• All patients are screened on admission to SICU
• Anterior nares and any open wd are cultured
• Any patient remaining in SICU for > 7 days are
•
cultured weekly
All patients colonized/infected with MRSA are placed
in Contact Precautions
SICU-Acquired MRSA Infections
Per 100 Patient-Days, Oct 2002 - Sep 2003
Infections/100 Pt-Days
Infect Control Hosp Epidemiol 2004; 25:395
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Screening Patients
on Admission
Oct 02 - Mar 03
Period 1
Apr 03 - Sep 03
Period 2
Impact of Routine ICU Surveillance Cultures
and Resultant Barrier Precautions on HospitalWide MRSA Bacteremia
Clin Infect Dis 2006; 43:971
Infections per 1000 pt days
MRSA HAI Rates 4W Unit, Pittsburgh
VA, Oct 1999 - 2004
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
2000
2001
2002
2003
2004
VA MRSA bundle was associated with a > 80% reduction of MRSA
infection rate on their surgical step down unit
MRSA HAI Rates MICU University of
Pittsburgh 2000-2005
3.8
100
90
90
86
80
3
2.7
2.7
70
60
2
50
40
30
29
1
0.71
0.55
20
% reduction from 2001
MICU MRSA HAI (per 1,000 pt-days)
4
0.37
10
0
2000
0
2001
0
2002
2003
2004
2005
UPMC MRSA bundle was associated with a > 90% reduction of MRSA
infection rate in our MICU (OR 10.4 95% CI 3-43, p=4.6X10-6)
Commonalities
•
•
•
•
•
•
ASC for High Risk Patients
Use of Barrier Precautions (BPs)
Clean or dedicated equipment
Enhanced environmental cleaning
Hand hygiene and other Standards (General Precautions)
Resources, Support, Leverage
•
•
•
•
•
•
ASC for High risk Patients   
Use of Barrier Precautions (BPs)   
Clean or dedicated equipment  
Enhanced environmental cleaning 
Hand hygiene and other Standard Precautions   
Resources, Support, Leverage   
•
Automatic Notification of New MRSA colonization status and Isolation
Requirements
Differences
•
•
Preemptive isolation of high-risk patients
Decolonization of carriers
There are a growing number of studies suggesting that
US healthcare facilities can successfully prevent MRSA
infections
Although the effectiveness of active surveillance to
reduce MRSA transmission has not been established in
randomized trials, there is mounting evidence that active
surveillance combined with other measures such as
contact isolation, hand washing, and education can
reduce MRSA transmission
SHEA Guidelines for Preventing Nosocomial
Transmission of MRSA
Infect Control Hosp Epidemiol 2003; 24:362
• Implement a program of active surveillance cultures and
•
contact isolation to control significant antibiotic-resistant
pathogens-most of the reservoir for spread of multiresistant pathogens come from asymptomatic, colonized
patients who are unrecognized
Surveillance cultures are indicated at the time of
admission for patients at high risk of MRSA
SHEA Guidelines #2
• Barrier precautions for patients with known or suspected
•
•
to be colonized or infected with antibiotic-resistant
pathogens such as MRSA
Antibiotic stewardship-avoid inappropriate or excessive
antibiotic prophylaxis and therapy
Use hospital computers to identify patients readmitted
with previous infection or colonization with multi-drug
resistant pathogens
HICPAC Guidelines
October 2006
Management of MDRO in Healthcare
Settings, 2006
Control Interventions
• Administrative
-communications e.g. computer alerts
-adequate sinks and alcohol dispensers
-staffing levels
-adherence to IC practices
• Education
• Judicious use of antimicrobial agents
Control Interventions #2
• MDRO surveillance
-antibiograms unit specific is possible
-MDRO infection rate
-molecular typing
-active surveillance (consider if incidence of
MDRO is not decreasing despite routine
measures)
-contact precautions (all patients either colonized or infected
Control Interventions #3
• When active surveillance is indicated as part of an
•
•
•
intensive MDRO program implement contact precautions
until culture is reported negative for target MDRO
Environmental measures
Decolonization-not sufficiently effective to warrant routine
use
Duration of Contact Precautions-unresolved issue
Institute for Healthcare
Improvement
Strategies to Win The
5 Million Lives Campaign
This document is in the public domain and may be used and reprinted without permission provided appropriate
reference is made to the Institute for Healthcare Improvement.
5 Million Lives Campaign
The Platform
Reduce Surgical Complications – Adopt
“SCIP”
Prevent Harm from High Alert Medications
Prevent MRSA Infections
Reduce Readmissions from Congestive Heart
Failure
Prevent Pressure Ulcers
Get Boards on Board
Prevent MRSA Infection
The Goal:
Reduce methicillin-resistant
Staphylococcus aureus (MRSA)
bloodstream infection by
December 2008
Focus on “getting to zero”
Five Key Interventions
 Hand hygiene
 Decontamination of the environment and



equipment
Active surveillance cultures (ASCs)
Contact precautions for infected and colonized
patients
Compliance with Central Venous Catheter and
Ventilator Bundles
Adverse Effects of Contact Isolation
Lancet 1999; 354:1177
• Health-care workers who treated patients in contact
•
•
isolation entered their rooms less frequently and had
less direct contact with them than those caring for
controls
Handwashing compliance was higher among healthcare workers who cared for patients in contact
isolation than among those who cared for controls
Physicians were less likely than other health-care
workers to wash their hands
Safety of Patients Isolated for Infection Control
JAMA 2003; 290:1899
• Isolated patients were less likely than control
•
•
patients to have their vital signs accurately
recorded, to have daily physician progress notes
documented, and to achieve selected disease
specific standards of care
Isolated patients were more likely to experience a
preventable adverse event and to express
dissatisfaction with their care
Hospital mortality rates were similar in both
groups
Active Surveillance Cultures
Pros
Cons
•
•
•
•
Iceberg effect
Clinical trial show benefit
↓Cost, morbidity & mortality
Other approaches have failed
•
•
•
•
•
Trials are quasi-experimental
Cost data limited
Attributable mortality difficult to judge
Assumes one size fits all
Unintended consequences
MRSA Risk Assessment
Conduct a risk assessment of MRSA incidence,
prevalence, acquisition, and transmission
•
•
•
•
•
Data useful in performing risk assessment
Proportion of S. aureus isolates resistant to methicillin
The number and/or incidence of new cases of MRSA
over time
The number of cases and/or incidence of one or more
specific types of MRSA infection (e.g. bacteremia) over
time
Point prevalence survey(s) of MRSA
colonization/infection
Colonization pressure (ratio of MRSA-carrier days to
total patient days) ICHE 2000; 21:718
Elements of an Effective ASC
Protocol
• Sound infection control department
• Institutional support
• Engage medical staff
• Microbiology protocol
• Involvement of multiple departments
throughout facility
• Patient and staff education
Steps to Consider Before
Implementing Active Surveillance
Clin Infect Dis 2007;44:1101
• Preparing the laboratory
• Monitoring and optimizing instituting
contact isolation
• Monitoring unintended consequences
contact isolation
• Measuring outcomes to evaluate
effectiveness of interventions
Patient Study
(IPM, IPS, ICU, ATU, Hemodialysis)
September 2006
MRSA Colonization Rates
by Traditional Culture & Rapid PCR Methods
30%
Overall S. aureus colonization = 32% (69/217)
of which 17 / 217 +MRSA = 7.8%
20%
11.7%
(25/214)
10%
7.8%
(17/217)
0%
Traditional Culture Method
n=217
Rapid PCR Method
n=214
Patient Study
(IPM, IPS, ICU, ATU, Hemodialysis)
September 2006
Traditional Culture Method
Rapid PCR Method
6.1%
(2/33)
A
A
TU
TU
6.1%
(2/33)
16.4%
(11/67)
od
ia
ly
si
s
4.5%
(1/22)
em
H
IC
IC
U
H
em
4.3%
(1/23)
U
od
ia
ly
si
s
10.4%
(7/67)
16.4%
(9/55)
IP
M
IP
M
7.1%
(4/56)
5.4%
(2/37)
IP
S
IP
S
7.9%
(3/38)
0%
10%
20%
30%
0%
10%
20%
30%
MRSA Prevalence Study
September/October 2006
Colonization Rates with Risk Factors
Rapid PCR Method
30%
23.6%
(17/72)
19.2%
(15/78)
20%
10%
5.6%
(1/18)
7.2%
(22/304)
10.2%
(10/98)
12.5%
(8/64)
1.3%
(1/76)
0%
Non-clinical
Personnel
LTC Stay
Overall
Healthcare
Workers
Prior Hosp
Prior Abx
Dialysis
Diabetes
Diabetes = Diagnosis of Diabetes or Oral Hypoglycemia or Insulin Rx
Prior Hosp = Inpatient stay within last year
LTC Stay = Any resident facility within last year
Prior Abx = Prior Antibiotic, Treatment or Empiric Within Last 6 Weeks;Excludes Surgical Prophylaxis
Dialysis
= Hemodialysis
40% reduction of MRSA
Infections!!
Effect on MRSA Transmission of Rapid PCR
Testing
J Hosp Infect 2007; 65:24
Voluntary passive
surveillance; feedback;
publication of national
aggregate voluntary data. No
effect on rates.
Mandatory surveillance of S.
aureus bacteraemia. Stabilisation
of rate nationally and in majority
of Trusts.
//
1990
Mandatory web-enabled
enhanced surveillance of
MRSA bacteraemia.
Introduction of Performance
Indicator
//
1997
2001
2002
Enhanced voluntary
surveillance. Stabilisation
of rates in participating
hospitals. Publication of
aggregate data.
2003
2004
2005
2003/04: Baseline year
for national target of
50% reduction in
MRSA bacteraemia
counts by 2008.
2006
Health Act.
Healthcare
Commission
improvement
powers.
2007
Number of reports (thousands)
S. aureus bacteraemia reports received under the mandatory and voluntary systems,
NHS acute trusts in England 2000-2006
12
10
8
6
4
2
0
2000
2001
2002
MRSA (mandatory)
MRSA (voluntary)
MSSA (mandatory)
Provisional data
2003
Year
2004
2005
2006
MRSA (voluntary)
MSSA (voluntary)
MSSA (voluntary)
Conclusions
•
Mandatory surveillance enhanced the completeness of
reporting of case numbers by ~50%
•
There was marked underreporting of risk factor and source
data where the data collection was based on voluntary
reporting.
•
Mandatory surveillance was introduced as a component of
performance management to achieve:
• National reduction of 50% in MRSA bacteraemia numbers
from a baseline of 7700 cases
• Trusts were set local trajectories for a 20% year-on-year
reduction
•
At the end of the second year of the three year programme a
3% per quarter reduction in rates appears to have been
achieved across the nine English regions of the NHS
•
The latest projection shows an increasing rate of reduction
Unresolved Questions
• Active Surveillance-anatomic site(s)-traditional vs. rapid screen
• ? Preemptive isolation
• Is active surveillance cost effective?
• How many cultures are necessary to remove a patient from
•
•
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isolation?
Do HCWs need to wear a mask?
Do visitors need to follow full contact isolation?
Is there staphylococcal resistance to mupirocin following
treatment?
Should decolonization of patients with MRSA be routinely
attempted?
Optimal treatment for invasive MRSA
What It Takes to Win
 Engagement
 Education
 Execution
Evaluation
US Approach to Strategies in the Battle
against HAI, 2006
J Hosp Infect 2007; 65:3
• No single intervention prevents any HAI; rather a
•
•
“bundle” approach, using a package of multiple
interventions based on evidence provided by the
infection control community and implemented by a
multidisciplinary team is the model for successful
HAI prevention
Benchmarking is inadequate and a culture of zero
tolerance is required
A culture of accountability and administrative support
is required
It Takes A Community!!!
It is not enough to say we are doing
our best. You have got to succeed in
doing what is necessary
Winston Churchill