Staphylococcus aureus

1 1 methicillin - resistant Staphylococcus aureus (MRSA) Prevention Tier 2 Interventions PresenterKyle Popovich, MDAssociate ProfessorRush University Medical CenterContributions byDavid P. Calfee, MD, MSWeill Cornell MedicineVineet Chopra, MD, MScUniversity of Michigan Russ Olmsted, MPH, CIC, FAPICT rinity Health, Livonia, MIPayal Patel, MD, MPHU niversity of Michigan2 Learning Objectives Outline the difference between horizontal and vertical infection control strategies Identify the enhanced Tier 2 strategies that can be used to reduce methicillin - resistant Staphylococcus aureus (MRSA) transmission and infection Recognize the importance of adherence to recommended infection control interventions3 Horizontal Infection Control StrategiesInterventions that can reduce MRSA transmission to other patients, but are NOTpathogen specificThese interventions have the additional benefit of preventing transmission of other organisms, including other multidrug- resistant organisms (MDROs)

2 4 Vertical Infection Control StrategiesInterventions that target a specific pathogen Active Surveillance Testing (AST) for high-risk patient populations Decolonization for patients colonized with MRSA or at high risk of infectionVertical ANDhorizontal strategies combined offer maximal benefit!5(Image Source: Biddle J, CDC, 1998)MRSATier 2 MRSA Prevention StrategiesDaily chlorhexidine gluconate (CHG) bathing in intensive care units (ICUs)MRSA decolonization therapyActive surveillance testing (AST) for MRSAU niversal gown and glove use in the ICU6 Chlorhexidine Gluconate (CHG)Daily bathing of ICU patients with CHG can decrease potential pathogens on patient skin , source controlDaily bathing with CHG leads to a significant reduction in the risk for acquisition of multidrug- resistant organisms and healthcare-acquired bloodstream infections7(Ridenour G, Infect Control HospEpidemiol2007; Evans HL, Arch Surg, 2010; ClimoM W, CritCare Med, 2009; KarkiS, J HospInfect, 2012; ClimoM W, N EnglJ Med, 2013)Why is Source Control Important?

3 8 Decrease burden of patientskin contaminationPrevent infections due to potential pathogens on patient skinDecrease contamination of health care personnel hands and the environmentDecrease spread of potential pathogens to other patients(Vernon MO, Arch Intern Med, 2006)CHG Bathing: ImplementationDevelop standardized or protocol-based order sets to optimize adherenceEnsure adequate supplies for CHG bathingEnsure skin products are compatible with CHGT rain health care personnel on appropriate application of CHG bathing techniquesProvide routine audits of adherence to CHG bathing with feedback to personnel9 MRSA Decolonization TherapyDecolonization therapy is the administration of antimicrobial or antiseptic agents to eradicate or suppress MRSA carriage Intranasal antibiotic or antiseptic ( , mupirocin, povidone-iodine) Topical antiseptic ( , chlorhexidine) +/- Systemic antibioticsMRSA decolonization has been associated with reduction in MRSA carriage, transmission and infection10(Calfee DP, Infect Control HospEpidemiol, 2014)MRSA Decolonization TherapyTargeted decolonization.

4 Administration of MRSA decolonization therapy to persons known to be colonized with MRSAU niversal decolonization: administration of MRSA decolonization therapy to all at-risk persons ( , all ICU patients) 11 MRSA Decolonization Therapy:Issues to ConsiderLogistics: who, with what, when, howadherencePotential for development of resistance to agents used for decolonization , mupirocin12(Calfee DP, Infect Control HospEpidemiol2014; Hayden MK, J ClinMicrobiol2016; AHRQ Publication No. 13-0052-EF, 2013)AHRQ Universal ICU Decolonization ToolkitActive Surveillance Testing (AST)AST refers to the collection of samples from patients for the purpose of detecting MRSA carriage Clinical cultures identify only a small proportion of patients who are colonized with MRSA Asymptomatic MRSA carriers may play a role in patient-to-patient transmission of MRSAAST is a vertical (MRSA specific) infection control strategy13(Calfee DP, Infect Control HospEpidemiol, 2014.)

5 Image Sources: , GathanyJ, CDC 2014)AST for MRSA Should be Part of a Larger MRSA Prevention ProgramAST by itself will not reduce MRSA transmission or infection Basic MRSA prevention strategies should be optimized AST results should lead to an intervention ( , isolation or decolonization)The role of AST in MRSA prevention remains controversial When considering AST, potential advantages and disadvantages of AST should be compared to those of other Tier 2 interventions14(Calfee DP, Infect Control HospEpidemiol, 2014)Active Surveillance Testing: Issues to Consider Logistics: who, with what, when, how Adherence Potential unintended consequences associated with contact precautions15 Which Enhanced Strategy to Choose? 16In adult ICUs, universal decolonization with intranasalmupirocin and daily CHG bathing was the most effectivestrategy for reducing rates of MRSA clinical isolates.

6 (Huang SS, N EnglJ Med, 2013)AST, Targeted Decolonization or Universal Decolonization?OutcomeAST plusIsolationAST plus Targeted DecolonizationUniversalDecolonization p- valueMRSAC linical Isolates (any pathogen) < Bloodstream (Huang SS, N EnglJ Med, 2013)Universal Glove and Gown UseUniversal gown and glove use did not result in a decrease in the acquisition of MRSA or VRE Fewer acquisitions for MRSAU niversal gown and glove use was associated with decreased health care personnel room entry, increased room-exit hand hygiene adherence, and no difference in adverse events18(Harris AD, JAMA, 2013)Universal Glove and Gown Use If MRSA infections persist, consider implementing a strategy where all health care personnel don gowns and gloves when caring for all patients in the ICU, instead ofContact Precautions only for individuals colonized or infected with MRSA Are there adverse effects to patients who are placed on Contact Isolation?

7 Adherence to the intervention is critical Hand hygiene is still essential19Ta ke-Home Points Adherence to recommended infection control strategies is essential Horizontal infection control strategies can impact MRSA in addition to other MDROs Consider local factors, epidemiology and logistics when selecting Tier 2 MRSA prevention strategies20 ReferencesCalfee DP, Salgado CD, MilstoneAM, et al. Strategies to prevent methicillin - resistant Staphylococcus aureus transmission and infection in acute care hospitals: 2014 update. Infect Control Hosp ; 35: , YokoeDS, Warren DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N EnglJ Med. 2013; 368: , SepkowitzKA, Zuccotti G, et al. The effect of daily bathing with chlorhexidine on the acquisition of methicillin - resistant Staphylococcus aureus , vancomycin- resistant Enterococcus, and healthcare-associated bloodstream infections: results of a quasi-experimental multicenter trial.

8 CritCare Med. 2009; 37: 1858 HL, DellitTH, Chan J, et al. Effect of chlorhexidine whole-body bathing on hospital acquired infections among trauma patients. Arch Surg. 2010; 145: 240 Public Health Library, ID #16813. Centersfor Disease Control and Prevention, CDC. 2014. Available at AD, PinelesL, Belton B, et al. Universal glove and gown use and acquisition of antibiotic- resistant bacteria in the ICU: a randomized trial. ; 310: 1571-1580. Hayden MK, LolansK, HaffenrefferK, et al. Chlorhexidine and mupirocinsusceptibility of methicillin - resistant Staphylococcus aureus isolates in the REDUCE-MRSA trial. J ClinMicrobiol. 2016; 54: SS, SeptimusE, KleinmanK, et al. Targeted versus universal decolonization to prevent ICU infection. N EnglJ Med. 2013; 368: , Cheng AC. Impact of non-rinse skin cleansing with chlorhexidine gluconate on prevention of healthcare-associated infections and colonization with multi- resistant organisms: a systematic review.

9 J Hosp Infect. 2012; 82: 71 G, LampenR, FederspielJ, et al. Selective use of intranasal mupirocinand chlorhexidine bathing and the incidence of methicillin - resistant Staphylococcus aureus colonization and infection among intensive care unit patients. Infect Control Hosp Epidemiol. 2007; 28: 1155 ICU Decolonization: An Enhanced Protocol. (Prepared by the REDUCE MRSA Trial Working Group, under contract HHSA290201000008i. AHRQ Publication No. 13-0052-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2013. MO, Hayden MK, Trick WE, et al. Chlorhexidine gluconate to cleanse patients in a medical intensive care unit: the effectiveness of source control to reduce the bioburden of vancomycin- resistant enterococci. Arch Intern Med. 2006; 166: NotesSpeaker Notes: Slide 1 Welcome to the second module of the methicillin - resistant Staphylococcus aureus , or MRSA prevention, Tier 2 course.)

10 This module will discuss additional MRSA prevention strategies that may be considered for use within a health care facility when the basic, or Tier 1, control measures, fail to adequately control MRSA infections or transmission within the facility. 23 Speaker Notes: Slide 2 This module was developed by national infection prevention experts devoted to improving patient safety and infection prevention Notes: Slide 3 After completing this module, you will be able the difference between horizontal and vertical infection control strategies, strategies that can be used in health care settings to reduce the transmission of MRSA, recognize the importance of adherence with recommended infection control interventions25 Speaker Notes: Slide 4 Horizontal infection control intervention is NOT pathogen specific. Horizontal strategies can reduce the transmission of MRSA to other patients, but in addition, have the added benefit of reducing transmission of other multidrug- resistant Notes: Slide 5In contrast, vertical infection control strategies are those that only target a specific pathogen such as MRSA.