Perspectives from Inside and Outside the Health Department

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Perspectives from Inside and Outside the Health
Department
4th Annual Betsy Lehman Center Patient Safety
Conference December 4, 2007

• Alfred DeMaria, Jr., M.D.
• Massachusetts Department of Public Health

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1940s 1980s
Nosocomial Organisms
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Public Health Patient Safety
Healthcare-Associated Infections New
Organisms Shorter LOS
NOW!
Out-Patient Settings Surgicenters, etc.
Rehabilitation LTCF Assisted Living
Home Care
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History of Infection Control

• 1847 - Semmelweiss chlorinated lime
  handwashing to prevent puerperal sepsis
• 1867 - Lister carbolic acid to prevent wound
  sepsis
• 1870-80s - Germ Theory Pasteur, Koch surgical
  asepsis
• 1930-40s - First antimicrobials
• 1951 - Gram-negative sepsis Waisbren
  emergence of penicillin-resistant S. aureus
• 1950s - Hospital-acquired staphylococcal
  infections development of infection control
  techniques
• 1963 - Founding of Infectious Diseases Society
  of America (IDSA)
• 1960s - Appearance of infection control
  professionals
• 1968 - Use of antibiotics and resistant
  organisms in hospitals emergence of MRSA
• 1970 - First International Conference on
  Nosocomial Infections, CDC, Atlanta National
  Nosocomial Infections Surveillance (NNIS) System
• 1972 - Founding of the Association for
  Practitioners in Infection Control (APIC)
• 1974 - Study on the Efficacy of Nosocomial
  Infection Control Project (SENIC), CDC
• 1976 - Joint Commission standard for
  surveillance and control
• 1978 - CDC Hospital Infections Program
• 1980 - Founding of Society for Healthcare
  Epidemiology of America (SHEA) APIC
  Certification in Infection Control (CIC)
• 1987 - Universal Blood and Body Fluid
  Precautions
• 1990 - Body Substance Isolation
• 1993 - Hospital Infection Control Practices
  Advisory Committee (HICPAC) established
• 1996 - Standard Precautions

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MRSA Why Now?

• Increase in incidence
• Change in the way health care delivered
• Emergence of community-onset MRSA infection
• Controversy about infection control procedures to
  address MRSA
• VISA, VRSA

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History of Methicillin-Resistant Staphylococcus
aureus

• 1959 - Methicillin introduced
• 1960 - Methicillin-resistant S. aureus identified
  with mecA gene and altered PBP2a
• 1968 First documented MRSA outbreak in U.S. at
  Boston City Hospital
• gt1968 Progressive increase in prevalence and
  reports of nosocomial outbreaks
• 1980-82 Community-acquired outbreak in Detroit
• 1990-96 Community-acquired strains in
  Australia, Canada
• 1998-99 Community strain outbreaks in U.S
• 1996-2000 VISA
• 2002 - VRSA

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• Finland, NEJM, 1955

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History of Penicillin Resistance in
Staphylococcus aureus
Hospital-associated
Community
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Patients Acquire Resistant Organisms

• From another colonized or infected individual
• By selection of resistant organisms through
  antibiotic exposure
• From the environment

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S. aureus ColonizationNHANES Nasal Swab Survey
2001-2
S. aureus 32 MRSA 0.8
Kuehnert et al. unpublished
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Prevalence of MRSA as cause of SSTI in Adult ED
Patients EMERGEncy ID Net, Moran GJ, et al, SAEM
2005
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7/13 (54)
11/28 (39)
3/20 (15)
32/58 (55)
43/58(74)
24/47 (51)
17/25 (68)
25/42 (60)
23/32 (72)
18/30 (60)
46/69 (67)
MSSA 17
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S. aureus Oxacillin Susceptibility Trendsplt0.0001
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Proportion of Methicillin-Resistant
Staphylococcus aureus in Massachusetts Hospitals
(antibiograms)
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Proportion of Methicillin-Resistant
Staphylococcus aureus in Massachusetts Hospitals
(antibiograms)
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Proportion of Methicillin-Resistant
Staphylococcus aureus in Massachusetts Hospitals
(antibiograms)
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MRSA Reported in MassachusettsUnder Active
Surveillance, 2001-2005Characteristics of Age
and Gender
Mean/Median Age 2001 70.6/74.4
2005 62.4/67.5
Male 54 Female 46
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Costs Associated with MRSA

• Causes greater than 50 of hospital -acquired
  Staphylococcus aureus infections
• Multivariate logistic regression analysis found
  MRSA infection to be an independent risk factor
  for mortality (OR, 3.0-4.2) (Conterno, 1998)
• Higher mortality associated with MRSA (49-58)
  than with MSSA (20-32) bacteremia (Romero-Vivas,
  1995)
• Meta-analysis with pooling with a random-effects
  model, OR for mortality with MRSA versus MSSA
  bacteremia 1.93 95 CI 1.54-2.42 (Cosgrove,
  2003)
• Cost attributable to a MRSA infection 35,367
  (Stone, 2002)
• Cost of treating MRSA infections in U.S.
  3.2-4.2 billion (Pfizer, ISPOR)

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2003
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Controversy Over Control of MRSA (and VRE) in
Healthcare Facilities

• Strict Isolationists
• versus
• Traditionalists

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Strict Isolationists

• Screen all admissions at risk of exposure with
  surveillance cultures
• Contact precautions until proven negative
• Contact isolation for colonized and infected
  patients
• Surveillance cultures

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Secular Trends in Antimicrobial Resistance Among
S. aureus Isolates Danish HospitalsDanMap 1998
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Traditionalists

• Standard precautions all the time for every
  patient
• Monitor incidence and prevalence of
  colonization/infection in clinical cultures
• Set levels of prevalence/incidence that trigger
  response
• Hierarchy of response
• Contact precautions for all infected/colonized

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Impact of Isolation for Infection
ControlStelfox, et al. JAMA 2003 290 1899-1905
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Issues for Debate

• Data from studies with multiple interventions
• Cost/benefit
• Heterogeneity of hospitals and problem (does one
  size fit all?)
• Adverse impact of isolation

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MDRO Control Measures - Increasing Level
of Recommendation/Evidence

• Education
• Emphasis on hand hygiene
• Antiseptic hand washes
• Contact precautions and/or gloves
• Private rooms
• Segregation of cases
• Cohorting of patients
• Cohorting of staff
• Change in antimicrobial use

• Surveillance cultures of patients
• Surveillance cultures of staff
• Environmental cultures
• Extra cleaning and disinfection
• Dedicated equipment
• Decolonization
• Ward closure to new patients

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