Moving from Infection Control
to Infection Prevention:
A Journey through MRSA
Joan M. Ivaska, BS, MPH, CIC
Objectives
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• Participants will understand the
differences between infection
control and infection prevention.
Understand the epidemiology of MRSA
Understand risk factors for MRSA
Review current MRSA management trends
Discuss MRSA prevention
and control strategies
Cardo et al. Infection Control and Hospital Epidemiology , Vol. 31, No. 11 (November 2010), pp. 1101-1105
Visitors and Family
Staff/ Medical Staff
Rehabilitation
Physician
Office
Home Care
Patient
Dialysis
Long Term
Care
Hospital
Surgery
Center
What is the role of Infection Prevention
and Epidemiology?
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Epidemiology is the cornerstone of public health
Inform policy decisions and evidence-based medicine
Identify risk factors for disease
Target prevention strategies
Infection control addresses factors related to the
spread of infections within the health-care setting
(whether patient-to-patient, from patients to staff and
from staff to patients, or among-staff)
• Interruption of outbreaks
When we are not proactive in doing the right thing,
we invite others to define the right thing for us
Wikipedia, September 2011
What is the difference between control and
prevention?
• Control:
– to exercise restraining or directing influence over
– to have power over
– to reduce the incidence or severity of especially to
innocuous levels
• Prevent:
– to be in readiness for
– to act ahead of
– To keep from happening or existing
www.merriam-webster.com/dictionary
A Tale of Two Cows
Adapted from Daniel Saman, DrPH, MPH, CPH,
HealthWatchUSA.com,2012.
Definitions
• CA-MRSA: Community-acquired MRSA
• HA-MRSA: Healthcare-associated MRSA
• Nosocomial: infection acquired while in the
hospital
• SSTI: Skin and Soft Tissue Infection
Staphylococcus aureus
• Staphylococcus aureus:
– common cause of infection in the community
– Lives on skin, in nose, in soil, water, dead plant
material
– Causes colonization or infection
• Methicillin-resistant Staphylococcus aureus
(MRSA):
– Increasingly important cause of healthcareassociated infections since 1970s
– In 1990s, emerged as cause of infection in the
community
Antibiotic resistance in S. aureus
• Penicillin, 1950
• Methicillin (= all β-lactam antibiotics), 1961
• Tetracycline, Co-trimoxazol, rifampin,
clindamycin, macrolides, quinolones
• Vancomycin, intermediate-R, 2000
• Vancomycin, high-level-R, 2002
• Linezolid, Daptomycin?
MRSA in Healthcare
• Historical Risk Factors
– Prolonged hospitalization
– Prolonged antimicrobial use
– Stay in an intensive care or burn unit
– Exposure to a colonized/infected person
– Residence in a nursing home
– Age >65
• Common infections include surgical
wound infections, urinary tract infections,
bloodstream infections, and pneumonia
Outbreaks of MRSA in the
Community
• Often first detected as clusters of
abscesses or “spider bites”
• Various settings
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Sports participants
Inmates in correctional facilities
Military recruits
Daycare attendees
Native Americans / Alaskan Natives
Men who have sex with men
Tattoo recipients
Hurricane evacuees in shelters
MRSA Skin and
Soft Tissue Infections
Comparison of Invasive Disease Incidence
per 100,000 Population, 2008
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Neisseria meningitidis
Haemophilus influenzae
Group B Streptococcus
Streptococcus pneumoniae
MRSA
0.3
1.5
7.5
14.5
29.5
http://www.cdc.gov/abcs/reports-findings/surv-reports.html
Colonization Sites
Infections
Wertheim H, et al. Lancet Infect Dis, 2005, 5: 751-762
MRSA Was the Most Commonly Identified Cause of
Purulent SSTIs Among Adult ED Patients
(EMERGEncy ID Net), 2004 to 2008
38%
40%
59%
44%
(98% USA300)
53%
72%
62%
58%
48%
57%
84%
56%
CID 2011:53 (15 July) Talan et al
MRSA Strain Characteristics Were
Initially Distinct
MRSA in
Healthcare
MRSA in the
Community
Prevalent genotypes (U.S.)
USA100,
USA200
USA300,
USA400
Antimicrobial resistance
Multiple
agents
Few agents
Types I-III
Types IV, V
Rare
Common
SCCmec (genetic element
carrying mecA resistance
gene)
PVL toxin gene
Gorwitz, R. CDC, 2007
Distribution of PFGE types among MRSA isolates
from nosocomial bloodstream infections,
Grady Memorial Hospital, 2004
PFGE
type
USA300
USA100
USA500
USA800
No. (%) of
nosocomial cases
(n = 49)
10 (20)
21 (43)
18 (37)
0 (0)
Historically community-acquired
Seybold U, et al. Clin Infect Dis 2006;42:647-656
ABC Surveillance, 2008
MRSA No. (Rate*) No. (Rate*) Inferred
Class Cases^
Deaths˜
PFGE
Type
(N,%)
Tot N±
Inferred
PFGE
Type
(N,%)
USA100
Inferred
PFGE
Type
(N,%)
USA300±
±
HO
1276 (6.7)
304 (1.6)
247
177
(71.7)
48 (19.4)
HACO
3203 (16.8) 481 (2.5)
585
363
(62.1)
157 (26.8)
CA
929 (4.9)
151
46 (30.5)
103 (68.2)
91 (0.5)
*CASES
PER 100,000 POPULATION FOR ABCS AREAS
˜N=20; COULD NOT BE CLASSIFIED AFTER CHART REVIEW
±1351 ISOLATES WERE ELIGIBLE FOR TESTING UP RECEIPT TO CDC, 1005 HAVE INFERRED
PFGE ALGORITHM, 13 WILL REQUIRE DIRECT PFGE
^N=151
http://www.cdc.gov/abcs/reports-findings/survreports/mrsa08.html
Factors that Facilitate Transmission
Frequent Contact
Crowding
Antimicrobial Use
Contaminated Surfaces
and Shared Items
Compromised Skin
Cleanliness
Preventing Transmission
in the Community
• Persons with skin infections should keep
wounds covered, wash hands frequently
(always after touching infected skin or
changing dressings), dispose of used
bandages in trash, avoid sharing personal
items.
• Uninfected persons can minimize risk of
infection by keeping cuts and scrapes clean
and covered, avoiding contact with other
persons’ infected skin, washing hands
frequently, avoiding sharing personal items.
www.cdc.gov
Preventing Transmission
in the Community
• Exclusion of patients from school, work,
sports activities, etc should be reserved for
those that are unable to keep the infected
skin covered with a clean, dry bandage and
maintain good personal hygiene.
• In general, it is not necessary to close
schools to “disinfect” them when MRSA
infections occur.
• In ambulatory care settings, use standard
precautions for all patients (hand hygiene
before and after contact, barriers such as
gloves, gowns as appropriate for contact with
wound drainage and other body fluids).
www.cdc.gov
Role of Pets
• Greatest risk of Staph aureus/MRSA exposure in most
humans is other humans
• When household pet animals carry MRSA, likely
acquired from a human
• Transmission of MRSA from an infected or colonized
pet to a human is possible, but likely accounts for a
very small proportion of human infections
• Reasonable to consider pet as a source if
transmission continues in a household despite
optimizing other control strategies
• Little evidence that antimicrobial-based eradication
therapy is effective in pets; however, colonization
tends to be short-term*
Barton et al 2006;Can J Infect Dis Med Microbiol
Healthcare Transmission Chain
Housekeeper does not adequately
disinfect the chair and cabinets
HCW starts dialysis on
Mr. Payne with finger of
glove removed
Mr. Payne develops
fever and sepsis next
day. Mr. Payne
hospitalized with MRSA
sepsis.
Mr. Payne dies 8 weeks
later.
Outpatient dialysis
patient is colonized
with MRSA and not
treated with
HCW does not perform
precautions
hand hygiene
Role of Screening
and Decolonization
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Pre-operative screening
High risk screening
Universal screening
Decolonization of skin
Decolonization of nose
Preventing Healthcare
Transmission:
• Standard Precautions
– Hand Hygiene
– Contain body fluids
• Transmission Based Precautions
– Contact Precautions
• Gown and gloves
• Appropriate use of antibiotics
Environmental Decontamination
• Adequate surface disinfection
• Validation of cleaning efficacy
• New technology
Validating cleaning by ATP
Preventing
Healthcare
Transmission:
Hand Hygiene
Communication
• Develop and use inter-facility reporting forms
• Use the network of experts in your community
• Get staff and medical staff engaged in reporting
Each infection discussed = Identified prevention strategies
Aim for Zero preventable infections…
don’t be the Cream of the Crap!
Education
• Patients and families
– Standardized hand outs
– Multi-media
• Staff and Medical Staff
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Inservices
Just in time
Safety Fairs
Make it fun, make it memorable
• Yourself
– Webinars
– Internet
– Peers
Present Actionable Data
Code Purple, using hall beds and
semi-privates
Disinfectant wipe conversion
Prevention
»Evaluate and implement best
practice regularly
»Engage staff…they are
smart people!
»Prevention doesn’t happen in
an office!
In Closing…