MRSA in the Netherlands

MRSA in the NL 01-‐03-‐13

Andreas Voss, MD, PhD 1

¤ E-‐MRSA ¤ HA-‐MRSA (HO-‐CA-‐MRSA, HO-‐LA-‐MRSA) ¤ CA-‐MRSA (CO-‐HA-‐MRSA, CO-‐LA-‐MRSA) ¤ LA-‐MRSA

The only type I am interested in: ¤ IDCWYCI-‐JTMHTFI-‐MRSA*

* I Don’t Care What You Call It – Just Tell Me How To Fix It – MRSA (ScoR Weese)

CA-‐MRSA HA-‐MRSA LA-‐MRSA

CA

HA

LA

“LiRle brother” “Main problem” “Giant trouble” CA-‐MRSA HA-‐MRSA LA-‐MRSA



¤ ProspecXve cohort study of MRSA infecXons idenXfied in 12 Minnesota laboratories in 2000

¤ 1100 MRSA infecXons ² 131 (12%): community-‐associated

² 937 (85%): health care-‐associated

¤ Epidemiological definiXon

Naimi et al. JAMA 2003; 290: 2976-84

CA-/HA-MRSA: Age Distribution!

Naimi et al. JAMA 2003; 290: 2976-84

No underlying condiXons as risk factor

Naimi et al. JAMA 2003; 290: 2976-84

CA-/HA-MRSA: Underlying conditions!

Predominantly skin and soc Xssue infecXons

CA-/HA-MRSA: Infection type!

Naimi et al. JAMA 2003; 290: 2976-84



SXll suscepXble to most other classes of anXbioXcs

CA-/HA-MRSA: Susceptibility!

Naimi et al. JAMA 2003; 290: 2976-84

Enriched with SCCmec IV, PVL and other exotoxins

Naimi et al. JAMA 2003; 290: 2976-84

CA-‐ strains geneXcally unrelated to HA-‐MRSA

CA-/HA-MRSA: Clonal spread!

¤ Aboriginals ¤ NaXve Americans (indians, eskimos) ¤ Jails ¤ Saunas ¤ Sport teams ¤ Homosexual men ¤ Military recruits ¤ Day Care Centers

King et al Ann Intern Med 2006;144:309-‐317

" SSTI caused by CO-‐MRSA in a non-‐outbreak se;ng (Atlanta, Q3+4 2003)

" 384 persons with documented CA-‐SSTI due to S. aureus



King et al Ann Intern Med 2006;144:309-‐317

nearly ¾ MRSA

nearly 90% US 300/400*

* 99% (155 of 157) of the typed CA-‐MRSA isolates were USA 300

¤ Aboriginals ¤ NaXve Americans (indians, eskimos) ¤ Jails ¤ Saunas ¤ Sport teams ¤ Homosexual men ¤ Military recruits ¤ Day Care Centers ¤ Animal lovers ?

First

cases

•  2004: 23%

•  2006: 50%

•  2010: >70%



•  50 farms/232 individuals –  50 farmers, 13 employees –  169 household members

•  Intensive pig contact (29%), medium contact (12%), person living on farm (2%) MRSA

•  Higher risk with sows and finishing pigs

P39 van Cleef et al. NVMM 2008 Van Cleef et al. Epidemiol Infect 2010 doi:10.1017/S09502688100000245

•  Three large pig slaughterhouses were studied in 2008 using �� human and environmental samples.

•  The overall prevalence of nasal MRSA carriage in employees �� of pig slaughterhouses was 5.6%

•  Working with live pigs was the single most important �� factor for being MRSA positive (OR 38.2, P<0.0001).

•  Exact transmission routes from animals to humans remain to �� be elucidated.

Graveland et al. PLOSone 2010; 5:e10990

¤ 15.9% of humans in contact with calves were MRSA+ ² 33% of the farmers (direct contact) ² 8% of the family members

Graveland et al.

Mulders et al. Epidemiol Infect 2010 doi: 10.1017/S095026881000000075

•  40 Dutch broiler flocks, in six slaughterhouses and 466 personnel •  26 (5.6%) employees were positive •  Risk was significantly higher for personnel having contact with live �� animals – especially hanging broilers on slaughterline (20.0%) vs all �� other (1.9%). •  Conventional electric stunning = higher risk of MRSA carriage than �� CO2 stunning (9.7% vs. 2.0%). •  From 40 Dutch slaughter flocks - 35.0% were positive. •  Of the 119 MRSA isolates, predominantly livestock-associated �� MRSA ST398 was found, although 27.7% belonged to ST9 (spa type �� t1430).



¤  Randomly selected adults (n=583) from 3 Dutch municipaliXes in high pig-‐desity regions

¤  Of the 534 persons without livestock-‐contact, one was posiXve for MRSA (0.2%).

¤  Of the 49 persons who did indicate to be working at or living on a livestock farm, 13 were posiXve for MRSA (26.5%). All spa-‐types belonged to CC398.

¤  LA-‐MRSA has a high prevalence in people with direct contact with animals. At this moment it has not spread from the farms into the community.

Use of anXmicrobials in food animal producXon à resistant m.o.’s and resistance genes can spread from

animals to humans Kluytmans JA Clin Microbiol Infect 2010;16:11

Buy two …

… get millions for free ! Kluytmans JA Clin Microbiol Infect 2010;16:11

11.9%

0

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180

2002 2003 2004 2005 2006 2007 2008

ST398 unexpected

ST398

Other MRSA unexpected

other MRSA

Frequency of newly idenXfied MRSA posiXve individuals increased from 16/year between 2002-‐2006 to 148/year between 2006-‐2008

930% increase of which 81% (108/132) was due to ST398



¤ More cases that need precauXons and isolaXon

¤ More HCWs complaining about extra work

¤ Problems of isolaXon ¤ “Destroy” part of S&D not possible with permanent source

¤ What to do with MRSA+ HCWs?

Nosocomial transmission of ST398 MRSA is 72% less likely

Wassenberg et al. Clin Microbiol Infect 2010 Wulf et al. Eurosurveillance 2008;13



¤ EsXmated “lower virulence than HA-‐MRSA”

¤ Many cases of skin and soc-‐Xssue infecXons acer direct inoculaXon (pig bite or injuries during work)

¤ Case of endocardiXs

¤ Case of osteomyeliXs

¤ Severe wound infecXons

¤ InfecXon acer total hip replacement

¤ … cases to common to publish

Van Rijn et al. P1951

Ekkelenkamp et al. Ned Tijdschr Geneesk 2006;150:2442-‐7

Declercq et al. Infec_on 2008 (epubl.)



MRSA bacteremia in Europe!

Source: EARSS report

¤ Search & Destroy (Control) strategy to avoid introducXon of MRSA into health-‐care setngs and reduce the chance of transmission: ² NaXonal MRSA guidelines (WIP) ² NaXonal detecXon methods (NVMM) ² Use fast and reliable detecXon methods

¤ IsolaXon and screening of risk-‐paXents on admission

² at all Xmes

² colonized and infected paXents

¤ DecolonizaXon of MRSA carriers

¤ Consequent acXons when transmissions occur

² screening of all paXents and HCWs at risk

² MRSA-‐posiXve HCWs not allowed to work

¤ Placement in isolaXon room

² with anteroom and negaXve pressure

¤ Gloves, gowns and face-‐masks

² for all entering the room

¤ Handhygiene



¤ IsolaXon and screening of risk-‐paXents on admission ² can’t determine paXents at risk ² only certain departments!

² not when too busy/weekends ² only infected paXents

¤ No decolonizaXon of MRSA carriers ¤ Non-‐consequent acXons when transmissions occur

² screening of all paXents but not HCWs à consequently MRSA-‐posiXve HCWs may conXnue to spread

0

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16001800

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Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2005 2006 2007 2008 2009

Counts of MRSA bacteraemia

Yea

r and

qua

rter

* DATA ARE PROVISIONAL NOT FOR WIDER CIRCULATION

BBC World news

Courtesy: A. Pearson (HPA, Sept 2009)

MRSA BSI episodes

V. Jarlier et al. Arch Intern Med 2010



¤ IsolaXon IntervenXons ¤ PromoXon of Hand Hygiene ¤ IdenXficaXon of paXents with MRSA infecXons or colonizaXons

¤ Feedback ¤ Annual reports

IsolaXon IntervenXons ¤ Placement of paXents with MRSA infecXons or colonizaXons in single-‐bed rooms whenever possible

¤ Barrier precauXons for paXents with MRSA infecXons or colonizaXons such as: ² disposable gloves worn before and discarded acer paXent contact

² disposable aprons worn for extensive contacts (eg, bed making)

² small equipment (eg, stethoscope) dedicated to the paXent.

Should we ask universal precauXons ?

PromoXon of Hand Hygiene

¤ Hand washing with disinfectant soap acer contact with paXents with MRSA infecXons or colonizaXons before leaving the room

¤ An insXtuXonal campaign for promoXng the use of alcohol-‐based hand-‐rub soluXons in place of hand washing ² launched in 2001 ² Training materials to the infecXon control teams (slide shows, 200 000 brochures, and 14 000 posters)

² formal leRers by the general director asking all administrators, heads of departments, and chief nurses to support the campaign.

IdenXficaXon of MRSA PaXents

¤ Passive surveillance through rouXne clinical specimens ¤ AcXve surveillance (screening) by culturing nares of

paXents with a high risk of MRSA colonizaXon, eg, intensive care unit (ICU) paXents and contacts of MRSA paXents

¤ Quick noXficaXon and flagging of new paXents with MRSA infecXons or colonizaXons by laboratories to medical teams

¤  IdenXficaXon of MRSA paXent rooms and charts (sXcker) ¤  Informing units to which paXents with MRSA are

transferred.

Feedback

¤  Feedback to the local hospital community on the results (MRSA rates and progress in program implementaXon).

Annual report

¤  Each hospital reporXng to the central administraXon

² size of the infecXon control team

²  implementaXon of the program

² organizaXon of audits (eg, on hand hygiene)

²  feed-‐back

² progress of the iniXaXve has been annually presented during meeXngs of infecXon control teams and bacteriologists from all AP-‐HP hospitals,



46 7734 41 54 67 97 104 100

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Each person only included once, unless a new subtype is found R. Skov 2009

020406080

100120140160180200220240

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Import HA HACO CA

R. Skov 2009 71% of the MRSA cases in Copenhagen area were community-onset MRSA (CO-MRSA)

... lines between categories may be “graying,” with community-‐associated strains encroaching on hospitals, and health-‐care associated strains

entering the community.

Stranden et al. InfecXon 2009;37:44

v  36.4% of 11 CA-‐MRSA and 43.9% of 66 HA-‐MRSA harbored SCCmec type IV/IVA. v  Type IV/IVA has become the most common SCCmec type in inpaXents of a Swiss university hospital. v  SCCmec type IV/IVA is present in both CA-‐MRSA and HA-‐MRSA limiXng its use as a marker for CA-‐MRSA.

¤  we have all kind of SSCmec-‐types in the hospital (including IV and V)

¤  we have healthcare outbreaks of ST398-‐MRSA and CA-‐MRSA strains

¤  we have HA-‐MRSA strains in the community, in pets and in livestock animals

¤  MRSA -‐ it’s not graying, it is gray!



CA-‐MRSA HA-‐MRSA LA-‐MRSA CA-‐MRSA HA-‐MRSA LA-‐MRSA Just-‐MRSA

¤  We know the risk factors for HA-‐MRSA ²  foreign admission/dialysis, adopXon, known outbreaks, (nursing homes)

¤  We know the risk factors for LA-‐MRSA ²  pig-‐ and calf-‐farming (poultry) ²  (but this may change)

¤  We know some of the risk factors for CA-‐MRSA ²  but can’t use them for S&D

¤  Consequent decolonizaXon of all MRSA carriers (especially outside the hospitals) is of upmost importance ! ²  works with HA-‐MRSA

²  should work with CA-‐MRSA

²  trouble LA-‐MRSA

020406080

100120140160180200220240

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

No.

of i

sola

tes

Import HA HACO CA

R. Skov 2009 71% of the MRSA cases in Copenhagen area were community-onset MRSA (CO-MRSA)

The Danish curbed this outbreak by ”destroying” the community sources



¤  To a certainly level it may be the major components that count not the details: ²  Good epidemiology ²  Screening ²  IsolaXon (single room and glove and gowns) ²  Hand hygiene ²  CommunicaXon ²  DecolonizaXon

While important other factors count:

¤  Compliance with basic infecXon control measures in all (healthcare) setngs

¤  Infrastructure of healthcare setngs

¤  HCW-‐paXent/client raXo

¤  AnXbioXc use

¤  Farming (!) & food (?)

¤  PDF of b/w slides (6 per page) at: hRp://www.slideshare.net/iPrevent/

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MRSA in the Netherlands