MRSA and Nursing hom es: Is there a problem and do we need to change our guidelines ? Dr. C. SUETENS, B. JANS, Scientific I nstitute of Public Health, Epidem iology, Dr. O. DENI S, Prof. M. STRUELENS, National MRSA reference laboratory, ULB, Brussels, BELGI UM 1 IPH Epidemiology
With the support of the federal platform for hospital hygiene With the support of the federal platform for hospital hygiene Belgian Antibiotic Policy Coordination Committee Belgian Antibiotic Policy Coordination Committee Belgian Infection Control Society Belgian Infection Control Society
Situation in Belgian acute care hospitals Situation in Belgian acute care hospitals National Campaign: Antibiotic Consumption - 2000 2004 and 2006 Hand hygiene campaigns GUIDELINES AB policy steering committee 2003: Revision (hospitals): 1993 in the hospitals -2002 GUIDELINES (Hosp.) Antibiotic prophylaxis in surgery: 1997 35 4.5 MRSA / 1000 admissions . 4 30 MRSA / SA (%) . 3.5 25 3 20 2.5 ? ? 2 15 1.5 � % MRSA+ � 10 % MRSA+ at at admission admission 1 5 NH = reservoirs reservoirs ? ? NH = 0.5 0 0 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 / / / / / / / / / / / / / / / / / / / / / / / 5 6 7 8 9 0 1 2 3 4 5 4 5 6 7 8 9 0 1 2 3 4 5 0 9 9 9 9 9 0 0 0 0 0 0 9 9 9 9 9 9 0 0 0 0 0 0 9 9 9 9 9 0 0 0 0 0 0 9 9 9 9 9 9 0 0 0 0 0 2 1 1 1 1 1 2 2 2 2 2 2 1 1 1 1 1 1 2 2 2 2 2 Study periods 3 Resistance rate Incidence of nosocomial MRSA
st national prevalence study on MRSA 1 st national prevalence study on MRSA- - carriage in NH carriage in NH 1 2005 2005 At random : Methodology Methodology region & proportion of m ajor care beds List of I NAMI / RI ZI V = 9 8 5 m ajor care NH Br. Wal. Luxemb. Namur Antw. Limb. Br. Wal. Luxemb. Namur Vl. Br. Limb. Antw. Br. Fl. O.-Vl. Brux. O.-Vl. Brussel Liège W.-Vl. Hain. n= 6 0 NH Liège W.-Vl. 5 0 residents/ NH Hain. Obj . 1: . 1: prevalence MRSA MRSA- - carriage carriage in in Belgian Belgian NH ? NH ? Obj prevalence Sampling: : nose nose, , throath throath & & wound wound, , urinary urinary meatus meatus Sampling Obj . 2: . 2: determinants of MRSA of MRSA- - carriage carriage at at resident resident Obj determinants and institutional institutional level level ? (questionnaire) ? (questionnaire) and 4 Obj . 3: . 3: molecular epidemiology epidemiology and AB and AB- - resistance resistance Obj molecular
Characteristics of participating NH Characteristics of participating NH Sam ple BELGI UM Sam ple BELGI UM Num ber of participating NH: 6 0 ( 6 .1 % ) 9 8 5 Num ber of participating NH: 6 0 ( 6 .1 % ) 9 8 5 Screened residents ( m ax.5 0 / NH) : 2 9 5 8 / 6 3 6 5 9 4 .5 1 5 Screened residents ( m ax.5 0 / NH) : 2 9 5 8 / 6 3 6 5 9 4 .5 1 5 ( 4 6 % of the sam ple) ( 4 6 % of the sam ple) Distribution of the NH by region: Distribution of the NH by region: Flanders 3 6 ( 6 0 % ) 5 8 6 ( 5 9 % ) ( 5 9 % ) Flanders 3 6 ( 6 0 % ) 5 8 6 1 8 ( 3 0 % ) 3 0 4 ( 3 1 % ) W alloon W alloon 1 8 ( 3 0 % ) 3 0 4 ( 3 1 % ) Brussels 6 ( 1 0 % ) 9 5 ( 1 0 % ) ( 1 0 % ) Brussels 6 ( 1 0 % ) 9 5 Ow nership: Private Private 4 1 ( 6 8 % ) 6 2 4 ( 6 3 % ) ( 6 3 % ) Ow nership: 4 1 ( 6 8 % ) 6 2 4 Mean % m ajor care beds: 4 6 % ( 1 5 ( 1 5 - - 9 7 % ) 9 7 % ) 4 9 % Mean % m ajor care beds: 4 6 % 4 9 % Mean num ber beds/ NH: 1 0 6 ( 3 8 ( 3 8 - - 2 7 9 beds) 2 7 9 beds) 9 6 Mean num ber beds/ NH: 1 0 6 9 6 Fl: 1 0 9 1 0 9 W : 8 7 8 7 : 1 4 4 1 4 4 ( p= 0 .0 4 7 ) Fl: W : BR : BR ( p= 0 .0 4 7 ) 5 Private: 1 0 4 1 0 4 Public : : 1 1 1 1 1 1 ( n.s n.s.) .) Private: Public (
Prevalence of S. aureus S. aureus and MRSA and MRSA Prevalence of Total number of screened residents : 2953 Total number of screened residents Weigthed mean MRSA-prevalence: 19% [ CI 95% 17-22] (min. 2% - max. 43% ) MRSA S . aureus n = 5 8 7 negative culture n = 1 4 5 3 49% Weighted mean resistance proportion: 38% [ CI 95% 33-42] (min. 4% - max. 75% ) MSSA n = 9 1 3 S . aureus positive culture n = 1 5 0 0 S. aureus prevalence : 51% 6 ( min. 22% - max. 70% )
Distribution of MRSA- - carriage carriage prevalence prevalence rates in NH rates in NH Distribution of MRSA (% MRSA/ residents residents) ) (% MRSA/ Q. 25 Median Q. 75 50 Weigthed mean MRSA-prevalence: 19% 40 % MRSA carriers/NH 30 20 10 2000 (n= 24 NH): 4.7% 0 1 31 41 21 11 51 23 53 30 12 37 32 59 29 7 49 50 60 2 58 33 22 13 9 19 28 39 43 8 10 3 57 38 27 18 42 52 20 17 47 48 40 24 34 56 25 26 55 44 45 4 14 54 36 5 16 35 46 15 6 7 participating NH
MRSA prevalence prevalence by by region region MRSA p= 0,13 p= 0,13 1 8 .1 % [ I C9 5 % 1 5 -2 1 .3 ] 2 2 .2 % [ I C9 5 % 1 7 .2 -2 7 .4 ] 40 1 7 .2 % [ I C9 5 % 1 3 .4 -2 1 ] 30 MRSA carriage % 20 10 0 8 Vlaanderen Brussels W a llo nie
How frequent frequent are infections in NH are infections in NH ’ ’s* ? s* ? How % % At least 1 outbreak during last year 22 At least 1 outbreak during last year 22 Type of outbreaks Type of outbreaks Gastro- Gastro - enteritis enteritis 59 59 Clostridium difficile difficile 18 Clostridium 18 MRSA 6 MRSA 6 Clostridium difficile difficile strains in hospitals strains in hospitals Clostridium % coming from NH- - residents residents 20 % coming from NH 20 MRSA- - carriage among NH carriage among NH- - residents residents 19 MRSA 19 Is MRSA problematic in your NH ? % MRSA Is MRSA problematic in your NH ? % MRSA Yes 55 19 Yes 55 19 No 13 15 15 No 13 Don’ ’t know, no answer t know, no answer 32 24 Don 32 24 . Underestimation of infectious problems in some NH . 56% of NH never take screening samples 9 * source: coordinating physician and nursing responsible * source: coordinating physician and nursing responsible
Coordination of medical medical and nursing care in the NH and nursing care in the NH Coordination of In Major care NH: 1 Coordinating physician (RD 24/ 6/ 1999) (RD 24/ 6/ 1999) coordination of medical activities, healthcare problems coordination of medical activities, healthcare problems potentially dangerous for residents/ staff and … potentially dangerous for residents/ staff 31 GP / NH (min. 3 - max. 96) 1 GP / 4.4 beds (min. 1/ 1.4 – – max. 1/ 36.7) max. 1/ 36.7) 1 GP / 4.4 beds (min. 1/ 1.4 GP/beds ratio % mean MRSA% MRSA > 19% . 1 GP/ < 4 beds 63.3 21.9 63.2 1 GP/ 4 beds and + 36.7 16.2 31.8 OR: 3.67 [1.05 - 13.26], p=0.02 AB-policy in the NH Yes (%) % MRSA . Use mupirocine for decolonisation of wounds 71 21 15 Creation formulary with GP’s = CP task 58 19 20 GP aggreements – AB use = task CP 32 22 19 Formulary used<> not used/ not available 29 15 22 Aggreements about AB-prescription 18 18 20 Written aggreements: AB-use 13 19 20 Limitation AB choice for prescription 7 16 20 10 Free use AB-ointments for wound care by nurse 3 29 20
Hand hygiene hygiene Hand 1 - Available products Yes MRSA% Availability of products for hand hygiene % Yes No Liquid soap 98 20 13 Hydro-alcoholic lotion or gel 84 20 20 Antiseptic soap 75 20 18 Bar solid soap 4 25 20 Type of towels . Single use or electric 90 19 22 2 – Use of gloves Indications for glove use . Residents with fecal incontinence 85 18 27 Wound care 77 19 22 Care urinary catheter 67 19 20 Desinfection of materiel 62 20 20 Gastrostomy 54 18 21 Residents with urinary incontinence 51 19 20 Residents with flu 34 15 22 11 NOTE: no hand hygiene after removing gloves = 8%
Management of MRSA- - carriers carriers Management of MRSA 1 – Room arrangements for MRSA carriers Yes MRSA% Proportion of single rooms % Yes No. All NH-rooms are single 13 18 20 Room arrangements for carriers . Isolation in single room 79 19 25 Cohorting carriers 54 20 20 Cohort nursing 32 18 21 2 - Additional precautions Additional precautions . Gloves 98 20 3 Mask 86 20 18 Apron 90 20 20 Reinforced cleaning (room) 92 20 18 3 – Written care protocols Availability of written care protocols . Protocol for management of MRSA-carriers 80 19 20 Isolation of contagious residents 54 17 22 12 Hygiene policy in the NH 47 20 19
Detection, , eradication eradication and and follow follow- - up up Detection Yes MRSA% 1 - Screening of reservoirs % Yes No. Residents after hospitalisation 44 18 22 Staff 22 19 20 2 - Decolonisation of carriers . Decolonisation of carriers 90 21 14 Control sample after decolonisation 97 20 14 Used decolonisation scheme (n=40) . Nasal decolonisation only 28 18 Nasal decolonisation + antiseptic bath 43 22 Not conform decolonisation scheme (AB) 10 21 Other answer 20 19 3 – Communication and collaboration . Always receive transfer document 68 19 22 Collaboration with experts . Advice regional platform Hospital hygiene 69 21 18 Collaboration with Hospital hygiene team 61 20 19 4 - Surveillance of MRSA . 13 Yes 64 19 21
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