MRSA in Mediterranean Mediterranean MRSA in countries countries - PowerPoint PPT Presentation

MRSA in Mediterranean Mediterranean MRSA in countries countries A. Pascual MD, PhD. University of Sevilla. Spain

Proportion of of MRSA in MRSA in participating participating countries countries Proportion in 2005. EARSS in 2005. EARSS

Antibiotic Resistance Resistance Surveillance Surveillance and and Control in Control in the the Antibiotic Mediterraneam Region Region ( ( ARMed ARMed Project) Project) Mediterraneam MA Borg et al. Eurosurveilance. Jul-Sept 2006

Potential repercussions repercussions of of high high levels levels of of Potential Methicillin resistance resistance in in southern southern and and Methicillin eastern mediterranean mediterranean countries countries eastern � Direct Direct repercussions repercussions for for the the � mediterranean countries countries. . mediterranean � I mportation I mportation ( ( and and spread spread?) ?) of of � multiresistant microorganisms microorganisms to to multiresistant european hospitals hospitals: : european � Tourism Tourism � � Migration Migration � MA Borg et al. Eurosurveilance. Jul-Sept 2006

Prevalence of of MRSA in MRSA in Spain Spain. 1986 . 1986- -2006 2006 Prevalence Participating centers centers. . Participating 1- -day day study study 1 20 20 14 14 3 13 13 143 Hospitals Hospitals 143 13 13 16 17 16 17 1.- Galicia, Asturias, Cantabria 24 2.- P. Vasco, Navarra, Rioja 24 3.- Cataluña 4.- Valencia, Murcia, Baleares 5.- Madrid 6.- Aragón, Castilla - La Mancha 22 22 7.- Castilla - León, Extremadura 8.- Andalucía, Ceuta, Melilla 9.- Canarias 4 4 Cercenado E. et al. Rev Clin Esp 1997 Cuevas O. et al. AAC 2004

50 45 40 S. aureus (%) 35 30 25 SARM 20 15 10 5 0 1986 1991 1994 1996 2002 2006* 1,5 11,2 16,6 17,9 31,2 29 SARM Cercenado E. et al. Rev Clin Esp 1997 Cuevas O. et al AAC 2004 * Preliminar data (E. Cercenado)

Prevalence of of MRSA by MRSA by Regions Regions. . Spain Spain. 2002 . 2002 Prevalence 31 % 31 % 31 % 16 % 16 % 16 % 24 % 24 % 24 % 31 % 31 % 31 % 36 % 36 % 36 % 55 % 55 % 55 % 21 % 21 % 21 % 31 % 31 % 33 % 33 % 33 % 0 % 0 % 0 % 7 cepas 7 cepas 7 cepas Cercenado E. et al. Rev Clin Esp 1997 Cuevas O. et al. AAC 2004

MRSA control measures measures in in Spain Spain. . MRSA control Project SARM 2003 GEI H/ GEMARA/ REI PI Project SARM 2003 GEI H/ GEMARA/ REI PI � Survey Survey to to 61 61 hospitals hospitals (16 (16 million million inhabitants inhabitants) ) � � 81.7% 81.7% had had an an specific specific MRSA control MRSA control program program. . � � I nfection I nfection control control practitioners practitioners � � > > 1 nurse/ 250 1 nurse/ 250 beds beds: 46% . : 46% . � � I solation I solation precautions precautions with with all all MRSA MRSA patients patients: : � 95% 95% � Use Use of of mupirocin mupirocin to to descolonize descolonize all all patients patients: 54% : 54% � � High High variability variability in in measures measures and and interpretation interpretation of of � the epidemiological the epidemiological situation situation. . A. Millán et al. Enferm Infecc Microbiol Clin. 2006

Control of of endemic endemic nosocomial nosocomial Control methicillin- -resistant resistant S. S. aureus aureus : : methicillin relevance of of active active surveillance surveillance and and relevance colonized health health care care workers workers. . colonized J. Rodrí íguez guez- -Ba Bañ ño o and and A. Pascual. A. Pascual. J. Rodr University Hospital Virgen Hospital Virgen University Macarena. Sevilla. Spain Spain. . Macarena. Sevilla. Submitted

Hospital characteristics Hospital characteristics � Regional University hospital: 1000 beds. Regional University hospital: 1000 beds. � � Medical and surgical acute patients Medical and surgical acute patients � � I CUs I CUs � � General: General: 30 30 beds beds � � Heart Heart surgery surgery: 15 : 15 beds beds � � Surgical Surgical: 6 : 6 beds beds � � Neonatal Neonatal unit unit and and paediatric paediatric I CU I CU �

MRSA: background MRSA: background � E End nde emic mic from from 1990. 1990. � � 1995 1995- -1997 1997: : 45 45- -50% 50% of of S. S. aureus aureus � were MRSA. MRSA. were � Cases in Cases in all all services services. . � � � � A control program was designed A control program was designed �

Epidemiological investigation investigation and and Epidemiological pre- -intervention intervention situation situation. . pre � January January 1998. 1998. � � Epidemiological Epidemiological investigation investigation � � I mplementation of contact precautions: I mplementation of contact precautions: � � Reinforcement Reinforcement of of hand hand hygiene hygiene. . � � Patients Patients in individual in individual rooms rooms or or in in cohorts cohorts � ( open open structure structure). ). ( � Contact Contact precautions precautions reinforced reinforced by by infection infection � control practicioner practicioner. . control � Strict Strict cleaning cleaning policy policy and and desinfectation desinfectation of of � devices. . devices

Active surveillance surveillance period period Active ( Period Period A) A) ( � January January 1999 (no 1999 (no changes changes). ). All All previous previous plus: plus: � � Units Units > 1 > 1 attributable attributable case case from from the the previous previous period period: : � � Screening Screening of of patients patients admitted admitted to to these these wards wards. . � � Screening Screening of of HCW HCW of of these these units units. . � � Screening Screening of of roommates roommates of of patients patients with with MRSA in MRSA in � wards not not subjet subjet to to active active surveillance surveillance. . wards � Treatment of colonized patients Treatment of colonized patients (nasal (nasal mupirocin mupirocin) ) � except: : open open wounds wounds, , respiratory respiratory tract tract colonization colonization, , except mechanical ventilation ventilation, , nasogastric nasogastric tube tube, , urinary urinary mechanical colonization ( ( catheterized catheterized patients patients), ), invasive invasive MRSA MRSA colonization infection and and high high level level mupirocin mupirocin resistance resistance. . infection

Extended control period Extended control period (Period B) (Period B) � January January 2000. 2000. All All previous previous plus: plus: � � Screening Screening patients patients admitted admitted from from other other health health � care facilities facilities and and readmitted readmitted colonized colonized patients patients. . care � Re Re- -evaluation evaluation of of patients patients that that had had not not been been � candidates for for decolonization decolonization during during candidates hospitalization. . hospitalization � Follow Follow up up of of colonized colonized patients patients after after discharge discharge. . � � Alcohol Alcohol solution solution dispensers dispensers in in all all rooms rooms. . �

Patients (1997 (1997- -2003) 2003) Patients � MRSA MRSA isolated isolated in 523 in 523 patients patients: : � � 29% : medical 29% : medical service service � � 33% : 33% : surgical surgical service service � � 37% : 37% : I CUs I CUs � � MRSA MRSA infections infections in 390 in 390 patients patients (75% ): (75% ): � � 38% : SSTI 38% : SSTI � � 26% : RTI 26% : RTI � � 26% : 26% : Primary Primary bacteremia bacteremia � � 14% : Vascular 14% : Vascular catheter catheter infection infection � � 10% : 10% : Other Other infections infections � � Crude Crude mortality mortality rate rate: 41% : 41% �

Evolution of of MRSA MRSA during during the the 3 3 periods periods. . Evolution Pre- - Post- - Post- - Pre Post Post intervention intervention intervention intervention intervention intervention period period A period B period period A period B (1997- -1998) 1998) (1999) (2000- -2003) 2003) (1997 (1999) (2000 Incidence rate of colonization or Incidence rate of colonization or 0.46 a a 0.12 a a 0.59 0.59 0.46 0.12 infection due to MRSA infection due to MRSA Percentage of methicillin methicillin resistance resistance Percentage of 35 a a 15) a a 47 (46- -48) 48) 11.5 (8- -15) 47 (46 35 11.5 (8 among S. among S. aureus aureus (range) (range) Incidence rate of bacteremia bacteremia due to due to Incidence rate of b a 0.10 0.06 b 0.02 a 0.10 0.06 0.02 MRSA MRSA Percentage of colonized patients Percentage of colonized patients 5.9 b b 13.5 c c 3.1 3.1 5.9 13.5 detected by active surveillance detected by active surveillance No. of health care workers No. of health care workers 0 10 12 0 10 12 colonized by MRSA colonized by MRSA No. of detected MRSA- -colonized colonized No. of detected MRSA 0 2 13 patients admitted from other 0 2 13 patients admitted from other hospitals hospitals P values with respect to period A: a P < 0.0001; b P = 0.2; c P = 0.01 I ncidence rates expressed as new cases per 1.000 patient-day