The

Year in Infec-on Control: MRSA, VRE,

Hand Hygiene & Surgical Site Infec<ons
Eli Perencevich

Conflicts of Interest Statement

No nancial conicts
! Sec<on Editor for Guidelines, Posi<on Papers,
and Invited Reviews @ ICHE
!

This talk will review the published literature

since the 2014 ECCMID
S. aureus, MRSA, VRE, VRSA

Surgical Site Infec-ons

Hand Hygiene + Few Surprises

Selec-on criteria were non-systema-c (i.e. arbitrary)

and I didnt inten-onally ignore your study

Staphylococcus aureus and MRSA

Reassess whether gowns/gloves/isola-on/cohor-ng

add anything to hand hygiene and decolonisa-on

!
!

MRSA is declining, other pathogens increasing

Despite many trials, most eec-ve strategy uncertain
!

Hand hygiene, screening, decoloniza-on, contact isola-on

Side-eects of isola-on
!

Fewer visits, depression/anxiety

Lancet 2015; 385:1146-49 (Viewpoint)

NICU: Careful aXen-on to handling of excrement in

newborn babies or infants

Two NICUs in Japan (2013), average age 20 days

! Nasal and fecal culture
!

!
!
!

Mul-plex PCR, MLST, SCCmec, spa-types, 4 exotoxin genes

15 % nasal screen posi-ve (26/169)
21 pa-ents included

ARIC 2014, 3:14

NICU: Careful aXen-on to handling of excrement in

newborn babies or infants

Mu-plex PCR
!

17 of 21 - Same in feces/nasal, 3 of 21 Same dominant clone

SCCmec types, spa-types and exotoxin repertoire 21/21

!

Hospital 1: 3 clones - CC5-SCCmec IIa, CC8-SCCmec IVl and CC8SCCmec IVb

Hospital 2: 1 clone - CC1-SCCmec IVa

ARIC 2014, 3:14

NICU: Current MRSA preven-on strategies like

screening and decoloniza-on dont work

!
!
!

Aim: Evaluateaggressive MRSA program in a single NICU

Retrospec-ve Cohort 2007-2011
Interven-on: weekly screening and admit screen for
transfers, hand hygiene, contact precau-ons, private rooms,
decoloniza-on mupirocin BID x 5 days plus CHG
HCW decoloniza-on: mup+CHG for 5 days

ICHE 2014 (April): 35(4)

NICU: Current MRSA preven-on strategies like

screening and decoloniza-on dont work

ICHE 2014 (April): 35(4)

Screening and Decoloniza-on Doesnt Work in NICU

!

74 (2.0%) were MRSA+ (multiple PFGE)

! 19

total developed infection (26%)

! 42% (8) infected before screening

84% (62/74) acquired MRSA in NICU

! Only 16% detected on admission
! 3.5% of HCW (7/204) MRSA+
!

Conclusion: Decolonization not enough

ICHE 2014 (April): 35(4)

Screening and Decoloniza-on doesnt work in nursing

homes either!

!
!
!
!

Cluster-RCT in Switzerland
104 Nursing Homes (53 interven-on, 51 control)
Consent!!!
All Screened: nasal, groin, ulcer, urine culture

ICHE (2015); 36(4):401-8

They worked hard and had a big bundle

!

Bundle:
! 5

days of nasal mupirocin

! 5 days of CHG oral rinse twice per day
! 5 days of CHG showers including CHG shampoo on
day 1 and 5.
! Environmental disinfection included daily clothing
changes for 5 days, new linens on day 1 and day 5,
and daily bed/table/phone/remote/wheelchair/
walker disinfection with 70% alcohol
! !!!!!!!!!!!!!!!!!!!
ICHE (2015); 36(4):401-8

But not maXer how they sliced their data,

screening/decoloniza-on didnt work

ICHE (2015); 36(4):401-8

But not maXer how they sliced their data,

screening/decoloniza-on didnt work

ICHE (2015); 36(4):401-8

MDRO Bundle in Nursing Homes: A Cluster-

randomized Trial

Cluster-RCT, 12 nursing homes (6 interven-on, 6 control)

Eligible residents: indwelling urinary catheters, feeding tubes, both

!

Consent

Targeted IP Bundle: (1) preemptive barrier precautions

(2) active surveillance for MDROs (BL, day 15 and monthly)

!

nares, oropharynx, feed tube, supra-pubic cath, groin, peri-rectal, wound

(3) NH staff education on key infection prevention practices

JAMA Intern Med. doi:10.1001/jamainternmed.2015.132

Broad outcomes evaluated but broad benets

not seen with bundle
!

Primary outcome: "overall MDRO prevalence density rate,

dened as each par<cipants total number of MDRO-posi<ve
anatomic sites across all MDROs per visit averaged over the
dura<on of his or her par<cipa<on."
!

This would result in residents "with persistent MDRO coloniza<on

(having) a higher prevalence than someone with intermiTent or no
coloniza<on" and residents colonized at more sites (up to seven
were tested) having a higher prevalence

Secondary outcomes included new MDRO acquisi<on and

device-associated HAI both with 1000 device-day
denominators.

JAMA Intern Med. doi:10.1001/jamainternmed.2015.132

Broad outcomes evaluated but broad benets

not seen with bundle
!

Primary outcome
!
!

27% of swabs were posi<ve (interven<on NH residents)

33% posi<ve in controls adjusted rate ra<o 0.77 (0.62-0.94)
"

Outcome driven by lower MRSA coloniza<on in residents with urinary

catheters, feeding tubes, or both and lower ce`azidime-resistant GNR
coloniza<on in residents with urinary catheters in the interven<on NHs.

JAMA Intern Med. doi:10.1001/jamainternmed.2015.132

MSSA not protec-ve of MRSA acquisi-on in acute-

care hospital ( at pa-ent level)

898 screened on admission and discharge (MRSA+MSSA)

!

!
!

21% MSSA on admission

70 pa-ents (8%) acquired MRSA, 828 controls

Predictors: age, length of stay, increased nursing workload,
macrolide exposure
MSSA: aOR 1.17 [95%CI 0.60-2.30]

ICHE (May 2014) 35(5): 527-33

MSSA appears protec-ve from MRSA at the facility

(i.e. nursing home) level

26 nursing homes (2008-2011)

!

7 excluded from admission swabs

1,661 admission swabs, 2,145 point prevalence swabs

Correla-on MRSA and MSSA

!
!

Admission prevalence: r = - 0.40, p=0.09

Point prevalence

ICHE (October 2014) 35(10):1257-62

MSSA inversely correlated with MRSA (point

prevalance) at the facility level

r = -0.67, p=0.0002)

ICHE (October 2014) 35(10):1257-62

Preven-ng MRSA and MSSA in an Urban Jail using CHG

Dallas, Texas Jail

4196 detainees, 68 deten-on divisions (tanks)

Cluster-randomized tanks into three groups

1.

CHG-soaked wash clothes apply to en-re body Monday/Wednesday/Friday

2.

Water-soaked wash clothes; same schedule

3.

Nothing

Cultured Hands/Nares baseline, 2 months, 6 months

ICHE (December 2014) 35(12):1466-73

MRSA, MSSA rates at baseline and 6 months

6 Months
! MRSA (p=0.655)
!

! 10% - no cloth
! 10.4% water cloth
! 8.7% CHG cloth
!

MSSA (p=0.091)
! 51.1% - no cloth
! 42.8% water cloth
! 40.7% CHG cloth

ICHE (December 2014) 35(12):1466-73

Livestock MRSA among veterinarians and household

members evidence of transmission

Perhaps 40% of MRSA strains in the Netherlands are LA-MRSA

Limited discrimina-on of spa typing MLVA for LA-MRSA (MC398/CC398)

Whole genome mapping has improved dieren-a-on

2 year analysis of 135 veterinarians and household members

!
!

Cultured at baseline, 2mo, 6mo, 10mo 14 mo

16 veterinarians (with 161 cultures included)

Appl Environ Microbiol. 2015 Jan;81(1):124-9

Whole genome mapping and LA-MRSA transmission

among household members
!

Whole genome maps

!

98% indis-nguishable

13 clusters, 8 singletons

10 clusters from single vets

3 clusters with two, two and 5 vets

LiXle variability among single vets

Carried, reacquired same strain

Carriage dura-on 4-14 months

14 of 16 households saw
transmission of a single strain
!

Carriage dura-on 4-8 months

Appl Environ Microbiol. 2015 Jan;81(1):124-9

Pig density near hospital predicts LA-MRSA risk

independent of direct livestock exposure

Prior, 0.2% without livestock exp CC398+

17 Netherlands Hospitals (2009-2010)

1020 newly MRSA+ and 649 (64%) MC398

!

271 (27%) are unknown origin by history/typing

Propor-on of unknown origin are MC398

22% (pigs) vs 5% (no pigs), RR 4.25, p<0.01

PLoS One. 2014 Jun 27;9(6):e100294

VRSA

VRE: Germany has high and increasing levels of VRE

German na-onal nosocomial infec-on surveillance system

(Krankenhaus-Infek-ons-Surveillance System; KISS)
2007-2012
ICU-KISS: nosocomial BSIs and UTIs in ICU

OP-KISS: SSI following 1660 procedures

Pathogen-KISS: VRE cases in ICUs (includes coloniza-on)

J. Antimicrob. Chemother. (2014) 69 (6): 1660-1664

VRE as propor-on of all enterococcal infec-ons

is increasingly causing HAI
BSI 265%, P<0.01

UTI 278%, P=0.07

SSI 526%, P<0.01

J. Antimicrob. Chemother. (2014) 69 (6): 1660-1664

Increase seen in belt of four federal states

J. Antimicrob. Chemother. (2014) 69 (6): 1660-1664

Total VRE cases rising to 3.1 per 1000 pa-ents

in ICU sesngs
282% increase

J. Antimicrob. Chemother. (2014) 69 (6): 1660-1664

Emergence of Community-strain of VRSA

70yo treated with 6 weeks IV vanco then po doxy for diabe-c foot osteo
!

Wounded con-nued to drain, MRSA with vanco MIC=256 ug/ml

CDC vanA posi-ve, US1100, t019, SCCmec IV, PVL nega-ve

!

Thus, CC30 (community) diers from prior 12 CC5 healthcare-associated US isolates

Resistant: cefoxi-n, vancomycin, clindamycin, erythromycin, levooxacin, and

tetracycline

Intermediately resistant: doxycycline and minocycline

Suscep-ble to chloram, dapto, gent, linezolid, rifampin, -gecycline, and tmp-sulfa

J Clin Microbiol. 2014 Mar;52(3):998-1002

USA1100, t019 and CC30 community strain

but clearly healthcare associated

J Clin Microbiol. 2014 Mar;52(3):998-1002

Community-strain of VRSA in So Paulo, Brasil

35 yo with mycosis fungoides, diabetes, cocaine use

celluli-s, skin infec-on MRSA bacteremia
!
!

Rx vancomycin 2 weeks, teicoplanin 2 weeks, TTE nega-ve

1 say post abx, MRSA reoccurred (vanco mic >32ug/ml, teico=32)

VRSA was ST8, SCCmec IVa, spa type t292 ~ USA300

Conjuga-ve plasmid carrying vanA was discovered

N Engl J Med. 2014 Apr 17;370(16):1524-31

Surgical Site Infections

Rates of SSI in colorectal surgery are reported for Japan

NHSN: SSI 5.6% in colon; 7.4% in rectal surgery (2008)

Japan Nosocomial Infec-ons Surveillance (JANIS)

44,751 colon

18,187 rectal

Infect Control Hosp Epidemiol, Vol. 35, No. 6 (June 2014), pp. 660-666

P<0.05
*NS

Independent risk factors similar in colon and

rectal surgeries

*not a risk in rectal surgery

Infect Control Hosp Epidemiol, Vol. 35, No. 6 (June 2014), pp. 660-666

SSI rates post c-sec-on in a 900-bed referral hospital

in northern Tanzania

Cesarean sec-on rates average 15% globally (1.6 to 40%)

! CS rates 21-32% in Tanzania
! SSI rates in CS range from 0.3 to 24%

345 pa-ents enrolled over 5 months (2011-2012)

! SSI rate 11.8% following emergent; zero ayer elec-ve

Antimicrob Resist Infect Control. 2014 Aug 11;3:25

Independent risks of SSI following c-sec-on

Antimicrob Resist Infect Control. 2014 Aug 11;3:25

Do we need an-bio-cs ayer cholecystectomy in mild

to moderate acute calculous cholecys--s?

!
!
!
!
!

Amoz-Clav TID pre-op, once intra-opera-vely

Open-label randomiza-on: 5 days post-op an-bio-cs vs none
4 week post-op follow-up for SSI
414 pa-ents
SSI: 15% (an-bio-cs) vs 17% (no an-bio-cs)

JAMA. 2014;312(2):145-154.

Lacks placebo and has a rela-vely large non-

inferiority outcome threshold (11%)

JAMA. 2014;312(2):145-154.

Poor compliance and resistance with mupirocin, could

povidone-iodine be as eec-ve?

Povidone-iodine 2x pre-op vs 5 days mupirocin BID

!
!

Applied twice to each nostril

All had CHG wipe baths the night before and morning of surgery

Primary or revision arthroplasty or spinal fusion

Modied inten-on-to-treat
!
!

Mupirocin - deep SSI 14 of 855 (1.6%)

Povidone-iodine deep SSI 6 of 842 (0.7%), p=0.1

ICHE, Vol. 35, No. 7 (July 2014), pp. 826-832

How much hand hygiene is going on, and where?

257 hrs, 1605 opportuni-es

77% RN, 8% MDs

Mean 4.2 op/hour

10.4/hr NICU

13.2/hr MSICU

Isolated pa-ents,
interac-ons (RR=0.55)

ICHE 35:7 (July 2014), pp. 826-832

10%
42%

9%

39%

Lots of hand hygiene opportuni-es going on

12 beds in gen med ward

Video 5 moments

!
!

72 op/pa-ent/day
! (3 op/day)

75% RN, 5% MD
If 200,000 pa-ent days
! 15 million/year!!!

Am J Infect Control. 2014 Jun;42(6):602-7

Social network or peer eects in hand hygiene

Custom hand hygiene wireless monitoring system

!
!

Detect if HCW prac-ced entry/exit hand hygiene

Es-mate loca-on of all other HCW in rela-on to HCW entering/exi-ng
"

Close proximity contacts

10-days in 20-bed medical ICU, University of Iowa

"

Pager/mote given to random HCW (MD, RN, other sta)

ICHE Vol. 35, No. 10 (October 2014), pp. 1277-1285

W1M = co-workers encountered in 1 minute

SRSSI = sum of received signal strength

W1M* = 2
SRSSI = 3 units

W1M* = 2
SRSSI = 2 units

*Circle on ground represents 1 minute

ICHE Vol. 35, No. 10 (October 2014), pp. 1277-1285

W1M* = 1
SRSSI=2 units

Not much hand hygiene but peer eects

maXer
!
!

12,919 HH events / 47694 opportuni-es = compliance 27%

W1M mean 2.92 (3.3 day, 2.5 night)
!

Compliance 20.8% (W1M=0), 27.9% (W1M>0), p<0.01

SRSSI mean 329.92 (372 day, 285 night)

ICHE Vol. 35, No. 10 (October 2014), pp. 1277-1285

Improving hand hygiene outweighs improving

terminal cleaning in MDRO preven-on

Agent-based model: hand hygiene vs terminal cleaning

!

Transmission of MRSA, VRE, Acinetobacter

175 scenarios tested

For all organisms tested, hand hygiene improvements

outweighed improvements in terminal cleaning
!

2:1 Ra-o for same eect; 20% TC equals 10% Hand Hygiene

ICHE 2014 Sep;35(9):1156-62

Have we been overvaluing bed-days in hospitals?

How much a bed-day is worth to a hospital can be a cri-cal

parameter for determining the costs of incident HAI
!

Accoun-ng method -> Hospital budget divided by provided bed-days

Willingness to pay -> con-ngent valua-on, how much theyd pay to liberate a day

Two Surveys maximum pay and scenario based (11 European hospitals)

WTP for ward-bed was 122, 82, 0 during high/medium/low demand days

WTP for ICU-bed was 228, 122, 13

ICHE Vol. 35, No. 10 (October 2014), pp. 1294-1297

Which method you chose profoundly alters

how you value hospital bed-days

ICHE Vol. 35, No. 10 (October 2014), pp. 1294-1297

Should society invest in programs targe-ng CLABSI

and VAP preven-on

Model aXributable long-term (life-me) outcomes for society of

preven-ng HAI in ICU sesngs
Six discrete states post-ICU discharge using Medicare parameter data
!

Outcomes: Cost per life-year and Cost/QALY

Interven-on and outcomes reported at ICU level

AJIC 2015 Jan;43(1):4-9

Long and short-term models of HAI preven-on

interven-ons analyzed at the ICU level

AJIC 2015 Jan;43(1):4-9

Infec-on Preven-on is Cost-Eec-ve!

AJIC 2015 Jan;43(1):4-9

Thank you

Fist bumps and weak handshakes only

Mela et al. AJIC 42 (8): 916-7, August 2014