MRSA Control : Belgian policy PEN ERY CLI DOT GEN KAN SXT CIP MIN RIF FUC MUP OXA Marc Struelens Service de microbiologie & unité d épidémiologie des maladies infectieuses Université Libre de Bruxelles
The Ever More Resistant Staphylococcus aureus Plasmid SCCmec Plasmid Tn4001 Plasmid Tn1546 Mutation 1950 Penicillin R 1961 Oxacillin R 2002 1969 Vancomycin Gentamicin R 1997 R Vancomycin I
The Lancet December 6, 1997
Epidemiologic importance of MRSA Increased morbidity, mortality & cost Epidemic MRSA adds to overall nosocomial infection rate. Suboptimal outcome of vancomycin treatment Emergence of vancomycin-intermediate (1997) and vancomycin-resistant (2002) S.aureus Clonal variation in genomic island allotype : variation in fitness & virulence. Emergence of community acquired, hyper-virulent MRSA worldwide : meticillin resistance island SCCmec type IV Few controlled trials on efficacy of control measures.
Cost-benefit of controlling endemic MRSA in an ICU Chaix JAMA 1999; 282:1745 Setting: 26-bed medical ICU in French univ.hospital 4% MRSA carriage on admission Mean cost of MRSA infection $ 9 275 (8.5 extra-icu days) Study: matched case-control (n=27 MRSA infections) Intervention screening of carriers, isolation precautions Cost (screening & precautions): $ 340-1 480 /patient Conclusion: Cost-beneficial strategy for MRSA prevalence 1-6 % if transmission decreased by > 14 %
Proportion MRSA in S.aureus bacteremia : EARSS 2001
Deplano et al Clin Microbiol Infect 2000;6:239
Emergence of GISA in Belgian hospital Electron microscopy of VISA strain (X 60.000 magnification) ATCC29213 P1V44 strain Denis J Antimicrob Chemother 2002;50:383
No of MRSA/ S.aureus bacteremia Mean meticillin resistance of S.aureus National bacteremia surveys in Belgium, 1984-1999 National policy 35 30 25 20 15 10 5 0 10 20 1984 1988 1992 1999/II Year of survey Reference Staphylococci Lab ULB & ISP-WIV /GDEPIH-GOSPIZ MRSA programme 31 23
Guidelines for the control and prevention of transmission of MRSA in Belgian hospitals GDEPIH-GOSPIZ Consensus Conference; Higher Council for Health, 1993 Acta Clinica Belgica 1994;49:63 Local evaluation of the clinical importance & epidemiology of MRSA Identification & elimination of the MRSA reservoir Patient isolation and barrier precautions Isolation of known carriers and transferred patients. Individual room preferred, or cohorting. Gloves, gown, mask; alcohol-based hand disinfection Removal of linen and waste as contaminated Communication within and between healthcare institutions
Adoption of national MRSA 1994 recommendation, Belgian hospitals policy changes, 1991-2002 100 90 80 70 60 50 40 30 20 10 0 1991 1994 2002 Single room Gloves Gown Mask % of hospitals using precautions Hand antisepsis Screening of carr... Decontamination... Struelens et al Infect Control Hosp Epidemiol 1996;17:503; Jans et al, personal com, 2002
National surveillance of nosocomial MRSA infections in Belgium Network of voluntary participants by 157 (79 %) Belgian hospitals: coordinated by GDEPIH-GOSPIZ; ISP; ULB-Ref Lab for staphylococci Since 1992: Bi-annual analysis of MRSA strains : molecular typing to track regional epidemics and antibiotic resistance Since 1994: Semi-annual report on prevalence and incidence for monitoring infection control measures Since 1999: Continuous bacteremia suraveillance (EARSS)
Semestrial prevalence and nosocomial incidence of MRSA, all participants, 1994-2001 N= 124 N= 115 M RSA / SA (%) 25 20 15 10 5 0-0,3/1000 adm. P= 0,007-1,9 %/ year P<0,001 + 2,2 %/ year P<0,001 + 0,2/1000 adm. n.s. 4 3.5 3 2.5 2 1.5 1 0.5 0 M RSA / 1000 adm issions 19 9 4 /2 19 9 5 /1 19 9 5 /2 19 9 6 /1 19 9 6 /2 19 9 7 /1 19 9 7 /2 19 9 8 /1 19 9 8 /2 19 9 9 /1 19 9 9 /2 2000/1 2000/2 2001/1 S tudy periods R esistance proportion Incid ence rate
EARSS-Belgium Percent M R SA 07/1999-06/2002 % M R S A 35,0% 30,0% 25,0% 20,0% 15,0% 10,0% 5,0% 0,0% 3-1999 4-1999 1-2000 2-2000 3-2000 4-2000 1-2001 2-2001 3-2001 4-2001 1-2002 2-2002 Quarter P = 0.03 Allisolates - a lllabs ISP / ULB MRSA Lab Ref; Hendrickx, Denis et al, unpublished.
MRSA Rapport incidence noso/importés 4 3 2 1 incidence acquisition / incidence importation 0 1991 1993 1995 1997 1999 2001 2003 année
Proportion of Nosocomial vs imported MRSA, National surveys in Belgium, 1995-2001 IM P O R T E D NOSOCOM IAL P ercent w ith acquisitio 100 90 80 70 60 50 40 30 20 10 0 33 15 22 1995 1997 2001 Year of survey Reference Staphylococci Lab ULB & ISP-WIV /GDEPIH-GOSPIZ MRSA programme
National Surveillance by PFGE Typing MRSA Surveys, Belgium, 1992-2001 Hospitals (%) 100 80 60 40 20 A1(Iberian) A20 B2 C3 G10 L1(UK-15) J1(UK-16) 0 D4 1992 (n=62) 1995 (n=85) 1997 (n=90) 1999 (n=33) 2001 (n=98) Year (No. of hospitals)
Evolution of the geographical distribution of epidemic MRSA clone B2 in Belgian hospitals 1992 1995 1997
Epidemiology of MRSA in Flemish Nursing Homes Hoefnagels-Schuermans ICHE 2002;23:546 Cross-sectional survey of 17 nursing homes in Flanders, 1997: 4.9 % prevalence of MRSA carriage PFGE: predominance of clone B2 (77 % of total; epidemic in 5 institutions) and clone C3
Why a recrudescence of MRSA? Emergence and introduction of new (more?) epidemic clones Increased reservoir of chronically-ill, elderly carriers Nursing home reservoirs? Community reservoirs? Faltering screening efforts? Cost containment, adverse effects Adherence to policy by healthcare workers?? Increased patient turnover and transfer Shortage of skilled nursing personnel Increased antibiotic pressure
What should we do to curb MRSA? Continued surveillance in hospitals Improved MRSA detection methods (CMD) Antibiotic policy : antibiotic management team (2002) Improved communication among health care workers Epidemiologic surveys in nursing homes and the community Update of national guidelines (2003) Promotion of hand hygiene Multi Center Trials of control strategies (6th FP) A lot has been done but much more is needed!
Acknowledgements ULB ISP-WIV Ariane Deplano Olivier Denis Claire Nonhoff Raf De Ryck Ricardo De Mendonça Baudouin Byl Francis Rost Huguette Strale Bea Jans Erik Hendrickx Carl Suetens BAPCOC GDEPIH-GOSPIZ All participants to the Belgian MRSA surveillance project