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How to Lower MRSA Risk with Nasal Decolonization

Reduce Isolation Days

Disclosures

Speaker provides consulting services to Global Life Technologies Corp.

1. S. aureus / MRSA facts

2. MRSA nasal colonization risks

3. Limitations in current strategies for MRSA risk mitigation

4. Benefits of universal nasal decolonization

• Nasal decolonization options

Contents

1. Understand the role of the nares in MRSA/MSSA infections.

2. Describe the risks MRSA/MSSA nasal carriage represents to

patients and others.

3. List three limitations of current MRSA risk mitigation programs.

4. Understand the benefits of universal decolonization versus

screen and isolate and targeted decolonization programs.

Learning Objectives

S. aureus/MRSA

Facts

CDC—March 2019 Vital Signs Data Overview

Decolonization:

• Bathe with an antiseptic on skin

• Apply antibiotic or antiseptic in the nose, because staph tends to live in the nose

CDC: Decolonization is a key way to prevent Staph aureus infections:

• Helps prevent colonized patient from getting an infection

• Reduces bacterial bioburden and likelihood of transmission so HCPs in contact with colonized patients are less likely to get bacteria on their skin and clothes and pass it on to the next person

“Decolonization prevents spread of pathogens and prevents the infection in the first place”

CDC—March 2019 Vital Signs Data Overview

• The most common pathogen causing VAP and SSI

• Of all S. aureus causing VAP and SSI, 44% were MRSA

• The second most common pathogen causing CLABSI

• Of all S. aureus causing CLABSI, 56% were MRSA

S. aureus / MRSA Facts

CDC Antimicrobial Resistance NHSN 2011-2014 Report

Staphylococcus aureus

* Zimlichman E et al.. JAMA Intern Med. 2013;173(22):2039-2046.

Cost to treat MRSA Infection*

SSI:$42,000

CLABSI:$58,500

Excess LOS days due to MRSA Infection*

SSI:23

CLABSI:15.7

MRSA HAI Facts

The primary reservoir

for S. aureus/MRSA

colonization is

the Nose.

S. aureus / MRSA Nasal Colonization Facts

* Wertheim HF, Lancet 2004; 364: 703–05 **Honda H, ICHE 2010 Jun; 31(6): 584–591

• ~13% of ICU patients are MRSA carriers on admission**

Patient S. aureus / MRSA Nasal Colonized

* Wertheim HF, Lancet 2004; 364: 703–05 **Honda H, ICHE 2010 Jun; 31(6): 584–591

• 8% - 10% of patients acquire MRSA colonization in the surgical ICU***

*** Warren DK, ICHE. 2006; 27(10):1032–1040

S. aureus / MRSA Nasal Colonization Facts

• 25% to 30% of healthy adults are carriers S. aureus at any given time*

MSSA/MRSA

Risks

14 - 20 times higher *

Risk of infection

MRSA non-carrierscarriers

The #1 Risk Factor for MRSA infection is MRSA nasal colonization!

MRSA Nasal Colonization Risk

vs

*Marzec et al.AJIC (2016) 405-8

MRSA ColonizationMRSA Infection

80%

** Kalmeijer, ICHE 2000;21:319-323* Von Eiff, NEJM, Vol. 344, No. 1 · January 4, 2001 * Wertheim HF, Lancet 2004; 364: 703–05

Correlation between nasal carriage and S. aureus / MRSA infections

~80% of S. aureus and MRSA BSI* and SSI** infection is endogenous and traced to the patient’s nasal flora.

MRSA BSI >20% mortality rate****

MRSA carriers 20 times higher risk for MRSA BSI***

~15 - 25% of carriers develop MRSA infection during hospitalization

or within 18 months***

• 13% ICU MRSA carriers are detected on admission*

• 8% become MRSA carriers – undetected**

MRSA Infection

Mortality

BSI

MRSA Nasal Colonization

MRSA Nasal Colonization Cascade in the ICU

MRSA BSI >20% mortality rate*****

MRSA carriers ~20 times higher risk for MRSA BSI****

~15 - 25% of carriers develop MRSA infection during hospitalization

or within 18 months***

• ~13% ICU MRSA carriers – identified on admission*

• ~8% become MRSA carriers – unidentified**

** Warren DK, ICHE. 2006; 27(10):1032–1040

MRSA Nasal Colonization Cascade in the ICU

***Huang SS et al, CID, Feb 2003, 36 (3): 281–285* Honda H, ICHE 2010 Jun; 31(6): 584–591. **** Marzec et al, AJIC (2016) 405-8 ***** Blot et al, Arch Int Med Oct 2002 (162) 2229-35

Treating a Sepsis Infection

FluidsSeveral liters initiallyColloidsCrystalloidAlbuminStarchesHigh chloride

AntibioticsEarly administration

EGDTEarly goal directed therapy

Goal-oriented therapy

Vasopressors1-6 hours after onsetNorepinephrineEpinephrineVasopressinDopaminePhenylephrine

Parenteral feeding Sedatives Enteral feeding

Molecular targeted-therapies

CorticosteroidsTNF-a

Insulin therapy

Lung Protective Ventilation

Urinary catheterDiagram by: Will Stahi Timmins©2016 BMJ Published group ltdIllustration: ©2019 Global Life Technologies Corp.

MRSA Nasal Colonization Risk of Infection

Patients with MRSA nasal colonization

pose a risk of transmission

are at risk of infecting themselves

and

• Nasal carriers are 7x more likely to have contaminated hands*

• We touch our nose over 100 times a day**

• S. aureus is transferred to the nose primarily by the hands***

*Tammelin, ICHE. 2010 Jun; 31(6): 584–591 ***Wertheim, Lancet Infect Dis 2005; 5: 751-762**Kwok YL, AJIC. 2015 Feb;43(2):112-4.

Nasal Colonization and Hand Contamination

Nasal Colonization and Transmission

Takeaways

• MSSA/MRSA continue to be major contributors to HAIs nationwide

• The nose is the primary reservoir for MSSA/MRSA and the most reliable predictor of colonization

• Nasal colonization is the #1 risk factor for subsequent infection

• 80% of MSSA/MRSA BSI and SSI infections are endogenous and traced to the patient’s nasal flora

Current MRSA Risk Mitigation Strategies

Objective

To reduce MRSA

transmission and

infection risk posed

by patients who are

MRSA colonized.

Risk Mitigation Strategy – Screen and Isolate

2. Screen high risk patients for MRSA colonization (MRSA surveillance practice)

3. Contact Isolation Precautions (CP) for detected MRSA colonized patients for length of stay

1. Identify patients with high risk of MRSA nasal carriage• Critical care patients (ICU)• ALF/Nursing home residents• Prior history of MRSA• Diabetics, oncology patients, etc.

???

Risk Mitigation Strategy – Screen and Isolate

MRSA Colonized

If identified positive, CP

Swab sent tolaboratory

Screen high risk patient

Current MRSA Surveillance Practice

Chromagar Culture5 - 15% False Negatives

PCR Amplification2 - 16% False Negatives2 - 4% False Positives

Turn around time from screen to results

Screening sensitivity and specificity

Improper swab collection *

Chromagar Culture **5 - 15% False Negatives

PCR Amplification**2 - 16% False Negatives2 - 4% False Positives

Time from Collection to

Results

Chromagar***

30 – 79 hours

PCR***

4 – 21 hours

*** Polisena. BMC Infectious Diseases2011;11:336** Lutejin. Clinical Microbiology and Infection 2011: 17(2); 46-154

Limitations of Screening for MRSA Colonization

*BD Diagnostics. 2013. BD Max MRSA XT package insert, vol 443461, P0167(01).

ICU patients screened1,000

Screened MRSA(-)870

Remains MRSA(-)800

Becomes MRSA(+)70

Screened MRSA(+)130

100%

~87%

~92% ~8%**

~13%*

* Honda H, ICHE 2010 Jun; 31(6): 584–591. ** Warren DK, ICHE. 2006; 27(10):1032–1040

MRSA(-)MRSA(+) IdentifiedMRSA(+) Not Identified

Key

Screening in the ICU

All patients screened on admission Screened for MRSA


~13% screened MRSA (+) identified and isolated

~8% acquire MRSA (+)

All ICU Patients screened on admission Screened MRSA (-)


~65% of MRSA (+) nasal carriers identified and isolated on admission

* Honda et al ICHE 2010 Jun; 31(6): 584–591.

Limitations with MRSA Surveillance practice in the ICU

~35% of MRSA (+) nasal carriers are not detected and not isolated • Carriage acquisition in ICU• Screening accuracy

KEY TAKEAWAY:~35% of the colonized patients are undetected and, thus, the risk represented by this undetected population is NOT addressed

Total MRSA colonized patients

Do I really know who is colonized and who is not?

Do I know in a useful timeframe?

How effective is CP?

Current Practice

Patient colonizedwith MRSA

Unidentified MRSA colonized

patient

Contamination ofenvironmental

surfaces

Transmission on HCP hands or shared

equipment

Transmission Risk of Unidentified MRSA Colonized Patient

• Does not reduce the risk of the patient contaminating the environment, which can be transmitted by HCPs to other patients.

• Does not prevent colonized patients from touching their nose and contaminating their hands.

• Does not reduce the greatest risk of endogenous infection [patient infecting themselves, via lines, tubes, incisions, airways]

Wertheim HF et al. Lancet Infect Dis. 2005 Dec;5(12):751-62. Worby C. et al. American Journal of Epidemiology, June 2013, pp 1306–1313.

Limitations with Contact Isolation Precautions

Isolation for MRSA Carriers

Isolation has adverse effects on:

• Patient

• Staff

• Facility

Isolation for MRSA Carriers

Detrimental to patients*

• Isolated patients get less care (quality & quantity)

• Isolated patients have worse outcomes

• Isolated patients have lower satisfaction scores

A hindrance to staff**

• Deterrent to frequent patient contact

• “Isolation fatigue”

• Results in lack of compliance with CP

A burden for the facility***

• Does not optimize patient flow

• Reduces throughput – utilization

• High costs of screening and isolation

* Morgan et al, AJIC. 2009 March ; 37(2): 85–93 *** Huang SS et al. ICHE, 2014; 35 (53); S23-31.** Dhar, ICHE March 2014, vol. 35, no. 3

Discontinuing CP

and using stepped up Standard Precautions

A responsible alternative?

Another Option?

• No amount of hand washing will prevent colonized patients from touching their nose and re-contaminating their hands.

• Does not address the primary reservoir of the pathogen you are trying to control (MSSA/MRSA).

*Wertheim HF et al. Lancet Infect Dis. 2005 Dec;5(12):751-62. **Worby C. et al. American Journal of Epidemiology, June 2013, pp 1306–1313.

Limitations of Standard Precautions

• Does not reduce the greatest risk—endogenous infection (~80%).

MRSA Nasal Colonization

How can we directly address

risk factors?

Is there a better way?

• 43 hospitals, 74 ICUs, 16 states

• 74,000 patients, 283,000 ICU patient days

• 18-month intervention (Apr 2010 – Sep 2011)

Huang SS et al. NEJM 2013; 368 (24):2255-65

2013 REDUCE MRSA Study:

REDUCE MRSA Study

Arm 1: Screen and Isolate

– Screened all ICU patients and isolated known MRSA (+)

Arm 2: Targeted Decolonization– Screened all ICU patients

– Targeted nasal decolonization/CHG bathing only for known MRSA (+)

Arm 3: Universal Decolonization– No screening

– Universal nasal decolonization/CHG bathing for all ICU patients

* Huang SS et al. N Engl J Med 2013; 368 (24) 2255-65.

REDUCE MRSA Study

ICU Universal Decolonization Arm

** Huang SS et al ICHE, 2014; 35 (53); S23-31.

Huang SS et al. NEJM 2013; 368 (24):2255-65

ARM 3- Universal Decolonization:- Superior to Screen & Isolate - Superior to Targeted decolonization*

Results: 37% decrease in MRSA clinical cultures28% decrease in MRSA blood stream infections44% decrease in all blood stream infections

Prevented: 9 BSIs per 1,000 ICU admissions

Cost-Savings: $171 per patient**

* Huang SS et al. N Engl J Med 2013; 368 (24) 2255-65.

Universal Decolonization Works

-0.5

0

0.5

1

1.5

2

2.5

3

Oct-12 May-13 Nov-13 Jun-14 Dec-14 Jul-15 Jan-16 Aug-16 Mar-17

MRSA bacteremia rate with & withoutUniversal Decolonization

UniversalDecolonization

(re-introduced)

* Bradley et al. ICHE 2017:1-6

Demonstrated effectiveness

Targeted Decolonization

(universal withdrawn)


Benefits of Universal Decolonization

Universal decolonizationTreat all patients regardless of colonization status

• eliminates MRSA surveillance tests and the associated contact precautions, which interfere with care

• begins on the first ICU day, avoiding the delay in decolonization pending results of screening tests.

• protects patients in the ICU from their own microbiota during a period of heightened vulnerability to infection.

• reduces the environmental pathogen burden, reducing opportunities for patient-to-patient transmission.

• lowers ICU costs—cost-effectiveness studies show cessation of screening, reduced contact precautions, and reduced infections offset product costs, resulting in savings

Advantages of Universal Decolonization

Reduce transmission and directly address infection risk — Improve patient safety —

Improving patient safety and satisfaction

Advantages of Universal Decolonization

MRSA/MSSA Risk FactorsContact

Precautions

Standard Precautions(without CP)


Patient MRSA/MSSA nasal carriage NO NO YES

Nose to hand to nose contamination NO NO YES

Risk of MRSA/MSSA transmission Limited NO YES

Endogenous/patient infection risk NO NO YES

Bioburden in environment/community Limited Limited YES

Risk Mitigation Program Comparison

ICU Universal Decolonization Protocol

On Admission

• Decolonize nares

• Decolonize body with CHG wipe/bath

Daily Protocol for LOS

Morning Protocol - Decolonize

• Nares

• Body with CHG wipe/bath

Evening Protocol - Decolonize

• Nares

Program Comparison

Screen & Isolate vs Universal Decolonization

ProgramColonized patients in isolation

Colonized patients not in Isolation

Total Colonized patients

Total Colonized

Patient days

Screen and Isolate 345 185 530 1748

Universal Decolonization* 0 0 0 0

Program Comparison

*For the purpose of this presentation, “decolonization” is defined as reducing MRSA pathogen burden significantly

Screen & Isolate vs Universal Decolonization in 30 Bed ICU, per year

MRSA (+) unidentified

screened MRSA (+) identified and isolated

Screened MRSA (-)

Screen and Isolate Universal Decolonization

~ %100 decolonized

Screen & Isolate vs Universal Decolonization

vs

Nurse hours spent gowning in and out

Gown in/out events

Nurse exposed to colonized patient

events

Screen and Isolate 1,000 68,000 36,000

Universal Decolonization 0 0 0

Program Comparison

Impact

Screen & Isolate vs Universal Decolonization in 30 Bed ICU, per year

Gown in / out events

VS


Gown in / out events

MRSAScreen & Isolate

68,000~ 0

Program Comparison*

*In a 30 bed ICU, per year

30 bed ICU Cost / Operating Impact

Typical Costs

Screen and Isolate program = ~$290K

Universal Decolonization program = ~$50-70K

Protocol Comparison - Cost Overview

+ +

+

decolonize

1. Topical antibiotic (mupirocin)

2. Povidone iodine based antiseptic

3. Alcohol based antiseptic

Nasal Decolonization Options

Antibiotic - Mupirocin (Bactroban®)• Was the only tool for many years – and is still used today

Limitations to consider:

• Selective mechanism of action (gram +)

• 5 day BID course – limited effectiveness until day 3*

• Does not comport with antibiotic stewardship*

• 60% - 93% effective*

• Resistance concerns**

* Anderson 2015 Antimicrobial Agents and Chemotherapy 59 (5), pp. 2765-2773. ** Miller MA et al. ICHE 1996;17:811 **Peterson LR et al. Open Forum Infect Dis 2017;4:ofx093

Antibiotic - Mupirocin

Antiseptic – Povidone iodine• Long history as a pre-op and wound antiseptic

• Effective against both gram (+) and (-) organisms

• Comports with antibiotic stewardship


• Nasal application developed for one time, pre-op use only

• 12 hr persistence – requires daily use to prevent recolonization • Cannot be used on patients with renal or hepatic failure, those with

thyroid disfunction nor patients with hyper sensitivities/allergies to iodine• FDA warning notice of potentially severe reactions

Antiseptic - Povidone Iodine

Antiseptic – Ethanol• Long history as a pre-op, wound and skin antiseptic

• Effective against both gram (+) and (-) organisms

• Comports with antibiotic stewardship


• 12 hr persistence – requires daily use to prevent recolonization

Antiseptic Universal Nasal Decolonization

Benefits Antibiotic (mupirocin)

Povidone-Iodine antiseptic

Alcohol-basedantiseptic

Effective against MRSA/MSSA ✔ ✔ ✔

Non-antibiotic ✖ ✔ ✔

Effective day 1 ✖ ✔ ✔

Easy to use / Pleasant ✖ ✖ ✔

Suitable for daily use ✖ ✖ ✔

All-inclusive: HCP/Caregiver use ✖ ✖ ✔

Comports with antibiotic stewardship ✖ ✔ ✔* Steed L, et al.AJIC, 2014:42(8):841-846.

Nasal Decolonization Options

Conclusions

1. Nasal carriage poses a substantial infection risk.

2. Limitations of current MRSA risk mitigation programs do not address the primary reservoir – the nose.

3. Universal ICU decolonization strategies replacing screen and isolate and targeted decolonization are feasible, cost effective and widely accepted.

4. Nasal decolonization antiseptics (which overcome the limitations of mupirocin) improve HAI outcomes, quality of care and patient/staff satisfaction.

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