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THA MRSA Action Plan Webinar Series

Topic: Reducing MRSA: Prevention of Surgical Site Infections

Speaker: Tom Talbot, MD, MPH - Professor of Medicine,

Vanderbilt University School of Medicine

Date: September 19, 2019

Announcements

• Type your questions in the chat box

• Register for upcoming webinar series

• Access MRSA resources and toolkit from

the website

http://tnpatientsafety.com/resources/mrsa-

reduction-campaign/

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Upcoming Webinars

• Wednesday, October 23rd 12:30 -1:30 pm CT

Topic: Practical Decolonization for Special Populations and Addressing Implementation Challenges

Speaker: Dr. Susan Huang

• Wednesday, November 20th 10 -11 am CT

• Wednesday, December 18, 2019 10-11 am CT

• Wednesday, January 22, 2019, 11-12 noon

Reducing MRSA:Prevention

of Surgical Site Infections

September 19, 2019

Tom Talbot, MD MPH

Professor of Medicine,

Vanderbilt University School of Medicine;

Chief Hospital Epidemiologist,

Vanderbilt University Medical Center

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DISCLAIMERS

• I am not a surgeon

• I do not believe that SSIs and lapses in practices are necessarily intentional/of malicious intent

Surgical Site Infections

• Major source of surgical infections = the patient’s own flora

• If the bacterial burden, esp. at the site of the incision, can be reduced → reduce risk of SSI

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Risk Factors for SSI

• Patient Factors:– Diabetes

– Periop hyperglycemia

– Tobacco use (current)

– Malnutrition

– Prolonged pre-op stay

– ? Age

– Irradiation

– ? Corticosteroid use

– Obesity

• Operative Factors:– Surgical technique

– Poor skin prep

– Incorrect abx prophylaxis

– Use of razor

– Shaving night before

– Break aseptic technique

– No pre-op antiseptic shower

– Prolonged procedure

Interventions to Prevent SSI

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SSI PREVENTION INTERVENTIONS THAT SPECIFICALLY TARGET MRSA

Staph. aureus Colonization as a Risk for Infection

• RCT of mupirocin in general, gynecologic, neurosurgical, and CT procedures

– OR of S. aureus SSI in colonized vs. non-colonized placebo recipients = 4.5 (2.5-8.2)

• Cardiac surgery patients:– Carriers 9.6 times more likely to have SSI than non-

colonized patients

• Harvest site infections:– RR of S. aureus SSI in colonized vs. non-colonized patients

= 7.1 (2.2-23.0)

Perl TM et al NEJM 2002;346:1871+Kluytmans JA et al L Infect Dis 1995;171:216+

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Carriage Eradication

• Elimination led to:

– ↓ carriage

– ↓ SSI in cardiothoracic pts.

– ↓ SSI in orthopedic pts.

– ↓ S. aureus infection in dialysis pts.

– ↓ S. aureus bacteremia

– ↓ catheter exit-site infections in dialysis pts.

RCTs of Mupirocin Decolonization

Nosocomial S. aureus infections among surgical pts with SA carriage

S. aureus SSIs among surgical pts with SA carriage

van Rijen MM et al J Antimicrob Chemother 2008;61:254+

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• RCT in Netherlands

• Adult patients admitted to departments of surgery and internal medicine screened for SA carriage (PCR)

• Carriers randomized to mupirocin-CHG decolonization vs. placebo soap & ointment

• Mupirocin: BID for 5 days

• CHG: Daily for 5 days

• Reapplication at 3 weeks and 6 weeks if still hospitalized

Bode LGM et al NEJM 2010;362:9+

• N = 6771 screened → 1251 SA+ (18.5%) → 918 randomized

• Placebo group with signif. more immunocompromised pts.

• No data on compliance w/ other SSI prevention measures

Bode LGM et al NEJM 2010;362:9+

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• Assessed bundle to reduce S. aureus SSIs

• 20 hospitals in 9 states

• Cardiac, hip arthroplasty, knee arthroplasty

• Bundle:

– If SA nasal screen +:

• Intranasal mupirocin BID and daily CHG bathing x 5 days pre-op

• Added vancomycin if MRSA + carrier

Schweitzer ML et al JAMA 2015;313:2162+

RR 0.58 (95% CI 0.29-0.80)

Schweitzer ML et al JAMA 2015;313:2162+

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Screening + Decolonization

• Benefits:

– It’s cheap (maybe)

– It’s easy (usually)

– It works (in some pts)

• Risks:

– Increased infections due to other pathogens?

– Resistance development

• Questions:

– Does effect last?

– Use in all populations?

– Costs of screening?

– Which screening test?

– Impact of mupirocin resistance

Decolonization Logistics:What Agent Should You Use

Respectfully borrowed from S. Huang (THA MRSA Kickoff)

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Rhee Y et al ICHE 2018;39:405+

CHG Application

Rhee Y et al ICHE 2018;39:405+

CHG Application (II)

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Decolonization Logistics:Intranasal Agents – Which One

• Mupirocin

• Povidone ointment

• Nozin – pre-post SSI decolonization study (spine surgery pts)

• Theraworx – Website cites “42 clinical studies” but does not provide citation other than journal names that include non-peer-reviewed journals

Bottom line – Aside from mupirocin and povidone, other agents not as thoroughly studied in terms of

outcomes and comparison to other treatments

Decolonization Logistics:Intranasal Agents – When

• Most studies have used 5 days pre-op

• Use post-op?

– Once wound closed, edema and fibrin make it more prohibitive for wounds to become seeded

• What if not completed pre-op?

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Published Studies & Intranasal Protocol

27.4%

83.4% 81.3%

93.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nt

wit

h S

tap

h C

arri

age

Era

dic

atio

n

Placebo Overal Mupirocin Arm 3-5 Doses of Mupriocin 6 or More Doses of Mupirocin

Recommended Course: 5 days BID

(10 doses)

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Respectfully borrowed from S. Huang (THA MRSA Kickoff)

Decolonization Logistics:Emergent Surgery

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Decolonization Logistics:Patient Education

Respectfully borrowed from S. Huang (THA MRSA Kickoff)

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Surgical Antibiotic Prophylaxis

Who Needs Surgical Antimicrobial Prophylaxis?

• Recommended for all clean contaminated procedures

– e.g. colon, small bowel, gyn

• Recommended for clean procedures:

a) involving insertion of intravascular prosthetic material or a prosthetic joint or

b) in which an SSI would pose catastrophic risk (e.g. cardiac surgery)

• Contaminated/dirty procedures:

– Assume already on abx

– Should also ensure Staphylococcal coverage

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Key Principles of Surgical Prophylaxis

• Tissue concentration of antimicrobial needs to be above the mean inhibitory concentration (MIC) of that drug for the organisms of concern AT THE TIME OF THE INCISION

• Get the D’s right:

– Right Drug

– Right Dose

– Right Delivery (i.e. timing)

– Right Duration

Antibiotic Concentration in Relation to Incision

Incision Incision Incision

MIC for likely encountered

organisms

Incision

Abx C

oncentr

ati

on in T

issu

e

Concentration TOO LOW

Concentration OK

Ab

x G

iven

17

0

1

2

3

4

5

6

>2 2 1 1 2 3 4 5 6 7 8 9 10 >10

Infe

ctio

n R

ate

(%

)

Hours After IncisionHours Before Incision

Incision

Time of Administration # Pts No (%) of SSI OR (95% CI)

>2 hrs before incision 369 14 (3.8%) 4.3 (1.8-10.4)

0-2 hrs before incision 1708 10 (0.6%) 1.0

0-3 hrs after incision 282 4 (1.4%) 2.1 (0.6-7.4)

3-24 hrs after incision 488 16 (3.3%) 5.8 (2.4-13.8)

RIGHT DELIVERY:Relation of Abx Timing to Risk for Developing SSI

Classen DC et al NEJM 1992;326:281+

Steinberg JP et al Arch Surg 2009;250:10+

RIGHT DELIVERY:Relation of Abx Timing to Risk for Developing SSI

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Koch CG et al J Thorac Cardiovasc Surg 2012;144:931+

• Spectrum of activity

– Cover the pathogens of concern at anatomic location

• Bioactivity/penetration into target tissues

• Limited toxicity

• Patient allergies

• Cost (if all other factors equal)

RIGHT DRUG: Basic Principles

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What About MRSA Coverage?

• Use of vancomycin recommended if outbreak situation or if local incidence levels are “high”

• Many communities do not know local incidence of MRSA (infection or colonization)

• Literature limited by use of non-standard dosing (e.g., 1gm Q 12 hrs instead of weight-based dosing)

Abx Choice: Guideline Recommendations

2017 HICPAC SSI Guideline

• No comment on abx choice

2016 WHO SSI Guideline

• No comment on abx choice

2013 Multispecialty Guideline

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RIGHT DRUG:Vancomycin for Routine Abx Prophylaxis

• RCT of 855 cardiac surgery patients

• Vancomycin vs. cefazolin for prophylaxis

0

5

10

15

20

25

Overall SSI MRSA SSI MSSA SSI

Vanc

Cefazolin

Rat

e p

er

10

0 p

roce

du

res

Finkelstein R et al J Thorac Cardiovasc Surg 2002;123:326+

• Retrospective analysis of all patients with SSI

• Multivariate analysis:

– Receipt of vancomycin prophylaxis not associated with reduced risk for MRSA SSI

– OR 1.9 (0.7-4.9)

RIGHT DRUG:Vancomycin for Routine Abx Prophylaxis

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Meta-analysis Studies

Study Population Sample Size Comparisons Results

Bolon et alCardiothoracic

pts7 RCTs

b-lactams vs. glycopeptides

SSI 30 days post-op RR 1.14

(95% CI 0.91-1.42)

Chambers et alClean & clean-contaminated

procedures14 RCTs

b-lactams vs. glycopeptides

Similar effectiveness for SSI prevention

Saleh et alCardiac, vascular, and orthopedic

surgical pts14 RCTs

b-lactams vs. glycopeptides

No difference in SSIs;Glycopep signif

reduced Staph SSI by 48% but increased resptract infections by 54%;Cardiac: b-lactam signif

reduced SSIs

Bolon MK et al Clin Infect Dis 2004;38:1357+Chambers D et al Surg Infections 2010;11:455+

Saleh A et al Ann Surgery 2015;261:72+

Crawford T et al Clin Infect Dis 2012;54:1474+

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Vancomycin for Surgical Prophylaxis

• What is the level of MRSA prevalence where vancomycin has benefit?

• STS: Use if known h/o MRSA colonization, undergoing prosthetic valve/graft placement, or healthcare exposures (hosp > 3 days, inpt transfer, on abx)

• Use of MRSA bundle

– Screen for carriage

– Decolonization with mupirocin • Nares and at chest tube sites

– Add vancomycin for MRSA + pts (continue cefazolin)

Decolonization of HCP

• Should OR staff be decolonized routinely?

• How to handle employees that are MRSA positive

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• Role of HCP carriage in MRSA transmission not well understood

• HCP have been implicated in HAI outbreaks

• Published trials of screening/decolonization in endemic settings are lacking

• Most data from outbreak reports where HCP intervention part of larger bundle

Hawkins G et al J Hosp Infect 2011;77:285+

Gurieva TV et al BMC Infect Dis 2012;12:302+

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“How to get provider and leadership buy-in for CHG and nasal decolonization.”

• Engage in planning (e.g. how measure, accountability)

• Partner with nursing leadership

• Identify early champions and highlight wins

Contact:

Lizzy Adeyemi

ladeyemi@tha.com

615.401.7465