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«Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings APIC’s mission is to improve ...»

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An APIC Guide

March 2007

Guide to the Elimination of Methicillin-Resistant

Staphylococcus aureus (MRSA) Transmission in

Hospital Settings

APIC’s mission is to improve health and patient safety by reducing risks of infection

and other adverse outcomes. The Association’s more than 11,000 members have

primary responsibility for infection prevention, control and hospital epidemiology

in health care settings around the globe, and include nurses, epidemiologists,

physicians, microbiologists, clinical pathologists, laboratory technologists and public health practitioners. APIC advances its mission through education, research, collaboration, practice guidance and credentialing.

Copyright © 2007 by the Association for Professionals in Infection Control and Epidemiology (APIC) All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of the publisher.

All inquiries about this document or other APIC products and services may be addressed to:

APIC Headquarters 1275 K Street NW, Suite 1000, Washington, DC 20005-4006 Phone 202.789.1890 E-mail apicinfo@apic.org Web www.apic.org Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings Table of Contents Pages Acknowledgements 4 Guide Overview 5-9 MRSA Risk Assessment 10–15 MRSA Surveillance Methodology 16–21 Hand Hygiene 22–2 Contact Precautions for MRSA 24–28 Environmental and Equipment Decontamination 29–0 Surveillance Cultures 1–7 Success Story - ASC 8–42 Making the Business Case 4–45 Cultural Transformation

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Acknowledgments The Association for Professionals in Infection Control and Epidemiology acknowledges the valuable

contributions from the following individuals:

Kathleen Meehan Arias, MS, MT, SM, CIC Kathryn Aureden, MS, MT (ASCP) SI, CIC Judene Bartley, MS, MPH, CIC Lillian Burns, MT, MPH, CIC Cheryl Creen, RN, MSN Tammy Lundstrom, MD, JD Shannon Oriola, RN, CIC, COHN Marcia Patrick, RN, MSN, CIC Kathleen Risa, MSN, CRNP, CIC Special thanks go out to Kathy Aureden and Marcia Patrick who worked tirelessly to make this Guide come together. Their tremendous efforts in collecting and collating the information allowed the publication to come to fruition.

4 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY

Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings Guide Overview Purpose The purpose of this document is to provide evidence-based practice guidance for the elimination of methicillin-resistant Staphylococcus aureus (MRSA) transmission in hospital settings.

Key Concepts Effective efforts to eliminate MRSA transmission are guided by completion of a comprehensive, facilityspecific risk assessment which describes current state and characteristics of the MRSA burden for that facility or setting. Knowledge obtained from the risk assessment drives the development of interventions that result in enhanced compliance with existing facility practices, or in implementation of appropriate additional interventions as described in this guidance document.

Background It is estimated that more than 70% of hospital-associated infections are caused by organisms exhibiting multidrug-resistance. These infections contribute to significant patient morbidity and mortality and result in limited antimicrobial treatment options as compared to infections caused by non-resistant organisms.

CDC Campaign to Prevent Antimicrobial Resistance in Healthcare Settings http://www.cdc.gov/drugresistance/healthcare/problem.htm

Drug-resistant pathogens are a growing threat to all people, especially in healthcare settings:

• Each year nearly two million patients in the United States get an infection in a hospital.

• Of those patients, about 90,000 die as a result of their infection.

• More than 70% of the bacteria that cause hospital-associated infections are resistant to at least one of the drugs most commonly used to treat them.

• Persons infected with drug-resistant organisms are more likely to have longer hospital stays and require treatment with second or third-choice drugs that may be less effective, more toxic and/or more expensive.

Increasing Prevalence of Multidrug Resistance:

For decades, MRSA has been the most commonly identified multidrug-resistant pathogen in Europe, Asia, Africa, the Middle East and the Americas. Increasing incidence of MRSA is a well-documented healthcare and community phenomenon of tremendous concern to medical, public health and lay communities around the world.2 In the early 1990s, MRSA was reported to account for 20 – 25 % of

–  –  –

Staphylococcus aureus isolates in hospitalized patients in the U.S. By the middle of the current decade, many hospitals experienced MRSA percentages in the range of 50-70 % of total Staphylococcus aureus isolates from clinical cultures.3 Similarly, National Nosocomial Infections Surveillance System (NNIS) data analysis for 1992 to 2003 showed that the percentage of Staphylococcus aureus isolates that were methicillinresistant increased from 35.9 % in 1992 to 64.4 % in 2003 in participating adult and pediatric ICUs.4





Changing Epidemiology of MRSA:

MRSA has a history of being frequently associated with healthcare, and conventional wisdom has categorized MRSA as a hospital problem until the late 1990s. But during that decade, data from the Canadian MRSA surveillance system showed that 5-7 % of reported MRSA infections occurred in individuals with no known healthcare-associated risk factors for acquisition.5 Concurrently, reports were being received by the CDC regarding MRSA infections in athletes,6 children,7 prisoners,8 military personnel9 and full-term newborn infants10,11 that were both phenotypically and genotypically characterized as community-associated strains. Research from the veterinary community on MRSA infection and colonization of animals and pets has identified yet another reservoir of MRSA that is transmissible to humans.12,13 Amplification of epidemiologic reservoirs of MRSA provides another incentive for aggressive action to eliminate transmission of MRSA in healthcare settings.

Cost Impact of Hospital MRSA Infections:

In a systematic audit of published hospital-associated infections reports, and interventions conducted by infection control professionals from 1990-2000, the mean cost attributable to an MRSA infection was $35,367.14 A recent extensive literature search presented at the spring 2006 meeting of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) estimated the annual cost to treat MRSA in hospitalized patients in the U.S. to be between $3.2 billion to $4.2 billion. These costs were associated with prolonged hospital stays (up to 10 days longer than patients who had methicillin-sensitive Staphylococcus aureus infections) and to the cost of critical care stays associated with these complications.15

Human Impact of Hospital MRSA Infections:

The human impact of hospital-associated MRSA infections makes efforts to eliminate MRSA transmission in healthcare settings compelling and necessary. Patient safety initiatives for hospital settings, whether facility derived or imported from national venues ( Joint Commission National Patient Safety Goals, IHI’s 5 Million Lives Campaign, etc.), are unanimous in the drive to prevent hospital-associated infections. In response to the huge human impact of hospital infections, actions are being taken in nonclinical arenas as well. There are many consumer groups that have instituted programs to educate patients and their families about the risks of hospital infections and about the risk-reduction steps that they should expect and demand from their healthcare providers (AARP, StopHospitalInfection.org, etc.).

Legislation related to hospital infections has been introduced or is being developed, and in some states bills filed are specific to MRSA (visit the APIC legislative map at www.apic.org). Payers are looking at non-reimbursement strategies in relation to hospital infections. For example, in October 2008, reduction in Medicare DRG acuity payments for at least two conditions related to hospital-associated infections occurring during a hospital stay will be implemented.

6 ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY

Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings Introduction to this Guide

The main components of the APIC Guide on the Elimination of MRSA Transmission in Hospital Settings are:

• MRSA risk assessment

• MRSA surveillance programs

• compliance with basic infection prevention and control strategies: hand hygiene

• compliance with basic infection prevention and control strategies: contact precautions

• compliance with basic infection prevention and control strategies: thorough environmental and equipment cleaning and decontamination

• enhanced infection prevention and control strategies (e.g., active surveillance cultures, etc.) when MRSA transmission rates are not decreasing

• making the business case for eliminating MRSA transmission

• cultural transformation and change management The ancillary topics of antimicrobial stewardship and MRSA decolonization are also aligned with these components.

Support from hospital leadership is essential. Therefore, this guide also includes an overview of “making the business case” for developing and implementing a program to eliminate MRSA transmission in a hospital, and on addressing the cultural transformation that will support an elimination program. Without strong leadership support, reaching the goal of eliminating the transmission of MRSA will be difficult, if not impossible, to achieve. Leadership must support and facilitate the build up of personnel and supply resources (including infection prevention and control staff, laboratory, information systems, nursing, decision support, public relations, etc.), development of teams and communication pathways, physician and staff buy-in, board of directors’ involvement and community outreach.

Valuable resources have been accessed to assist in the development of this guide. Many of the components outlined in this document are also found in the following guidelines and can be readily accessed as needed in facility-specific program development.

The Healthcare Infection Control Practices Advisory Committee (HICPAC) guideline “Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006,” has outlined a comprehensive, two-tiered approach with a built-in flexibility designed to accommodate the variety of settings and situations in which healthcare professionals coordinate infection prevention and control programs. It outlines an approach to determine when an “active surveillance protocol” may be applied.

http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf In 2003, the Society for Healthcare Epidemiology of America (SHEA) introduced the “SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains of Staphylococcus aureus and Enterococcus.” One component of this 2003 guideline was the recommendation for active surveillance cultures, in addition to contact isolation, in order to reduce the transmission of MRSA and VRE. While not all experts in the healthcare

–  –  –

community were in agreement regarding the role of universal active surveillance, this recommendation has been instrumental in generating research in this controversial area and has been used by some hospitals in successful MRSA elimination programs.

http://www.shea-online.org/Assets/files/position_papers/SHEA_MRSA_VRE.pdf The Institute for Healthcare Improvement’s (IHI) “5 Million Lives” Campaign includes a “Getting Started Kit: Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) Infection How-to Guide.” The five components of care in this guide are hand hygiene, decontamination of the environment and equipment, active surveillance, contact precautions and device bundles.

This 2006 guide recommends the Plan-Do-Study-Act strategy of action for key interventions and gives useful examples of changes that can be made to result in improvements.

http://www.ihi.org/ihi Although components of this guide provide the “how-to” when applying “active surveillance” protocols, it is crucial to acknowledge there are multiple ways to eliminate MRSA and other sensitive and resistant organisms. The two-tiered CDC MDRO guidelines should be reviewed for their systematic approach to determining when to apply an “active surveillance” protocol as noted earlier for MRSA or other targeted resistant organisms. A statewide initiative, the Michigan Hospital Association’s Keystone Center program, has focused on elimination of infections, citing “no infection, no resistance.” The success of this approach, using “bundling” of evidence-based practices to reach zero infections, has been recently published by Pronovost in the New England Journal of Medicine. The Veterans Administration, the Southwestern Pennsylvania Professionals in Infection and Control and Evanston Northwestern Medical Center in Illinois have each published success stories related to MRSA interventions (see the APIC webinar series on MRSA, “Designing a Program to Eliminate MRSA Transmission Part I: Making the Clinical Case.” Dr. Muto - December 6, 2006).

Cited References

1. Centers for Disease Control and Prevention. Campaign to Prevent Antimicrobial Resistance in Healthcare Settings.

Available at http://www.cdc.gov/drugresistance/healthcare/problem.htm.

2. Grundmann H, Aires-de-Sousa M, Boyce J, Tiemersma E. Emergence and resurgence of methicillin-resistant Staphylococcus aureus as a public-health threat. Lancet. 2006;368:874-885.



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