MRSA INFECTIONSbasics, implications, and prevention

1. MRSA INFECTIONS
basics, implications, and
prevention
Dr.T.V.Rao MD
18-10-2016 Dr.T.V.Rao MD @ MRSA

2. Purpose of the lecture
•Participants will understand the differences
between infection control and infection
prevention
•Understand the epidemiology of MRSA
•Understand risk factors for MRSA
•Review current MRSA management trends
•Discuss MRSA prevention and control strategies
18-10-2016 Dr.T.V.Rao MD @ MRSA

3. Staphylococcus aureus
• Staphylococcus aureus:
– common cause of infection in the community
– Lives on skin, in nose, in soil, water, dead plant material
– Causes colonization or infection
• Methicillin-resistant Staphylococcus aureus
(MRSA):
– Increasingly important cause of healthcare-associated
infections since 1970s
– In 1990s, emerged as cause of infection in the community
18-10-2016 Dr.T.V.Rao MD @ MRSA

4. History of MRSA
• Methicillin-resistance in S. aureus was first identified
in the 1960s primarily among hospitalized patients
• Since that time, methicillin-resistant S.
aureus(MRSA) has become a predominant cause of S.
aureus infections in both healthcare and community
settings
Primarily due to transmission of relatively few
ancestral clones rather than the de novo development
of methicillin resistance among susceptible strains
18-10-2016 Dr.T.V.Rao MD @ MRSA

5. Definition of MRSA
• Staphylococcus aureus (S.
aureus) commonly colonises
the skin and nose. Methicillin-
resistant Staphylococcus
aureus (MRSA) infection is
caused by a strain of bacteria
that has become resistant to
the antibiotics commonly used
to treat ordinary
staphylococcal infections.
18-10-2016 Dr.T.V.Rao MD @ MRSA

6. Definitions of different
MRSA
•CA-MRSA: Community-acquired MRSA
•HA-MRSA: Healthcare-associated MRSA
•Nosocomial: infection acquired while in the
hospital
•SSTI: Skin and Soft Tissue Infection
18-10-2016 Dr.T.V.Rao MD @ MRSA

7. MRSA in Healthcare
• Historical Risk Factors
– Prolonged hospitalization
– Prolonged antimicrobial use
– Stay in an intensive care or burn unit
– Exposure to a colonized/infected person
– Residence in a nursing home
– Age >65
• Common infections include surgical wound
infections, urinary tract infections, bloodstream
infections, and pneumonia18-10-2016 Dr.T.V.Rao MD @ MRSA

8. MRSA is Contagious
MRSA is usually spread by unwashed hands.
Even a person who does not have an infection and is only
colonized can spread MRSA.
It is also spread when someone comes in contact with
MRSA infected skin or touches something that has
been in contact with MRSA skin.
Personal items such as towels, bandages, razors, etc.
If you touch your infected skin and touch other things
around you before washing your hands, the item you
touched can carry the MRSA bacteria – it is considered
contaminated.
18-10-2016 Dr.T.V.Rao MD @ MRSA

9. Who are at Risk with MRSA
• People with higher risk of MRSA
infection are those with skin breaks
(scrapes, cuts, or surgical wounds)
or hospital patients with
intravenous lines, burns, or skin
ulcers. In addition, MRSA may infect
people with weak immune systems
(infants, the elderly, people with
diabetes or cancer, or HIV-infected
individuals) or people with chronic
skin diseases (eczema and
psoriasis) or chronic illnesses.
18-10-2016 Dr.T.V.Rao MD @ MRSA

10. Treatment Options Limited
• Treatment options for
MRSA are limited and
less effective than
options available for
susceptible S. aureus
infections and result in
higher morbidity and
mortality
18-10-2016 Dr.T.V.Rao MD @ MRSA

11. Increasing Risk with MRSA
•A patient acquiring MRSA
colonization during a
hospital stay has
increased risk for MRSA
infections following
discharge, or during
subsequent acute and
long-term care
admissions
18-10-2016 Dr.T.V.Rao MD @ MRSA

12. Colonization Sites
Dr.T.V.Rao MD @ MRSA
I
n
f
e
c
t
i
o
n
s
18-10-2016

13. Common Infections with MRSA
18-10-2016 Dr.T.V.Rao MD @ MRSA

14. MRSA can cause Severe
Infections
•In the right setting MRSA
can cause severe and at
times fatal infections
such as bloodstream
infection (BSI), infective
endocarditis, pneumonia
and skin and soft tissue
infections (SSTI
18-10-2016 Dr.T.V.Rao MD @ MRSA

15. Factors that Facilitate Transmission
Cleanliness
Contaminated Surfaces
and Shared Items
Frequent Contact
Crowding
Compromised Skin
Antimicrobial Use
18-10-2016 Dr.T.V.Rao MD @ MRSA

16. MRSA Skin and
Soft Tissue Infections
18-10-2016 Dr.T.V.Rao MD @ MRSA

17. Antibiotic resistance in S. aureus
• Penicillin, 1950
• Methicillin (= all β-lactam antibiotics), 1961
• Tetracycline, Co-trimoxazol, rifampin,
clindamycin, macrolides, quinolones
• Vancomycin, intermediate-R, 2000
• Vancomycin, high-level-R, 2002
• Linezolid, Daptomycin?18-10-2016 Dr.T.V.Rao MD @ MRSA

18. Cardo et al. Infection Control and Hospital Epidemiology , Vol. 31, No. 11 (November 2010), pp. 1101-1105
How we can work on this Matter
18-10-2016 Dr.T.V.Rao MD @ MRSA

19. Patient
Rehabilitation
Home Care
Surgery
Center
Hospital
Long Term
Care
Dialysis
Physician
Office
Staff/ Medical Staff
Visitors and Family
18-10-2016 Dr.T.V.Rao MD @ MRSA

20. Standard Precautions
• Apply to all patients
• Integrate and expand Universal Precautions
to include organisms spread by blood and
also
• Body fluids, secretions, and excretions except
sweat, whether or not they contain blood
• Non-intact (broken) skin
• Mucous membranes
18-10-2016 Dr.T.V.Rao MD @ MRSA

21. Elements of Standard Precautions
• Handwashing
• Use of gloves, masks, eye protection, and
gowns
• Patient care equipment
• Environmental surfaces
• Injury prevention
18-10-2016 Dr.T.V.Rao MD @ MRSA

22. Preventing Transmission
in the Community
• Persons with skin infections should keep wounds
covered, wash hands frequently (always after
touching infected skin or changing dressings), dispose
of used bandages in trash, avoid sharing personal
items.
• Uninfected persons can minimize risk of infection by
keeping cuts and scrapes clean and covered, avoiding
contact with other persons’ infected skin, washing
hands frequently, avoiding sharing personal items.
Dr.T.V.Rao MD @ MRSA
18-10-2016

23. Preventing Transmission
in the Community
• Exclusion of patients from school, work, sports activities,
etc should be reserved for those that are unable to keep
the infected skin covered with a clean, dry bandage and
maintain good personal hygiene.
• In general, it is not necessary to close schools to
“disinfect” them when MRSA infections occur.
• In ambulatory care settings, use standard precautions for
all patients (hand hygiene before and after contact,
barriers such as gloves, gowns as appropriate for contact
with wound drainage and other body fluids).
Dr.T.V.Rao MD @ MRSA
18-10-2016

24. Role of Screening
and Decolonization
• Pre-operative screening
• High risk screening
• Universal screening
• Decolonization of skin
• Decolonization of nose
18-10-2016 Dr.T.V.Rao MD @ MRSA

25. Prevention and
control
18-10-2016 Dr.T.V.Rao MD @ MRSA

26. Responsibilities of Health care
Workers
• Screening -
Infection prevention and control measures in the
acute hospital setting -
MRSA in the non-acute healthcare setting -
MRSA in obstetrics and neonates -
Community-associated MRSA -
MRSA decolonisation -
Antimicrobial stewardship and the prevention and
control of MRSA - Occupational health aspects of
MRSA18-10-2016 Dr.T.V.Rao MD @ MRSA

27. Preventing Healthcare Transmission:
• Standard Precautions
–Hand Hygiene
–Contain body fluids
• Transmission Based Precautions
–Contact Precautions
•Gown and gloves
• Appropriate use of antibiotics
18-10-2016 Dr.T.V.Rao MD @ MRSA

28. Environmental
Decontamination• Adequate surface disinfection
• Validation of cleaning efficacy
• New technology
18-10-2016 Dr.T.V.Rao MD @ MRSA

29. Core Prevention Strategies:
Hand Hygiene
• Hand hygiene should be a
cornerstone of prevention
efforts – Prevents
transmission of pathogens via
hands of healthcare personnel
• As part of a hand hygiene
intervention, consider: –
Ensuring easy access to soap
and water/alcohol-based hand
gels
18-10-2016 Dr.T.V.Rao MD @ MRSA

30. Why Is Hand Hygiene
Important?
•Hands are the most common mode of
pathogen transmission
•Reduce spread of antimicrobial
resistance
•Prevent health care-associated18-10-2016 Dr.T.V.Rao MD @ MRSA

31. Hands Need to be Cleaned
When
• Visibly dirty
• After touching contaminated
objects with bare hands
• Before and after patient
treatment (before glove
placement and after glove
removal)

32. Hand Washing
Procedure for Washing Hands:
 Wet hands with warm, running water and apply liquid, bar or powder
soap.
 Rub hands together vigorously to make a lather and scrub all surfaces.
Scrub well for 15-20 seconds! It takes that long to dislodge and remove
stubborn germs. To time yourself, sing the ABCs once or the “Happy
Birthday” song twice.
 Rinse the soap off under running water.
 Dry hands with a paper towel or air dryer.
 If possible, turn the faucet off with the paper towel.
18-10-2016 Dr.T.V.Rao MD @ MRSA

33. Special Hand Hygiene
Considerations
• Use hand lotions to prevent skin dryness
• Consider compatibility of hand care products with
gloves (e.g., mineral oils and petroleum bases may
cause early glove failure)
• Keep fingernails short
• Avoid artificial nails
• Avoid hand jewelry that may tear gloves
18-10-2016 Dr.T.V.Rao MD @ MRSA

34. Education of Health care workers
• Education for healthcare
personnel and patients –
Observation of practices -
particularly around high-risk
procedures (before and after
contact with colonized or
infected patients) –
Feedback – “Just in time”
feedback if failure to perform
hand hygiene observed
18-10-2016 Dr.T.V.Rao MD @ MRSA

35. Contact Precautions
•Involves use of gown and
gloves for patient care –
Don equipment prior to
room entry – Remove
prior to room exit •
Single room (preferred)
or cohorting for MRSA
colonized/infected
patients
18-10-2016 Dr.T.V.Rao MD @ MRSA

36. Preventing
Healthcare
Transmission:
Hand Hygiene
18-10-2016 Dr.T.V.Rao MD @ MRSA

37. Hospital staff
•Hospital staff who come into contact with patients
should maintain high standards of hygiene and take
extra care when treating patients with MRSA.
•Staff should thoroughly wash their hands before and
after caring for a patient, before and after touching
any potentially contaminated equipment or
dressings, after bed making and before handling
food.
18-10-2016 Dr.T.V.Rao MD @ MRSA

38. Soap water and common sense
are best antiseptics
WILLIAM OSLER
•Hands can be
washed with soap
and water or, if they
are not visibly dirty,
a fast-acting
antiseptic solution
like a hand wipe or
hand gel.18-10-2016 Dr.T.V.Rao MD @ MRSA

39. Use of Disposable Gloves
•Disposable gloves should
be worn when staff have
physical contact with
open wounds – for
example, when changing
dressings, handling
needles or inserting an
intravenous drip. Hands
should be washed after
gloves are removed.18-10-2016 Dr.T.V.Rao MD @ MRSA

40. General Hygiene too Matters
• The hospital
environment, including floors,
toilets and beds, should be kept
as clean and dry as possible.
• Patients with a known or
suspected MRSA infection
should be isolated.
• Patients should only be
transferred between wards
when it is strictly necessary.
18-10-2016 Dr.T.V.Rao MD @ MRSA

41. Cleaning your Environment
Frequently clean surfaces that touch people’s bare skin and surfaces that
people touch often such as:
 Doorknobs, handles and light switches.
 Phones, remotes and keyboards.
 Counters, tables, sinks and toilets.
 Weight and locker room benches.
 Athletic gear and other shared equipment.
Launder clothes, towels, bedding and gear regularly.
 Change clothes daily.
 Do not put clothes that have been worn with clean clothes.
 Wash and dry clothing in the warmest temperature listed on the clothing label.18-10-2016 Dr.T.V.Rao MD @ MRSA

42. WHAT REALLY WE NEED TODAY
• Always washing your hands after using the toilet or
commode (many hospitals now routinely offer hand wipes)
• Always washing your hands or cleaning them with a hand
wipe immediately before and after eating a meal
• Following any advice you're given about wound care and
devices that could lead to infection (such as urinary
catheters)
• Reporting any unclean toilet or bathroom facilities to staff –
don't be afraid to talk to staff if you're concerned about
hygiene18-10-2016 Dr.T.V.Rao MD @ MRSA

43. Protecting Yourself in the Community
Avoid excessive antibiotic use.
Shower daily and after work outs.
Wash hands or use a hand sanitizer often; especially
after shopping, using the bathroom and before eating.
Do not share towels, soap, razors, water bottles and
other personal items with other people.
Use a towel as a barrier between you and exercise
equipment.
Wash athletic clothing daily.
Clean, disinfect and dry your gym bag.
18-10-2016 Dr.T.V.Rao MD @ MRSA

44. Education
• Patients and families
• Standardized hand outs
• Multi-media
• Staff and Medical Staff
• In-services
• Just in time
• Safety Fairs
• Make it fun, make it memorable
• Yourself
• Webinars
• Internet18-10-2016 Dr.T.V.Rao MD @ MRSA

45. Prevention
•Evaluate and implement
best
practice regularly
•Engage staff…they are
smart people!
•Prevention doesn’t
happen in an office!
18-10-2016 Dr.T.V.Rao MD @ MRSA

46. •Program Created by Dr.T.V.Rao MD for
Medical and Health professionals for
Improving the Hygiene and Control of
Hospital associated Infections
Email
doctortvrao@gmail.com
18-10-2016 Dr.T.V.Rao MD @ MRSA