Infection Prevention and NHSN Webinar Series: MRSA Bacteremia How - PowerPoint PPT Presentation

An Initiative of the Florida Hospital Association Hospital Improvement Innovation Network Infection Prevention and NHSN Webinar Series: MRSA Bacteremia – How to Assess Root Cause and Prevention Strategies March 26, 2019

Agenda • Welcome & FHA Mission to Care HIIN Overview – Cheryl Love, RN, BSN, BS‐HCA, MBA, LHRM, CPHRM, Director of Quality and Patient Safety and Improvement Advisor, FHA • MRSA Bacteremia – How to Assess Root Cause and Prevention Strategies – Linda R. Greene, RN, MPS, CIC, FAPIC, Manager of Infection Prevention, UR Highland Hospital, Rochester, NY • Q&A • Upcoming HIIN Events and Opportunities • Evaluation Survey & Continuing Nursing Education

HIIN Core Topics – Aim is 20% reduction • Adverse Drug Events (ADE) • Catheter‐associated Urinary Tract Infections (CAUTI) • Clostridium Difficile Infection (CDI) • Central line‐associated Blood Stream Infections (CLABSI) • Hospital‐onset MRSA Bacteremia • Injuries from Falls and Immobility • Pressure Ulcers (PrU) • Sepsis • Surgical Site Infections (SSI) • Venous Thromboembolisms (VTE) • Ventilator‐Associated Events (VAE/IVAC/PVAP) • Readmissions (12% reduction) • Worker Safety

MDRO Resources, Trainings and Tools  Mission to Care Website  HRET HIIN Website Resources to prevent MDRO:  MDRO Change Package  MDRO Checklist  Acute Care Facility MDROs Control Activity Tool  CDC MRSA Infections Presentation  Watch Past Virtual Trainings  HRET HIIN Resource Library  SOAP UP

UP Campaign: Spreading Cross Cutting Strategies Designed to reduce multiple forms of harm with simple, easy-to-accomplish activities that cut across several topics to decrease harm. Focused on four components: • SOAP UP: Hardwire Hand Hygiene • GET UP: Mobilize Patients • WAKE UP: Prevent Over-sedation • SCRIPT UP: Optimize Inpatient Medications 5

FHA Mission to Care Update: MRSA Rates 0.10 0.08 Rate per 1,000 0.06 0.04 0.02 0.00 BL 10/16 11/16 12/16 1/17 2/17 3/17 4/17 5/17 6/17 7/17 8/17 9/17 10/17 11/17 12/17 1/18 2/18 3/18 4/18 5/18 6/18 7/18 8/18 9/18 10/18 11/18 12/18 1/19 FL Rate 0.07 0.07 0.06 0.07 0.05 0.07 0.06 0.06 0.07 0.06 0.08 0.08 0.07 0.07 0.05 0.06 0.08 0.06 0.06 0.07 0.07 0.07 0.05 0.06 0.07 0.05 0.05 0.05 0.07 HRET HIIN Rate 0.06 0.06 0.06 0.06 0.06 0.06 0.06 0.05 0.06 0.06 0.06 0.05 0.05 0.06 0.05 0.06 0.06 0.05 0.05 0.06 0.07 0.06 0.06 0.06 0.05 0.05 0.05 0.06 0.06 # FL Reporting 88 88 88 88 88 88 88 88 89 89 89 89 89 89 89 89 87 88 88 88 88 88 88 88 88 88 88 88 71 #HRET HIIN Reporting 1,401 1,548 1,549 1,557 1,572 1,571 1,573 1,571 1,573 1,575 1,574 1,571 1,573 1,572 1,568 1,568 1,569 1,566 1,568 1,570 1,563 1,560 1,556 1,550 1,546 1,519 1,490 1,479 1,189 Source: HRET Comprehensive Data System, March 22, 2019

MRSA – Part 2 Linda R. Greene, RN, MPS,CIC,FAPIC Manager, Infection Prevention UR Highland Hospital Rochester, NY linda_greene@urmc.rochester.edu

Objectives  Review the epidemiology of MRSA  Discuss recent information regarding MRSA incidence and prevalence  Identify opportunities for prevention of MRSA

CDC Vital Signs Report

Polling Question 1 What is your background? 1. Infection Prevention 2. Quality or patient safety 3. Management 4. Staff nurse 5. Other

Staph Infections MRSA is well known but any staph can be deadly.  Staph is a leading cause of infections in US healthcare facilities.  Current recommendations have reduced MRSA in healthcare, but progress has slowed.  Recent data suggest MSSA rates are not declining.  The rise of staph infections in communities may be connected to the opioid crisis.  In 2016, 9% of all serious staph infections happened in people who inject drugs—rising from 4% in 2011.

MRSA and MSSA

Definitions Colonization Growth and Multiplication without Disease Infection Clinical or subclinical response

MRSA- Let’s Review Again  Staphylococcus aureus- Resistant to Antibiotics Normally used to treat staph infections Microbiology – Gr+ cocci with many virulent factors ฀ Frequent nosocomial- and community-acquired pathogen ฀ Mode of transmission – contact ฀ Clinical manifestations: ฀ • Skin and soft tissue infections • Pneumonia • Osteomyelitis / Arthritis • Bacteremia / Sepsis • Endocarditis • Toxin-mediated disease

Where does MRSA reside? Epidemiologic niche: ฀ • Nasal carriage (anterior nares) • GI tract (rectal) • Perineal • Throat Nasal carriage – 30% of adults ฀ • 20% Persistent carriers • 60% Transient carriers • 20% Never carriers Nosocomial transmission – transient hand carriage ฀

H ow does resistance develop?  Beta-lactams are antibiotics that prevent SA (and other germs) from producing cell walls. That's generally bad news for the bacteria. (i.e. penicillin, cephalosporins, monbactams, carbapenems)  Some SA have a gene, however, that allows them to form an enzyme called beta-lactamase. The enzyme destroys beta-lactams before the beta-lactams can destroy the bacterium.

Clinical Significance Staphylococcus aureus is a frequent colonizer of the skin and mucosa and can cause a broad range of clinical manifestations. Risk factors for complications of S. aureus infection include community acquisition of bacteremia, presence of a prosthetic device, and underlying medical conditions including immunosuppression. Clinical manifestations of S. aureus infection include skin and soft tissue infection, bacteremia, and associated conditions (including infective endocarditis, cardiac device infection, intravascular catheter infection, and toxic shock syndrome).

Clinical Significance Con’t  ( Bacteremia may develop as a complication of a primary S. aureus infection (such as skin and soft tissue infection). Bacteremia may also lead to subsequent S. aureus infection at a previously sterile site (such as vertebral osteomyelitis).  Development of back or joint pain should raise the suspicion of an occult site of infection in patients with current or recent S. aureus bacteremia. In adults, hematogenous osteomyelitis most commonly presents in the form of vertebral involvement.

MRSA  In the hospital, contaminated fomites and medical devices may play a role as intermediate sources of MRSA infection  Ultimately these originate from patients or hospital personnel that carry MRSA. The anterior nares are the most frequent site of  S . aureus carriage  An association between S . aureus nasal carriage and disease has been noted in 1931  Since then, several studies have confirmed the hypothesis that most S . aureus infections originate from strains that colonize the nose

Pathogenesis  20% of individuals are persistently colonized in the nose  30% are transiently colonized Infections occur frequently as a consequence of S.  aureus inoculation into an open wound.  In the upper airway, viral infection damages mucosal linings and predisposes the host to S. aureus pneumonia, which classically presents a week after onset of influenza infection

What about the Immune System?  Neutrophils – Most prevalent WBC. Secreted in response to a pathogen. Acts by phagocytosis  Upon arriving at the infection site, neutrophils unleash a battery of antimicrobial substances, including antimicrobial peptides, reactive oxygen species (ROS), reactive nitrogen species (RNS), proteases, and lysozyme  Staph aureus counters by secreting specific toxins, which lyse neutrophils.

Risk Factors  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 pneumonia

Assess Your Patient Population Drug Abuse Dialysis Nursing Home Long Term Antibiotic Use

Contact Pathogen Spread  From person to person directly  On hands of health care workers to other patients  From environment to patient

Special Note  Cleaning and Disinfection  Methicillin-resistant Staphylococcus aureus (MRSA) can survive on some surfaces, like towels, razors, furniture, and athletic equipment for hours, days, or even weeks.  It can spread to people who touch a contaminated surface MRSA can cause infections if it gets into a cut,  scrape, or open wound.

Staph Aureus Bacteremia Current outcome measure is LAB ID. Proxy measure – includes prevalence and incidence Health care onset ( new MRSA occurs on day 4 or greater of inpatient stay) HO Let’s take a deeper dive

Bacteremia  Bacteremia due to S. aureus can be classified into three categories ● Health care associated, hospital onset (i.e., nosocomial) ● Health care associated, community onset ● Community acquired