MRSA and Nursing hom es: Is there a problem and do we need to - - PowerPoint PPT Presentation

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MRSA and Nursing hom es: Is there a problem and do we need to change our guidelines ?

• Dr. C. SUETENS, B. JANS, Scientific I nstitute of Public Health, Epidem iology,
• Dr. O. DENI S, Prof. M. STRUELENS, National MRSA reference laboratory, ULB,

Brussels, BELGI UM IPH Epidemiology

Belgian Antibiotic Policy Coordination Committee Belgian Antibiotic Policy Coordination Committee Belgian Infection Control Society Belgian Infection Control Society

With the support of the federal platform for hospital hygiene With the support of the federal platform for hospital hygiene

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5 10 15 20 25 30 35

1 9 9 4 / 2 1 9 9 5 / 1 1 9 9 5 / 2 1 9 9 6 / 1 1 9 9 6 / 2 1 9 9 7 / 1 1 9 9 7 / 2 1 9 9 8 / 1 1 9 9 8 / 2 1 9 9 9 / 1 1 9 9 9 / 2 2 / 1 2 / 2 2 1 / 1 2 1 / 2 2 2 / 1 2 2 / 2 2 3 / 1 2 3 / 2 2 4 / 1 2 4 / 2 2 5 / 1 2 5 / 2

Study periods MRSA / SA (%) . 0.5 1 1.5 2 2.5 3 3.5 4 4.5 MRSA / 1000 admissions . Resistance rate Incidence of nosocomial MRSA

GUIDELINES (hospitals): 1993 2003: Revision GUIDELINES (Hosp.) 2004 and 2006 Hand hygiene campaigns National Campaign: Antibiotic Consumption - 2000 Antibiotic prophylaxis in surgery: 1997 AB policy steering committee in the hospitals -2002

• % MRSA+

% MRSA+ at at admission admission NH = NH = reservoirs reservoirs ? ?

Situation in Belgian acute care hospitals Situation in Belgian acute care hospitals

? ?

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Antw. O.-Vl. W.-Vl. Hain. Liège Brussel

• Vl. Br.

Luxemb. Namur Limb.

• Br. Wal.

List of I NAMI / RI ZI V = 9 8 5 m ajor care NH

Methodology Methodology

At random : region & proportion of m ajor care beds

Antw. O.-Vl. W.-Vl. Hain. Liège Brux.

• Br. Fl.
• Br. Wal.

Limb. Namur Luxemb.

n= 6 0 NH 5 0 residents/ NH

Obj Obj . 1: . 1: prevalence prevalence MRSA MRSA-

• carriage

carriage in in Belgian Belgian NH ? NH ? Sampling Sampling: : nose nose, , throath throath & & wound wound, , urinary urinary meatus meatus Obj Obj . 2: . 2: determinants determinants of MRSA

• f MRSA-
• carriage

carriage at at resident resident and and institutional institutional level level ? (questionnaire) ? (questionnaire) Obj Obj . 3: . 3: molecular molecular epidemiology epidemiology and AB and AB-

• resistance

resistance

1 1 st

st national prevalence study on MRSA

national prevalence study on MRSA-

• carriage in NH

carriage in NH 2005 2005

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Sam ple Sam ple BELGI UM BELGI UM Num ber of participating NH: Num ber of participating NH: 6 0 ( 6 .1 % ) 6 0 ( 6 .1 % ) 9 8 5 9 8 5 Screened residents ( m ax.5 0 / NH) : Screened residents ( m ax.5 0 / NH) : 2 9 5 8 / 6 3 6 5 2 9 5 8 / 6 3 6 5 9 4 .5 1 5 9 4 .5 1 5 ( 4 6 % of the sam ple) ( 4 6 % of the sam ple) Distribution of the NH by region: Distribution of the NH by region: Flanders Flanders 3 6 ( 6 0 % ) 3 6 ( 6 0 % ) 5 8 6 5 8 6 ( 5 9 % ) ( 5 9 % ) W alloon W alloon 1 8 ( 3 0 % ) 1 8 ( 3 0 % ) 3 0 4 3 0 4 ( 3 1 % ) ( 3 1 % ) Brussels Brussels 6 ( 1 0 % ) 6 ( 1 0 % ) 9 5 9 5 ( 1 0 % ) ( 1 0 % ) Ow nership: Ow nership: Private Private 4 1 ( 6 8 % ) 4 1 ( 6 8 % ) 6 2 4 6 2 4 ( 6 3 % ) ( 6 3 % ) Mean % m ajor care beds: Mean % m ajor care beds: 4 6 % 4 6 % ( 1 5 ( 1 5 -

• 9 7 % )

9 7 % ) 4 9 % 4 9 % Mean num ber beds/ NH: Mean num ber beds/ NH: 1 0 6 1 0 6 ( 3 8 ( 3 8 -

• 2 7 9 beds)

2 7 9 beds) 9 6 9 6 Fl: Fl: 1 0 9 1 0 9 W : W : 8 7 8 7 BR BR: : 1 4 4 1 4 4 ( p= 0 .0 4 7 ) ( p= 0 .0 4 7 ) Private: Private: 1 0 4 1 0 4 Public Public: : 1 1 1 1 1 1 ( ( n.s n.s.) .)

Characteristics of participating NH Characteristics of participating NH

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Prevalence of Prevalence of S. aureus

• S. aureus and MRSA

and MRSA

Total number of screened residents Total number of screened residents:

2953

• S. aureus

negative culture n = 1 4 5 3 MRSA n = 5 8 7 MSSA n = 9 1 3

• S. aureus

positive culture n = 1 5 0 0

49%

• S. aureus prevalence: 51%

(min. 22% - max. 70% )

Weigthed mean MRSA-prevalence: 19% [ CI 95% 17-22] (min. 2% - max. 43% ) Weighted mean resistance proportion: 38% [ CI 95% 33-42] (min. 4% - max. 75% )

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23 53 24 30 12 1 37 32 59 29 7 34 31 49 50 60 2 58 33 22 56 25 26 55 41 44 45 13 9 21 19 4 28 39 14 43 8 10 54 3 57 38 27 36 18 11 42 5 52 16 20 35 17 46 51 47 48 40 15 6 participating NH 10 20 30 40 50 % MRSA carriers/NH

• Q. 25
• Q. 75

Median

Distribution of MRSA Distribution of MRSA-

• carriage

carriage prevalence prevalence rates in NH rates in NH (% MRSA/ (% MRSA/ residents residents) )

Weigthed mean MRSA-prevalence: 19% 2000 (n= 24 NH): 4.7%

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10 20 30 40 MRSA carriage % Vlaanderen Brussels W a llo nie

2 2 .2 % [ I C9 5 % 1 7 .2 -2 7 .4 ] 1 7 .2 % [ I C9 5 % 1 3 .4 -2 1 ] 1 8 .1 % [ I C9 5 % 1 5 -2 1 .3 ]

MRSA MRSA prevalence prevalence by by region region

p= 0,13 p= 0,13

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How How frequent frequent are infections in NH are infections in NH ’ ’s* ? s* ?

% % At least 1 outbreak during last year At least 1 outbreak during last year 22 22 Type of outbreaks Type of outbreaks Gastro Gastro-

• enteritis

enteritis Clostridium Clostridium difficile difficile MRSA MRSA 59 59 18 18 6 6 Clostridium Clostridium difficile difficile strains in hospitals strains in hospitals % coming from NH % coming from NH-

• residents

residents 20 20 MRSA MRSA-

• carriage among NH

carriage among NH-

• residents

residents 19 19 Is MRSA problematic in your NH ? Is MRSA problematic in your NH ? Yes Yes No No Don Don’ ’t know, no answer t know, no answer 55 55 13 13 32 32 % MRSA % MRSA 19 19 15 15 24 24 . Underestimation of infectious problems in some NH . 56% of NH never take screening samples

* source: coordinating physician and nursing responsible * source: coordinating physician and nursing responsible

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Coordination of Coordination of medical medical and nursing care in the NH and nursing care in the NH

In Major care NH: 1 Coordinating physician (RD 24/ 6/ 1999) (RD 24/ 6/ 1999) coordination of medical activities, healthcare problems coordination of medical activities, healthcare problems potentially dangerous for residents/ staff potentially dangerous for residents/ staff and … 31 GP / NH (min. 3 - max. 96) 1 GP / 4.4 beds (min. 1/ 1.4 1 GP / 4.4 beds (min. 1/ 1.4 – – max. 1/ 36.7)

• max. 1/ 36.7)

GP/beds ratio % mean MRSA% MRSA > 19% . 1 GP/ < 4 beds 63.3 21.9 63.2 1 GP/ 4 beds and + 36.7 16.2 31.8 OR: 3.67 [1.05 - 13.26], p=0.02 AB-policy in the NH Yes (%) % MRSA . Use mupirocine for decolonisation of wounds 71 21 15 Creation formulary with GP’s = CP task 58 19 20 GP aggreements – AB use = task CP 32 22 19 Formulary used<> not used/ not available 29 15 22 Aggreements about AB-prescription 18 18 20 Written aggreements: AB-use 13 19 20 Limitation AB choice for prescription 7 16 20 Free use AB-ointments for wound care by nurse 3 29 20

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1 - Available products

Yes MRSA% Availability of products for hand hygiene % Yes No Liquid soap 98 20 13 Hydro-alcoholic lotion or gel 84 20 20 Antiseptic soap 75 20 18 Bar solid soap 4 25 20 Type of towels . Single use or electric 90 19 22

2 – Use of gloves

Indications for glove use . Residents with fecal incontinence 85 18 27 Wound care 77 19 22 Care urinary catheter 67 19 20 Desinfection of materiel 62 20 20 Gastrostomy 54 18 21 Residents with urinary incontinence 51 19 20 Residents with flu 34 15 22 NOTE: no hand hygiene after removing gloves = 8%

Hand Hand hygiene hygiene

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1 – Room arrangements for MRSA carriers

Yes MRSA% Proportion of single rooms % Yes No. All NH-rooms are single 13 18 20 Room arrangements for carriers . Isolation in single room 79 19 25 Cohorting carriers 54 20 20 Cohort nursing 32 18 21

2 - Additional precautions

Additional precautions . Gloves 98 20 3 Mask 86 20 18 Apron 90 20 20 Reinforced cleaning (room) 92 20 18

3 – Written care protocols

Availability of written care protocols . Protocol for management of MRSA-carriers 80 19 20 Isolation of contagious residents 54 17 22 Hygiene policy in the NH 47 20 19

Management of MRSA Management of MRSA-

• carriers

carriers

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Yes MRSA%

1 - Screening of reservoirs

% Yes No. Residents after hospitalisation 44 18 22 Staff 22 19 20

2 - Decolonisation of carriers

. Decolonisation of carriers 90 21 14 Control sample after decolonisation 97 20 14 Used decolonisation scheme (n=40) . Nasal decolonisation only 28 18 Nasal decolonisation + antiseptic bath 43 22 Not conform decolonisation scheme (AB) 10 21 Other answer 20 19

3 – Communication and collaboration

. Always receive transfer document 68 19 22 Collaboration with experts . Advice regional platform Hospital hygiene 69 21 18 Collaboration with Hospital hygiene team 61 20 19

4 - Surveillance of MRSA

. Yes 64 19 21

Detection Detection, , eradication eradication and and follow follow-

• up

up

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National recommendations for National recommendations for the prevention of transmission of the prevention of transmission of methicillin methicillin resistant Staphylococcus resistant Staphylococcus aureus aureus (MRSA) (MRSA) in Belgian Nursing Homes in Belgian Nursing Homes

• June

June 2005 2005 -

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84% of NH used guidelines for creation of indoor protocol Since the last year, adaptation of: Hand hygiene practice 91% Register of MRSA-carriers 80% Additional precautions (MRSA) 61% Screening practices 52% Decolonisation of carriers 48% AB-policy 25% To do: Improve communication and collaboration Install specific infection prevention structure in NH Perform training of all NH professionals Additional ressources

One One year year later later, , … …