Community-acquired methicillin-resistant Staph. aureus (CA-MRSA): Amarillo experience Infectious Disease Epidemiology Work Group Texas Department of State

Community-acquired methicillin-resistant Staph. aureus (CA-MRSA): Amarillo experience

Infectious Disease Epidemiology Work Group Texas Department of State Health ServicesJanuary 4, 2008

J Rush Pierce Jr, MD, MPHPublic Health Authority, Amarillo Bi-City-County Health DistrictAssociate Professor, Dept of Internal Medicine, TTUHSC

Todd E. Bell, MDAssistant Professor, Department of Internal Medicine, TTUHSC

CA MRSA: Amarillo Experience. Preliminary data. Not for publication

2

Amarillo, Texas

MSA 2006 estimated population = 236,113

Three hospitals Health Department

serves citizens in two counties

69% White, 22% Hispanic, 6% African American


3

Community Acquired MRSA in Amarillo

Passive reports of CA-MRSA

99

223

408

512

0

100

200

300

400

500

600

2003 2004 2005 2006

year


4

Origin of local CA-MRSA Advisory Committee Passive surveillance and reports from

practitioners noted marked rise in CA-MRSA in 2004

Requests to Health Dept from schools, LTCF’s and hospitals for recommendations

MRSA Advisory Committee appointed April, 2005 and recommended investigation of 2004 cases


5

Strategy of Community Investigation of CA-MRSA 1. Get list of MRSA isolates from hospital

labs 2. Review hospital and outpatient records to

exclude hospital-associated MRSA 3. Call remainder

Exclude hospital-associated MRSA Inquire about risk factors and other items Get risk factors on another household member

who did not have CA-MRSA


6

Amarillo CA-MRSA Investigation – Exclusion criteria Any hospitalization in the year before the culture Any surgery during in the year before the culture Any dialysis in the year before the culture Any stay in a long-term care facility in the year

before the culture Presence of any of the following at the time of

culture: tracheotomy, gastrostomy, urinary catheter, intravenous catheter


7

Amarillo CA-MRSA Investigation - Results Over 1100 ED and outpatient charts

reviewed; 299 met criteria for CA-MRSA At least 2 phone calls and mail request 35 no contact info, 3 dead, 8 declined

survey, 110 not reached and did not respond to mail request = 143 included in investigation (48% response rate)

Of 143 included, 10 (7%) had exclusion criteria after interview


8

Amarillo CA-MRSA Investigation - gender

44%

56%

Female Male


9

Amarillo CA-MRSA Investigation - ethnicity

5%

11%

73%

11%

Black Hispanic White Other


10

Demographics cases Proportion, cases

Proportion, Potter/Randall

counties

p

Age (n=132)

0-19

20-64

65+

25

96

11

0.19

0.73

0.08

0.29

0.59

0.12

0.009

0.001

NS

Race/Ethnicity

(n=120)

Black

Hispanic

White

6

14

100

0.05

0.12

0.83

0.06

0.22

0.69

NS

0.001

NS


11

6

32

6

8

1211

22

20

23

910

0

5

10

15

20

25

0-1 2-5 6-10 11-15 16-19 20-24 25-29 30-39 40-49 50-59 60-69 >69

AGE

Amarillo CA-MRSA Investigation - age


12

Amarillo CA-MRSA Investigation – location of infection

0

5

10

15

20

25

30

35

40

45

Head Trunk Upper Extremities Low er Extremities Genital Area Internal

LOCATION OF INFECTION


13

Mistaken for spider bite by either patient or physician

39%

59%

2%

Yes No Unknown


14

MRSA Infections by month of diagnosis

4

5

7

3

8

12

20

21

15

10

11

15

0

5

10

15

20

25

January February March April May June July August September October November December


15

CA-MRSA Antibiotic Resistance

93

48

10

89

0.1

37

100 95

0.2 0.3 0 00

20

40

60

80

100

120

Ampic

illin

Ciprof

loxac

in

Clinda

myc

in

Eryth

rom

ycin

Genta

mici

n

Levo

floxa

cin

Oxicilli

n

Penici

llin

Rifam

pin

Tetra

cycli

ne

Trim

/Sul

fa

Vanco

myc

in

%


16

MRSA – Antibiotic treatment

87

41

4

0

10

20

30

40

50

60

70

80

90

100

Multi-Drug Therapy Single Abx. Treatment Unknown


17

CA-MRSA – time to healing

4

48

31

5

2

57

30

0

10

20

30

40

50

60

<1 w eek 1-4 w eeks 1-2 months 3-4 months 5-6 months 6-12 months recurring unsure/ noansw er


18

CA-MRSA – exposure

31%

67%

2%

Previous Staph Exposure No Previous Staph Exposure Unknown


19

CA-MRSA – Are you familiar?

23%

77%

Yes No


20

CA-MRSA Investigation Conclusions CA-MRSA is common –est. incidence in 2004 =

106/100,000 population Involves all ages, all ethnic groups and all areas

of District Frequently mistaken for spider bites Most commonly skin and soft tissue infection Some increase seen in summer Almost always sensitive to rifampin, TCN, TMP-

SMX, genta, vanc – 90% sens to clinda Patients commonly (1/3) had contact with

someone else that had MRSA Most (3/4) patients not familiar with it


21

MRSA related public health activities in Amarillo

Continued voluntary reporting Public and HCW education Interventions developed for responding to

reported clusters Population based surveillance cultures by

TTUHSC investigator Meetings with school nurses and other

groups to review TDSHS guidelines Continued MRSA Advisory Group activities


22

MRSA Advisory Committee: hospital sharing of data Surgical site infection rate for elective total

knees 3x national average – not hospital or surgeon specific

Community deaths 2006 = 14 2007 = 17

Surveillance cultures to ICU (by one hospital) 12% positive; but less than 2% nosocomial transmission with out special isolation


23

MRSA Advisory Committee: Isolation Guidelines in hospitals Gown and glove for all hospital personnel

entering room if patient in contact isolation Gown and glove for visitors patients with

MRSA


24

MRSA Advisory Committee: surveillance guidelines for hospitals Contact isolation for patients admitted who

have had positive MRSA culture in previous six months

Surveillance cultures for all patients undergoing elective total knee replacement

Recommend public health data base


25

Other recommendations of MRSA Advisory Committee

Evidence based pre-operative decontamination regimen

Recommendation for single dose of pre-operative vancomycin, clindamycin, or linezolid for patients colonized with MRSA

Documents

Community-acquired methicillin-resistant Staph. aureus (CA-MRSA): Amarillo experience Infectious Disease Epidemiology Work Group Texas Department of State