Fighting MRSA: Fighting MRSA: Our quest against Our quest against

bacterial bacterial resistanceresistanceLourdes M. Irizarry, M.D.Lourdes M. Irizarry, M.D.

Chief of StaffChief of Staff

Albany VAAlbany VA

Natural Natural Disasters Disasters

Global warming

News mediaNews media

““Super bugs”Super bugs”

“ “ End of miracle drugs”End of miracle drugs”

““Arms race against Arms race against infections”infections”

Progressive Emergence of Progressive Emergence of Gram-Positive Organisms as Gram-Positive Organisms as

Dominant IsolatesDominant Isolates

(%)Isolates

Jones RN. SENTRY Antimicrobial Surveillance Program Data. 1997-1998.

EORTC Trials, 1973-1994

Year

PRSA MRSA PRSP MRSA VRE VISA VTSP* VRSAClassic MDR Mupirocin RSA

1944 1961 1967 1975 1986 1996 1999 2002

Significant Gram positive pathogensDevelopment of resistance

T I M E L I N E

* VTSP = Vancomycin tolerant S pneumoniae

Worldwide epidemiology of MRSAWorldwide epidemiology of MRSABacterial real state: Bacterial real state: location, location, location, location,

locationlocation

1/99 – 12/02 495 hospitals, 26 1/99 – 12/02 495 hospitals, 26 countriescountries

Prevalence MRSA: Prevalence MRSA: < 1% Northern Europe< 1% Northern Europe > 40% Southern and Western > 40% Southern and Western

EuropeEurope 26% (1986) – 77% (2001) in Taiwan26% (1986) – 77% (2001) in Taiwan 64% Korea64% Korea

MRSA bacteremia rates MRSA bacteremia rates across Europeacross Europe

% MRSA% MRSA+BC/1,000 d+BC/1,000 d

NrNr 00 11 GerGer 1919 3.293.29 PolPol 2020 1.121.12 SpSp 2626 66 FrFr 2929 11.7911.79 IsraIsra 3939 12.1612.16 PorPor 4646 17.5817.58 MalMal 5656 19.2919.29 Rom 73Rom 73 1.921.92

0

10

20

30

40

50

60

70

80

Nr Gr Po Sp Fr Is Pr Ma Ro

%MRSA+BC/1000 day

National Nosocomial National Nosocomial Infections Surveillance Infections Surveillance

System (USA)System (USA) S. aureusS. aureus bacteremia has trebled in bacteremia has trebled in

the last 20 yearsthe last 20 years 50%-60% SA are MRSA50%-60% SA are MRSA MRSA most commonlyMRSA most commonly

46% lung (Biofilm: Endotracheal tubes)46% lung (Biofilm: Endotracheal tubes)

38% urinary tract38% urinary tract 30% bloodstream30% bloodstream 30% soft tissue30% soft tissue

Prevalence of Methicillin-Resistance Prevalence of Methicillin-Resistance among among S. aureus S. aureus Infections, Denmark and US, Infections, Denmark and US,

1960-20041960-2004

0

10

20

30

40

50

60

70

1960 1963 1966 1969 1972 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002

% R

esis

tan

t

USA (ICUs) Denmark (BSIs)

Changing MRSA Changing MRSA epidemiological profileepidemiological profile

Increase in CA-MRSA and HA-MRSAIncrease in CA-MRSA and HA-MRSA MRSA 50% SA infections in ICU MRSA 50% SA infections in ICU MRSA 40% SA outside ICUMRSA 40% SA outside ICU CA-MRSA outbreaksCA-MRSA outbreaks

Native Americans, Correctional Native Americans, Correctional facilities, Competitive sports, Military facilities, Competitive sports, Military personnelpersonnel

57% initial inappropriate antibiotics57% initial inappropriate antibiotics Soft tissue infections (77%), wound Soft tissue infections (77%), wound

infections, UTI, bacteremias, necrotizing infections, UTI, bacteremias, necrotizing pneumoniapneumonia

Adapted from Shorr CID 2007

New England

IP 49.9%

OP 37.6%

South Atlantic

IP 59.8

OP 50.6%

East SCIP 63%OP 63%

West SCIP 59.2%OP 56.8%

PacificIP 51%OP 44.4%

MountainIP 57%OP 46.5%

West NCIP 53.8%OP 46.2%

East NCIP 58.9%OP 40.8%

Prevalence of MRSA in the USA according the US Census Bureau1998-2005

MRSA (Network 2)MRSA (Network 2)

46

48

50

52

54

56

58

60

62

Al Sy Bu0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10

Al Sc

Al Cl

Sy Sc

Sy Cl

Bu Sc

Bu Cl

51%

54%

61%

Cost of MRSACost of MRSA Drug resistance Drug resistance

associated expenditures associated expenditures in USA range form $4 in USA range form $4 billion - $30 billionbillion - $30 billion

2005 Pennsylvania: 2005 Pennsylvania: Reportable nosocomial Reportable nosocomial infectionsinfections 12.2 pts/1,000 had 12.2 pts/1,000 had

nosocomial infectionsnosocomial infections Average cost $185,260 vs Average cost $185,260 vs

$31,389$31,389 Surgical site infectionsSurgical site infections

No infection No infection = $ = $ 29,45529,455

MSSA infectionMSSA infection = $ = $ 52,79152,791

MRSA infectionMRSA infection = $ = $ 92,36392,363

02468

101214161820

Gramneg

MR MS

Effect on LOS

Burden of MRSABurden of MRSA

Mortality MRSA Mortality MRSA doubles MSSAdoubles MSSA 1941 mortality 1941 mortality

rate for S. aureus rate for S. aureus bacteremia 82%bacteremia 82%

97% > 50 y/o97% > 50 y/o 1944 mortality 1944 mortality

dropped to 25%dropped to 25% 2008 mortality 2008 mortality

rates 15%-60%rates 15%-60%MRSA 29% - 80%MRSA 29% - 80%

MSSA 12% - 36%MSSA 12% - 36%

0

10

20

30

40

50

60

70

+BC SBE

Bacterial Bacterial ResistanceResistance

J. ErlichJ. Erlich

19141914

Antibiotics Antibiotics Mechanisms of ActionsMechanisms of Actions Mechanisms Mechanisms

of resistanceof resistance Interfering cell wall Interfering cell wall

synthesissynthesis Beta lactams, monobactams, Beta lactams, monobactams,

carbapenems, glycopeptidescarbapenems, glycopeptides Inhibiting protein synthesisInhibiting protein synthesis

Macrolides, streptogramins, Macrolides, streptogramins, aminoglycosides, aminoglycosides, tetracycline, tetracycline, chloramphenicol, chloramphenicol, oxazolidoneoxazolidone

Interfering with nucleic acid Interfering with nucleic acid synthesissynthesis FluoroquinolonesFluoroquinolones

Inhibiting metabolic Inhibiting metabolic pathwayspathways SulfanomidesSulfanomides

Inactivation of Inactivation of antibiotic by antibiotic by destruction or destruction or modificationmodification Beta-lactamsesBeta-lactamses Aminoglycoside Aminoglycoside

inatvitaing enzymesinatvitaing enzymes

Prevention of access to Prevention of access to targettarget Efflux pumpsEfflux pumps Deletion of porinsDeletion of porins

Alteration of target siteAlteration of target site PBP changesPBP changes

Acquisition of Acquisition of ResistanceResistance

Chromosomal mutationChromosomal mutation Inductive expression of a latent Inductive expression of a latent

chromosomal genechromosomal gene Exchange of genetic material Exchange of genetic material

through:through: transformation (DNA exchange)transformation (DNA exchange) transduction (via bacteriophage)transduction (via bacteriophage) conjugation by plasmid conjugation by plasmid

(extrachromosomal DNA)(extrachromosomal DNA)

TransformationTransformation

TransductionTransduction

ConjugationConjugation

PlasmidPlasmid

The evolution of MRSAThe evolution of MRSA

Structural gene for MR, mecA, encodes a Structural gene for MR, mecA, encodes a novel PBP 2’ with reduced affinity for B-novel PBP 2’ with reduced affinity for B-lactamslactams

Gene carried on Staphylococcal chromosomal Gene carried on Staphylococcal chromosomal casette (SCC)mec inserted in staphylococcal casette (SCC)mec inserted in staphylococcal chromosomechromosome

Four forms of SCC mecFour forms of SCC mec Plasmid genes for non beta-lactams, Plasmid genes for non beta-lactams,

disinfectants and heavy metals integrated into disinfectants and heavy metals integrated into SCC mecs contributing to size heterogeneitySCC mecs contributing to size heterogeneity 67 kb class67 kb class

R

R

RR

R

S

S

SS

S

SS

S

SS

Main forms of SCC mecMain forms of SCC mec

Type I (archaic clone)Type I (archaic clone) Found in 1Found in 1stst MRSA from 60’s MRSA from 60’s

Type II & IIIType II & III Typical modern clonesTypical modern clones

Type IVType IV CA-MRSACA-MRSA Only 21 kb in lengthOnly 21 kb in length

HA-MRSAHA-MRSA

Nosocomial MRSA clonal patternNosocomial MRSA clonal pattern 11 major clones within 5 groups of 11 major clones within 5 groups of

related genotypesrelated genotypes 5 major MRSA clones account for 5 major MRSA clones account for

70% of MRSA (USA, S America, 70% of MRSA (USA, S America, Europe)Europe)

mec A gene encodes resistance to mec A gene encodes resistance to multiple antibiotcs multiple antibiotcs EMRSA-17 UK (meth, quinolones, EMRSA-17 UK (meth, quinolones,

macrolides, amino, tetra, rifampin)macrolides, amino, tetra, rifampin)

CA-MRSACA-MRSA Only 21 kb long: more mobile, fitter, Only 21 kb long: more mobile, fitter,

persistspersists More susceptible to: tetra, clinda, More susceptible to: tetra, clinda, ++ cipro cipro Higher infection rate (3% MSSA vs 38% Higher infection rate (3% MSSA vs 38%

MRSA)MRSA) Mortality rate 75%Mortality rate 75% More virulentMore virulent

High percentage carry genes for Panton-High percentage carry genes for Panton-Valentine leukocidin Valentine leukocidin (93% furunculosis, 85% necrotizing (93% furunculosis, 85% necrotizing pneumonia France)pneumonia France)

Cytotoxin that causes leukocyte destruction and tissue Cytotoxin that causes leukocyte destruction and tissue necrosis associated with high morbidity & mortalitynecrosis associated with high morbidity & mortality

Bacterial virulence Bacterial virulence factorsfactors

Quorum sensingQuorum sensing Staphylococcal toxinsStaphylococcal toxins SOS responseSOS response Adhesion potentialAdhesion potential Intracellular toxinsIntracellular toxins

Quorum sensingQuorum sensing Expanding bacterial populations are subject Expanding bacterial populations are subject

to chemical signalingto chemical signaling Quorum sensing detects density of their own Quorum sensing detects density of their own

speciesspecies Requirement for colonization is superseded Requirement for colonization is superseded

by requirement for deeper penetration into by requirement for deeper penetration into tissue once number of cells reaches a set tissue once number of cells reaches a set levellevel Repress adhesions genesRepress adhesions genes Facilitates invasion (agr gene also encodes toxins)Facilitates invasion (agr gene also encodes toxins)

Insufficient or inappropriate antibiotic will Insufficient or inappropriate antibiotic will remove susceptible commensals encourages remove susceptible commensals encourages MRSA grow turning newly acquired colonies MRSA grow turning newly acquired colonies to invadersto invaders

Staphylococcal toxinsStaphylococcal toxins

Alpha-toxin encoded by hla geneAlpha-toxin encoded by hla gene S. aureus growing in the presence of S. aureus growing in the presence of

beta lactams beta lactams (and to lesser degree (and to lesser degree quinolones)quinolones) expresses alpha-toxin and expresses alpha-toxin and Panton Valentine leucocidin (PVL)Panton Valentine leucocidin (PVL)

MRSA may produce 30 fold alpha MRSA may produce 30 fold alpha toxin in beta- lactamtoxin in beta- lactam Clindamycin inhibits expression of toxinsClindamycin inhibits expression of toxins Synercid and Linezolid reduce TNF Synercid and Linezolid reduce TNF

activityactivity

SOS responseSOS response Bacterial DNA damage create Bacterial DNA damage create

unfavorable conditions = SOS reactionunfavorable conditions = SOS reaction SOS up-regulate genes for DNA repair SOS up-regulate genes for DNA repair

and cell survivaland cell survival May generate horizontal transfer of May generate horizontal transfer of

mobile genetic elements (plasmids, mobile genetic elements (plasmids, bacteriophages, transposons) which bacteriophages, transposons) which may promote resistance and virulence may promote resistance and virulence (toxins and biofilm promoters)(toxins and biofilm promoters)

Non lethal b-lactam doses,quinolone Non lethal b-lactam doses,quinolone and bactrim induce SOS responseand bactrim induce SOS response

Adhesion potentialAdhesion potential

Adhesion important for colonization Adhesion important for colonization and infectionand infection

S. aureus adheres to plasma proteins S. aureus adheres to plasma proteins as fibronectin and fibrinogen, which as fibronectin and fibrinogen, which coat implanted biomaterialscoat implanted biomaterials

Sub-inhibitory fluoroquinolone Sub-inhibitory fluoroquinolone exposure increases expression of exposure increases expression of fibronectin adhesins fibronectin adhesins

VISA adheres better than MRSAVISA adheres better than MRSA

Intracellular persistenceIntracellular persistence S. aureus penetrates and survives within S. aureus penetrates and survives within

host cells (phagocytes and non-phagocytes)host cells (phagocytes and non-phagocytes) Linezolid, rifampin, clindamycin and Linezolid, rifampin, clindamycin and

erythromycin supress cytotoxin but erythromycin supress cytotoxin but exception of rifampin cell will regain toxicity exception of rifampin cell will regain toxicity after antibiotic is removedafter antibiotic is removed Daptomycin + gentamicin + rifampin may be Daptomycin + gentamicin + rifampin may be

effectiveeffective Treatment failures after removalTreatment failures after removal

Colony variants during exposure to triclosan Colony variants during exposure to triclosan impregnated siliconimpregnated silicon

Biofilms: cross-resistance via plasmids with Biofilms: cross-resistance via plasmids with disinfectantsdisinfectants

Antibiotic exposureAntibiotic exposure Countries with Countries with

higher antibiotic higher antibiotic use have higher use have higher rates of MRSArates of MRSA

Sub-optimal doses Sub-optimal doses of antibiotics may of antibiotics may lead to resistancelead to resistance

Potential exposures Potential exposures to antibiotics may to antibiotics may have an effect on have an effect on development of development of resistanceresistance

Gene pool Gene pool accessible to accessible to bacteria by bacteria by exposure to exposure to selective pressure selective pressure of antibiotic usage of antibiotic usage for:for: hospital usehospital use agriculturalagricultural veterinaryveterinary animal animal

husbandryhusbandry

Animal Performance Animal Performance EnhancersEnhancers

Avoparcin Avoparcin (Vancomycin)(Vancomycin)

Tylosin Tylosin (Macrolide)(Macrolide)

Virginiamycin Virginiamycin (Pristynamicin(Pristynamicins)s)

BiocidesBiocides::

Continuation of the cycleContinuation of the cycle

High level of concerns for High level of concerns for resistanceresistance

++

Lack of local antibiogram Lack of local antibiogram datadata

==

Inappropriate antibiotic choicesInappropriate antibiotic choices

Antibiotic stewardshipAntibiotic stewardshipThe antibiotic bundleThe antibiotic bundle

Basic principles of antibiotic prescribingBasic principles of antibiotic prescribing Need assessmentNeed assessment Site of actionSite of action Individual patientIndividual patient Ecology of the institutionEcology of the institution EfficacyEfficacy ToxicityToxicity CostCost Pharmacodynamics: Relation to antimicrobial Pharmacodynamics: Relation to antimicrobial

resistanceresistance Duration of therapyDuration of therapy

Pharmodyamics: Pharmodyamics: PharmacokineticsPharmacokinetics

Optimal dosing: Optimal dosing: microbiological activity of antibiotic microbiological activity of antibiotic

+ susceptibilty of bacteria + PK of + susceptibilty of bacteria + PK of antibiotic in relation to patient = antibiotic in relation to patient = PDPD

3 PK/PD parameters3 PK/PD parameters Cmax/MICCmax/MIC AUC/MICAUC/MIC T>MICT>MIC Post antibiotic effectPost antibiotic effect

Mutant Prevention Mutant Prevention ConcentrationConcentration

MIC for the less susceptible mutant MIC for the less susceptible mutant strain in the populationstrain in the population

MPC must be achieved and sustained MPC must be achieved and sustained for sufficient time to eradicate strains for sufficient time to eradicate strains less susceptibleless susceptible

Focus on maintaining concentration Focus on maintaining concentration throughout a dosing interval or throughout a dosing interval or exposure level to decrease emergence exposure level to decrease emergence of resistanceof resistance

S. aureus: quinolonesS. aureus: quinolones

““

““Prediction is very difficult, Prediction is very difficult, particularly about the particularly about the

futurefuture.” .” Neils BohrNeils Bohr

Disappointments and Disappointments and OpportunitiesOpportunities

SA exposure to host cells induce SA exposure to host cells induce antimicrobial antimicrobial peptides: antimicrobial antimicrobial peptides: MRSA is less susceptibleMRSA is less susceptible

Vaccines: Disappointing results in Vaccines: Disappointing results in dialysis patientsdialysis patients

Non-Ab approachNon-Ab approach Quorum sensing peptides inhibitorsQuorum sensing peptides inhibitors Bacteriolytic enzymesBacteriolytic enzymes

Newer antibioticsNewer antibiotics

AntibioticsAntibiotics

On the marketOn the market Quinupristin/dalfopristinQuinupristin/dalfopristin LinezolidLinezolid DaptomycinDaptomycin TigecyclineTigecycline

Under studyUnder study Dalbavancin, Oritavancin & TelavancinDalbavancin, Oritavancin & Telavancin Ceftobiprole, CeftarolineCeftobiprole, Ceftaroline

““Giving doctors Giving doctors antibiotics without antibiotics without

education is like giving education is like giving your alcoholic patient a your alcoholic patient a

finer brandy”finer brandy”Dennis Maki, MDDennis Maki, MD

IDSA 1998IDSA 1998

Environmental issuesEnvironmental issuesHA-MRSAHA-MRSA

Gram positive bacteria survives on dry Gram positive bacteria survives on dry surfaces for months (up to 64% surfaces for months (up to 64% persistance)persistance) Bedside rails, pressure cuffs, TV remotes, Bedside rails, pressure cuffs, TV remotes,

bedside tables and commodes, toilet rails, bedside tables and commodes, toilet rails, dressers, door knobs, iv pumps, EKG ledsdressers, door knobs, iv pumps, EKG leds

Key boards, stethoscopes, pagersKey boards, stethoscopes, pagers Higher inoculum = longer persistenceHigher inoculum = longer persistence Transmission by hands is very Transmission by hands is very

successfulsuccessful

Environmental issuesEnvironmental issuesCA-MRSACA-MRSA

CContact (direct skin-skin)ontact (direct skin-skin) CCleanliness leanliness CCompromised skin integrityompromised skin integrity CContaminated objects surfaces ontaminated objects surfaces

and itemsand items CCrowded living conditionsrowded living conditions Exposure to antibiotic Exposure to antibiotic CCapsulesapsules

MRSA in animalsMRSA in animals

Role of hand Role of hand transmissiontransmission

42 % nurses gloves MRSA by 42 % nurses gloves MRSA by touching surfaces in room (not the touching surfaces in room (not the patient)patient)

37%-65% gowns MRSA after 37%-65% gowns MRSA after morning caremorning care

MRSA transmission decreased MRSA transmission decreased 16.9% to 9.9% by improving rate of 16.9% to 9.9% by improving rate of compliance with hand hygiene from compliance with hand hygiene from 48% 68%48% 68%

Success storiesSuccess stories

Active surveillance, Hand hygiene, Active surveillance, Hand hygiene, Barrier precautions, Barrier precautions, Decontamination, Antiobiotic Decontamination, Antiobiotic stewardship, stewardship, ++ Decolonization Decolonization Denmark : Prevalence of MRSA 33% Denmark : Prevalence of MRSA 33%

1960 down to 1% in 25 years1960 down to 1% in 25 years Finland and Netherlands maintaining Finland and Netherlands maintaining

prevalence of <0.5%prevalence of <0.5% Veterans Affairs USAVeterans Affairs USA

Incidence* of MRSA from Clinical Cultures, Incidence* of MRSA from Clinical Cultures, Veteran’s Affairs Medical Center, PittsburghVeteran’s Affairs Medical Center, Pittsburgh

FY2000-2006FY2000-2006

0

0.5

1

1.5

2

2.5

3

MR

SA Is

olat

es p

er 1

,000

pat

ient

day

s

MRSA MSSA

MR

SA

Iso

late

s p

er 1

000

BD

OC

““The Bug Stops Here”The Bug Stops Here”

““You have to run You have to run towards where the towards where the ball is going to be.”ball is going to be.”

YogiYogi BerraBerra

Prevalence rates of MRSAPrevalence rates of MRSANetwork 2Network 2

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10

Al Sc

Al Cl

Sy Sc

Sy Cl

Bu Sc

Bu Cl

Highest prevalence : Screening 19.5 Clinical 3.1

Historical MRSA Historical MRSA epidemiologyepidemiology

1941 Penicicllin use (5% SA resistant to 1941 Penicicllin use (5% SA resistant to penicillin)penicillin)

1959 methicillin use in Europe1959 methicillin use in Europe 1961 methicillin use in USA1961 methicillin use in USA 1961 11961 1stst MRSA: UK, Japan, Autralia MRSA: UK, Japan, Autralia 1968: MRSA USA1968: MRSA USA MRSA outbreaks in 70’sMRSA outbreaks in 70’s 2004 59.5% SA in ICUs = MRSA2004 59.5% SA in ICUs = MRSA 1996 VISA1996 VISA

Biofilm: Catheters and Biofilm: Catheters and Endotracheal tubesEndotracheal tubes

Genetic materialGenetic material Released DNA is Released DNA is

stable in environmentstable in environment Antibiotic Antibiotic

preparations preparations contaminated with contaminated with DNA encoding DNA encoding resistanceresistance

Large pool of Large pool of antibiotic resistance antibiotic resistance genes in naturegenes in nature

Gene flux between Gene flux between bacteriabacteria

Gene pool Gene pool accessible to accessible to bacteria by bacteria by exposure to exposure to selective pressure selective pressure of antibiotic usage of antibiotic usage for:for: hospital usehospital use agriculturalagricultural veterinaryveterinary animal husbandryanimal husbandry

MRSA Real StateMRSA Real StateLocation, location, locationLocation, location, location

Differences between Differences between Hospital areasHospital areas CitiesCities StatesStates CountriesCountries

VHA MRSA VHA MRSA Prevention Prevention

Implementation Implementation Task ForceTask ForceTechnical Advisory Group Conference Technical Advisory Group Conference

CallCall

Jan. 30, 2006 - 12Noon ESTJan. 30, 2006 - 12Noon EST

1-800-767-1750; 759251-800-767-1750; 75925

AgendaAgenda

I.I. Welcome/IntroductionWelcome/Introduction

Dr. Rajiv Jain, Dr. Rajiv Jain, Project DirectorProject Director

II.II. War Against MRSAWar Against MRSA

Dr. John Jernigan, CDC/NHSNDr. John Jernigan, CDC/NHSN

III. III. Getting to Zero: The Evidence Getting to Zero: The Evidence

Dr. Robert Muder, Chief Infection Control Dr. Robert Muder, Chief Infection Control VAPHSVAPHS

IV.IV. National Initiative GoalsNational Initiative Goals

Dr. Rajiv JainDr. Rajiv Jain

V.V. Open DiscussionOpen Discussion

VI.VI. Wrap-Up/AdjournmentWrap-Up/Adjournment

MRSA VHA BUNDLEMRSA VHA BUNDLE11

Active SurveillanceActive Surveillance

Aggressive Hand HygieneAggressive Hand Hygiene

Contact PrecautionsContact Precautions

Cultural TransformationCultural Transformation

1 Society of Healthcare Epidemiology of America   http://www.shea-online.org/Assets/files/position_papers/SHEA_MRSA_VRE.pdf

VA Pittsburgh – 4 West VA Pittsburgh – 4 West MRSA Infection Rates/BDOCMRSA Infection Rates/BDOC

Fig 1. MRSA Infections/1000 BDOC - 4W Surgical Ward

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

24 Mo. Pre FY02 FY03 FY04 FY05 FY06

Intervention begun

MR

SA

Inf

ectio

ns/1

000

BD

OC

VA Pittsburgh – SICU VA Pittsburgh – SICU MRSA Infection Rates/BDOCMRSA Infection Rates/BDOC

Fig. 2. MRSA Infections/1000 BDOC - SICU

0

1

2

3

4

5

6

24 Mo Pre FY04 FY05 FY06

Intervention begun

MR

SA

Inf

ectio

ns/1

000

BD

OC

UD MRSA Hospital-acquired Infection

0.00.10.20.30.40.50.60.70.80.91.0

FY04 FY05 FY06

# MRSA HAI/1000 BDOC

VA Pittsburgh – UD VA Pittsburgh – UD MRSA HAI Rates/BDOCMRSA HAI Rates/BDOC

#MR

SA

HA

I/10

00 B

DO

C

VA Pittsburgh - UDVA Pittsburgh - UD Resistant Organism and CDAD Resistant Organism and CDAD

RatesRates UD Resistant Organism and CDAD Rates

0.00.51.01.52.02.53.0

HA

I & M

RSA

Tra

nsm

issi

ons/

1000

BD

OC

MRSA HAI MRSA Transmission VRE HAI ESBL HAI CDAD

Definitions to ConsiderDefinitions to Consider

Infection DefinitionsInfection Definitions Number of MRSA HAI/ 1000 Bed Days of CareNumber of MRSA HAI/ 1000 Bed Days of Care Number of MRSA HA Device-Related Infections / Number of MRSA HA Device-Related Infections /

Patient Device Days (x 1000)Patient Device Days (x 1000) (required for critical care units; optional for non-(required for critical care units; optional for non-

critical care units)critical care units)

Transmission DefinitionsTransmission DefinitionsMRSA negative or not done on admission and the MRSA negative or not done on admission and the 11stst MRSA colonization or MRSA infection occurs MRSA colonization or MRSA infection occurs

greater than greater than 48 hours after admission.48 hours after admission. Number of MRSA HA Transmissions / Bed Days of Number of MRSA HA Transmissions / Bed Days of

Care (x 1000)Care (x 1000)

Getting to Zero GoalsGetting to Zero Goals

Goal 1:Goal 1: Reduce MRSA Infections by 50% of Reduce MRSA Infections by 50% of facility baseline*. This is based upon 2yr facility baseline*. This is based upon 2yr retrospective review of clinical cultures.retrospective review of clinical cultures.

Goal 2:Goal 2: Reduce incidence of clinical isolates by Reduce incidence of clinical isolates by 50% of facility baseline*. Also based upon 2yr 50% of facility baseline*. Also based upon 2yr retrospective review.retrospective review.

Initially these will be based upon data for the pilot Initially these will be based upon data for the pilot unit(s)unit(s)

only. Facility-wide baseline information will be only. Facility-wide baseline information will be expected for any facility wishing to seek exemption expected for any facility wishing to seek exemption status.status.

Questions or Questions or CommentsComments