community-acquired methicillin-resistant staph. aureus (ca-mrsa): amarillo experience infectious...
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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 Not for publication
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Amarillo, Texas
MSA 2006 estimated population = 236,113
Three hospitals Health Department
serves citizens in two counties
69% White, 22% Hispanic, 6% African American
CA MRSA: Amarillo Experience. Preliminary data. Not for publication
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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
CA MRSA: Amarillo Experience. Preliminary data. Not for publication
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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
CA MRSA: Amarillo Experience. Preliminary data. Not for publication
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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
CA MRSA: Amarillo Experience. Preliminary data. Not for publication
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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
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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
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Amarillo CA-MRSA Investigation - gender
44%
56%
Female Male
CA MRSA: Amarillo Experience. Preliminary data. Not for publication
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Amarillo CA-MRSA Investigation - ethnicity
5%
11%
73%
11%
Black Hispanic White Other
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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
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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
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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
CA MRSA: Amarillo Experience. Preliminary data. Not for publication
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Mistaken for spider bite by either patient or physician
39%
59%
2%
Yes No Unknown
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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
CA MRSA: Amarillo Experience. Preliminary data. Not for publication
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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
%
CA MRSA: Amarillo Experience. Preliminary data. Not for publication
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MRSA – Antibiotic treatment
87
41
4
0
10
20
30
40
50
60
70
80
90
100
Multi-Drug Therapy Single Abx. Treatment Unknown
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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
CA MRSA: Amarillo Experience. Preliminary data. Not for publication
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CA-MRSA – exposure
31%
67%
2%
Previous Staph Exposure No Previous Staph Exposure Unknown
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CA-MRSA – Are you familiar?
23%
77%
Yes No
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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
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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
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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
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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
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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
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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