mrsa in correctional facilities · georgia prison 1 200 bed, short-term (90 days) rate - 423...
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MRSA in Correctional Facilities
Michael Kelley, M.D., M.P.H.Director of Preventive MedicineTexas Department of Criminal Justice
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CA-MRSA BackgroundInjection drug users - Detroit, 1980
Identified injection drug users as high risk1
Jail outbreaksGeorgia (2001), LA County (2002, 2003), Tennessee, 2002
PrisonsMS (2000), GA (2001, 2002)
SF County jailMRSA increased from 29% of isolates in 1997 to 74% in 20022
1 Ann Int Med 1982; 97:325-9,Ann Int Med 1982; 96:11-6
2 Clin Inf Dis 2003; 37(10):1384
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Georgia Prison 1200 bed, short-term (90 days)Rate - 423 infections/1,000 offender-yearsInterventions
Screening for skin diseaseStandard antibiotic recommendationsInmate educationAlcohol-based hand rubs
No cases for 8 months after interventions94.3 infections/1,000 offender-years in next 6 months MMWR 2003; 52(41):992-6
Inf Cont Hosp Epidemiol 2004; 25(5):402-7
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Georgia Prison 21,500 bed, long termRate - 60.4 infections/1,000 offender-yearsRisk factors
Previous antibiotic useSelf-draining of boilsSkin lacerationWashing clothes by handSharing soapIncarcerated in 2001 or later
MMWR 2003; 52(41):992-6
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Georgia Prison 2Initial Interventions
“Appropriate” launderingImproved access to wound careIncreased access to soapOffender education
Later InterventionsCohorting of infected offenders5-day course of chlorhexidine soap for all offenders
No sustained response to interventions seen
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Mississippi PrisonRisk Factors (multivariate analysis)
Sharing pillows or bed sheets (AOR = 40.6)Touching another offender’s boil (AOR = 21.4)Beta-lactam prescription within 1-12 months (AOR = 5.7)Using state-issued soap (AOR = 5.0)Self-reported insect bites (AOR = 4.2)
AOR = adjusted odds ratio
MMWR 2001; 50(42):919-22
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Mississippi PrisonNasal Colonization with MRSA
Female - 5.9%, Male - 2.5%Risk factors for colonization (multivariate)
Housed in disability sectionPicking/popping furunclesDoctor visit in past yearLonger incarceration
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Mississippi PrisonInterventions
Improved surveillanceOptimized antibiotic recommendationsReinforcing infection control practices in clinicsOffender educationUse of antimicrobial soap
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Georgia jail2,800 beds, average stay 25 daysRate
13.7 infections/1,000 offender-years initially84.3/1,000 offender-years with case finding
Inappropriate antibiotic use (beta-lactams) noted, even when MRSA culturedInterventions
Screening for skin infectionStandardized treatment regimensHygiene education for offendersChanges in laundry practice
MMWR 2003; 52(41):992-6
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Other jailsTennessee
Associated MRSA infection with tattooingNot associated with the tattooing apparatusContact with infected offenders after skin was broken by tattooing
LA CountyLarge numbers reported after surveillance started (46.1 - 77.6/1,000 offender-years)*
* MMWR 2003; 52(5):88MMWR 2003; 52(41):992-6
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Staph Infections in TDCJ
0
10
20
30
40
50
Infe
ctio
ns/1
,000
/yea
r
1996 1997 1998 1999 2000 2001 2002 2003 2004*
MRSA MSSA
*projected as of 6/30/04
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TDCJ149,424 Offenders
Prison - 104,430State Jail and SAFP - 28,887Transfer - 16,107
106 facilitiesAbout 1/3 population turnover/year1-2% in transit on any given dayFacilities are not air conditioned
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MRSA by Facility Type - 2002
MRSA Rate MRSA PercentTransfer 56.5 74%State Jail 53.1 79%Prison 29.7 60%
Rate expressed as cases/1000 offender-years
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Surveillance Jan-July 2004<1% of MRSA cases serious - pneumonia, sepsis, etc.15% classified as “serious skin infection” or cellulitis85% minor skin infectionsFemales - 28.3 cases/1000 offender-yearsMales - 32.0 cases/1000 offender-years
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Risk Factors - surveillance data (MRSA+MSSA)
4.6% of infections with known HIV status were HIV + (81% w/status known)5.1% had diabetes mellitus20% had a prior skin rash or lesion2.9% had been hospitalized within 30 daysRate of staph infections in 2002:
HIV + - 163 infections/1000/year (MRSA=101)Diabetics - 82 infections/1000/year (MRSA=53)General Population - 74.5 infections/1000/year
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Case-control study - MRSAWeak association with conviction in Harris County (OR 1.53, 95% CI 1.00-2.33)
Associated factors:School attendancePrevious skin infectionClose contact to case within 30 days
No association withJob assignmentSharing soap, clothing, linen, grooming itemsRecent tattooRecent medical encounter
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Medical Risk Factors in TDCJOffenders incarcerated 1999-2001Medical Alert Codes reviewedIncreased risk of MRSA if
FemaleAge < 30Non-Hispanic whiteState Jail or SAFP inmate
Clin Inf Dis 2004; 38:e92-5
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Medical Risk Factors - TDCJCondition Rate RR 95% CI
Circulatory 18 1.5 1.2-2.0Cardiovascular 17 1.3 1.1-1.7Diabetes 20 1.7 1.5-1.9ESLD 24 2.0 1.4-2.9ESRD 27 2.3 1.5-3.3HIV/AIDS 32 2.6 2.3-3.0
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Medical Risk Factors in TDCJOverall risk for MRSA was 12 initial infections/1,000 offender-yearsNo association found with skin diseaseMedical Alert Codes may be inaccurateCannot r/o associations being a surrogate for frequent medical encounter84% of infections not associated with any of the medical risk factors listed
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Nasal ColonizationNasal Carriers Infection Rates*
Facility MSSA MRSA MSSA MRSAA 30.5% 3.1% 27.0 224.7B 33.0% 2.7% 28.4 60.4C 15.1% 15.1% 14.9 56.2D 25.8% 4.9% 42.4 129.6
*Infections/1000/year
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MRSA (and MSSA) Control in TDCJ
Treat dermatitis promptly and aggressivelyStress good hygiene with staff and offendersCulture draining lesions - diagnose earlyTreat appropriatelyCover draining lesions or single-cell
Do not routinely isolate
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TreatmentAssure drainage is containedAssure adherence to therapyEmpiric initial therapy trimethoprim/sulfa and/or clindamycin
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MSSA
0%
20%
40%
60%
80%
100%
1998 1999 2000 2001 2002 2003 2004
Per
cent
Sus
cept
ible
Tm/S CIP CLIN ERY TCN
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Initial MRSA
0%
20%
40%
60%
80%
100%
1998 1999 2000 2001 2002 2003 2004
Per
cent
Sus
cept
ible
Tm/S CIP CLIN RIF TCN
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Recurrent MRSA
0%
20%
40%
60%
80%
100%
1998 1999 2000 2001 2002 2003 2004
Per
cent
Sus
cept
ible
Tm/S CIP CLIN RIF TCN
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Total Staph
0%
20%
40%
60%
80%
100%
1998 1999 2000 2001 2002 2003 2004
Per
cent
Sus
cept
ible
Tm/S CIP CLIN ERY OX TCN
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What Hasn’t WorkedDecolonization after first infectionCohortingChlorhexidine for cohorted offendersFrequent (TID) disinfection of common areasNot clear whether the intervention was ineffective or the implementation was inadequate
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Total Staph Infections/month
0200
400600
8001000
1200
Jan-0
0Mar-
00May
-00Ju
l-00
Sep-00
Nov-00
Jan-0
1Mar-
01May
-01Ju
l-01
Sep-01
Nov-01
Jan-0
2Mar-
02May
-02
Triclocarbanstopped
Triclocarbanresumed
Lab reporting
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Total Staph Infections/month
0
200
400
600
800
1000
1200
1400
Jan-
00Apr
-00
Jul-0
0Oct-
00Ja
n-01
Apr-0
1Ju
l-01
Oct-01
Jan-
02Apr
-02
Jul-0
2Oct-
02Ja
n-03
Apr-0
3Ju
l-03
Oct-03
Jan-
04Apr
-04
Jul-0
4
Triclocarbanstopped
Lab reporting
Triclocarbanresumed