MRSA Prescreening and MRSA Prescreening and Eradication:Eradication:New England Baptist New England Baptist Hospital ExperienceHospital Experience

David H. Kim, MDDavid H. Kim, MDDirector of Medical EducationDirector of Medical EducationNew England Baptist HospitalNew England Baptist HospitalBoston, MABoston, MA

New EnglandBaptist Hospital 150-bed adult

medical/surgical hospital located in Mission Hill area of Boston

Orthopaedic subspecialty hospital & “Center of Excellence”– Acute inpatient discharges:

75% Orthopedic 8% General Surgery 17% Medical

Orthopaedic Surgery ~ 10,000/cases a year

Total Inpatient Volume Massachusetts MarketOrthopaedic Surgery

54,17153,823

52,625

51,127

48,213

45,000

46,000

47,000

48,000

49,000

50,000

51,000

52,000

53,000

54,000

55,000

2002 2003 2004 2005 2006

New England Baptist HospitalMarket Growth ~ 11%

10.82%

8.20%

6.22%5.80%

4.25%

0%

2%

4%

6%

8%

10%

12%

NEBH MGH BWH UMASS Baystate

2002 2003 2004 2005 2006

Methicillin-resistant Methicillin-resistant Staphylococcus AureusStaphylococcus Aureus

S. AureusS. Aureus

Most important Most important pathogen in SSIpathogen in SSI

Most SSI caused by Most SSI caused by strains carried by strains carried by patient into hospitalpatient into hospital

Anterior nares main Anterior nares main nicheniche

Nasal carriage of Nasal carriage of S. S. aureusaureus is risk factor is risk factor for SSI for SSI [Kluytmans et al, [Kluytmans et al, Clin Microbiol Rev 1997]Clin Microbiol Rev 1997]

MRSA vs. MSSAMRSA vs. MSSA

Infection associated with higher Infection associated with higher mortalitymortality [Melzer et al, Clin Infect Dis 2003][Melzer et al, Clin Infect Dis 2003]

Survive in dry conditions & on Survive in dry conditions & on inanimate surfaces up to 20 days inanimate surfaces up to 20 days [Clarke et al, Ir Med J 2001][Clarke et al, Ir Med J 2001]

Prevalence increasingPrevalence increasing

History of MRSAHistory of MRSA

Resistance to PCN within 1 yrResistance to PCN within 1 yr– By 1950’s, 3/4 of By 1950’s, 3/4 of S. aureusS. aureus strains PCN- strains PCN-

resistantresistant– Today, 90-95% clinical strains PCN-resistantToday, 90-95% clinical strains PCN-resistant

1959—methicillin (11959—methicillin (1stst antistaph PCN) antistaph PCN) introducedintroduced– 11stst MRSA strain within 2yrs MRSA strain within 2yrs– 60% of clinical 60% of clinical S. aureusS. aureus strains isolated strains isolated

from ICU’s are MRSAfrom ICU’s are MRSA

LinezolidLinezolid

Introduced in 2000 for MRSAIntroduced in 2000 for MRSA

–Resistant strain reported within 1 yearResistant strain reported within 1 year[Tsiodras et al, Lancet 2001][Tsiodras et al, Lancet 2001]

Daptomycin

Introduced in 2003 for MRSA

• Resistant strain reported within 2 yearsResistant strain reported within 2 years[Mangili et al, Clin Infect Dis 2005][Mangili et al, Clin Infect Dis 2005]

Vancomycin Vancomycin ResistanceResistance Recognized after almost 40 yrsRecognized after almost 40 yrs

– 11stst glycopeptide-intermediate glycopeptide-intermediate S. aureusS. aureus (GISA) isolated in Japan in 1996 (GISA) isolated in Japan in 1996 [Hiramatsu et al, J Antimicrob Chemother 1997]

High level resistance appeared in High level resistance appeared in Detroit in 2002Detroit in 2002– vanAvanA gene complex acquired from VRE gene complex acquired from VRE

[Centers for Disease Control and Prevention, MMWR [Centers for Disease Control and Prevention, MMWR Morb Mortal Wkly Rep 2002]Morb Mortal Wkly Rep 2002]

22ndnd strain in Philadelphia strain in Philadelphia 33rdrd strain in New York strain in New York

MIC CreepMIC Creep

Increases in vancomycin MIC in both MRSA Increases in vancomycin MIC in both MRSA & MSSA over time & MSSA over time [Rhee et al, Clin Infect Dis 2005][Rhee et al, Clin Infect Dis 2005]

Largest study of >6000 Largest study of >6000 S. aureusS. aureus isolates isolates over 5 yrs in California university hospitalover 5 yrs in California university hospital– Drift towards reduced susceptibilityDrift towards reduced susceptibility ing percentage of isolates with MIC ≥ 1.0 ing percentage of isolates with MIC ≥ 1.0

μμg/mLg/mL 19.9% in 200019.9% in 2000 70.4% in 200470.4% in 2004 [Wang et al, J Clin Microbiol 2006][Wang et al, J Clin Microbiol 2006]

MIC CreepMIC Creep

’’d vancomycin failure rate in d vancomycin failure rate in MRSA infections in setting of MRSA infections in setting of ’d ’d MICsMICs– [Sakoulas et al, J Clin Microbiol 2005][Sakoulas et al, J Clin Microbiol 2005]

Surgical Site Infection Surgical Site Infection (SSI)(SSI) Increased costsIncreased costs

– Median hospital stay Median hospital stay increased 2 wksincreased 2 wks

– Rehospitalization Rehospitalization rates doubledrates doubled

– Overall costs tripledOverall costs tripled

[Whitehouse et al, Infect Control Hosp Epidemiol 2002]

SSI CostsSSI Costs

CapitationCapitation– DRGs do not cover DRGs do not cover

cost of treating cost of treating nosocomial nosocomial infection infection (considered (considered “preventable”)“preventable”)

Risk of SSI Increased Risk of SSI Increased in Nasal Carriersin Nasal Carriers Nasal carriage only independent risk Nasal carriage only independent risk

factor for factor for S. aureusS. aureus SSI in orthopaedic SSI in orthopaedic implant surgeryimplant surgery– Kalmeijer et al, Infect Control Hosp Epidemiol 2000Kalmeijer et al, Infect Control Hosp Epidemiol 2000

SSI rate 2-9x higher in carriersSSI rate 2-9x higher in carriers– Kluytmans et al, Clin Microbiol Rev 1997Kluytmans et al, Clin Microbiol Rev 1997– Perl et al, Ann Pharmacother 1998Perl et al, Ann Pharmacother 1998– Wenzel et al, J Hosp Infect 1995 Wenzel et al, J Hosp Infect 1995

In In S. aureusS. aureus SSI, SSI, S.aureusS.aureus isolates from isolates from wound match nares 85% of time wound match nares 85% of time – Perl et al, N Engl J Med 2002Perl et al, N Engl J Med 2002

Risk Factors forRisk Factors forS. AureusS. Aureus SSI SSI

Observational study of 357 cardiac Observational study of 357 cardiac surgery patientssurgery patients

27% nasal carriers27% nasal carriers SSI rate 6.4%SSI rate 6.4%

– S. aureusS. aureus in 64% in 64%– 8/16 infections in nasal carriers8/16 infections in nasal carriers

Independent risk factorsIndependent risk factors– Diabetes (RR 5.9)Diabetes (RR 5.9)– Reoperation (RR 3.1)Reoperation (RR 3.1)– S. aureusS. aureus nasal carriage (RR 3.1) nasal carriage (RR 3.1)

[Munoz et al, J Hosp Infect 2008]

Risk of MRSA Nasal Risk of MRSA Nasal CarriageCarriage

Case-control study of 308 Case-control study of 308 vascular surgery pts (nasal vascular surgery pts (nasal swabs)swabs)– 11.4% MSSA carriers11.4% MSSA carriers– 4.2% MRSA carriers4.2% MRSA carriers

2.9% on admission2.9% on admission 1.3% acquired in hospital1.3% acquired in hospital

Transfer from another dept or Transfer from another dept or facility risk factors for MRSA facility risk factors for MRSA carriagecarriage

MRSA infection rateMRSA infection rate– 30.8% in MRSA carriers30.8% in MRSA carriers– 0.68% in noncarriers0.68% in noncarriers

[Morange-Saussier et al, Ann Vasc Surg 2006]

Environmental Environmental ReservoirsReservoirs

MRSA infected/colonized pts MRSA infected/colonized pts contaminate rooms, contribute to contaminate rooms, contribute to endemic MRSAendemic MRSA

Prospective study of 25 MRSA ptsProspective study of 25 MRSA pts Sampling of isolation roomsSampling of isolation rooms

– 53.6% of surface samples positive53.6% of surface samples positive– 28% of air samples28% of air samples– 40.6% of settle plates40.6% of settle plates

Isolates identical or closely related Isolates identical or closely related in 70% of patientsin 70% of patients

[Sexton et al, J Hosp Infect 2006]

Environmental Environmental ReservoirsReservoirs

[Sexton et al, J Hosp Infect 2006]

Potential Airborne Potential Airborne TransmissionTransmission

[Sexton et al, J Hosp Infect 2006]

Airborne TransmissionAirborne Transmission

MRSA counts MRSA counts remain elevated remain elevated for up to 15 for up to 15 minutes after bed minutes after bed makingmaking

Consider air Consider air ventilation & ventilation & filtrationfiltration

Keep doors closedKeep doors closed[Shiomori et al, J Hosp Infect 2002]

Inadequate Patient Inadequate Patient SpaceSpace 18-month 18-month

prospective studyprospective study Addition of fifth Addition of fifth

bed to four-bed bed to four-bed baybay

’’d relative risk of d relative risk of MRSA colonization MRSA colonization 315%315%

[Kibbler et al, J Hosp Infect 1998]

Long-term Care Long-term Care FacilitiesFacilities 44% of 44% of

environmental environmental surfaces tested surfaces tested positive for MRSApositive for MRSA

[Asoh et al, Intern Med 2005]

Decolonization of Decolonization of CarriersCarriers

Intranasal mupirocin Intranasal mupirocin (Bactroban)(Bactroban)

Eradicates nasal Eradicates nasal colonization in most colonization in most patientspatients

Reduces Reduces S. aureusS. aureus infectionsinfections– Herwaldt, J Hosp Infect 1998; Herwaldt, J Hosp Infect 1998;

Kluytmans et al, Infect Control Hosp Kluytmans et al, Infect Control Hosp Epidemiol 1996; Tacconelli et al, Clin Epidemiol 1996; Tacconelli et al, Clin Infect Dis 2003 (Infect Dis 2003 (dialysisdialysis))

– Cimochowski et al, Ann Thorac Surg Cimochowski et al, Ann Thorac Surg 2001; Kluytmans et al, Infect Control 2001; Kluytmans et al, Infect Control Hosp Epidemiol 1996 (Hosp Epidemiol 1996 (CardiovascCardiovasc))

– Gernaat-van der Sluis et al, Acta Gernaat-van der Sluis et al, Acta Orthop Scand 1998 (Orthop Scand 1998 (orthoortho))

– Perl et al, N Engl J Med 2002 (Perl et al, N Engl J Med 2002 (mixedmixed))

Mupirocin and the Risk Mupirocin and the Risk of of S. Aureus S. Aureus (MARS) (MARS) StudyStudy

University of IowaUniversity of Iowa Prospective randomized double-blind placebo-Prospective randomized double-blind placebo-

controlledcontrolled 4020 enrolled, 3864 analyzed4020 enrolled, 3864 analyzed

– Elective cardiothoracic, general, oncologic, gyn, neuro surgeryElective cardiothoracic, general, oncologic, gyn, neuro surgery Rate of Rate of S. aureus S. aureus SSI (primary endpoint)SSI (primary endpoint)

– 2.3% in mupirocin pts2.3% in mupirocin pts– 2.4% in placebo pts2.4% in placebo pts

No reduction in rate of S. aureus SSINo reduction in rate of S. aureus SSI– Among nasal carriers, risk of nosocomial Among nasal carriers, risk of nosocomial S. aureus S. aureus infection infection

decreased by half (7.7% to 4.0%)decreased by half (7.7% to 4.0%)

[Perl et al, N Engl J Med 2002]

MARS StudyMARS Study

Mupirocin nasal swab for up to 5 daysMupirocin nasal swab for up to 5 days Chlorhexidine shower for cardiothoracic Chlorhexidine shower for cardiothoracic

pts night before & morning of surgerypts night before & morning of surgery Power analysisPower analysis

– 4046 pts to detect 50% 4046 pts to detect 50% in in S. aureus S. aureus SSI SSI (estimated reduction of 2.8% (57 pts) to (estimated reduction of 2.8% (57 pts) to 1.4% (28 pts) with 85% power1.4% (28 pts) with 85% power

4030 enrolled, 3551 completed study4030 enrolled, 3551 completed study– 82.6% received at least 3 mupirocin doses 82.6% received at least 3 mupirocin doses

[Perl et al, N Engl J Med 2002]

MARS Study Infection MARS Study Infection RatesRates

Risk of Risk of S. aureus S. aureus infection among nasal carriers cut in halfinfection among nasal carriers cut in half S. aureus S. aureus SSI 4.5x higher in carriers receiving placeboSSI 4.5x higher in carriers receiving placebo 84.6% isolates from SSI pts identical between wound & nares84.6% isolates from SSI pts identical between wound & nares 39 different strains among 77 patients39 different strains among 77 patients Mupirocin resistance in 6/1021 (0.6%) isolates over 4 yrsMupirocin resistance in 6/1021 (0.6%) isolates over 4 yrs

Effect of Universal Effect of Universal Screening: University of Screening: University of Geneva HospitalGeneva Hospital [Harbarth et al, JAMA [Harbarth et al, JAMA

2008]2008] Prospective interventional cohort with crossoverProspective interventional cohort with crossover 21,754 pts (multiple surgical subspecialty wards)21,754 pts (multiple surgical subspecialty wards) Rapid screening + standard infection control Rapid screening + standard infection control

measures vs. standard measures alonemeasures vs. standard measures alone MRSA Screening before or on admission by PCRMRSA Screening before or on admission by PCR Standard infection control for MRSA carriersStandard infection control for MRSA carriers

– Contact isolationContact isolation– Gown, mask, glovesGown, mask, gloves– Adjusted perioperative abxAdjusted perioperative abx– Mupirocin & chlorhexidine x 5 daysMupirocin & chlorhexidine x 5 days

Universal rapid MRSA admission screening did Universal rapid MRSA admission screening did not reduce nosocomial MRSA infectionnot reduce nosocomial MRSA infection

Incidence of MRSA Incidence of MRSA Infections Infections [Harbarth et al, JAMA 2008][Harbarth et al, JAMA 2008]

Harbarth et al: ResultsHarbarth et al: Results 94% (10,193/10,844) screened94% (10,193/10,844) screened

– 21,754 pts--70% power to detect reduction in MRSA infection 21,754 pts--70% power to detect reduction in MRSA infection rate from 0.9% to 0.6%rate from 0.9% to 0.6%

5.1% (515 pts) MRSA-positive5.1% (515 pts) MRSA-positive No difference in MRSA SSI rateNo difference in MRSA SSI rate

– 0.99% (76 pts) without screening0.99% (76 pts) without screening– 1.14% (93 pts) with screening1.14% (93 pts) with screening

57% (53/93 pts) with nosocomial MRSA infection 57% (53/93 pts) with nosocomial MRSA infection during screening period were MRSA-free on during screening period were MRSA-free on admissionadmission– 31% of MRSA carriers identified after surgery31% of MRSA carriers identified after surgery– 43% of MRSA carriers identified before surgery rec’d 43% of MRSA carriers identified before surgery rec’d

appropriate abx prophylaxis appropriate abx prophylaxis

Harbarth et alHarbarth et al

None of MRSA carriers detected during None of MRSA carriers detected during outpatient preop visits developed outpatient preop visits developed MRSA infectionMRSA infection– all received decolonization treatment & all received decolonization treatment &

appropriate antibiotic prophylaxisappropriate antibiotic prophylaxis 57% of infections hospital-acquired57% of infections hospital-acquired

Preoperative Preoperative DecolonizationDecolonization University of PittsburghUniversity of Pittsburgh Prospective Prospective

observational studyobservational study Total joint arthroplastyTotal joint arthroplasty 1966 patients1966 patients

– 636 screened (nasal)636 screened (nasal) 26% positive for S. 26% positive for S.

aureus (164/636)aureus (164/636) 23% MSSA (147/636)23% MSSA (147/636) 3% MRSA (17/636)3% MRSA (17/636)

– 1330 control (not 1330 control (not screened)screened)

[Rao et al, Clin Orthop Relat Res 2008]

Pittsburgh ProtocolPittsburgh Protocol

DecolonizationDecolonization– Pts educated 1 wk preopPts educated 1 wk preop– Mupirocin nasal ointment BID x 5 Mupirocin nasal ointment BID x 5

daysdays– Chlorhexidine bath QD x 5 daysChlorhexidine bath QD x 5 days

Pittsburgh ResultsPittsburgh Results

Pittsburgh ResultsPittsburgh Results

No increase in infection from other No increase in infection from other pathogenspathogens

Estimated economic gain of $231,741/yrEstimated economic gain of $231,741/yr

NEBH Experience: Background FY06 - 46 SSI in 8986 surgical pts (0.5%)

– National rate for orthopedic SSI ~ 1.5% 57% SSI due to S. aureus

– 16 (35%) MSSA – 10 (22%) MRSA

PFGE of isolates documented community acquired strains

February 2006--133 anonymous nares cultures after patient anesthetized

Results:

38 – S. aureus (29%)

*5 - MRSA ( 4%)

•all previously undiagnosed

*no precautions used in OR, PACU or nursing units

*Cefazolin used for antibiotic prophylaxis

Anonymous Nasal Surveillance Cultures

Screening Proposals

February 2006 – prepared three screening proposals with costs1) Traditional nasal cultures - 3 day results

$245,000.00 2) Purchase rapid PCR equipment

$337,338.00 3) Lease rapid PCR equipment

$259,990.00 March 2006 –Board approval of

equipment purchase

March – October 2006– Weekly meetings:

surgical services, infection control, micro, administration, & medical staff members

– July 2006 – letter to surgeons – July 17, 2006 – initiated pilot on Spine

Service– August 2006 – letter to medical staff – September 2006 – initiated universal

program for all inpatient surgery

Implementation – 8 Months

Policy & Procedure Formalization Protocol developed for all departments & units

affected– OR Scheduling– Patient Access– Prescreening Unit – Pre-surgical unit – OR– PACU– Nursing Units– Microbiology Lab– Ancillary Departments: Housekeeping, Central

Transport, Radiology, etc.

NEBH Program: Preoperative NEBH Program: Preoperative Outpatient ScreeningOutpatient Screening Nasal swabs during

prescreening Microbiology Laboratory PCR

detects presence of bacteria-specific DNA– Cepheid GeneXpert – Results within 24 hrs for S. aureus,

2 hrs for MRSA Topical decolonization protocol

for patients found to be carriers of S. aureus or MRSA

Topical DecolonizationTopical Decolonization

ProtocolProtocol Intranasal 2% mupirocin

ointment (Bactroban) BID x 5 days

Shower with 2% chlorhexidine (Hibiclens) daily x 5 days

Patients called by PASU to initiate treatment protocol

Repeat call to document compliance

MRSA carriers re-screened prior to surgery

Contact precautions if 2nd MRSA screen positive

Vancomycin preop antibiotic prophylaxis for all patients with history of MRSA carrier status

Results

Study group (7/17/06 to 9/30/07)

– 7019 patients screened 5122 (73.0%) non-carriers 1588 (22.6%) S. aureus positive 309 ( 4.4%) MRSA positive

13/7019 (0.18%) SSI cases in screened patients– 7/5122 (0.14%) in noncarriers

(0.14%) 1/5122 MRSA (0.02%) 6/5122 S. aureus (0.11%)

– 6/1897 (0.31%) in carriers 3/309 + MRSA (0.97%) 3/1588 + S. aureus (0.19%)

SSI rate higher in carriers, highest in MRSA carriers

S. aureusS. aureus & MRSA SSI & MRSA SSI RateRate

Time Period Inpatient surgeries Total SSI SSI Rate

FY06 (no screening) 10/01/05-07/16/06 5293* 24 0.46%

FY07 (prescreening)07/17/06-09/30/07 7019** 13 0.18%

*historical controls **study group

MRSA & S. Aureus SSI Rates

•61% Reduction in S. aureus/MRSA SSI Rate

0

0.05

0.1

0.15

0.2

0.25

0.3

1 2

0.18%

0.06%

0.26%

0.13%

50% Reduction in MSSA SSI

60% Reduction in MRSA SSI

MRSA SSI Rate MSSA SSI Rate

10/01/05-07/16/06 07/17/06-09/30/07 10/01/05-07/16/06 07/17/06-09/30/07

Study LimitationsStudy Limitations

– Use of historical controls

Problem with Problem with Historical ControlsHistorical Controls

University of Amsterdam, The NetherlandsUniversity of Amsterdam, The Netherlands Prospective double-blind, placebo-controlledProspective double-blind, placebo-controlled 614 pts614 pts

– Elective ortho surgery with implants (hip, knee, Elective ortho surgery with implants (hip, knee, spine)spine)

Eradication rate 83.5% mupirocin, 27.8% Eradication rate 83.5% mupirocin, 27.8% placeboplacebo

No reduction in SSI rateNo reduction in SSI rate (primary outcome) (primary outcome)– Rate of endogenous Rate of endogenous S. aureus S. aureus infection 5x lowerinfection 5x lower

[Kalmeijer et al, Clin Infect Dis 2002][Kalmeijer et al, Clin Infect Dis 2002]

SSI RateSSI Rate

Spontaneous disappearance of deep Spontaneous disappearance of deep infections (SSI surveillance effect?)infections (SSI surveillance effect?)– Implications for use of historical controlsImplications for use of historical controls

[Kalmeijer et al, Clin Infect Dis 2002][Kalmeijer et al, Clin Infect Dis 2002]

NEBH SSI Rates 2003-2008NEBH SSI Rates 2003-2008

GENERAL SSI FY03 FY04 FY05 FY06 FY07FY08(Oct-Jun)# Infections 6 1 3 4 2 2# Procedures 1073 920 780 692 380Infection Rate 0.6 0.1 0.4 0.5 0.3 0.5

ORTHOPEDIC SSI

# Infections 63 60 49 46 39 28# Procedures 8837 9669 9216 8986 9027 6809Overall Infection Rate 0.7 0.6 0.5 0.5 0.4 0.4#Hip Infections 14 5 4 7 5 4 Hip Prosthesis Rate 1.0 0.3 0.2 0.4 0.3 0.3 Hip 0 Index 0.0 0.0 0.0#Knee Infections 21 14 11 7 7 10 Knee Prosthesis Rate 1.6 1 0.7 0.4 0.3 0.6 Knee 0 Index 0.2 0.2 0.4#Laminectomy Infec. 6 9 7 7 12 4 Laminectomy Rate 0.7 0.9 0.6 0.8 1.3 0.6#Spinal Fusions Infec. 5 15 12 12 5 2 Spinal Fusion Rate 0.8 2 1.4 1.1 0.4 0.2Other Ortho Infections 17 15 13 10 6 Other Ortho Rate 0.4 0.4 0.3 0.3

ConclusionsConclusions::

Program for comprehensive prescreening/treatment of S. aureus & MRSA prior to elective surgery is readily established & well-received

Program allows early identification of colonized patients, treatment, & adjustment of antibiotic prophylaxis, early isolation & contact precautions for MRSA

Associated with significant reduction in infections due to S. aureus & MRSA

MRSA colonized patients continue to have higher rate of SSI

First year costs ~$400,000

~$100,000 for 2 full-time positions:

•Microbiologist & PASU Medical Technician

~$60,000 PCR rapid test equipment

~Lab cost for PCR $40.00/test

(compared to routine culture ~ $20.00)

~ 6,000 inpatient surgeries = $240,000

NEBH Program Cost

Cost-effectiveness Cost-effectiveness AnalysesAnalyses

Compared 3 strategiesCompared 3 strategies Screen & treatScreen & treat Treat allTreat all NothingNothing

– AssumptionsAssumptions S. aureusS. aureus carrier rate 23.1% carrier rate 23.1% Mupirocin efficacy 51%, cost $48.36Mupirocin efficacy 51%, cost $48.36 Costs: septicemia $25,128, pneumonia $18,366, SSI $16,256Costs: septicemia $25,128, pneumonia $18,366, SSI $16,256

Both treatment strategies cost-savingBoth treatment strategies cost-saving– Treat all: prevents 1 infection/116 pts; 1 Treat all: prevents 1 infection/116 pts; 1

death/10,000 pts; save $88/ptdeath/10,000 pts; save $88/pt– Screen & treat: prevents 1 infection/27 pts; 1 Screen & treat: prevents 1 infection/27 pts; 1

death/2500 pts; save $102/ptdeath/2500 pts; save $102/pt

[Young and Winston, Infect Control Hosp Epidemiol 2006][Young and Winston, Infect Control Hosp Epidemiol 2006]

Cost-effectivenessCost-effectiveness

Budget impact model of rapid testing & Budget impact model of rapid testing & decolonizationdecolonization– 7,181,484 elective surgeries in US (2003)7,181,484 elective surgeries in US (2003)– Rapid test cost $25/ptRapid test cost $25/pt

sensitivity 52%sensitivity 52% Specificity 85%Specificity 85%

– Decolonization cost $72.50/ptDecolonization cost $72.50/pt 56.5% effective56.5% effective

– 7.5% SSI rate7.5% SSI rate 7.5% in carriers7.5% in carriers 1.5% in noncarriers1.5% in noncarriers

$231,538,400 cost saving, 364,919 fewer $231,538,400 cost saving, 364,919 fewer hospital days, 935 fewer in-hospital deaths hospital days, 935 fewer in-hospital deaths

[Noskin et al, Infect Control Hosp Epidemiol 2008]Noskin et al, Infect Control Hosp Epidemiol 2008]

Intangible BenefitsIntangible Benefits

NEBH S. aureus/MRSA prescreening & eradication program viewed very favorably as positive pro-active infection control measure by staff, patients, family members & media

Allows additional patient education on importance of hand hygiene, prevention of SSI, & infection control measures in home to reduce transmission of MRSA & S. aureus

ConcernsConcerns

NEBH Screening Results

7/17/06 to 9/30/07– 7019 patients screened

1588 (22.6%) S. aureus positive 309 ( 4.4%) MRSA positive

through April 30, 2008– 10,815 patients screened

2712 ( 25%) S. aureus positive 507 ( 5%) MRSA positive

Repeat nasal screens of MRSA carriers reveal 78% eradication rate

Prevalence of carriers increasing

Time Period Inpatient surgeries Surgical Infections Infec. Rate

FY06 10/01/05-07/16/06 5293 24 0.46%

FY0707/17/06-09/30/07 7019 13 0.18%

FY0810/01/07-06/30/08 4770 4 0.08%

New England Baptist Hospital

MRSA/MSSA Infection Rates

ConclusionsConclusions

Targeted active surveillance usefulTargeted active surveillance useful– In outbreaksIn outbreaks– In high-risk populations, e.g. ICU’sIn high-risk populations, e.g. ICU’s

Efficacy of universal surveillance & Efficacy of universal surveillance & eradication remains unproveneradication remains unproven– Depends on regional variations in Depends on regional variations in

MRSA/MSSA epidemiologyMRSA/MSSA epidemiology– Depends on hospital surveillance dataDepends on hospital surveillance data

Stanford vs. UCSFStanford vs. UCSF

AcknowledgementsAcknowledgements

Maureen Spencer, RN

Brian Kwon, MD

NEBH Board of Trustees

Joseph Dionisio, NEBH President and CEO

Ling Li, PhD

David Hunter, MD, PhD

Thank YouThank You