MRSA screening -Pros & Cons- - PDF 무료 다운로드

그람양성다제내성세균격리 -Pros & Cons- 서울대학교의과대학내과학교실분당서울대학교병원감염내과 / 감염관리실김홍빈

Increasing prevalence of MRSA & VRE 100 80 Resistant (%) 60 40 Penicilllin non-susceptible S. pneumoniae Methicillin-resistant S. aureus 20 0 Vancomyci n-resi stant E. faecium 1970 1975 1980 1985 1990 1995 2000 2005 2010 Year ( 정영희 & 김홍빈. 대한내과학회지 2015;88:487-501)

오늘다룰내용들 Infection Control Programs : horizontal versus vertical approaches Methicillin-resistant S. aureus (MRSA) Vancomycin-resistant enterococci (VRE) Clostridium difficile infections (CDI) Conclusions

Infection control programs -Horizontal versus Vertical- (Wenzel RP & Edmond MB. Int J Infect Dis 2010;14S4:S3-S5)

Infection control interventions Horizontal All infections due to all pathogens Vertical A single pathogen or single anatomic site Standard precautions Universal use of gloves or gloves & gowns Universal decolonization Antimicrobial stewardship Environmental cleaning & disinfection Active surveillance testing Contact precautions Decolonization (Septimus E et al. Infect Control Hosp Epidemiol 2014;35:797-801)

The general classification depending on the type of study design (Wenzel RP & Edmond MB. Int J Infect Dis 2010;14S4:S3-S5)

Hierarchy of quasi-experimental study designs (Harris AD et al. Clin Infect Dis 2005;41:77 82)

Overall Level of Evidence Behind IDSA Practice Guidelines 4218 individual recommendations in the 41 analyzed guidelines 14% classified as level I, 31% as level II, and 55% as level III evidence Among class A recommendations (good evidence for support), 23% as level I ( 1 randomized controlled trial) & 37% based on expert opinion only (level III). (Lee DH & Vielemeyer O. Arch Intern Med. 2011;171(1):18-22)

Search-and-destroy policy Contact tracing of identified MRSA patients Screening of high-risk patients upon admission Increased adherence to standard hygiene and isolation precautions The use of rapid diagnostic tests (http://ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/database/pages/map_reports.aspx/)

Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) Trial Intensive versus standard control strategies Active surveillance, universal gloving, contact precautions proper hand hygiene, use of standard precautions, collection of surveillance cultures without reporting of results to these sites (Huskins WC et al. N Engl J Med 2011;364:1407-1418)

Universal Glove and Gown Use & MDRO in the ICU: cluster-randomized trial (Harris AD et al. JAMA 2013;310(15):1571-1580)

Decolonization using CHG For high-risk patients (ex. ICU) Lower incidence of bacteremia (Milstone AM et al. Lancet 2013;381(9872):1099-1106) Reduced risk for acquisition of MDROs and development of hospital-acquired bloodstream infections (Climo MW et al. N Engl J Med 2013;368(6):533-542) Lower rates of MRSA clinical isolates and bloodstream infection from any pathogen (Huang SS et al. N Engl J Med 2013;368(24):2255-2265)

Quality & Level of evidence

What to do?

Iceberg effect Asymptomatic colonizer: substantial reservoir for MDROs Clinical culture alone 5~10% MRSA or VRE Active surveillance culture 20~25% MRSA or VRE (Morgan DJ et al. JAMA 2014;312(4):1395-6)

MDROs 의출현은운명! penicillin susceptible Staphylococcus aureus penicillin penicillin resistant Staphylococcus aureus MRSA VISA/VRSA methicillin vancomycin cefotaxime susceptible Klebsiella pneumoniae cefotaxime ESBL producing Klebsiella pneumoniae carbapenem CRE (Carbapenem- Resistant Enterobacteriaceae) colistin? linezolid, daptomycin, QP/DP

중환자실의다제내성균 (2007-2013, KONIS) 100% 86.6% 2008 2009 2010 2011 2012 2013 83.1% 80% 66.2% 60% 60.5% 59.6% 40% 46.8% 44.5% 40.1% 20% 4.0% 0% MRSA VRE faecalis VRE faecium E. coli (CTX-R) K. pne (CTX-R) E. coli (CIP-R) K. pne (CIP-R) IRPA IRAB

Increasing MRSA prevalence in Korea 100 90 80 70 Resistance (%) 60 50 40 30 20 10 0 1976 1981 1986 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 2000 Year (Lee K et al. Yonsei Med J 2003;44:571-8)

Standard approaches for the control of endemic MRSA Reduce antibiotic use Education Restriction Identify carriers Screening Isolation Stop transmission Hand hygiene Eliminate reservoirs Decontamination

Screening & isolation to control MRSA -sense, nonsense, & evidence- (Fatkenheuer G et al. Lancet 2015;385:1146-9)

Uncertainty over the most effective strategies to control endemic MRSA Baseline MRSA prevalence & strain characteristics Hand hygiene compliance Placement of patients with MRSA in private rooms Frequency of bathing patients The agents used for bathing Methods of decolonization Methods of screening Time from screening to notification of results Efforts to decrease CLABSI or VAP

Institutional control of MRSA is like a marathon, not a sprint French experiences (38 hospitals, 15 years) Changes in the use of alcoholbased hand-rub solutions Change in MRSA incidence per 1000 HDs (Jarlier V. et al. Arch Intern Med 2010;170:552-559)

National Cleanyourhands Campaign (Stone S P et al. BMJ 2012;344:bmj.e3005)

Healthcare associated MRSA infections in VA facilities (Jain R et al. N Engl J Med 2011;364:1419-30)

Hand hygiene compliance Hospital-onset MRSA bacteremia From Jan 2008 to Jun 2014 Bayesian structural time-series models HH compliance: 33.2 to 90.2% Amount of hand sanitizer per 1000 PD: 28% (95% CI 13~42%) The incidence of HO-MRSAB per 1000 PD: 33% (95% CI -58~- 8.2%) A reduction of 54 HO-MRSAB cases during 48 months Total benefit/cost $1,095,876/$126,610 (unpublished data at SNUBH)

VRE 가중요한이유? 병원성이강하지는않다 : Low virulence 대부분 colonization >> pathogen S. aureus 에반코마이신내성전달가능 심각한기저질환을앓고있는환자에게흔함 선택할수있는치료약제가제한됨

반코마이신내성 S. aureus 출현

Placement of VRE-infected or colonized patients in a single room

환경관리도중요! X represents VRE culture positive sites ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

VRE 격리병실준비물 - 상단 : 천가운, 장갑 - 첫째서랍 : 장갑, 바이오하자드백, Alert sticker, 손씻기안내서등 - 둘째, 셋째서랍 : 가운과햄퍼주머니, 주황색비닐여유분

VRSA isolates till now 13 cases in USA (Limbago BM et al. J Clin Microbiol 2014;52(3):998-1002) 1 case in Latin America (Brazil) (Rossi F et al. N Engl J Med. 2014;370(16):1524-31) 1 case in Europe (Melo-Cristino J et al. Lancet 2013;382:205) 2 cases in Asia (Iran) (Aligholi M et al. Med Princ Pract 2008;17:432 434)

Efficacy of Infection Control Strategies to Reduce Transmission of VRE at SMC (4-Year Follow-Up Study) (YoonChang SW et al. Infect Control Hosp Epidemiol 2007;28(4):493-5)

Infection control & prevention measures to reduce the spread of VRE -a systematic review & meta-analysis- (De Angelis G et al. J Antimicrob Chemother 2014;69:1185 92)

Natural history of colonization with VRE: a systematic review model-estimated median time to clearance 26 weeks for VRE-colonized patients (Shenoy ES et al. BMC Infect Dis 2014;14:177)

Adverse outcomes associated with contact precautions Compliance>80% training & monitoring Financial & environmental costs Unintended consequences 25-50% less frequent visits Delays in hospital admission & discharge Lower patient satisfaction, depression, anxiety, or preventable adverse events including falls, pressure ulcers, or hypoglycemia (Morgan DJ et al. Am J Infect Control 2009;37(2):85-93)

간병인과방문객은?

More is not necessarily better

Incidence of CDI in Korea (Kim YS et al. Epidemiol Infect 2013;141(1):189-94)

격리입원실질환유형별격리기간 -2014 년 10 월 23 일보도자료 - 격리실입원료급여기준 [ 일반원칙 ] 에관한세부사항고시가신설 고시됨 (2014.9.1. 시행 ) 적용수가 : 제 1 장기본진료료가 -10 격리실입원료 (Isolation Room Patient Care) 격리입원실질환유형별격리기간 은다음과같이인정함. 마 ) 기타감염병 : 파종성대상포진, 로타바이러스, C. difficile, 옴 - C. difficile 감염증 : 치료기간 치료기간 : 항생제또는항바이러스제를사용하는경우는약제투여기간을의미하며, 대증치료를하는경우는증상이지속되는기간을의미함 (http://www.hira.or.kr/)

C. difficile 병원감염관리지침권고 ( 안 ) ( 배현주. 2014 정책연구용역사업최종결과보고서 - 의료기관내클로스트리듐디피실레감염실태파악및관리지침개발 ) (Surawicz CM et al. Am J Gastroenterol. 2013;108(4):478-98) (Dubberke ER et al. Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol 2014; 35(S2):S48-S65)

In the real world VRE 보균자격리에서겪었던어려움들이다시반복될가능성 다인실증가 1 인실확보의어려움 권고안의근거수준?

How far to go?

Think Globally, Act Locally

Conclusions 적용가능하고지속할수있는중재방안! Horizontal (hand hygiene, antimicrobial stewardship, & environmental cleaning) >> Vertical 1 st tier (basic practices), and then moving to 2 nd tier when an epidemiologically important MDRO are newly emerging or endemic rates of a target MDRO are not decreasing One Size Does Not Fit All Effectiveness vs costs vs adverse effects PDSA (Plan-Do-Study-Act) cycles MRSA: hand hygiene>> VRE: isolation in a single room or cohort<< CDI: ideal real?

SHEA Spring 2015 Conference (http://www.medscape.com/viewarticle/845404

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