The document discusses different types of methicillin-resistant Staphylococcus aureus (MRSA) including community-associated MRSA (CA-MRSA), healthcare-associated MRSA (HA-MRSA), and livestock-associated MRSA (LA-MRSA). It notes that CA-MRSA strains are genetically unrelated to HA-MRSA strains and are enriched with genes like SCCmec IV and PVL toxin. The document also discusses transmission of MRSA between livestock animals like pigs and humans with occupational exposure, finding increased risk of MRSA carriage in those with direct contact to live animals. Overall, the document examines epidemiological characteristics and transmission dynamics of different MRSA strains, especially the emergence of LA-MR

1. MRSA
in
the
NL
01-­‐03-­‐13
¤ E-­‐MRSA
¤ HA-­‐MRSA
(HO-­‐CA-­‐MRSA,
HO-­‐LA-­‐MRSA)
¤ CA-­‐MRSA
(CO-­‐HA-­‐MRSA,
CO-­‐LA-­‐MRSA)
¤ LA-­‐MRSA
The
only
type
I
am
interested
in:
¤ IDCWYCI-­‐JTMHTFI-­‐MRSA*
*
I
Don’t
Care
What
You
Call
It
–
Just
Tell
Me
How
To
Fix
It
–
MRSA
(ScoR
Weese)
LA
HA
CA
CA-­‐MRSA
HA-­‐MRSA
LA-­‐MRSA
CA-­‐MRSA
HA-­‐MRSA
LA-­‐MRSA
“LiRle
brother”
“Main
problem”
“Giant
trouble”
Andreas
Voss,
MD,
PhD
1

2. MRSA
in
the
NL
01-­‐03-­‐13
CA-/HA-MRSA: Age Distribution!
¤ ProspecXve
cohort
study
of
MRSA
infecXons
idenXfied
in
12
Minnesota
laboratories
in
2000
¤ 1100
MRSA
infecXons
² 131
(12%):
community-­‐associated
² 937
(85%):
health
care-­‐associated
¤ Epidemiological
definiXon
Naimi et al. JAMA
2003; 290: 2976-84
Naimi et al. JAMA 2003; 290: 2976-84
CA-/HA-MRSA: Underlying conditions! CA-/HA-MRSA: Infection type!
Predominantly
skin
and
soc
Xssue
infecXons
No
underlying
condiXons
as
risk
factor
Naimi et al. JAMA 2003; 290: 2976-84 Naimi et al. JAMA 2003; 290: 2976-84
Andreas
Voss,
MD,
PhD
2

3. MRSA
in
the
NL
01-­‐03-­‐13
CA-/HA-MRSA: Susceptibility!
Enriched
with
SCCmec
IV,
PVL
and
other
exotoxins
SXll
suscepXble
to
most
other
classes
of
anXbioXcs
Naimi et al. JAMA 2003; 290: 2976-84 Naimi et al. JAMA 2003; 290: 2976-84
CA-/HA-MRSA: Clonal spread!
¤ Aboriginals
¤ NaXve
Americans
(indians,
eskimos)
¤ Jails
¤ Saunas
¤ Sport
teams
¤ Homosexual
men
¤ Military
recruits
¤ Day
Care
Centers
CA-­‐
strains
geneXcally
unrelated
to
HA-­‐MRSA
" SSTI
caused
by
CO-­‐MRSA
in
a
non-­‐outbreak
se;ng
(Atlanta,
Q3+4
2003)
" 384
persons
with
documented
CA-­‐SSTI
due
to
S.
aureus
King
et
al
Ann
Intern
Med
2006;144:309-­‐317
Andreas
Voss,
MD,
PhD
3

4. MRSA
in
the
NL
01-­‐03-­‐13
¤ Aboriginals
¤ NaXve
Americans
(indians,
eskimos)
¤ Jails
nearly
¾
¤ Saunas
MRSA
¤ Sport
teams
¤ Homosexual
men
nearly
90%
¤ Military
recruits
US
300/400*
¤ Day
Care
Centers
*
99%
(155
of
157)
of
the
typed
CA-­‐MRSA
isolates
were
USA
300
¤ Animal
lovers
?
King
et
al
Ann
Intern
Med
2006;144:309-­‐317
st
Fir es
cas
• 2004:
23%
• 2006:
50%
• 2010:
>70%
Andreas
Voss,
MD,
PhD
4

5. MRSA
in
the
NL
01-­‐03-­‐13
• 50
farms/232
individuals
– 50
farmers,
13
employees
• Three large pig slaughterhouses were studied in 2008 using
– 169
household
members
human and environmental samples.
• Intensive
pig
contact
(29%),
• The overall prevalence of nasal MRSA carriage in employees
medium
contact
(12%),
of pig slaughterhouses was 5.6%
person
living
on
farm
(2%)
MRSA
• Working with live pigs was the single most important
factor for being MRSA positive (OR 38.2, P0.0001).
• Higher
risk
with
sows
and
finishing
• Exact transmission routes from animals to humans remain to
pigs
be elucidated.
Van
Cleef
et
al.
Epidemiol
Infect
2010
doi:10.1017/S09502688100000245
P39
van
Cleef
et
al.
NVMM
2008
¤ 15.9%
of
humans
in
contact
with
calves
were
MRSA+
² 33%
of
the
farmers
(direct
contact)
² 8%
of
the
family
members
Graveland
et
al.
PLOSone
2010;
5:e10990
Graveland
et
al.
• 40 Dutch broiler flocks, in six slaughterhouses and 466 personnel
• 26 (5.6%) employees were positive
• Risk was significantly higher for personnel having contact with live
animals – especially hanging broilers on slaughterline (20.0%) vs all
other (1.9%).
• Conventional electric stunning = higher risk of MRSA carriage than
CO2 stunning (9.7% vs. 2.0%).
• From 40 Dutch slaughter flocks - 35.0% were positive.
• Of the 119 MRSA isolates, predominantly livestock-associated
MRSA ST398 was found, although 27.7% belonged to ST9 (spa type
t1430).
Mulders
et
al.
Epidemiol
Infect
2010
doi:
10.1017/S095026881000000075
Andreas
Voss,
MD,
PhD
5

6. MRSA
in
the
NL
01-­‐03-­‐13
¤ Randomly
selected
adults
(n=583)
from
3
Dutch
municipaliXes
in
high
pig-­‐desity
regions
¤ Of
the
534
persons
without
livestock-­‐contact,
one
was
posiXve
for
MRSA
(0.2%).
¤ Of
the
49
persons
who
did
indicate
to
be
working
at
or
living
on
a
livestock
farm,
13
were
posiXve
for
MRSA
(26.5%).
All
spa-­‐types
belonged
to
CC398.
Use
of
anXmicrobials
in
food
animal
producXon
à
¤ LA-­‐MRSA
has
a
high
prevalence
in
people
with
direct
contact
with
animals.
At
this
moment
it
has
not
spread
from
the
farms
into
the
resistant
m.o.’s
and
resistance
genes
can
spread
from
community.
animals
to
humans
Kluytmans
JA
Clin
Microbiol
Infect
2010;16:11
Buy two …
11.9%
… get millions for free !
Kluytmans
JA
Clin
Microbiol
Infect
2010;16:11
180
160
930%
increase
of
which
81%
140 (108/132)
was
due
to
ST398
120
ST398 unexpected
100
ST398
Other MRSA unexpected
80
other MRSA
60
40
20
0
2002 2003 2004 2005 2006 2007 2008
Frequency
of
newly
idenXfied
MRSA
posiXve
individuals
increased
from
16/
year
between
2002-­‐2006
to
148/year
between
2006-­‐2008
Andreas
Voss,
MD,
PhD
6

7. MRSA
in
the
NL
01-­‐03-­‐13
¤ More
cases
that
need
precauXons
and
isolaXon
¤ More
HCWs
complaining
about
extra
work
¤ Problems
of
isolaXon
¤ “Destroy”
part
of
SD
not
possible
with
permanent
source
¤ What
to
do
with
MRSA+
HCWs?
Nosocomial
transmission
of
ST398
MRSA
is
72%
less
likely
Wassenberg
et
al.
Clin
Microbiol
Infect
2010
Wulf
et
al.
Eurosurveillance
2008;13
Andreas
Voss,
MD,
PhD
7

8. MRSA
in
the
NL
01-­‐03-­‐13
¤ EsXmated
“lower
virulence
than
HA-­‐MRSA”
¤ Many
cases
of
skin
and
soc-­‐Xssue
infecXons
acer
direct
inoculaXon
(pig
bite
or
injuries
during
work)
¤ Case
of
endocardiXs
Ekkelenkamp
et
al.
Ned
Tijdschr
Geneesk
2006;150:2442-­‐7
¤ Case
of
osteomyeliXs
Van
Rijn
et
al.
P1951
¤ Severe
wound
infecXons
Declercq
et
al.
Infec_on
2008
(epubl.)
¤ InfecXon
acer
total
hip
replacement
¤ …
cases
to
common
to
publish
Andreas
Voss,
MD,
PhD
8

9. MRSA
in
the
NL
01-­‐03-­‐13
MRSA bacteremia in Europe!
Source: EARSS report
¤ Search
Destroy
(Control)
strategy
to
avoid
introducXon
of
MRSA
into
health-­‐care
setngs
and
reduce
the
chance
of
transmission:
² NaXonal
MRSA
guidelines
(WIP)
² NaXonal
detecXon
methods
(NVMM)
² Use
fast
and
reliable
detecXon
methods
¤ IsolaXon
and
screening
of
risk-­‐paXents
on
admission
² at
all
Xmes
¤ Placement
in
isolaXon
room
² colonized
and
infected
paXents
² with
anteroom
and
negaXve
pressure
¤ DecolonizaXon
of
MRSA
carriers
¤ Gloves,
gowns
and
face-­‐masks
¤ Consequent
acXons
when
transmissions
occur
² for
all
entering
the
room
² screening
of
all
paXents
and
HCWs
at
risk
² MRSA-­‐posiXve
HCWs
not
allowed
to
work
¤ Handhygiene
Andreas
Voss,
MD,
PhD
9

10. MRSA
in
the
NL
01-­‐03-­‐13
¤ IsolaXon
and
screening
of
risk-­‐paXents
on
admission
² can’t
determine
paXents
at
risk
² only
certain
departments!
² not
when
too
busy/weekends
² only
infected
paXents
¤ No
decolonizaXon
of
MRSA
carriers
¤ Non-­‐consequent
acXons
when
transmissions
occur
² screening
of
all
paXents
but
not
HCWs
à
consequently
MRSA-­‐posiXve
HCWs
may
conXnue
to
spread
MRSA
BSI
episodes
2000
1800
Year and quarter
1600
1400
BBC
World
news
1200
1000
800
600
400
200
0
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2005 2006 2007 2008 2009
Counts of MRSA bacteraemia
Courtesy: A.DATA ARE(HPA, Sept 2009) FOR WIDER CIRCULATION
* Pearson PROVISIONAL NOT
V.
Jarlier
et
al.
Arch
Intern
Med
2010
Andreas
Voss,
MD,
PhD
10

11. MRSA
in
the
NL
01-­‐03-­‐13
IsolaXon
IntervenXons
¤ IsolaXon
IntervenXons
¤ Placement
of
paXents
with
MRSA
infecXons
or
¤ PromoXon
of
Hand
Hygiene
colonizaXons
in
single-­‐bed
rooms
whenever
possible
¤ Barrier
precauXons
for
paXents
with
MRSA
infecXons
¤ IdenXficaXon
of
paXents
with
MRSA
or
colonizaXons
such
as:
infecXons
or
colonizaXons
² disposable
gloves
worn
before
and
discarded
acer
paXent
¤ Feedback
contact
² disposable
aprons
worn
for
extensive
contacts
(eg,
bed
¤ Annual
reports
making)
² small
equipment
(eg,
stethoscope)
dedicated
to
the
paXent.
PromoXon
of
Hand
Hygiene
¤ Hand
washing
with
disinfectant
soap
acer
contact
with
paXents
with
MRSA
infecXons
or
colonizaXons
before
leaving
the
room
¤ An
insXtuXonal
campaign
for
promoXng
the
use
of
alcohol-­‐
based
hand-­‐rub
soluXons
in
place
of
hand
washing
² launched
in
2001
² Training
materials
to
the
infecXon
control
teams
(slide
shows,
200
000
brochures,
and
14
000
posters)
² formal
leRers
by
the
general
director
asking
all
administrators,
heads
of
departments,
and
chief
nurses
to
support
the
campaign.
Should
we
ask
universal
precauXons
?
IdenXficaXon
of
MRSA
PaXents
Feedback
¤ Feedback
to
the
local
hospital
community
on
the
results
(MRSA
¤ Passive
surveillance
through
rouXne
clinical
specimens
rates
and
progress
in
program
implementaXon).
¤ AcXve
surveillance
(screening)
by
culturing
nares
of
paXents
with
a
high
risk
of
MRSA
colonizaXon,
eg,
intensive
Annual
report
care
unit
(ICU)
paXents
and
contacts
of
MRSA
paXents
¤ Each
hospital
reporXng
to
the
central
administraXon
¤ Quick
noXficaXon
and
flagging
of
new
paXents
with
MRSA
² size
of
the
infecXon
control
team
infecXons
or
colonizaXons
by
laboratories
to
medical
teams
² implementaXon
of
the
program
¤ IdenXficaXon
of
MRSA
paXent
rooms
and
charts
(sXcker)
² organizaXon
of
audits
(eg,
on
hand
hygiene)
¤ Informing
units
to
which
paXents
with
MRSA
are
transferred.
² feed-­‐back
² progress
of
the
iniXaXve
has
been
annually
presented
during
meeXngs
of
infecXon
control
teams
and
bacteriologists
from
all
AP-­‐HP
hospitals,
Andreas
Voss,
MD,
PhD
11

12. MRSA
in
the
NL
01-­‐03-­‐13
900 851 854
Each
person
only
included
once,
800 unless
a
new
subtype
is
found
705
R.
Skov
2009
700 659
600 547
No. of isolates
500
400
300
229
200
77 97 104 100
100 46 54 67
34 41
0
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
19
19
19
19
19
19
20
20
20
20
20
20
20
20
20
Import HA HACO CA
240
R.
Skov
2009
220 71% of the MRSA cases in Copenhagen area
were community-onset MRSA (CO-MRSA)
200
180
160
No. of isolates
140
120
100
80
60
...
lines
between
categories
may
be
“graying,”
with
40 community-­‐associated
strains
encroaching
on
20 hospitals,
and
health-­‐care
associated
strains
0 entering
the
community.
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
¤
we
have
all
kind
of
SSCmec-­‐types
in
the
hospital
(including
IV
and
V)
¤
we
have
healthcare
outbreaks
of
ST398-­‐MRSA
and
CA-­‐MRSA
strains
v
36.4%
of
11
CA-­‐MRSA
and
43.9%
of
66
HA-­‐MRSA
harbored
SCCmec
type
IV/IVA.
¤
we
have
HA-­‐MRSA
strains
in
the
community,
in
v
Type
IV/IVA
has
become
the
most
common
SCCmec
type
in
pets
and
in
livestock
animals
inpaXents
of
a
Swiss
university
hospital.
v
SCCmec
type
IV/IVA
is
present
in
both
CA-­‐MRSA
and
HA-­‐MRSA
limiXng
its
use
as
a
marker
for
CA-­‐MRSA.
¤
MRSA
-­‐
it’s
not
graying,
it
is
gray!
Stranden
et
al.
InfecXon
2009;37:44
Andreas
Voss,
MD,
PhD
12

13. MRSA
in
the
NL
01-­‐03-­‐13
CA-­‐MRSA
HA-­‐MRSA
LA-­‐MRSA
CA-­‐MRSA
HA-­‐MRSA
LA-­‐MRSA
Just-­‐MRSA
¤
We
know
the
risk
factors
for
HA-­‐MRSA
²
foreign
admission/dialysis,
adopXon,
known
outbreaks,
(nursing
homes)
¤
We
know
the
risk
factors
for
LA-­‐MRSA
²
pig-­‐
and
calf-­‐farming
(poultry)
²
(but
this
may
change)
¤
We
know
some
of
the
risk
factors
for
CA-­‐MRSA
²
but
can’t
use
them
for
SD
Import HA HACO CA
¤
Consequent
decolonizaXon
of
all
MRSA
240
R.
Skov
2009
71% of the MRSA cases in Copenhagen area
220
carriers
(especially
outside
the
hospitals)
is
of
200
were community-onset MRSA (CO-MRSA)
The
Danish
curbed
this
outbreak
by
upmost
importance
!
180 ”destroying”
the
community
sources
160
No. of isolates
²
works
with
HA-­‐MRSA
140
120
²
should
work
with
CA-­‐MRSA
100
80
²
trouble
LA-­‐MRSA
60
40
20
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Andreas
Voss,
MD,
PhD
13

14. MRSA
in
the
NL
01-­‐03-­‐13
¤
To
a
certainly
level
it
may
be
the
major
components
that
count
not
the
details:
While
important
other
factors
count:
¤
Compliance
with
basic
infecXon
control
²
Good
epidemiology
measures
in
all
(healthcare)
setngs
²
Screening
¤
Infrastructure
of
healthcare
setngs
²
IsolaXon
(single
room
and
glove
and
gowns)
²
Hand
hygiene
¤
HCW-­‐paXent/client
raXo
²
CommunicaXon
¤
AnXbioXc
use
²
DecolonizaXon
¤
Farming
(!)
food
(?)
¤
PDF
of
b/w
slides
(6
per
page)
at:
hRp://www.slideshare.net/iPrevent/
June
25-­‐28,
2013
Geneva
Switzerland
www.icpic2013.com
“We
appreciate
you
“Before
you
criXsize
someone
you
should
walk
a
reading
ciXng
ARIC
and
welcome
mile
in
their
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…
your
manuscripts”
…
that
way,
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he
gets
angry,
he'll
be
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away,
and
you
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their
shoes
”
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Homer
Simpson
“SlideShare
iPrevent”
Andreas
Voss,
MD,
PhD
14