Post on 27-Mar-2015
transcript
Methicillin resistant Staphylococcus aureus (MRSA)
in the Nordic countries
Petter ElstrømAdvisor
Norwegian Institute of Public Health
Objective
Prevent establishment of MRSA in hospitals
• Increased rate of MRSA enforce changes in empiric treatment of S. aureus-infections
• Changes in antibiotic-guidelines will lead to more resistant bacteria and increase the cost
Historical overview • Penicillin G introdused in 1941• Penicillin resistant (-lactamase prod.) S.aureus isolated
in 1942• Meticillin introdused in 1959 as the first -lactamase resistant penicillin• Meticillin resistant S.aureus first described in 1961• In late sixties MRSA was identified as a nosokomial
pathogen • In late nineties reduced sensitivity against Vancomycin
(VISA) was reported • Vancomycin resistant S.aureus (VRSA) isolated in 2002
First ”MRSA-wave”• Meticillin resistant first described in 1961• Worldwide spread of a single arcaic clone
Second “MRSA-wave”• Outbreaks in hospitals• 5 dominant clones
Third “MRSA-wave”• CA-MRSA• Evolution of ”old” clones• Continually new MRSA-strains discovered
Historical overview
CA-MRSA
• Both epidemiological and microbiological definition
• Increased incidence among people outside hospitals• Young people with no known risk factors for MRSA
• Differ genetically from strains inside hospitals– SCCmec IV, PVL
• Less resistant• Mainly skin- and soft tissue infections Occasionally
severe infections (necrotizing pneumonia)
Changed epidemiology
• Earlier:– Imported cases
– Related to hospital admission or employment
• Now:– Most domestic cases
– Increasing rate of cases not related to hospitals
– Often no known risk factors for MRSA
– Outbreaks in nursing homes
MRSA in western Europe
Source: www.earss.rivm.nl
Proportion of invasive isolates resistant to methicillin 2003
MRSA in England og Wales
0
5
10
15
20
25
30
35
40
45
50
Proportion (%) of MRSA i blood culture, 1989-2002
MRSA in the Nordic countries
*Estimated for 2005
Source: http://www.srga.org/SSAC/doc/2005/SSAC_MRSAreport_2004.pdf
0
5
10
15
20
25
30
Year
Inc
ide
nc
e (
No
/10
0.0
00
) Sweden
Finland
Denmark
Norway
Iceland
MRSA in DenmarkDistribution by place of transmission
0
50
100
150
200
250
300
1999 2000 2001 2002 2003 2004
No
. of c
ases
CO-MRSA
HA-MRSA
Imported
Source: Robert Skov, State serum institute, Sept. 2005
MRSA i Danmark
0
5
10
15
20
25
30
35
40
45
<1 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 >81
Age group
No
. of
ca
se
s
CA-MRSA
HA-MRSA
Distribution by age group, 2003
Source: Robert Skov, State serum institute, Sept. 2005
MRSA in Sweden
Community
Hospital
Primary care
Home for the elderly
Abroad (communityand hospital)
Unknown
S
2003 2004
Source: Otto Cars, Smittskyddsinstitutet, sept. 2005
Distribution by place of transmission
MRSA in NorwayNo. of cases, 1995 – 15.nov. 2005
0
50
100
150
200
250
300
350
400
450
500
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
No
. of
ca
se
s
Infection Colonization
0
2
4
6
8
10
12
14
16
18
20
No
. pe
r 1
00
00
0 2004
15. nov. 05
MRSA in NorwayProportion by county, 2004 - 2005
MRSA in NorwayDistribution by place of transmission
0
20
40
60
80
100
120
140
160
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
No
. o
f ca
ses
Domestic
Imported
Unknown
Hospitalized:
MRSA in NorwayDistribution by place of infection onset
0
20
40
60
80
100
120
140
160
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
No
. o
f ca
ses
Yes
No
Unknown
Reported outbreaks in health care institutions
0
1
2
3
4
5
6
7
2002 2003 2004 2005
Sykehus Sykehjem
MRSA in Norway
2003: 2 hospitals, 3 nursing homes
2004: 2 hospitals, 4 nursing homes
2005: 8 nursing homes
Challenges
• Increasing incidence of MRSA• Changing epidemiology• Bacterial evolution• Laboratorial methods are not optimal• Lack in knowledge• Differs in national and regional guidelines• Compliance of infection control measures are
not optimal
Actions
• Coordinate the guidelines in the Nordic countries • Discuss and coordinate advices and guidelines in
Norway• Better survey through genotyping of all isolates• Continue rational use of antibiotics• Science
• High quality in hygiene and other infection control measures