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MRSA – MRSPInfection control
the Vet & the Human View
Monika LinekDip ECVDEuropean Specialist ofVeterinary Dermatology®
Dr. med. vet. Katja Reitt FAMH FVHHead of Veterinary diagnostics
St. Gallen
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Cleaning reduces 90% of pathogens Organic material has to be removed as it inactivates
disinfectants
Infection controll
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Staphylococci adhere to skin squames & hair30% body’s protein intake for skin & hairS. aureus isolated from air & surfaces around
peopleStaphylococci can survive on dry surfaces >12
months (including MRSA)In humans: mainly transmitted by hand contact
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Infection control
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Sources & Dynamics of Infection____________________________________________
Man:HA-MRSA Nosocomial MRSA: originate from 5 clustersCA-MRSA Community acquired MRSA: high varietyMRSP in pet owners – from their pets
Small nosocomial outbreaks, human to human withorigin in pets
Animal:MRSA mainly human origin (dogs, pigs, horses)MRSP originate from animals and environment (tenacity!)
Starlander G . et al: Cluster of infections caused by methicillin-resistant Staphylococcus pseudintermedius in humans in a tertiaryhospital. J Clin Microbiol. 2014 Aug;52(8):3118-20.
ESVD Therapeutics Workshop Davos 2018
MRSA-MRSP Infection control; the «human view»
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Sources of Infection____________________________________________
SA predominantly anthropozoonoticSP predominantly zoonotic
SA predominantly short-time & intermittent carriageSP prolonged / permanent carriage in dogs and intermittent in man
ESVD Therapeutics Workshop Davos 2018
MRSA-MRSP Infection control; the «human view»
Gómez-Sanz E. et al. Clonal dynamics of nasal Staphylococcus aureus and Staphylococcus pseudintermedius indog-owning household members. Detection of MSSA ST(398). (PLoS One. 2013 Jul 9;8(7)
Laarhoven L. et al: Longitudinal Study on Methicillin-Resistant Staphylococcus pseudintermedius in Households. (PLoS One. 2011Nov 6;11(6)
Wipf JR & Perreten V: Methicillin-resistant Staphylococcus aureus isolated from dogs and cats in Switzerland. Schweizer Archiv furTierheilkunde, 01 Jun 2016, 158(6):443-450
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Surfaces contacted by animals or hospital staff 1
Clothes of staff 2
Cellular phones3
Air samples 12% MRS positive4
MRSP contamination in animal hospitals
1Bergström A et al J. Small Anim. Pract 2012. Occurrence of methicillin-resistantstaphylococci in surgically treated dogs and the environment in a Swedish animalhospital2Singh A et al. Veterinary Surger 2013. Methicillin-Resistant StaphylococcalContamination of Clothing Worn by Personnel in a Veterinary Teaching Hospital3Julian T et al BMC Res Notes. 2012. Methicillin-resistant staphylococcal contaminationof cellular phones of personnel in a veterinary teaching hospital.4Lutz LA et al American journal of infection controll 2013. Nonoutbreak-relatedairborne Staphylococcus spp in a veterinary hospital
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13 vetclinics at 200 sites7 clinics MRSP-positive7-71% of the samples were positiveAfter cleaning and disinfection–3/6 clinics still MRSP positive sites
MRSP contamination in animal hospitals
van Duijkeren E et al., Transmission of methicillin-resistant Staphylococcus pseudintermedius betweeninfected dogs and cats and contact pets, humans and the environment in households and veterinary clinics.Vet. Microbiol. 2011
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MRSP riskfactors
MRSP is a nosocomial infection= hospital associated infection,
veterinary-care-associated epidemiology
risk factors for carriage, colonisation and infection:number of visits to animal care centers ( clinics,hospitals, practises)hospitalisation
Nienhoff et al 2011, Bergstrom 2012, Soares-Magalhaes et al., 2010, Lehner et al 2013
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Infection controll the Vet View
Implementation of a standard hygiene programmEducation of staffProcedures in known or suspected MDR infectionsScreening programms
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Standard hygiene programm
personel protective equipmenthand hygienecleaning and desinfection of premises,surfaces and equipment
Vet Clin Small Anim 45(2015)http://dx.doi.org/10.1016/
j.cvsm.2014.11.011
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Standard hygiene programm
personel protective equipmentprotective clothing worn at any times at the
working place and handling patientsnever outside the working placeshort sleeved lab coat/ free ellbowsprotecting all „street“ clothestrousersall clothing washable > 60° C (daily)shoes washable/ desinfectable
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1995
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Standard hygiene programm
personel protective equipmentprofessional laundry or in-clinicsseperation of clean and dirty laundryclean laundry stored at dedicated areas ideallynot on open spaces/shelves
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Wash your hands: simple habitsBefore, during, and after preparing foodBefore eating foodBefore and after caring for someone who is sickBefore and after treating a cut or woundAfter using the toiletAfter changing diapers or cleaning up a child who has usedthe toiletAfter blowing your nose, coughing, or sneezingAfter touching an animal, animal feed, or animal wasteAfter handling pet food or pet treatsAfter touching garbage
Standard hygiene programm
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Wash your hands simple habitsWet your hands with clean, running water (warm or cold),turn off the tap, and apply soapLather your hands by rubbing them together with the soap.Be sure to lather the backs of your hands, between yourfingers and under your nailsScrub your hands for at least 20 seconds. Need a timer?Hum the “Happy Birthday” song from beginning to endtwiceRinse your hands well under clean, running waterDry your hands using a clean towel or air dry them
Standard hygiene programm
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Hand hygieneno jewelry, no wristwatchno nail polish, artifical nails, short nailswash hands if visibly soileduse alcohol-based hand sanitizers 70-90%– before and after any handling of patients– before you touch anything else !– before and AFTER gloving
Standard hygiene programm
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Hand hygieneHow to use alcohol-based hand sanitizers 70-90%
apply ca 3ml"responsible application“ = cover all surfaces of
both hands with hand sanitizer and rub until dryor 5 step application30 sec
Standard hygiene programm
CDC. Guideline for Hand Hygiene in Health-Care Settings. MMWR Morb Mortal Wkly Rep.2002;51(RR16):1-44. Kampf G, Reichel M, Feil Y, Eggerstedt S, Kaulfers PM. Influence of rub-intechnique on required application time and hand coverage in hygienic hand disinfection. BMCInfect Dis. 2008;8:149.
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How to use alcohol-based hand sanitizers 70-90%
Standard hygiene programm
Influence of rub-in technique on required application time and hand coverage in hygienic handdisinfection. BMC Infect Dis. 2008;8:149.
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How to use alcohol-based hand sanitizers 70-90%
Standard hygiene programm
Influence of rub-in technique on required application time and hand coverage in hygienic handdisinfection. BMC Infect Dis. 2008;8:149.
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Hand hygiene controllMonitor hand sanitizers per clinic, per roomMonitor the convenience of locationMonitor the volume of hand sanitizers used per
patients per day/monthMonitor volume of pump levelMonitor performance by reference alcohol,
supplemented with 0.98% of fluorescent dye (Visirub,Bode Chemie GmbH & Co. KG, Hamburg, Germany
Standard hygiene programm
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AniCura Data on handsanitizers
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...........Hand hygiene improved significantly among nurses andnursing assistants, but remained poor among doctors----the consumption of alcohol-based handrub solutionincreased from 3.5 to 15.4 L per 1000 patient-days between1993 and 1998 (p<0.001).----During the same period, overall nosocomial infectiondecreased (prevalence of 16.9% in 1994 to 9.9% in 1998;p=0.04)---MRSA transmission rates decreased (2.16 to 0.93 episodesper 10,000 patient-days; p<0.001)
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N.Glos
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Standard hygiene programm
after every visiteverything touched without desinfected handsstethoscope, otoscop-handle, thermometer,
pencilsmuzzelsmicroskop? ........
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CONFIDENTIAL34British Small Animal Veterinary Association (BSAVA) Hygiene recommendations. http://www.bsava.com/Advice/MRSA/24 February2013.Weese JS. Staphylococcal control in the veterinary hospital. Vet Dermatol 2012;
Daily cleaning or more often on demandDoor handles, telephones, computer keyboards –
mouse and mousepads, light switches,Reception deskWagesVisitors chairs / arm rest
Standard hygiene programm
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COMMON AREAS (ENTRANCES, RECEPTION,WAITING ROOMS AND CORRIDORS)
Clean and disinfect daily and when visibly soiledor contaminated.
WARDS, ISOLATION AND INTENSIVE CARE UNITSClean and disinfect before and after each patient andwhen visibly soiled or contaminated.
Standard hygiene programm
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Products:plain, anionic detergent should be chosen as a
basic cleanerdouble bucket system for normal cleaningsponges ? rags?desinfectants
– resting time– prepackaged disinfectant wipes
Standard hygiene programm
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Vet Clin Small Anim 45 (2015)
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Infection controll the Vet View
Implementation of a standard hygieneprogrammEducation of staffProcedures in known or suspected MDR
infectionsScreening programms
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Education of staff
how oftenhear ..see... feel...do
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Education of staff
professional training !in-house training (every 2-4 months)hygiene officer in staffwritten hygiene concepts and protocolls
– daily, weekly monthly cleaning procedures– creation and implementation of a written
infection control plan
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Infection controll the Vet View
Implementation of a standard hygiene programmEducation of staffProcedures in known or suspected MDR infectionsScreening programms
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Screening in Man____________________________________________
ESVD Therapeutics Workshop Davos 2018
MRSA-MRSP Infection control; the «human view»
Hospital: All patients admitted from foreign countries (Switzerland)
Patients with history of MRSA colonization (isolated initially pending results)
Patients in intensive care units (ICUs)
Patients who are immunocompromised
Residents of long-term care facilities
Patients on hemodialysis
Patients hospitalized in the previous 12 months
Patients who have received antibiotic therapy in the last three months
Patients with skin or soft tissue infection at admission
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Screening in Man____________________________________________
ESVD Therapeutics Workshop Davos 2018
MRSA-MRSP Infection control; the «human view»
Set of screening swabs: nose, throat, hairline, axillae, perineum/groin, skin lesions,sites of indwelling devices
Laboratory simple procedure on screening media(Selection through cefoxitin, hydrolysisof substrate -> pink/lilac colonies)PGFE – typing of Isolates
Becton Dickinson Chromagar MRSA II
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Procedures in known MDR infections
Appointment at the end of the dayprohibit waiting area, corridorstake directly into consultation roomideally directly on the tablewear gloves and disposable scrubs, apronstie hairsdo not touch anything after touching the dogTransport in cages/trolleys/Barriers at cages in stationary patient
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Procedures in known MDR infections
Change gloves when moving from dirty to cleanprocedures on the same patient.Change gloves before touching equipment, doorhandles and keyboardsStaff with major skin barrier defects should not
handle patientdesinfect room, table corridors immediately after
the patient leftchange protective clothing after the patient
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Procedures in known MDR infections
MRSA shedding is relatively short term (days toweeks) after resolution of clinical infection,MRSP shedding may be prolongedMarking system for dogs, that have been idenitified
as MRSP infectedOwner educationRestriction /isolation as long as infected
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Handouts for clientswww.wormsandgermsblog.com
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In AnimalsNo studies publishedUse of fusidic acid?Benefit to human health espc when MRSAIn conjunction with other control strategies
Decolonisation/Isolation
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Decolonization in Man____________________________________________
ESVD Therapeutics Workshop Davos 2018
MRSA-MRSP Infection control; the «human view»
Screening as above: infection sites must be known
Corporal wash with chlorhexidineNasal application of mupirocin ointment
Repeated treatment and testing until swabs are negative
Harris A. et al: Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Prevention andcontrol,www.uptodate.com
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Anderson MEC, Montgomery J, Weese JS et al.Infection Prevention and Control Best Practices forSmall Animal Veterinary Clinics. Guelph, ON:Canadian Committee on Antibiotic Resistance,2008. Available at: http://www.wormsandgermsblog.com/files/2008/04/CCAR-Guidelines-Final2.pdfAccessed Jan 21, 2017.British Small Animal Veterinary Association practiceguidelines – reducing the risk from MRSA and MRSP.BSAVA, 2011. Available at:https://www.bsava.com/Portals/0/resources/docume nts/BSAVA_MRSA_Guidelines_0711.pdfAccessed Jan 21, 2017. .
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Infection controll the Vet View
Implementation of a standard hygiene programmEducation of staffProcedures in known or suspected MDR infectionsScreening programms
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Screening programms
Screening of staff– voluntary, anonymus
Screening of healthy patients– epidemiology– Pre-surgery in high risk patients1
Screeining of environment– methodically , intention?– indicator organsim for C/D procedures
1Nazarali A, Singh A, Moens NM et al. Association between methicillin-resistantStaphylococcus pseudintermedius carriage and the development of surgical site infectionsfollowing tibial plateau leveling osteotomy in dogs. J Am Vet Med Assoc 2015; 247: 909–916.
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