Case two: Outbreak of a PVL producing MRSA

Case two: Outbreak of a PVL producing MRSA Dr Mark Garvey, Principal Clinical Scientist in Microbiology Associate Director of Infection Prevention and Control [email protected] or [email protected] @drmarkgarvey @uhbipc Overview

MRSA Panton Valentine leukocidin (PVL) Case studies PVL Outbreak Conclusions Staphylococcus aureus S. aureus:

Gram positive cocci Frequently coloniser in humans found in nose of up to 30% of healthy individuals Opportunistic pathogen: Wide range of infections including skin and soft tissue infections (SSTIs), bloodstream infection, pneumonia, endocarditis Toxins mediated infection such as Toxic shock syndrome

Meticillin-resistant (flucloxacillinresistant) Staphylococcus aureus (MRSA) Contains resistance island called Staphylococcal chromosome cassette (SCC) mec is the genetic element confers resistance to meticillin

mecA encodes for PBP2a; low affinity for meticillin and confers meticillin resistance on S. aureus (ie MRSA) Six types of SCC harbouring different resistance determinants Problem route of transmission The bugs themselves arent the problem Its where they can get to that is Healthcare is increasingly invasive and we are working with even more vulnerable patients as medical science progresses

MRSA seek and destroy i.e. screen and decolonise Kiernan M IPS 2018 Panton Valentine Leukocidin (PVL) Panton-Valentine Leukocidin First described in 1894 Pore forming toxin

Leukotoxin produced by S. aureus 2 exoproteins (LukS & LukF) SSTIs Garvey MI et al., J Infect Prev 2017 PVL: epidemiology & risk factors 2-10% clinical S. aureus isolates are PVL positive Predominantly associated with community S.

aureus (MSSA & MRSA) Modest disease burden in UK & rest of Europe currently compared with USA Highly transmissible especially in community Close contacts e.g. families, social groups, military, gyms. Garvey MI et al., J Infect Prev 2017 UK epidemiology of PVL UK PVL have been estimated to be carried in less than 2% of clinical isolates of MSSA.

Reference laboratories only receive a small number of selected isolates so this is likely to under estimate the true burden of the disease In England, the majority of PVL-positive strains have been MSSA Garvey MI et al., J Infect Prev 2017 Questions When to suspect a PVL? How many do laboratory inhouse PVL

testing? How many send away for PVL testing? When to suspect PVL? S. aureus (MSSA/MRSA) from a patient with: Recurrent/multiple boils/abscess Especially if Necrotising skin and soft tissue infection <40yrs Necrotising pneumonia Antimicrobial susceptibility patterns are highly variable

Detection of PVL S. aureus infection depends on clinical suspicion of PVL-related syndrome Garvey MI et al., J Infect Prev 2017 PVL Outbreak Description of cases Sept 14 Jan 15: 4 patients acquired PVL MRSA, spa type t852, associated with an index case. Index case Admitted to a bay

Admission screen negative for MRSA Garvey MI et al., J Infect Prev 2017 Patient 1 Patient 1 was admitted on 2 separate occasions First admission was in the same bay as index case Patient 1 subsequently acquired MRSA in October 2014 (acquisition) Garvey MI et al., J Infect Prev 2017

Patient 2 Patient 2 admitted October 2014 for elective surgery Acquired MRSA during second admission to Trust During second admission was in same bay as patient 1 Garvey MI et al., J Infect Prev 2017 Patient 3 Patient 3 complex surgical case admitted in Sept 2014 Found to be MRSA positive in December 2014

(acquisition) MRSA bacteraemia January 2015 Garvey MI et al., J Infect Prev 2017 Patient 4

Patient 4 admitted and discharged in December 2014 Patient 4 readmitted to Trust with community acquired pneumonia in February 2015 and was subsequently found to be MRSA positive that month (acquisition), however was on a different ward at the time Typing revealed same strain as Urology outbreak MRSA bacteraemia March 2015 Garvey MI et al., J Infect Prev 2017 Outbreak control

What would you do if had this situation? Would you screen staff? How many undertake staff screening in outbreaks? What would you do with wondering patients? What was done? After the second case an outbreak control team was formed Included DIPC, Infection Control Nurses, ward medical and nursing staff, domestics, PHE, local commissioners, managerial nurses and

Trust communications Screening of all patients in ward to identify other possible cases of transmission Staff screening with skin complaints e.g. eczema & boils undertaken after 4th case no staff positives Improving hand hygiene compliance Garvey MI et al., J Infect Prev 2017 Other key interventions Adherence to Trust MRSA screening procedures

Local infection prevention control training sessions Improvement in antimicrobial prescribing Warning when flucloxacillin is prescribed in MRSA positive patients via electronic prescribing system Enhanced daily cleaning of bed spaces Garvey MI et al., J Infect Prev 2017 Cleaning & environmental screening Do you undertake environmental

screening? What do you screen? When do you undertake? What do you do with results? What we did? Before enhanced cleaning 16/ 40 sites were positive for MRSA After enhanced cleaning 6/ 40 sites were positive for MRSA Summary of PVL MRSA outbreak

Molecular typing & whole genome sequencing revealed all five strains were the same spa type t852, MLST CC 22, EMRSA 15 (ST22-IV) Strain recognised in Indian sub continent as well as UK Epidemiology suggests person to person transmission occurred Garvey MI et al., J Infect Prev 2017 Final thoughts Risk of spread of this clone in a healthcare setting is high

Potential pathogenicity of strain seemed to be high associated in this outbreak with 2 MRSA bacteraemias Molecular typing of MRSA acquisitions was essential to identify and help control outbreak Stringent adherence to infection prevention and control practice in outbreaks is key to prevent further spread of healthcare associated infections Thank you Questions?

Supplementary - cleaning Environmental survival of key pathogens on hospital surfaces Pathogens Survival times S. aureus (including MRSA) 7 days to >12 months

Enterococcus spp. (including VRE) 5 days to >48 months Acinetobacter spp. 3 days to 11 months Clostridium difficile (spore form)

>5 months Norovirus 8 hours to 28 days (temperature dependent) Pseudomonas aeruginosa 6 hours to 16 months

Klebsiella spp. 2 hours to >30 months Neisseria gonorrhoae 20 seconds Hota B et al., Clin Infect Dis 2011 Kramer A et al., BMC Infect Dis 2007 Dancer SJ et al. Clin Micro Rev 2014

Vickery K et al., J Hosp Infect 2012 Contamination of the environment and transmission of pathogens in healthcare settings Otter JA et al., ICHE 2011 Face touching S. aureus Adults touch their face 23 times per hour 44% mucous membrane

36% mouth 31% nose 27% eyes 6% all three Mouth 4x

Nose 3x Eye 3x Kwok et al., AJIC 2015 Evidence for organism transfer in clinical environments Inoculation of cauliflower mosaic virus DNA onto phone in an neonatal unit ICU cubicle Virus spread to 58% of ward sampling sites within 7 days of inoculation Spread to all five other cubicles

Door handles in other cubicles became positive first Oelberg DG et al., Detection of pathogen transmission on neonatal nurseries using DNA markers as surrogate indicators pediatrics (2000) Risk of transmission from previous room occupant Meta analysis of all studies with evidence of transmission Pooled acquisition odds for MRSA

1.89 for Gram positives (95% CI: 1.62-2.21) Mitchell B et al., J Hosp Infect 2015 Transmission of organisms Prospective cohort study in ICU Successive occupiers of a room at risk from organisms from previous occupants Quality audits showed 56% of rooms were not cleaned correctly

Audits were visual only, failure in room door handles (45%), monitor screens (27%) and bedside tables (16%) Nseir et al., CMI 2010 Who does the cleaning of bed spaces in your hospital? MRSA and environment Doorknobs, bed rails, curtains, touchscreens, contaminated by hands which transmit to other surfaces

keyboards MRSA on door handles of 19% of rooms housing MRSA & 7% of door handles of non-MRSA rooms Oie S et al., J Hosp Infect 2002 Staff often say but I did not touch the patient

42% of nurses contaminated gloves with MRSA with no direct contact but by touching objects in rooms of MRSA patients Boyce JM et al., ICHE 1997 How many gloves? Do you know the at our hospital 23 millions pairs of gloves are used

40% of gloves used in NHS is inappropriate! Cost savings huge Audit of equipment Many items of clinical equipment do not receive appropriate cleaning attention ATP score showed surfaces cleaned by professional cleaning staff was 64% lower than those by other staff (P=0.019)

Do we clean well? Of 27 items cleaned by clinical staff, 89% failed This is failure Training

Allocation of responsibility Anderson RE et al., J Hosp Infect 2011 Questions Do we clean well?

Do Doctors clean well? Or know about importance of cleaning? What do you think are the most clean areas? What about stethoscopes? How do you measure cleaning? Supplementary - final thoughts Cleaning is a Science Time to recognize it as such New RCT-level research on the use of UV-C

showed clinically significant reductions in infections Anderson DJ et al., Lancet 2017

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