Title

Author(s)

MRSA bloodstream infection and the efficacy of an infection

control program in a local Hong Kong hospital

Tse, Yin-fung;

Citation

Issued Date

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Rights

2011

http://hdl.handle.net/10722/173744

Creative Commons: Attribution 3.0 Hong Kong License

MRSAbloodstreaminfectionandtheefficacyofaninfectioncontrolprogramina
localHongKonghospital

By

TseYinFung

Thisworkissubmittedto
FacultyofMedicineofTheUniversityofHongKong
Inpartialfulfillmentoftherequirementsfor
ThePostgraduateDiplomainInfectiousDiseases,PDipID(HK)

Date:30/05/2012

Supervisor:ProfKYYuen

Declaration

I,TseYinFung,declarethatthisdissertationrepresentsmyownworkandthatithas
notbeensubmittedtothisorotherinstitutioninapplicationforadegree,diplomaor
anyotherqualifications.
I,TseYinFungalsodeclarethatIhavereadandunderstandtheguidelineonWhat
is plagiarism? published by The University of Hong Kong (available at
http://www.hku.hk/plagiarism/) and that all parts of this work complies with the
guideline.

Candidate: TseYinFung

Signature:

Date:

30/05/2012

Acknowledgements
TheauthorwishestothankProf.KYYuenforguidance,DrWKToforproviding
requireddata,andMsCarolLeungfordetailsofhospitalinfectioncontrolprogram.
Theauthorreportsnoconflictsofinterestrelevanttothisarticle.

Abstract
Objective.
(1)Toevaluatetheefficacyofenhancedinfectioncontrolmeasures
againsthospitalacquiredmethicillinresistantStaphylococcusaureus(MRSA)
bacteremiainalocalhospital.(2)Todeterminethedemographiccharacteristicsof
patientswithMRSAbacteremiaandidentifypossiblesourcesofinfection.
Setting.
A720bedcommunityhospitalinHongKong.
Methods.
CaseswithMRSAbacteremiaswereretrospectivelyanalyzedbetween
January2009andDecember2011.Isolateswereidentifiedbyhospitalmicrobiology
laboratoryandthedischargesummariesofpatientswithpositiveMRSAblood
cultureswerereviewed.TheratesofMRSAbacteremiabeforeandafterinfection
controlmeasureswerecompared.
Results.
AsignificantreductionofhospitalacquiredMRSAbacteremiawas
observedaftertheinfectioncontrolprogram.Themajorsourcesofbacteremiawere
bone/skin/softtissueinfections,respiratorytractandurinarytractdespitealarge
proportionofcaseshadanunknownsource.Therewasnosignificantdifferencein
thesourceofbacteremiaforhospitalandcommunityacquiredcases.Mortalitywas
significantlyhigherforcaseswithhospitalacquiredbacteremia.
Conclusions. Implementationofanenhancedinfectioncontrolprogrameffectively
decreasedtherateofhospitalacquiredMRSAbacteremia.

Backgroundandstudyobjectives
MethicillinresistantStaphylococcusaureus(MRSA)isasourceofseriousnosocomial
infectionsworldwide.BloodstreaminfectionsbyMRSA,eitheracquiredinthe
communityorinthehospital,carryahighmortalityrate.Giventhelimited
treatmentoptionsforresistantstrainsofS.aureus,variousinfectioncontrol
measureshavebeentestedandemployedtoreducenosocomialinfectionsbyMRSA.
Inthepresentstudy,thedemographiccharacteristicsofMSRAbacteremiafoundina
localHongKonghospitalwereanalyzed.Theefficacyofinfectioncontrolmeasures
toreducehospitalacquiredMRSAbacteremiaswasalsoinvestigated.

Methodology
Setting
YanChaiHospital(YCH)isa720bedhospitallocatedinTsuenWanDistrictofHong
Kong,providingacute,rehabilitation,convalescentandinfirmaryservices.Itisalsoa
referralcentreforEar,NoseandThroat(ENT)patientswithinitscluster.Anisolation
wardundertheDepartmentofMedicineisinoperationforpatientsrequiring
droplet/airborneprecautions.In2011,thetotalemergencyadmissionsamountedto
35649,whilethetotalpatientdayswere203431.
Studypopulationanddesign
ThisretrospectivereviewincludedallepisodesofMRSAbacteremiafoundatour
hospitalfromtheyears2009to2011.Allbloodstreaminfectionswereidentifiedby
thehospitalsmicrobiologylaboratory.S.aureuswasidentifiedusingroutine
laboratorymethods.Susceptibilitytestingwasdoneusingdiscdiffusionagainsta
numberofantibiotics.Episodedatawereretrievedfromthemicrobiologylaboratory
databasewithhelpofourinfectioncontrolteam.Demographicandclinicaldata
wereretrievedsubsequentlyviaHospitalAuthorityElectronicPatientRecord(ePR)
system.
Definitions
ThepresenceofMRSAinfectionwasdefinedaccordingtoCDCguidelines.Episodeof
MRSAbacteremiawasdefinedashavingatleastonesetofpositivebloodculturein
apatientepisode.Multiplepositiveswiththesameclinicalcircumstanceswere
countedasonesinglepatientepisode.MRSAbacteremiawasclassifiedas
communityacquiredifthecollectiondatewaslessthanorequalto48hoursafter
theadmissiondate,whileitwasclassifiedashospitalacquiredifthecollectiondate
wasmorethan48hoursaftertheadmissiondate.
InfectionControlmeasures
ToreducenosocomialMRSAinfections,enhancedinfectioncontrolmeasureswere
startedsinceSeptember2010.ForpatientswithahistoryofMRSAinfection,a
cornerbedwouldbeassigned,environmentaldisinfectionby1:49sodium
hypochloritewasdonedaily,andachlorhexidinebathwasgivenonceupon
admission.ForpatientswithMRSAinfectionreportedinthecurrentadmission,
besidestheusualcontactprecautions,designatedequipmentandroomisolation,
therewouldbeadditionalenvironmentaldisinfectiontwicedailyandchlorhexidine
bathalternatedayforthreetimesifnoroomisolationavailable.Forgeneralpatients,
theywouldhavearoutinebathwithchlorhexidineinsteadofsoap.Therewasactive
surveillancetowardsrenalpatientsonrenalreplacementtherapy.Foranynew
catheterinsertionfordialysis,therewillbeMRSAcarrierscreeningbeforeprocedure,
5

andsubsequentdecolonizationifscreenedpositive.AnMRSAcohortcubiclewasin
operationsince31.8.11,withdesignatedHCAs(healthcareworkers)forthecubicle.
TheinfectioncontrolmeasuresforMRSApatientsinYCHaresummarizedintable1.

BeforeSept2010

AfterSept2010

2011

ForhistoryofMRSApatients
contactprecautions
designatedequipment

ForhistoryofMRSApatients
contactprecautions
designatedequipment
cornerbed
environmentaldisinfection1:49
sodiumhypochloritedaily
chlorhexidinebathonceupon
admission

ForacuteMRSApatients(+ve
MRSAresultreportedincurrent
admission)
contactprecautions
designatedequipment
roomisolation
MRSApatientswouldbe
taggedinClinical
ManagementSystem(CMS)
foronemonthbythetwo
ICNs

ForacuteMRSApatients
contactprecautions
designatedequipment
roomisolation
environmentdisinfectiontwice
daily
chlorhexidinebathalternateday
forthreetimes(noroom
isolation)
completethechecklistandreturn
toICN
MRSApatientswouldbetaggedin
ClinicalManagementSystem
(CMS)foroneyearbythetwo
ICNs

Forgeneralpatients
environmentalcleaning
withdetergent
routinebathwithsoap

Forgeneralpatients
Routinebathwithchlorhexidine

Forrenalpatient
Forrenalpatient
centrallinebundlewhileinsertion chlorhexidinegel

MRSAcohortcubicle
(effectiveon31.8.11)
DesignatedHCAfor
cohortcubicle
(19.11.11)

Forgeneralpatients
centrallinebundlewhile
insertionofcentralline
(Feb2011)

ofcentralline
activesurveillanceofHDpatients
withcentrallineortenckhoff:
1. Newcatheterinsertion:

Screening
before
insertion
If
positive:
Decolonization
Rescreen
after
3
months if the catheter
stillinsitu
2. Tenckhoff:
Detect & destroy:
MRSA +ve & presence
of
Tenckhoff

Decolonization
Pre
insertion
screening*: if positive:
decolonization
+/
vancomycinprophylaxis

dressingforHDpatients
withcentralline
(effectiveon22.10.11)

Table1.SummaryofinfectioncontrolmeasuresforMRSApatients

Statisticalanalysis
TheSPSSsoftware(StatisticalPackagefortheSocialSciencesv17.0)wasutilizedfor
statisticalanalysis.Anysignificantdifferencebetweendemographiccharacteristicsof
hospitalacquiredandcommunityacquiredMRSAbacteremiawasdeterminedbyChi
squaretestandttest.TheChisquaretestwasusedtodeterminethesignificanceof
anychangeinnumbersofhospitalacquiredMRSAbacteremiaaftertheenhanced
infectioncontrolmeasures.Apvalueoflessthan0.05denotedastatistically
significantresult.

Results
Patientdata
Atotalof115casesofbacteremiawereidentifiedfromtheyears2009to2011.The
totalnumberofcasesofMRSAbacteremiain2009,2010and2011are39,47and29
respectively.Ofwhich19(48.7%),21(44%),and11(37.9%)arehospitalacquired
bacteremia(Fig.1).TherateofhospitalacquiredMRSAbacteremiawere0.9per
10000patientdaysin2009,0.98in2010,and0.54in2011.

Fig.1NumberofcasesofMRSAbacteremiaaccordingtoyear

Thedemographiccharacteristicsofthe115casesareasfollows:meanage75.4(SD
15.0),withapproximatelyequalsexdistribution.Themajorityofpatients(54.8%)
residedinoldagehomesandwaspremorbidbedorchairbound.Thenumberof
hospitalizationsinthepast1yearwas4+/5.6onaverage.Themediandurationof
hospitalizationwas15butitwashighlyvariable,rangingfrom1to338.
Theunderlyingconditionsofthepatientswerealsoanalyzed.Outofthe115patients,
14(12.2%)hadmalignancy,7(6.1%)hadchronicobstructivepulmonarydisease,41
(35.7%)hadrenalimpairment,42(36.5%)haddiabetesmellitus,and51(44.3%)had
8

ahistoryofstroke.Theoverallmortalitywas44.3%.
Whenthepatientswerestratifiedaccordingtothebacteremiabeingcommunity
acquiredorhospitalacquired,asignificantdifferencewasobservedconcerningthe
premorbidcondition,mortalityanddurationofstay.Morecommunityacquired
bacteremiasoccurredinpremorbidalreadybedorchairboundpatients.Since
bed/chairboundpatientshadahigherchanceofdevelopingdecubitusulcersin
general,theyarepronetobacteremiasecondarytoinfectedpressureulcers.The
differenceinnumbersofcommunityacquiredversushospitalacquiredbacteremiain
bed/chairboundpatientsmayimplythatthewoundcareoutsideofhospitalwas
inferiortothatduringinhospitalstay.However,sincethepresenceofdecubitus
ulcerswasusuallynotroutinelydocumentedinpatientsdischargesummaries,it
wasdifficulttoobtainfurtherdatatoprovethisargument.
ThemortalitywassignificantlyhigherinhospitalacquiredMRSAbacteremia,upto
54.9%inthisstudy.Datafromarecentarticle(1)in2012investigatingnosocomial
bloodstreaminfectioninpatientscausedbyS.aureusquotedacrudemortalityof
MRSAbacteremiatobe33.3%.Thiswasmuchlowerthanthatofourstudy
population,butitmaybeexplainedbyamuchyoungergroupofpatientsunder
study(meanage55.9),havingpresumablybetterphysicalconditionandimmunity.
Forhospitalacquiredbacteremia,themediantimetopositiveculturewas9.5days
(mean22.5,SD27.6).Unsurprisingly,thedurationofhospitalstaywassignificantly
longerforhospitalacquiredbacteremiagroup.Thiscanbeeitherthecauseoreffect
ofMRSAbacteremia,sinceaprolongedhospitalstayforwhateverreasonwill
definitelyincreasethechanceofhavinghospitalacquiredMRSAbacteremia,and
onceahospitalacquiredMRSAbacteremiaisdiagnosed,afurthercourseof
intravenousantiobioticsisrequiredbeforethepatientcanbedischarged.On
average,anadditional12.5daysofhospitalizationwasrequiredoncehospital
acquiredMRSAbacteremiawasdiagnosed.Thedemographicdataofthestudy
populationaresummarizedintable2.

Community
Acquired
(N=64)

Hospital
Acquired
(N=51)

Total
(N=115)

Sig.(p
value)

Age(years)

Mean(+/SD)

77.3+/14.7

73.1+/15.2

75.4+/15.0

NS(0.22)

Malesex

28(43.8%)

30(58.8%)

58(50.4%)

NS(0.11)

OldAgeHome
resident

39(60.9%)

24(47.1%)

63(54.8%)

NS(0.14)

Premorbid

44(68.8%)

24(47.1%)

68(59.1%)

S(0.02)
9

bed/chairbound
Numberof
hospitalizationsin
thepast1year
(median+/SD)

4.0+/4.2

3.0+/7.1

4.0+/5.6

NS(0.97)

Underlying
Conditions

Malignancy

5(7.8%)

9(17.6%)

14(12.2%)

NS(0.11)

Chronic
4(6.3%)
Obstructive
PulmonaryDisease

3(5.9%)

7(6.1%)

NS(0.63)

Renalimpairment

20(31.3%)

21(41.2%)

41(35.7%)

NS(0.27)

DiabetesMellitus

19(29.7%)

23(45.1%)

42(36.5%)

NS(0.09)

Stroke

27(42.2%)

24(47.1%)

51(44.3%)

NS(0.60)

Durationofstay:
Median(+/SD)

10.5+/18.7

26.5+/59.8

15+/45.3

S(0.00)

Mortality

23(35.9%)

28(54.9%)

51(44.3%)

S(0.04)

Table2.Demographicdataandcalculatedmortalityofstudypopulation

Intervention:enhancedinfectioncontrolmeasures
Theefficacyoftheenhancedinfectioncontrolmeasuresmentionedearlierwas
evaluated.SincesuchmeasureswereineffectfromSeptember2010onwards,the
casesofMRSAbacteremiafromtheperiodSeptember2009toAugust2010(before
intervention),andSeptember2010toAugust2011(afterintervention)were
selectedforcomparison.Atotalof36caseswereidentifiedwithinthetwotime
periods.24caseswereidentifiedbeforeinterventionand12casesafterintervention.
Thedropof12cases(50%)wasastatisticallysignificantimprovement(p=0.046).
Whentakingpatientdaysintoaccount,therewereonaverage1.11casesper10000
patientdaysbeforeintervention,and0.57casesper10000patientdaysafter
intervention.Thisamountstoa49%improvement.
Oncomparison,thenumberofcasesofcommunityacquiredbactermiabeforeand
afterinterventionremainsstatic.Therewere21and23casespreand
postinterventionrespectively(p=0.76).Therewere0.97casesper10000patient
dayspreinterventionand1.1casesper10000patientdayspostintervention.
Asquotedbefore,themediandurationofstayforpatientswithMRSAbacteremia
was15.0(mean30.6,SD45.3).Therewasnostatisticallysignificantdifference
betweenthedurationofhospitalizationbeforeandafterintervention.However,
patientburdentothehospitalisstilldecreasedinviewoftheabsolutedecreasein
10

casesafterintervention.
Thefiguresoftheyear2009and2011werealsocompared.Thenumberofhospital
acquiredbacteremiadecreasedfrom19in2009to11in2011,amountingtoa42.1%
improvement.However,suchresultwasnotstatisticallysignificant(p=0.14).Onthe
otherhand,thenumberofcommunityacquiredbacteremiaremainedstatic,from20
in2009to18in2011(table4).Concerningthenumberofcasesperpatientdays,
therewas0.90casesper10000patientdaysin2009,and0.54casesper10000
patientdaysin2011.Thiswasa40%improvement.
RatiobetweenimportedandsecondaryMRSAcases(Transmissionindex)
Thetransmissionindexwasdefinedastheratiobetweensecondarycasesand
importedcasesofMRSAinfection.Forinstance,atransmissionindexof1.0indicates
thateachimportedMRSAcasegeneratedoneadditionalsecondaryMRSAcase.
Asteadydecreaseofthetransmissionindexwasobservedfromtheyears2009to
2011.Thetransmissionindicesfor2009to2011were0.9,0.81and0.61respectively.
Whenconsideringthe1yearperiodsbeforeandafterintervention,thetransmission
indexcalculatedwas1.14beforeinterventionand0.52afterintervention.This
signifiesa54%improvement.

Fig.2.

Community
Acquired
(N=44)

HospitalAcquired
(N=36)

Total
(N=80)

11

Numberofcases
withinperiodSep09
Aug11:
Beforeintervention
Afterintervention
PercentageChange

21
23
+9.5%(p=0.76)

24
12
50% (p=0.046)

45
35
22.2%(p=0.25)

Casesper10000
patientdayswithin
periodSep09Aug
11:
Beforeintervention
Afterintervention
PercentageChange

0.97
1.10
+13.4%

1.11
0.57
48.6%

2.08
1.67
19.7%

Table3.Results1yearpreandpostintervention.

Community
Acquired
(N=38)

HospitalAcquired
(N=30)

Total
(N=68)

Numberofcases
in:
2009
2011
Percentage
Change

20
18
10%(p=0.72)

19
11
42.1%(p=0.14)

39
29
25.6%(p=0.21)

Casesper10000
patientdays:
2009
2011
Percentage
Change

0.95
0.88
7.4%

0.90
0.54
40%

1.85
1.43
22.7%

Table4.Resultsinyear2009and2011

Sourceofbacteremia
ThepossiblesourceofMRSAbacteremiawasinvestigated.Ofthetotal115cases,54
caseshadanunknownsourceorpossiblecontamination.15cases(13%)weredueto
respiratorytractinfections,2cases(1.7%)wereofGI/HBPsource,10(8.7%)fromthe
urinarytract,24(20.9%)fromskinandsofttissue,9(7.8%)werecatheterrelated.
Thesinglecaseinotherswasduetoinfectiveendocarditis.
12

Thecaseswerethenstratifiedintocommunityacquiredandhospitalacquiredfor
furtheranalysis.Theresultsweresimilarbetweenthetwogroups.Thedatashowed
nostatisticallysignificantdifferencebetweenthesourceofcommunityacquiredand
hospitalacquiredbacteremia.Whencomparedtoarecentretrospectivereviewof
communityassociatedversushealthcareassociatedMRSAbacteremia(2),thestudy
quoteda29.2%ofinfectionsrelatedtointravascularcatheter,followedbyprimary
bacteremia(18.5%),skin/softtissue(15.7%)andrespiratorytract(11.2%).Thestudy
alsofoundthathealthcareassociatedhospitalonsetMRSAbacteremiawasmore
likelytobeduetoaninfectedintravasculardevicethanHACOMRSA
bacteraemia(38.7%vs22.3%,p=0.018).Incontrast,skin/softtissueinfectionwasless
frequentlyidentifiedasthesourceofhealthcareassociatedhospitalonsetMRSA
bacteraemiathanhealthcareassociatedcommunityonsetMRSAbacteraemia
(9.3%vs20.4%,p=0.045).Suchresultswerenotfoundinthepresentstudy;a
possibleexplanationwasthatasignificantproportionofthestudypopulationhadan
unknowncauseofbacteremia(upto51.6%inthecommunityacquiredgroup)since
nosuspectedsourcewasdocumentedinthecasenotes.

Community
Acquired
(N=64)

Hospital
Acquired
(N=51)

Total
(N=115)

Respiratorytract

7(10.9%)

8(15.7%)

15(13%)

GI/HBP

0(0%)

2(3.9%)

2(1.7%)

Urinarytract

5(7.8%)

5(9.8%)

10(8.7%)

Bone/Skin/softtissue

14(21.9%)

10(19.6%)

24(20.9%)

Catheterrelated

4(6.3%)

5(9.8%)

9(7.8%)

Others

1(1.6%)

0(0%)

1(0.9%)

21(41.2%)

54(47%)

Unknown/contamination 33(51.6%)
Table5.Sourceofbacteremia

13


Discussion
ThecontrolofdrugresistantpathogenssuchasMRSAisofparamountimportancein
thehealthcaresettinganditissubjectedtoincreasingpublicattention(3).Strategies
have been formulated to reduce transmission of multidrug-resistant organisms in healthcare settings,
and these were made a priority by the Centers for Disease Control and Prevention (CDC) (4). This
study confirmed the efficacy of an enhanced infection control program to reduce the rates of hospital
acquired MRSA bacteremia. However, several limitations were recognized in this study. Firstly,it

wasassumedthatthecasemix,numberofsurgical/medicalprocedures,clinical
managementprotocols,staffcomposition,ormedicalexperienceremained
unchangedinthestudyperiod.Alsonootheractivitieswereassumedtohavebeen
undertakentodirectlyinfluenceMRSAtransmission.Anotherlimitationwasthatthe
compliancewiththeinfectioncontrolmeasureswasnotaudited.Moreover,sincea
numberofdifferentmeasureswerestartedatthesametime,theirindividual
influenceonMRSAinfectionratescouldnotbeseparatelyevaluated.Despitethe
limitations,thisstudyhaspointedouttheimportanceofacomprehensiveand
structuredinfectioncontrolprograminreducingtheMRSAnosocomialinfection
rates.Multidisciplinaryteamworkandstrictcompliancetotheinfectioncontrol
measuresarerequiredforthesuccessofsuchprograms.

14


Referencelists
1. CHENetal.Nosocomialbloodstreaminfectioninpatientscausedby
Staphylococcusaureus:drugsusceptibility,outcome,andriskfactorsfor
hospitalmortality.ChinMedJ2012;125(2):226229
2. Robinsonetal.Communityassociatedversushealthcareassociated
methicillinresistantStaphylococcusaureusbacteraemia:a10year
retrospectivereview.EurJClinMicrobiolInfectDis(2009)28:353361
3. Leeetal.ControlofMethicillinresistantStaphylococcusaureus.InfectDis
ClinNAm25(2011)155179
4. Manginietal.ImpactofContactandDropletPrecautionsontheIncidenceof
HospitalAcquiredMethicillinResistantStaphylococcusaureusInfection.
InfectControlHospEpidemiol2007;28:12611266
5. SiegelJ,RhinehartE,JacksonM,ChiarelloL,theHealthcareInfectionControl
PracticesAdvisoryGroup.Managementofmultidrugresistantorganismsin
healthcaresettings,2006.Atlanta,GA:CentersforDiseaseControland
Prevention;2006.Availableat:
http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf.

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