1 Staphylococcus aureus Meticilino resistente (MRSA)Dr. Elio Ochoa Maldonado Infectólogo Plan de seguridad del paciente Programa de prevencion de infecciones Hospital del IESS Guayaquil

2 50 años masculino, hernia discal- IQ, cultivo muestra transoperatorio:SAMR

3 42 años masculino, Trauma Fx tibia – clavo endomedular - IQ, cultivo muestra transoperatorio:SAMR

4 35 años masculino, Politraumatismo, SDRA, larga internacion, ARM, cultivo : SAMR

5 Staphylococcus aureus Meticilino resistentePrimer reporte en 1961 en el Reino Unido En 1963 se reporta el primer brote en USA A partir de 1990 se reporta en la comunidad Cepas comunitarias diferententes a las hospitalarias En USA: USA300, 400 Europa: productoras de leucocidinas Ecuador: PVL

6 Staphylococcus aureus Meticilino resistenteMutaciones cromosomicas gen mecA Suelen presentar otras mutaciones que confieren resistencia a varios antibiot Alteracion de las PBP, ( sitio diana) Fatores de virulencia Adhesion a fibrinogeno, cell Evasion del sistema inmune Adhesion alfa toxin, beta gamma delta hemolisinas

7 Staphylococcus aureus Meticilino resistenteCOMUNITARIAS HOSPITALARIAS

8 Most Invasive MRSA Infections Are Healthcare-Associated14% 86% Community-Associated Healthcare-Associated Klevens et al JAMA 2007;298:

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10 MRSA Strain Characteristics Were Initially DistinctMRSA in Healthcare MRSA in the Community Prevalent genotypes (U.S.) USA100, USA200 USA300, USA400 Antimicrobial resistance Multiple agents Few agents SCCmec (genetic element carrying mecA resistance gene) Types I-III Types IV, V PVL toxin gene Rare Common These community strains do not appear to have been transferred from the hospitals. Patients with MRSA acquired in the community usually have no previous contact with healthcare centers clinical manifestations are also different, Community strains cause mostly skin and soft tissue infections, but rarely cause upper respiratory or urinary tract infections, which are common with healthcare strains The community strains are only resistant to beta-lactams and sometimes other antimicrobial group, in contrast to the multi-resistant pattern of the healthcare strains This different antimicrobial susceptibility is explained by a distinct genetic background and, although still in debate, the difference in clinical manifestations may be due to the presence in community strains of toxins such as PVL or Panton Vanlentine Leukocidine, that causes severe inflammation

11 MRSA Was the Most Commonly Identified Cause of Purulent SSTIs Among Adult ED Patients (EMERGEncy ID Net), August 2004 59% (97% USA300) 54% 39% 15% 55% 74% 51% 68% 60% 60% 72% 67% Moran et al NEJM 2006;355:

12 COMUNITARIA

13 Staphylococcus aureus Estrategias de control

14 Guia IRLANDA 20013

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16 TRATAMIENTO

17 Neumonía: Linezolide, Vancomicina, Clindamicina Bacteremia: Vancomicina, Daptomicina Partes blandas: complicada: Vanco, linezolide, dapto, clinda.

18 Partes blandas: NO complicada: TMS, clinda, Doxiciclina, Minociclina, SNC: Vanco, Line, TMS Osteomielitis: Vanco, Line, TMS, Rifa, Mino, Doxi

19 TRATAMIENTO BACTEREMIA

20 TRATAMIENTO BACTEREMIA

21 Clinical Considerations - EvaluationMRSA belongs in the differential diagnosis of skin and soft tissue infections (SSTI’s) compatible with S. aureus infection: Abscesses, pustular lesions, “boils” “Spider bites” Cellulitis?

22 Clinical Considerations - EvaluationMRSA should also be considered in differential diagnosis of severe disease compatible with S. aureus infection: Osteomyelitis Empyema Necrotizing pneumonia Septic arthritis Endocarditis Sepsis syndrome Necrotizing fasciitis Purpura fulminans

23 MONITOREAR NIVEL SERICO OTROS ANTIMICROBIANOSNEFROTOXICIDAD MONITOREAR NIVEL SERICO OTROS ANTIMICROBIANOS LINEZOLIDE DAPTO QUINU/DALFO

24 COLONIZACION

25 S. aureus Nasal Colonization National Health and Nutrition Examination Survey 2001-02S. aureus: 32.4% = 89.4 M people MRSA: 0.8% = 2.3 M people MRSA colonization associated with age >= 60 years & being female

26 Staphylococcus aureus

27 PORTACION TRABAJADOR SALUD

28 AISLAMIENTO DE CONTACTO

29 Staphylococcus aureus Prevencion de InfeccionesPrecauciones de contacto Higiene de manos Baño corporal con clorhexidina Higiene bucal Descolonizacion Monitoreo de personal de salud Limpieza ambiental Gestion de antimicrobianos (Stewardship)

30 SAMR PROGRAMA DE VIGILANCIA ACTIVA

31 DEBEMOS DESCOLONIZAR LOS TRABAJADORES DE SALUD Y PACIENTES COLONIZADOS?

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33 GRACIAS