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

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

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

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

Staphylococcus aureus Meticilino resistente Primer 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

Staphylococcus aureus Meticilino resistente Mutaciones 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

Staphylococcus aureus Meticilino resistente COMUNITARIAS HOSPITALARIAS

Most Invasive MRSA Infections Are Healthcare-Associated 14% 86% Community-Associated Healthcare-Associated Klevens et al JAMA 2007;298:1763-71

MRSA Strain Characteristics Were Initially Distinct MRSA 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

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;355:666-674

COMUNITARIA

Staphylococcus aureus Estrategias de control

Guia IRLANDA 20013

TRATAMIENTO

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

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

TRATAMIENTO BACTEREMIA

TRATAMIENTO BACTEREMIA

Clinical Considerations - Evaluation MRSA 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?

Clinical Considerations - Evaluation MRSA 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

MONITOREAR NIVEL SERICO OTROS ANTIMICROBIANOS NEFROTOXICIDAD MONITOREAR NIVEL SERICO OTROS ANTIMICROBIANOS LINEZOLIDE DAPTO QUINU/DALFO

COLONIZACION

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

Staphylococcus aureus

PORTACION TRABAJADOR SALUD

AISLAMIENTO DE CONTACTO

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

SAMR PROGRAMA DE VIGILANCIA ACTIVA

DEBEMOS DESCOLONIZAR LOS TRABAJADORES DE SALUD Y PACIENTES COLONIZADOS ?

GRACIAS