Transcript Community-Associated Methicillin

Infections and Infection
Prevention &Control Practices in
Iowa’s High School Athletic
Programs
Loreen A. Herwaldt
Mark Pedersen
The University of Iowa Colleges of
Medicine and Public Health
Disclosures
• Loreen Herwaldt: 3M, Sage, CDC, AHRQ
research grants
• Mark Pedersen: Nothing to disclose
Background
• Community-associated methicillin-resistant
Staphylococcus aureus (CA-MRSA) often
causes skin and soft tissue infections among
young healthy persons.
• CA-MRSA has caused outbreaks among
athletes, including:
– Football (American) players
– Football (Soccer) players
– Fencers
Goals
Survey high school athletic departments
in Iowa to:
– Assess infection control measures and
hygiene practices
– Assess the frequency of MRSA skin and soft
tissue infections
– Assess the frequency of skin
infections caused by other
pathogens
Methods
• Collaborated with staff from the Iowa High
School Athletic Association
• Created and administered a web-based survey
• Statistical Analyses
– Standard descriptive analyses
– Cochran-Armitage trend test
– Jonkheere-Terpstra test
– Wilcoxon Rank-Sum
– Pearson chi-square
Results
• 229/393 (58.4%) of the high schools with
athletic programs responded
• 219 (96%) were completed by athletic directors
• Athletes per program: median = 125;
25th to 75th percentiles = 82-250
Results: Provided by Schools
Supplies/Equipment
Soap for showers
Towels for showers
Launder uniforms
Cardio equipment
Weights
Whirlpool
Number of Schools
143 (62.7%)
86 (37.6%)
81 (35.7%)
181 (80.1%)
228 (99.6%)
124 (55.5%)
Results: Turf, Floor, Mat Burns
Managed by:
Person who Manages Lesions
Athlete
Athletic trainer
Manager
Number
90 (39.3%)
68 (29.7%)
23 (10.0%)
Results: Risky Activities
Activity
Shave arms and legs (n = 224)
Number of Schools
58 (25.9%)
Shave other areas (n = 225)
Share razors (n= 223)
Share protective equipment
(n = 220)
Share towels (n = 226)
Share bottles of water or sports
drinks (n = 226)
40 (17.8%)
1 (0.45%)
19 (8.6%)
23 (10.2%)
70 (31.0%)
Results: Infections
Infection
Tinnea
S. aureus
Herpes simplex
Streptococci
Number of Schools
Reporting
56 (43.1%)
36 (27.7%)
26 (20.0%)
17 (13.1%)
Results: Sport, Education, and SSTI
Sport
Wrestling
Football
Boys
Basketball
Girls
Basketball
Educate
Athletes
164 (71.6%)
145 (63.3%)
106 (46.3%)
0 Athletes
w/ SSTI
113 (53.1%)
157 (73.7%)
201 (94.4%)
> 1 Athlete
w/ SSTI
75 (35.2%)
30 (14.0%)
1 (0.47%)
99 (43.2%)
204 (95.8%)
3 (1.4%)
Results
Class
Number
(%)
No. of
Athletes
(Range)
Employ a
CAT (%)*
1A
76 (33)
7-170
25 (33)
2A
81 (36)
50-384
36 (44)
3A
37 (16)
45-620
25 (68)
4A
33 (15)
270-1008
31 (94)
Overall
229
7-1008
117 (51)
CAT = Certified Athletic Trainer; *P < 0.0001
Frequency of Cleaning
Locker Rooms
Daily
Weekly
When Soiled
After each use
Other
Never
Increased by school classification; P = 0.02
Frequency of Cleaning Daily:
School Classification
Class Locker Showers Trainrooms
ing
equipment
1A
59%
44%
19%
Practice
uniforms
29%
Train- Pt care
ing
areas
tables
29%
26%
2A
79%
71%
24%
32%
34%
40%
3A
83%
54%
26%
41%
52%
48%
4A
81%
79%
35%
37%
62%
64%
P
0.02
< 0.0001
0.0004
0.012
0.0002
0.055
Frequency of Cleaning
After Each Use
•
•
•
•
•
Game uniforms: 69%-84%
Protective equipment: 8%-17%
Wrestling mats, practices: 19%-27%
Wrestling mats, tournaments: 37%-60%
The frequency of cleaning these items did not
vary by school classification.
The Frequency of Cleaning:
CAT vs. No CAT
• Training equipment
(P = 0.012)
– CAT: Daily or after each use = 41%
– No CAT: Daily or after each use = 23%
• Protective equipment (P = 0.054)
– CAT: Weekly, daily, or after each use = 63%
– No CAT: Weekly, daily, or after each use = 42%
• Training table (P = 0.015)
– CAT: Daily or after each use = 77%
– No CAT: Daily or after each use = 60%
Education, Policies, SSTI, MRSA SSTI:
School Classification
Class
1A
Educate
re. SSTI
67%
Policy re. Athletes
SSTI
w/ SSTI
26%
34%
Athletes
w/ MRSA
5%
2A
90%
35%
63%
4%
3A
92%
46%
73%
8%
4A
88%
61%
79%
24%
P
0.002
0.0004
< 0.0001
0.002
Education, SSTI, MRSA SSTI:
CAT vs. No CAT
90
80
%
70
60
50
CAT
No CAT
40
30
20
10
0
Educate
P
0.058
SSTI
0.011
MRSA SSTI
0.018
Association of Education & Policies
with SSTI
100
90
%
80
70
60
SSTI
No SSTI
50
40
30
20
10
0
Education
P < 0.0001
0.016
Policy
Policies
• Preventing participation in practices/games/meets
– Athletes w/ SSTI: 37%
– Athletes w/ other infections: 22%
• Requiring hand hygiene
–
–
–
–
Before taping each athlete: 11%
After taping each athlete: 12%
Before caring for injured athletes: 23%
After caring for injured athletes: 26%
• Requiring gloves when caring for
athletes who might be bleeding: 79%
Summary and Conclusions
• Wrestling programs >> football programs >
basketball programs reported having > 1
athlete per season with SSTIs.
• CA-MRSA SSTIs still appear to be infrequent
among Iowa’s high school athletes.
• Tinnea & S. aureus are the most common skin
pathogens.
• School classification, the number of athletes,
and having a CAT were highly correlated.
Summary and Conclusions
Ironically, schools;
•
•
•
•
In higher classifications
That educated athletes about SSTIs
That had certified athletic trainers
That had appropriate policies
were more likely to identify athletes
with SSTIs, including MRSA SSTIs.
Summary and Conclusions
• We doubt these are risk factors for infection.
But they may indicate that these programs
have more resources for surveillance or that
they are more aware of the issues.
• One alternative explanation could be that
higher numbers of athletes means crowding
and that crowding facilitates transmission of
infectious agents.
Suggestions for Improvement
All schools should develop policies:
• Specifying when athletic staff and student
managers should do hand hygiene;
• Specifying the frequency of cleaning shared
supplies & equipment;
• Regarding athletes with SSTI participation in
practices, games, or meets;
• Preventing athletes with SSTI from using the
whirlpool or other shared equipment.
Thank you!
Hand Hygiene: Present
Loreen Herwaldt, MD*
Hospital Epidemiologist
Professor
*I have no relevant conflicts of interest.
Thanks to:
Garrett Wilcox for his work on the survey.
Hsiu-yin Chiang, Sandra Cobb, Melissa Ward,
and Laurie Leder for hand hygiene observations.
David Herwaldt for graphic design.
Survey Respondents
601 nurses
419 physicians
319 other HCWs
1,339 Healthcare Workers
Do you know
hand hygiene indications?
% answering “most” or “all”
physicians
nurses
other
Unrecognized
hand hygiene indications
% physician respondents
before
contact
before
device
moving
after
contact
after
environ
before
gloves
after
gloves
How much effort
does hand hygiene require?
% answering “none” or “a little”
physicians
nurses
other
How difficult is it to do
hand hygiene when indicated?
% answering “not at all” or “a little”
physicians
nurses
other
Perceived
Hand Hygiene Adherence
• % time you do hand hygiene:
median = 90%
• % time your colleagues do hand hygiene:
median = 80%
Why don’t physicians
do hand hygiene?
% physician respondents
forgot
little
contact
no time
patient
need
wore
gloves
How much could you
improve your hand hygiene?
% answered "a little bit" or "somewhat"
physicians
nurses
other
How can hand hygiene
be improved?
% physician respondents
know
infection
rates
better
access
signs
at doors
mentors,
monitors,
peers
better
product
adherence
feedback
Are your patients interested
in your hand hygiene?
% answering “quite interested” or “extremely interested”
physicians
nurses
other
Is your mentor interested
in your hand hygiene?
% answering “quite interested” or “extremely interested”
physicians
nurses
other
Are colleagues interested
in your hand hygiene?
% answering “quite interested” or “extremely interested”
physicians
nurses
other
Does your hand hygiene
affect behavior of colleagues?
% answering “likely” or “extremely likely”
physicians
nurses
other
• Need SICU graphs here
Perceived
Hand Hygiene Efficacy
90.3% of physicians think that hand hygiene is a very
effective or extremely effective way to prevent
healthcare-associated infections
Take Home Question
Which healthcare tasks or procedures can safely
be done right 3 of 4 times or 9 of 10 times?
•Placing a central venous catheter?
•Giving a blood transfusion?
•Doing a thoracentesis?
•Passing medications?
•Doing an ERCP?
Take Home Question
If you had a central venous catheter, would you
want someone to manipulate it who had been:
•Touching your bedside table
•Handling your Foley catheter
•Typing on a computer key board
•Handling your roommate’s Foley catheter
IF that person had not done hand hygiene?
Benjamin Franklin
Want of care does us more damage
than want of knowledge . . . . Sometimes
a little neglect may breed great mischief.
from Poor Richard’s Almanac
Benjamin Franklin
For want of a nail the shoe was lost;
for want of a shoe the horse was lost;
and for want of a horse the rider was lost,
being overtaken and slain by the enemy,
all for want of care about a horse-shoe nail.