Presentation on theme: "Identifying and Preventing Healthcare-Associated Infections: A Global Challenge Kate Ellingson, PhD Epidemiologist, Division of Healthcare Quality Promotion."— Presentation transcript:
1 Identifying and Preventing Healthcare-Associated Infections: A Global Challenge Kate Ellingson, PhDEpidemiologist, Division of Healthcare Quality PromotionCenters for Disease Control and PreventionOctober 11, 2012Division of Healthcare Quality Promotion
2 Healthcare-Associated Infection (HAI) Types PneumoniaUrinary tract infectionBloodstream infectionSurgical Site InfectionOthersVentilator-associated (VAP)Catheter-associated (CAUTI)Central line-associated (CLABSI)Device-associated infections(subtypes)HAI types include <click>pneumonia, <click>urinary tract infections, and <click>bloodstream infections among <click>others.<click>Device-associated infections are specific subtypes of HAIs where a medical device has been in place. <click>Ventilator-associated pneumonia (VAP), <click>catheter-associated urinary tract infection (CAUTI), and <click>central line-associated bloodstream infection (CLABSI) are device-associated infection types and <click>have been the target of many prevention efforts.Target of many prevention effortsPicture courtesy S Schrag
3 HAI: Pathogens Reservoirs Antimicrobial resistance Skin: Staphylococcus aureusWater/environment: gram-negative organisms (e.g., Klebsiella spp., E. coli, Pseudomonas aeruginosa, Acinetobacter spp.)Antimicrobial resistanceSeverely limits treatment optionsMethicillin-resistanceExtended-spectrum β lactamase production (E. coli, Klebsiella spp.)Multidrug resistancePathogens causing HAI can be associated with different reservoirs. For instance the patient’s skin is a common site for colonization of Staph aureus. In contrast, the water and environment often harbor gram negative organisms such as Klebsiella, E coli, Pseudomonas, and Acinetobacter.Antimicrobial resistance in HAI often severely limits treatment options.Key resistance categories include methicillin resistance, extended-spectrum beta-lactamase production such as in E coli and Klebsiella, and multidrug resistance.
4 ObjectivesProvide overview of the current national landscape of HAI activitiesProvide justification for a global approachWorldwide burden of HAIsGlobal proliferation of invasive healthcareAntimicrobial resistanceDescribe examples of CDC’s international HAI effortsDiscuss key elements of a responsible global approach to HAI prevention moving forward
5 HAIs Under the National Spotlight Paradigm shift in past decade: HAIs increasingly viewed as preventablePrevention research demonstrates dramatic decreases in HAI rates with implementation of evidence-based practicesConsumers mobilized, demanding action and transparencyStates begin to pass laws mandating reporting of HAIsFirst HHS Action Plan finalized in 2009HAIs become CDC Winnable Battle$39 million to state health departments to build local capacity for HAI surveillance and preventionAHRQ funds national prevention effortsCMS invokes payment non-reimbursement incentives for hospital-acquired conditions and incentives for reportingPartnership for Patients established
6 Stakeholder Landscape: Increasing Demands, Need for Coordination Federal agencies and programsSocieties, organizations, and initiativesState Health DepartmentLocal UniversitiesState QIOState survey and certificationState Hospital AssociationsLocal APIC ChaptersState Public Health Labs
7 Vision: Coordinated Public Health Approach Other Non-Governmental InitiativesPrevention Collaborative CoordinationSurveillanceInfrastructureHAI expertiseOutbreak responseSurvey/CertPH LabStandardized Metrics
9 Need for a Global Approach Global burden: HAIs lead to excess morbidity, mortality, and healthcare costs worldwideProliferation of invasive healthcare internationally without commensurate infection prevention infrastructureAntimicrobial resistance: everyone’s problem
10 Global BurdenHealthcare-associated infection (HAI) in the United States (2002)1/20 patients1.7 million HAIs99,000 deathsDeveloping countriesLimited data from low income countriesEstimated prevalence: at least three times greater than United StatesHealthcare-associated infections are a major global problem.It is estimated that healthcare-associated infection, or HAI, in the United States in 2002, was present in 1/20 hospitalized patients, resulting in 1.7 million HAIs and 99,000 deaths.In developing countries, the limited data available estimates the prevalence to be at least three times greater than in the United States.Klevens et al Public Health Reports 2007.Allegranzi et al Lancet 2011.
11 International Nosocomial Infection Control Consortium 422 ICUs in 36 countries in Latin America, Asia, Africa, and Europe used National Healthcare Safety Network (NHSN) definitions for device-associated infectionsHealthcare-associated infections are a major global problem.It is estimated that healthcare-associated infection, or HAI, in the United States in 2002, was present in 1/20 hospitalized patients, resulting in 1.7 million HAIs and 99,000 deaths.In developing countries, the limited data available estimates the prevalence to be at least three times greater than in the United States.Similar amount of device use in INICC units as in US hospitalsRosenthal et al. Am. J. Infection Control. 2012.
12 Why might there be more HAIs in middle- and low-income countries? Less infection prevention and control infrastructureTraining lacking in general infection controlImproper use of equipment (e.g., reuse of single-use equipment)Insufficient reprocessingLess surveillance, awareness, and targeted prevention effortsProliferation of invasive medical care across the globeLarge dialysis organizations expanding across boardersIncrease in medical tourismHealthcare-associated infections are a major global problem.It is estimated that healthcare-associated infection, or HAI, in the United States in 2002, was present in 1/20 hospitalized patients, resulting in 1.7 million HAIs and 99,000 deaths.In developing countries, the limited data available estimates the prevalence to be at least three times greater than in the United States.
13 Increase in Incidence and Prevalence of ESRD Internationally The US Naval Medical Research Unit 3, or NAMRU-3, a medical research facility in Cairo is a CDC international emerging infections program site and collaborates with the division of global disease detection at CDC.In April 2011, NAMRU-3 implemented a pilot HAI surveillance system in Egyptian hospitals with the following goals:To establish baseline HAI rates to determine the burden of HAI and increase awareness; to inform specific prevention efforts to reduce HAI rates; and to inform sustained national surveillance.USRDS 2009 Report. Published 2011.
14 Antimicrobial Resistance Studies suggest that approximately ½ of antimicrobial use in US healthcare settings is inappropriateRising resistance leads to decreasing treatment options and increasing costInappropriate prescribing contributor to C. difficile epidemicHealthcare-associated infections are a major global problem.It is estimated that healthcare-associated infection, or HAI, in the United States in 2002, was present in 1/20 hospitalized patients, resulting in 1.7 million HAIs and 99,000 deaths.In developing countries, the limited data available estimates the prevalence to be at least three times greater than in the United States.
15 National Estimates of US Short-Stay Hospital Discharges with C National Estimates of US Short-Stay Hospital Discharges with C. difficile, National Inpatient SampleAny listedPrimaryNumber of DischargesYearElixhauser, A. (AHRQ), and Jhung, MA. (Centers for Disease Control and Prevention). Clostridium Difficile-Associated Disease inU.S. Hospitals, 1993–2005. HCUP Statistical Brief #50. April Agency for Healthcare Research and Quality, Rockville, MD. And unpublished data
16 Gram Negative Pathogens Reported to NHSN Jan 2006- Sept 2007 Overall percentage (rank)CLABSICAUTIVAPSSIE. coli10% (5)3%21%5%10%P. aeruginosa8% (6)16%6%K. pneumoniae6% (7)8%18%A. baumannii3% (9)2%1%.6%Hidron A, et al. Infect Control Hosp Epidemiol 2008; 29:16
17 Klebsiella Pneumoniae Carbapenemase KPC confers resistance to all b-lactams including extended-spectrum cephalosporins and carbapenemsIs the predominant mechanisms of carbapenem resistance in Enterobacteriaceae (CRE) in the US.
18 Mortality-associated with Resistance Patel et al. Infect Control Hosp Epidemiol 2008;29:18
19 Geographic Distribution of KPC-Producers: 2006 Patel, Rasheed, Kitchel Clin Micro NewsMMWR MMWR Morb Mortal Wkly Rep Jun 25;59(24):750.MMWR Morb Mortal Wkly Rep Sep 24;59(37):1212.CDC, unpublished data
20 Geographic Distribution of KPC-Producers: 2010 Patel, Rasheed, Kitchel Clin Micro NewsMMWR MMWR Morb Mortal Wkly Rep Jun 25;59(24):750.MMWR Morb Mortal Wkly Rep Sep 24;59(37):1212.CDC, unpublished data
21 Novel Mechanisms Conferring Carbapenem Resistance Since 2009, in addition to KPC-producing Enterobacteriaceae, several different metallo-β-lactamase-producing strains have been identifiedNew Delhi metallo-β-lactamase (NDM)Verona integron-encoded metallo-β-lactamase (VIM)imipenemase (IMP) metallo-β-lactamaseEnzymes are more common in other areas of the worldIn United States generally been found among patients who received medical care in countries where these organisms are known to be present.Healthcare-associated infections are a major global problem.It is estimated that healthcare-associated infection, or HAI, in the United States in 2002, was present in 1/20 hospitalized patients, resulting in 1.7 million HAIs and 99,000 deaths.In developing countries, the limited data available estimates the prevalence to be at least three times greater than in the United States.
22 Geographic Distribution of KPC-Producers: 2012 KPC, NDMKPC, NDM,VIMKPC, NDM,VIM, IMPPatel, Rasheed, Kitchel Clin Micro NewsMMWR MMWR Morb Mortal Wkly Rep Jun 25;59(24):750.MMWR Morb Mortal Wkly Rep Sep 24;59(37):1212.CDC, unpublished data
23 Novel Enzymes: Many Related to Healthcare Exposure Outside US To date CDC has confirmed14 NDM-producing Enterobacteriaceae ( all but 1 had received care outside the U.S.3 IMP-producing Enterobacteriaceae3 VIM-producing Enterobacteriaceae (2/3 had received care outside the US)2 OXA-48 producing Enterobacteriaceae (both with healthcare exposure outside the US)Spread of novel resistance mechanisms is bidirectional between US and other countries
24 Worldwide Distribution of KPC Walsh International Journal of Antimicrobial Agents
27 International Efforts Abroad Two case examples:Surveillance and prevention in EgyptInfection Control training and infrastructure building in KenyaBoth countries CDC International Emerging Infection Program Sites11 hospitals with 45 intensive care units, or ICUs, from 5 Egyptian governorates participated in surveillance.Data from April 2011 to January 2012 was analyzed.The surveillance population was patients admitted to ICUs in selected hospitals during the surveillance period.
28 Egypt: Successfully Partnered International Agencies 2-year interagency agreement between USAID and NAMRU-3: “Promotion of Quality and Safety of Healthcare in Egypt”28
29 Egypt: Program Components 4. Strengthen/create hospital infection control programs in Egypt3. Optimize Antibiotic Use in Egypt2. Implement targeted IC prevention strategies to reduce rates of HAIs1. Design, pilot & implement a surveillance system to measure HAIs and AMRWe have made significant progress on all strategic elements of the national program
30 Challenges in Implementing Surveillance for HAIs and AMR in Egypt Complexity of CDC case definitionsLimited ResourcesLabor intensiveStaff not motivatedLimited financial and human capacitiesData management capabilitiesLimited hospital laboratory capacitiesMedical Records not well maintainedPolitical- confidentiality issues
31 Infection Control Unit Global Disease Detection & Response Program US Naval Medical Research Unit No.3HeadIC specialistsIC training coordinatorEpidemiologistsM &E specialistsPharmacistHealth communication specialistAnthropologist
32 What is the Best Strategy for Surveillance of HAIs and AMR in Egypt? 1st Panel of experts: Jan, 2011Infection Control UnitCDC/DHQPWHO/HQCornell UniversityMOH/University Reps
33 Proposed Surveillance Approach Panel of Experts - January 2011 Phase I: (Pilot - 9 months)Active prospective surveillanceCDC – NHSN case definitionsSelect eligible hospitalsOnly ICUsAll types of HAI monitoredFour pathogens reported by infection typeRegular monitoring to hospitalsEvaluation - 6 months after implementation
35 Training to Implement Surveillance Surveillance trainingEpi & SurveillanceClinical practice in identifying HAIUse of PDAs583 people trainedMicrobiology trainingstandardized lab techniques:Organism identificationAntimicrobial susceptibility testing40 lab people trained
36 System Description Denominator data collected manually: - Pt days Surveillance Coordinators attend ICU roundsReview Clinical, Lab, Radiology resultsDenominator data collected manually:- Pt days- Device daysRequest more investigationsSuspect HAI?Surveillance coordinators attend clinical rounds three times weekly with attending physiciansDecision support toolsIC teams only responsible to “suspect HAI”PDA asks questions to look for criteria satisfying a case definitionKey for operation of the systemIdentify patients with suspect clinical signs and symptomsEnter all information of suspect patients on the PDARequest necessary investigations to support diagnosis of HAIsLaboratoryRadiologicalYESEnter in PDALab & x-rays resultsPDA confirms one of 43 HAIs coded
37 Device-Associated Infection Rates, Selected ICU Types HAI/1,000 device-daysCLABSIVAPCAUTI ICU typeAdult Medical1.076.230.95Adult Surgical9.71Adult/Ped Surgical0.7013.25 3.70 NICU1.575.59NAPediatric Med/Surg0.486.88Script for slides 23-24This table shows device-associated infection rates. Each row reports infection rates pooled across selected ICU types. Rates are calculated per 1,000 device-days.Note that the highest CLABSI rate <click> was reported from NICUs. Also note that VAP rates<click> are greater than CLABSI rates.<click for next slide, 24>To put this in perspective, rates from the united states have been added where comparable ICUs exist.<click> Reported CLABSI rates in the US are higher than in Egypt but are most similar for NICUs.<click> VAP rates in Egypt are several fold higher than in US ICUs.<click> CAUTI data is difficult to compare because NICUs do not report and because adult/pediatric combined surgical ICUs do not have a comparable counterpart in the US.NHSN Annual Report.
38 Pathogens Reported: All HAIs Most common pathogens reported for all HAI, N = 533*RankPathogenNo. reported% of total isolatesEgyptUSAcinetobacter spp.11522114Klebsiella spp.971924Pseudomonas aeruginosa771535S. aureus6713Candida spp.61127Other10620*More than one pathogen/HAI can be reportedScript on previous pageThis table shows the five pathogens most commonly reported for HAIs in Egypt and compares this ranking with the United States.<click for next slide, 27>The three most common pathogens, <click>Acinetobacter Klebsiella and Pseudomonas, are gram-negative organisms often associated with environmental sources—these are not the leading pathogens <click> reported in the United States.NHSN unpublished data.
39 Antimicrobial Resistance for Isolates Received, Selected Pathogens (N=180) This column chart shows results of antimicrobial resistance testing for selected organisms from a large convenience sample.Over half of isolates show significant antimicrobial resistance. Of note, <click> 100% of Acinetobacter isolates are multidrug resistant.<click for CONCLUSIONS title slide><click for Summary slide>Acinetobacter spp.K. pneumoniaePseudomonas aeruginosaS. aureusE. coliMultidrug resistanceExtended-spectrum β- lactamaseMethicillin resistanceExtended-spectrum β lactamaseN=39N=42N=27N=21N=11
40 Recommendations HAI prevention should focus on: Pneumonia (all ICUs)CLABSI (NICUs)Identify sources of multidrug-resistant organisms and implement measures to control transmissionBuild laboratory capacityThe following recommendations can be made from this analysis:HAI prevention efforts should focus on pneumonia across all ICUs and on CLABSI in NICUs.To combat high levels of antimicrobial resistance, efforts should be made to identify sources of multidrug-resistant organisms and implement measures to control transmission.This includes the following:Early identification of patients infected with antimicrobial-resistant organisms for isolationEnvironmental cleaningAnd Improved reprocessing of ventilator equipment<click for acknowledgements>I would like to thank the following people for their assistance with this analysis and presentation.<click for last slide>Thank you.
41 Egypt-specific adaptation of VAP prevention materials
42 Kenya –Medical Education Partnership Initiative Healthcare-associated infection “carve out” from PEPFAR fundsCDC guidance for infection prevention in resource-limited settingsModules to be vetted and piloted in Kenya, then disseminated more broadly
43 Kenya- Local Production Project iFund grant to improve HH in Kenyan hospitals through local production of ABHRProduction underway in 3 hospitals using WHO recipe for local production of ABHRMixed-methods evaluation underway
44 Kenya: ABHR Project Adapt training materials to local context Use permanent ink to mark the 5-Litre water level.
45 Calibrate and Label 20-Litre Jerrican for First Use (cont.) Kenya: ABHR Project Adapt training materials to local contextCalibrate and Label 20-Litre Jerrican for First Use (cont.)Repeat this process until the 20-Litre jerrican is marked with the 5 Litre, 7.5 Litre, and 10 Litre calibration marks
46 Step 1: Add isopropyl alcohol Kenya: ABHR Project Adapt training materials to local contextStep 1: Add isopropyl alcoholPour a total of 7515 mL of 99.8% isopropyl alcohol into the 20L jerrican. (This can be done in three increments using the 5-litre container and a funnel).
47 CDC Kenya: Infrastructure Building Production of ABHR occurring at 3 hospitalsIntervention staggered for intervention-control evaluationHand hygiene audit rates fed back to healthcare workersFinal report in 2013 to be sent to ministry for broader considerationOther CDC-Kenya HAI-related effortsSyndromic surveillance for respiratory HAIsLaboratory capacity building for MDRO surveillanceIntegration of HAI training into medical school curriculums
48 Future Considerations Related to Global HAI Infrastructure, Surveillance, and Prevention Raising awareness of HAI as a public health issue is keyParadigm shift in United states mobilized actionCan learn from successes/failures of US approachBasic training and infrastructure are the foundation of robust surveillance and prevention effortsBefore implementing surveillanceFocus on documentation and laboratory capacityUnderstand local barriersMulti-facility, infection-specific collaborative models have shown success globallyPrioritization and balance is key
49 Thank You! I look forward to further discussion firstname.lastname@example.org National Center for Emerging and Zoonotic Infectious DiseasesDivision of Healthcare Quality Promotion
51 Surveillance and Definitions Facilities/Regions should have an awareness of the prevalence of CRE in their Facility/RegionCould concentrate on Klebsiella and E. coliCDC definition (based on 2012 CLSI definitions):Your lab might not be using these definitionsNS to one of the carbapenems (doripenem, meropenem, imipenem)Resistant to all 3rd generation cephalosporins testedSome Enterobacteriaceae are intrinsically resistant to imipenem (Morganella, Providencia, Proteus)
52 Interventions * Included in 2009 document Core Supplemental Hand hygieneContact Precautions*HCP educationMinimizing device usePatient and Staff cohortingLaboratory notification*Antimicrobial stewardshipCRE Screening*SupplementalActive surveillance culturesChlorhexidine bathing* Included in 2009 document
53 Hand Hygiene Proper protocols Available supplies (soap, towels, etc.) HCP educationAdherence monitoring and feedbackMore information:
54 HCP Education Regular education about MDROs Proper use of CP Hand hygiene
55 Contact Precautions CP for patients colonized or infected with CRE Systems in place to identify patients at readmissionDuration of CP unclearEducation of HCP about use and rationale behind CPAdherence monitoringConsideration of pre-emptive CP in patients transferred from high-risk settings
56 Contact Precautions in Long-Term Care CP could be modified in these settings:CP should be used for residents with CRE who are at higher risk for transmissionDependent upon HCP for their activities of daily livingVentilator-dependentIncontinent of stoolWounds with drainage that is difficult to controlFor other residents the requirement for Contact Precautions might be relaxedStandard Precautions should still be observed
57 Device Use Minimize use of invasive devices Urinary cathetersCentral venous cathetersHICPAC recommendations for:Central lines
58 Patient and Staff Cohorting CRE patients in single rooms (when available)Cohorting (even when in single rooms)Staff cohortingRecommendation applies to both acute and long-term care settingsPreference for single rooms should be given to patients at highest risk for transmission such as patients with incontinence, medical devices, or wounds with uncontrolled drainage
59 Laboratory Notification Facilities should have protocols for timely notification of appropriate staff when CRE isolated from surveillance or clinical specimensFacilities who send cultures to off-site laboratories should ensure that protocols are established with those labs
60 Antimicrobial Stewardship Programs to ensure:Antimicrobials used for proper indications and durationAppropriate spectrumLink to Get Smart for Healthcare:
61 Antimicrobial Stewardship and MDR GNRs Antimicrobial stewardship program in Surgical/Trauma ICUSpecific protocol for therapeutic antibioticsSurgical antibiotic prophylaxis protocolsQuarterly rotation and limitation of dual antibiotic classesDortch et al Surgical Infections 2011; 12:15-25
62 Antimicrobial Stewardship and MDR GNRs Proportion of MDR GNR pathogens decreased (37% to 9%)Rate of infections caused by MDR GNRs decreased yearly by 0.78/ 1,000 patient daysYearly decrease was for:MDR Pseudomonas (-0.14/1,000 pd),MDR Acinetobacter (-0.49/1,000 pd),MDR Enterobacteriaceae (-0.14/ 1,000 pd)Dortch et al Surgical Infections 2011; 12:15-25
63 CRE ScreeningUsed to identify unrecognized CRE colonization among contacts of CRE patientsStool, rectal, peri-rectalLink to laboratory protocolApplicable to both acute and long-term care settingsDescription of typesPoint prevalence surveyRapid assessment of CRE Prevalence on particular wards/unitsMight be useful if lab review identifies one or more previously unrecognized CRE patient on a particular unitScreening of epidemiologically linked patientsRoommatesPatients who shared primary HCP
64 Active Surveillance Cultures ControversialStudies suggest that only a minority of patients colonized with CRE will have positive clinical culturesCRKP Point prevalence study in Israel (5.4% prevalence rate); fewer than 5/16 had a positive clinical culture for CRKP. (Weiner-Well et al. J Hosp Infect 2010;74:344-9)A study of surveillance cultures at a US hospital found that they identified a third of all positive CRKP patients. Placing these patients in CP resulted in about 1400 days from unprotected exposure. (Calfee et al. ICHE 2008;29:966-8.r
65 Active Surveillance Cultures One study from Israel used surveillance cultures - (ICU) admission and weekly; (non-ICU) patients with epi-links to CRE patientsFound a 4.7-fold reduction in in CRKP infection incidenceKochar et al. used rectal surveillance cultures as part of a multifaceted intervention in an ICUFound decrease in number of new patients per 1,000 patient days per quarter that were positive for CRKPBen-David et al. ICHE 2010; 31:620-6Kochar et al. ICHE 2009; 30:447-52
66 Active Surveillance Cultures Potential considerations:Focus on patients admitted to certain high-risk settings (e.g., ICU) or specific populations (e.g., from LTCF/LTAC)Generally done at admission but can also be done periodically during admissionPatients identified as positive on these surveillance cultures should be treated as colonized Applicable to both acute and long-term care settings.
67 Chlorhexidine Bathing Reviews basics of this processLimited evidence for CREUsed effectively by Munoz-Price in outbreak in LTAC as part of a package of interventionsApplied to all patients regardless of CRE colonization statusIn long-term care:Might be used on targeted high-risk residents (e.g., residents that are totally dependent upon healthcare personnel for activities of daily living, are ventilator-dependent, are incontinent of stool, or have wounds whose drainage is difficult to control)Might be less frequent depending on the facility’s usual bathing protocol.Munoz-Price et al. ICHE 2010;31:341-7