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Kate Ellingson, PhD Epidemiologist, Division of Healthcare Quality Promotion Centers for Disease Control and Prevention October 11, 2012 Identifying and.

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Presentation on theme: "Kate Ellingson, PhD Epidemiologist, Division of Healthcare Quality Promotion Centers for Disease Control and Prevention October 11, 2012 Identifying and."— Presentation transcript:

1 Kate Ellingson, PhD Epidemiologist, Division of Healthcare Quality Promotion Centers for Disease Control and Prevention October 11, 2012 Identifying and Preventing Healthcare-Associated Infections: A Global Challenge Division of Healthcare Quality Promotion

2 Healthcare-Associated Infection (HAI) Types Picture courtesy S Schrag HAI Pneumonia Ventilator- associated (VAP) Urinary tract infection Catheter- associated (CAUTI) Bloodstream infection Central line- associated (CLABSI) Surgical Site Infection Device- associated infections (subtypes) Target of many prevention efforts Others

3 HAI: Pathogens  Reservoirs  Skin: Staphylococcus aureus  Water/environment: gram-negative organisms (e.g., Klebsiella spp., E. coli, Pseudomonas aeruginosa, Acinetobacter spp.)  Antimicrobial resistance  Severely limits treatment options  Methicillin-resistance  Extended-spectrum β lactamase production (E. coli, Klebsiella spp.)  Multidrug resistance

4 Objectives  Provide overview of the current national landscape of HAI activities  Provide justification for a global approach  Worldwide burden of HAIs  Global proliferation of invasive healthcare  Antimicrobial resistance  Describe examples of CDC’s international HAI efforts  Discuss 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 preventable  Prevention research demonstrates dramatic decreases in HAI rates with implementation of evidence-based practices  Consumers mobilized, demanding action and transparency  States begin to pass laws mandating reporting of HAIs  First HHS Action Plan finalized in 2009  HAIs become CDC Winnable Battle  $39 million to state health departments to build local capacity for HAI surveillance and prevention  AHRQ funds national prevention efforts  CMS invokes payment non-reimbursement incentives for hospital-acquired conditions and incentives for reporting  Partnership for Patients established

6 Stakeholder Landscape: Increasing Demands, Need for Coordination Federal agencies and programs Societies, organizations, and initiatives State Public Health Labs State Hospital Associations State QIO State Health Department State survey and certification Local Universities Local APIC Chapters

7 Vision: Coordinated Public Health Approach Infrastructure Surveillance Prevention Collaborative Coordination Standardized Metrics HAI expertise Outbreak response Survey/Cert PH Lab Other Non- Governmental Initiatives

8 CDC’s DHQP: Response Surveillance Prevention Local Capacity

9 Need for a Global Approach  Global burden: HAIs lead to excess morbidity, mortality, and healthcare costs worldwide  Proliferation of invasive healthcare internationally without commensurate infection prevention infrastructure  Antimicrobial resistance: everyone’s problem

10 Global Burden  Healthcare-associated infection (HAI) in the United States (2002)  1/20 patients  1.7 million HAIs  99,000 deaths  Developing countries  Limited data from low income countries  Estimated prevalence: at least three times greater than United States Klevens et al Public Health Reports 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 infections Rosenthal et al. Am. J. Infection Control  Similar amount of device use in INICC units as in US hospitals

12 Why might there be more HAIs in middle- and low-income countries?  Less infection prevention and control infrastructure  Training lacking in general infection control  Improper use of equipment (e.g., reuse of single-use equipment)  Insufficient reprocessing  Less surveillance, awareness, and targeted prevention efforts  Proliferation of invasive medical care across the globe  Large dialysis organizations expanding across boarders  Increase in medical tourism

13 Increase in Incidence and Prevalence of ESRD Internationally USRDS 2009 Report. Published 2011.

14 Antimicrobial Resistance  Studies suggest that approximately ½ of antimicrobial use in US healthcare settings is inappropriate  Rising resistance leads to decreasing treatment options and increasing cost  Inappropriate prescribing contributor to C. difficile epidemic

15 Any listed Number of Discharges Year National Estimates of US Short-Stay Hospital Discharges with C. difficile, National Inpatient Sample Elixhauser, A. (AHRQ), and Jhung, MA. (Centers for Disease Control and Prevention). Clostridium Difficile-Associated Disease in U.S. Hospitals, 1993–2005. HCUP Statistical Brief #50. April Agency for Healthcare Research and Quality, Rockville, MD. And unpublished data Primary

16 Gram Negative Pathogens Reported to NHSN Jan Sept 2007 Overall percentage (rank) CLABSICAUTIVAPSSI E. coli10% (5)3%21%5%10% P. aeruginosa8% (6)3%10%16%6% K. pneumoniae6% (7)5%8%18%3% A. baumannii3% (9)2%1%8%.6% Hidron A, et al. Infect Control Hosp Epidemiol 2008; 29:

17 Klebsiella Pneumoniae Carbapenemase  KPC c onfers resistance to all  -lactams including extended-spectrum cephalosporins and carbapenems  Is 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: OR 3.71 ( ) OR 4.5 ( )

19 Geographic Distribution of KPC- Producers: 2006 Patel, Rasheed, Kitchel Clin Micro News MMWR 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 News MMWR 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 identified  New Delhi metallo-β-lactamase (NDM)  Verona integron-encoded metallo-β-lactamase (VIM)  imipenemase (IMP) metallo-β-lactamase  Enzymes are more common in other areas of the world  In United States generally been found among patients who received medical care in countries where these organisms are known to be present.

22 Patel, Rasheed, Kitchel Clin Micro News MMWR MMWR Morb Mortal Wkly Rep Jun 25;59(24):750. MMWR Morb Mortal Wkly Rep Sep 24;59(37):1212. CDC, unpublished data Geographic Distribution of KPC- Producers: 2012 KPC KPC, NDM KPC, NDM, VIM, IMP KPC, NDM, VIM

23 Novel Enzymes: Many Related to Healthcare Exposure Outside US  To date CDC has confirmed  14 NDM-producing Enterobacteriaceae ( all but 1 had received care outside the U.S.  3 IMP-producing Enterobacteriaceae  3 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

25 Prevention

26 How Should we Approach HAIs Globally?

27 International Efforts Abroad  Two case examples:  Surveillance and prevention in Egypt  Infection Control training and infrastructure building in Kenya  Both countries CDC International Emerging Infection Program Sites

28 Egypt: Successfully Partnered International Agencies 2-year interagency agreement between USAID and NAMRU-3: “Promotion of Quality and Safety of Healthcare in Egypt”

29 4. Strengthen/create hospital infection control programs in Egypt 3. Optimize Antibiotic Use in Egypt 2. Implement targeted IC prevention strategies to reduce rates of HAIs 1. Design, pilot & implement a surveillance system to measure HAIs and AMR Egypt: Program Components

30 Challenges in Implementing Surveillance for HAIs and AMR in Egypt  Complexity of CDC case definitions  Limited Resources  Labor intensive  Staff not motivated  Limited financial and human capacities  Data management capabilities  Limited hospital laboratory capacities  Medical Records not well maintained  Political- confidentiality issues

31 Infection Control Unit Global Disease Detection & Response Program US Naval Medical Research Unit No.3  Head  IC specialists  IC training coordinator  Epidemiologists  M &E specialists  Pharmacist  Health communication specialist  Anthropologist

32 1 st Panel of experts: Jan, 2011  Infection Control Unit  CDC/DHQP  WHO/HQ  Cornell University  MOH/University Reps What is the Best Strategy for Surveillance of HAIs and AMR in Egypt?

33 Proposed Surveillance Approach Panel of Experts - January 2011 Phase I: (Pilot - 9 months)  Active prospective surveillance  CDC – NHSN case definitions  Select eligible hospitals  Only ICUs  All types of HAI monitored  Four pathogens reported by infection type  Regular monitoring to hospitals Evaluation - 6 months after implementation

34 Apr/2011 Oct/ 2012 Phase 1 = pilot Phase 2 = limited roll-out Phase 3 = full-scale surveillance Egypt HAI Surveillance Timeline Oct/2011 Goal: Inform surveillance methodology for phase 2

35 Training to Implement Surveillance  Surveillance training  Epi & Surveillance  Clinical practice in identifying HAI  Use of PDAs  583 people trained  Microbiology training standardized lab techniques:  Organism identification  Antimicrobial susceptibility testing  40 lab people trained

36 System Description Surveillance Coordinators attend ICU rounds Suspect HAI? Enter in PDA PDA confirms one of 43 HAIs coded Review Clinical, Lab, Radiology results YES Request more investigations Lab & x-rays results Denominator data collected manually: - Pt days - Device days

37 Device-Associated Infection Rates, Selected ICU Types HAI/1,000 device-days CLABSIVAPCAUTI ICU type Adult Medical Adult Surgical Adult/Ped Surgical NICU NA Pediatric Med/Surg NHSN 2010 Annual Report.

38 Pathogens Reported: All HAIs Most common pathogens reported for all HAI, N = 533* Rank PathogenNo. reported% of total isolatesEgyptUS Acinetobacter spp Klebsiella spp Pseudomonas aeruginosa S. aureus Candida spp Other10620 *More than one pathogen/HAI can be reported NHSN unpublished data.

39 Antimicrobial Resistance for Isolates Received, Selected Pathogens (N=180) Acinetobacte r spp. K. pneumoniae Pseudomona s aeruginosa S. aureusE. coli Multidrug resistance Extended- spectrum β- lactamase Multidrug resistance Methicillin resistance Extended- spectrum β lactamase N=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 transmission  Build laboratory capacity

41 Egypt-specific adaptation of VAP prevention materials

42 Kenya –Medical Education Partnership Initiative  Healthcare-associated infection “carve out” from PEPFAR funds  CDC guidance for infection prevention in resource-limited settings  Modules 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 ABHR  Production underway in 3 hospitals using WHO recipe for local production of ABHR  Mixed-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.) Repeat this process until the 20-Litre jerrican is marked with the 5 Litre, 7.5 Litre, and 10 Litre calibration marks Kenya: ABHR Project Adapt training materials to local context

46 Step 1: Add isopropyl alcohol  Pour 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). Kenya: ABHR Project Adapt training materials to local context

47 CDC Kenya: Infrastructure Building  Production of ABHR occurring at 3 hospitals  Intervention staggered for intervention-control evaluation  Hand hygiene audit rates fed back to healthcare workers  Final report in 2013 to be sent to ministry for broader consideration  Other CDC-Kenya HAI-related efforts  Syndromic surveillance for respiratory HAIs  Laboratory capacity building for MDRO surveillance  Integration of HAI training into medical school curriculums

48  Raising awareness of HAI as a public health issue is key  Paradigm shift in United states mobilized action  Can learn from successes/failures of US approach  Basic training and infrastructure are the foundation of robust surveillance and prevention efforts  Before implementing surveillance  Focus on documentation and laboratory capacity  Understand local barriers  Multi-facility, infection-specific collaborative models have shown success globally  Prioritization and balance is key Future Considerations Related to Global HAI Infrastructure, Surveillance, and Prevention

49 For more information, please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone, CDC-INFO ( )/TTY: Web: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Thank You! I look forward to further discussion National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

50 Prevention

51 Surveillance and Definitions  Facilities/Regions should have an awareness of the prevalence of CRE in their Facility/Region  Could concentrate on Klebsiella and E. coli  CDC definition (based on 2012 CLSI definitions):  Your lab might not be using these definitions  NS to one of the carbapenems (doripenem, meropenem, imipenem)  Resistant to all 3 rd generation cephalosporins tested  Some Enterobacteriaceae are intrinsically resistant to imipenem (Morganella, Providencia, Proteus)

52 Interventions  Core  Hand hygiene  Contact Precautions*  HCP education  Minimizing device use  Patient and Staff cohorting  Laboratory notification*  Antimicrobial stewardship  CRE Screening* * Included in 2009 document  Supplemental  Active surveillance cultures  Chlorhexidine bathing

53 Hand Hygiene  Proper protocols  Available supplies (soap, towels, etc.)  HCP education  Adherence monitoring and feedback  More 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 readmission  Duration of CP unclear  Education of HCP about use and rationale behind CP  Adherence monitoring  Consideration 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 transmission Dependent upon HCP for their activities of daily living Ventilator-dependent Incontinent of stool Wounds with drainage that is difficult to control  For other residents the requirement for Contact Precautions might be relaxed  Standard Precautions should still be observed

57 Device Use  Minimize use of invasive devices  Urinary catheters  Central venous catheters  HICPAC recommendations for:  Urinary catheters  Central lines

58 Patient and Staff Cohorting  CRE patients in single rooms (when available)  Cohorting (even when in single rooms)  Staff cohorting  Recommendation applies to both acute and long- term care settings  Preference 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 specimens  Facilities 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 duration  Appropriate spectrum  Link to Get Smart for Healthcare: 

61 Antimicrobial Stewardship and MDR GNRs  Antimicrobial stewardship program in Surgical/Trauma ICU  Specific protocol for therapeutic antibiotics  Surgical antibiotic prophylaxis protocols  Quarterly rotation and limitation of dual antibiotic classes Dortch 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 days  Yearly 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 Screening  Used to identify unrecognized CRE colonization among contacts of CRE patients  Stool, rectal, peri-rectal  Link to laboratory protocol _E.coli.pdf _E.coli.pdf  Applicable to both acute and long-term care settings  Description of types  Point prevalence survey Rapid assessment of CRE Prevalence on particular wards/units Might be useful if lab review identifies one or more previously unrecognized CRE patient on a particular unit  Screening of epidemiologically linked patients Roommates Patients who shared primary HCP

64 Active Surveillance Cultures  Controversial  Studies suggest that only a minority of patients colonized with CRE will have positive clinical cultures  CRKP 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: r

65 Active Surveillance Cultures  One study from Israel used surveillance cultures - (ICU) admission and weekly; (non-ICU) patients with epi-links to CRE patients  Found a 4.7-fold reduction in in CRKP infection incidence  Kochar et al. used rectal surveillance cultures as part of a multifaceted intervention in an ICU  Found decrease in number of new patients per 1,000 patient days per quarter that were positive for CRKP Ben-David et al. ICHE 2010; 31:620-6 Kochar 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 admission  Patients 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 process  Limited evidence for CRE Used effectively by Munoz-Price in outbreak in LTAC as part of a package of interventions  Applied to all patients regardless of CRE colonization status  In 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


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