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Identifying and Preventing Healthcare-Associated Infections: A Global Challenge Kate Ellingson, PhD Epidemiologist, Division of Healthcare Quality Promotion.

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

2 Healthcare-Associated Infection (HAI) Types
Pneumonia Urinary tract infection Bloodstream infection Surgical Site Infection Others Ventilator-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 efforts Picture courtesy S Schrag

3 HAI: Pathogens Reservoirs Antimicrobial resistance
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 Pathogens 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 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 Health Department Local Universities State QIO State survey and certification State Hospital Associations Local APIC Chapters State Public Health Labs

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

8 CDC’s DHQP: www.cdc.gov/hai
Response Prevention Local Capacity Surveillance

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 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. 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 infections 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. Similar amount of device use in INICC units as in US hospitals Rosenthal 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 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 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.

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 inappropriate Rising resistance leads to decreasing treatment options and increasing cost Inappropriate prescribing contributor to C. difficile epidemic 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.

15 National Estimates of US Short-Stay Hospital Discharges with C
National Estimates of US Short-Stay Hospital Discharges with C. difficile, National Inpatient Sample Any listed Primary Number of Discharges Year 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

16 Gram Negative Pathogens Reported to NHSN Jan 2006- Sept 2007
Overall percentage (rank) CLABSI CAUTI VAP SSI E. coli 10% (5) 3% 21% 5% 10% P. aeruginosa 8% (6) 16% 6% K. pneumoniae 6% (7) 8% 18% A. baumannii 3% (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 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: 18

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. 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, NDM KPC, NDM, VIM KPC, NDM, VIM, IMP 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

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

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

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 Denominator data collected manually: - Pt days
Surveillance Coordinators attend ICU rounds Review Clinical, Lab, Radiology results Denominator data collected manually: - Pt days - Device days Request more investigations Suspect HAI? Surveillance coordinators attend clinical rounds three times weekly with attending physicians Decision support tools IC teams only responsible to “suspect HAI” PDA asks questions to look for criteria satisfying a case definition Key for operation of the system Identify patients with suspect clinical signs and symptoms Enter all information of suspect patients on the PDA Request necessary investigations to support diagnosis of HAIs Laboratory Radiological YES Enter in PDA Lab & x-rays results PDA confirms one of 43 HAIs coded

37 Device-Associated Infection Rates, Selected ICU Types
HAI/1,000 device-days CLABSI VAP CAUTI  ICU type Adult Medical 1.07 6.23 0.95 Adult Surgical 9.71 Adult/Ped Surgical 0.70 13.25  3.70  NICU 1.57 5.59 NA Pediatric Med/Surg 0.48 6.88 Script for slides 23-24 This 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* Rank Pathogen No. reported % of total isolates Egypt US Acinetobacter spp. 115 22 1 14 Klebsiella spp. 97 19 2 4 Pseudomonas aeruginosa 77 15 3 5 S. aureus 67 13 Candida spp. 61 12 7 Other 106 20 *More than one pathogen/HAI can be reported Script on previous page This 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. pneumoniae Pseudomonas aeruginosa S. aureus E. coli Multidrug resistance Extended-spectrum β- lactamase Methicillin resistance Extended-spectrum β lactamase N=39 N=42 N=27 N=21 N=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 The 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 isolation Environmental cleaning And 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 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.)
Kenya: ABHR Project Adapt training materials to local context 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

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

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 Future Considerations Related to Global HAI Infrastructure, Surveillance, and Prevention
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

49 Thank You! I look forward to further discussion kellingson@cdc.gov
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 3rd generation cephalosporins tested Some Enterobacteriaceae are intrinsically resistant to imipenem (Morganella, Providencia, Proteus)

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

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: 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 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;29:966-8. r

65 Active Surveillance Cultures
One study from Israel used surveillance cultures - (ICU) admission and weekly; (non-ICU) patients with epi-links to CRE 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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