1. Healthcare-associated Infections – Moving from Headlines to Solutions
Dale W. Bratzler, DO, MPH
Professor and Associate Dean
University of Oklahoma Health Sciences Center
College of Public Health, Oklahoma City, OK
Texas Partnership for Patients
May 1, 2013

2. How big is the problem?
HAIs - Infections that patients acquire while receiving treatment for medical or surgical conditions.
Significant toll on human life
1.7 million infections
99,000 deaths annually
Estimated that HAIs incur an estimated $28 to $33 billion in excess healthcare costs each year
Four categories of infections account for approximately three quarters of HAIs in the acute care hospital setting. These four categories are: 1) Surgical site infections; 2) Central line-associated bloodstream infections; 3) Ventilator-associated pneumonia, and; 4) Catheter-associated urinary tract infections.

4. Healthcare-associated Infections
While can occur in any care setting, are particularly related to:
Use of medical devices
Complications of surgical procedures
Transmission between patients and healthcare workers
Antibiotic overuse

5. But, don’t forget…..
The incidence of C. difficile infections in the in- and out-patient setting is increasing
While CLABSI infections are reported far less commonly in the ICU setting, they remain a serious problem in other settings (PICC lines, dialysis units, non-ICU)
Growing incidence of multi-drug resistant organisms
Vancomycin Resistant Enterococci (VRE)
Methicillin Resistant Staphylococcus aureus (MRSA)
Extended spectrum ß-lactamse (ESBLs) producing Gram-negative bacteria
Klebsiella pneumonia carbapenemase (KPC) producing Gram-negatives
Multi-drug resistant Acinetobacter baumannii
Multi-drug resistant Pseudomonas aerginosa
Metallo-beta-lactamase (NDM-1) organisms

6. HAIs in the Nursing Home Setting
The most common infections are respiratory, urinary, skin and soft tissue, and gastrointestinal infections
Influenza and invasive pneumococcal disease
CAUTI
MRSA and/or VRE colonization and infection
C. difficile

7. …….. Sixty-eight ASCs were assessed; 32 in Maryland, 16 in North Carolina, and 20 in Oklahoma……..
….. Overall, 46 of 68 ASCs (67.6%; 95% confidence interval [CI], 55.9%-77.9%) had at least 1 lapse in infection control; 12 of 68 ASCs (17.6%; 95% CI, 9.9%-28.1%) had lapses identified in 3 or more of the 5 infection control categories.
JAMA. 2010;303(22):

8. Dialysis Centers
Infection is a leading cause of morbidity and is second only to cardiovascular disease as the leading cause of death in the chronic uremic patient on hemodialysis (HD).
As compared to the general population, the incidence of sepsis in patients with end-stage renal disease can be up to 100 times higher.
Infections also confer a higher risk of mortality than in the general population

9. Why the rush to public reporting of healthcare-associated infections?
Consumer groups are demanding transparency – particularly about complications and healthcare-associated infections

10. Therefore, legislators respond……
State Mandatory And Public Reporting Laws For Hospital-Acquired Infections, 2010.
State Mandatory And Public Reporting Laws For Hospital-Acquired Infections, 2010
Halpin H A et al. Health Aff 2011;30:

11. …including Federal legislators
Required CMS to adjust hospital payment beginning in FY 2013 for healthcare-associated infections.
Final Inpatient Prospective Payment System Rule for FY 2011 required that all PPS hospitals participating in the Hospital Inpatient Quality Reporting Program submit data on their rate of CLABSI for all ICUs.
Final Inpatient Prospective Payment System Rule for FY 2012 requires that all PPS hospitals participating in the Hospital Inpatient Quality Reporting Program submit data on CLABSI, CAUTI, and SSI beginning with January 1, 2012 discharges

12. Exciting time in healthcare quality and infection prevention!

13. National Quality Strategy
Three Broad Aims –
Better health care;
Better health for people and communities;
Lower costs through improvement
Available at:

14. Making Care Safer Goal:
Eliminate preventable health care-acquired conditions
Opportunities for success:
Eliminate hospital-acquired infections
Reduce the number of serious adverse medication events
Illustrative measures:
Standardized infection ratio for central line-associated blood stream infection as reported by CDC’s National Healthcare Safety Network
Incidence of serious adverse medication events
Available at:

15. Partnership for Patients
The two goals of this new partnership are to:
Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.
Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.

16. Partnership for Patients Areas of Focus
The Partnership for Patients has identified nine areas of focus:
Adverse Drug Events (ADE)
Catheter-Associated Urinary Tract Infections (CAUTI)
Central Line Associated Blood Stream Infections (CLABSI)
Injuries from Falls and Immobility
Obstetrical Adverse Events
Pressure Ulcers
Surgical Site Infections
Venous Thromboembolism (VTE)
Ventilator-Associated Pneumonia (VAP)
Other Hospital-Acquired Conditions

17. HHS Action Plan to Prevent Healthcare-associated Infections
Tier One focuses on six high priority HAI-related areas within the acute care hospital setting.
Surgical site infections, central line-associated bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections, Clostridium difficile, and Methicillin-resistant Staphylococcus aureus (MRSA)
Tier Two expands efforts outside of the acute care setting into outpatient facilities. It includes strategies to reduce HAIs in:
Ambulatory surgical centers and end-stage renal disease facilities, as well as a strategy to increase influenza vaccination coverage among healthcare personnel

18. What can you do tomorrow? A systems approach…

19. Prioritize those things that matter..

20. What practices do we need every day?
Focus less on preventing “an” infection
Focus more on preventing “all” infections

21. Policies are Important
Written infection prevention policies are up to date
Support from a trained infection preventionist
HCWs receive job-specific training on infection prevention practices

22. Healthcare Workers are the Model
They get their influenza vaccine annually
They are up to date on vaccines such as DTaP, hepatitis vaccination, screened for TB

23. Universal Precautions!

24. We give more than lip service to guideline implementation………and we hold people accountable for guideline adherence

25. HICPAC Recent and Ongoing Activities
New guidelines
Prevention of Catheter-associated Urinary Tract Infections (Sept 2010)
Prevention of Intravascular Catheter-Related Bloodstream Infections (2011)
Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings (2011)
Prevention of Infections Among Patients in NICU
Healthcare Personnel Guidelines
Prevention of Surgical Site Infections

26. We Implement Checklists that are Evidence Based

27. Focus on the Environment
Policies and training on routine cleaning and disinfection
Periodic monitoring of cleaning procedures
Focus on reusable medical devices

29. Sir Alexander Fleming discovered penicillin
“The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily under dose himself and, by exposing his microbes to non-lethal quantities of the drug, educate them to resist penicillin.”
Nobel lecture, 1945
Key Points:
Antimicrobials have only been around for about 50 years.
Fleming discovered Penicillin and he mentioned the possibility of antimicrobial resistance in his Nobel lecture in 1945.
His words are a reminder that what we know doesn’t always translate to practice – and this has consequences! 29

30. We use a lot! 200-300 million antibiotics are prescribed annually
25-40% of all hospitalized patients receive antibiotics
Key Points:
This is a high volume, high cost area so appropriate use is key.
Overuse is well documented.
The drug class of unique inappropriate use of antibiotics can yield resistance and thus less efficacy in treating other patients. 5

31. We use a lot! Hospital Antibiotics Outpatient Antibiotics
At least 30% are unnecessary or sub-optimal
5% of hospitalized patients experience an adverse reaction
Outpatient Antibiotics
>$1.1 billion spent annually on unnecessary adult antibiotic prescriptions for upper respiratory infections
50-80% of outpatient antibiotic use is inappropriate
Key Points:
This is a high volume, high cost area so appropriate use is key.
Overuse is well documented.
The drug class of unique inappropriate use of antibiotics can yield resistance and thus less efficacy in treating other patients. 5

32. The Antibiotic Pipeline is Dry….

33. We’re running out……. New Antibacterial Agents Approved 1983-2011
Key Points:
We are down to only 2 new drugs approved for use each year.
There won’t be any help from new drugs right now, so we have to use what we have and try our best to extend their lifespan.
Adapted from Spellberg B et al. Clin Infect Dis. 2004;38:

34. Most Common Reasons for Unnecessary Days of Therapy in Inpatients
576 (30%) of 1941 days of antimicrobial therapy deemed unnecessary
Key Points:
The 3 most common reasons for unnecessary therapy for inpatients are
Duration of therapy is longer than necessary
Antibiotics used to treat nonbacterial or noninfectious syndromes
Inappropriate treatment of colonization or contamination
The majority of inappropriate outpatient antibiotic use falls into the second category—treatment of non-bacterial infections—sinusitis, bronchitis, otitis media which are largely due to viruses.
For outpatients, using antibiotics to treat of non-bacterial or non-infectious organisms is very common.
References: Hecker MT et al. Arch Intern Med. 2003;163:
Hecker MT et al. Arch Intern Med. 2003;163:

35. The bugs are getting tougher!

36. Antibiotic Consumption Drives Resistance!
Resistance patterns of strains of P. aeruginosa
Lepper PM et al. Antimicrob Agents Chemother 2002;46:

37. Antibiotic exposure is the single most important risk factor for the development of Clostridium difficile associated disease (CDAD).
Up to 85% of patients with C. difficile-associated disease have antibiotic exposure in the 28 days before infection

38. Increased risk of death (OR) Attributable LOS (days)
Impact of Antibiotic Resistance What happens if the patient gets infected?
Organism
Increased risk of death (OR)
Attributable LOS (days)
Attributable cost
MRSA bacteremia
1.9
2.2
$6,916
MRSA surgical infection
3.4
2.6
$13,901
VRE infection
2.1
6.2
$12,766
Resistant Pseudomonas infection
3.0
5.7
$11,981
Resistant Enterobacter infection
5.0 9
$29,379
Key Points:
Multi-drug resistant infections have high cost – both of life and of added medical care.
This kind of data gets the health facility administration interested in talking about stewardship.
Cosgrove SE. Clin Infect Dis. 2006; 42:S82-9.

39. An issue for Public Health!
Antibiotics are unlike any other drug: use of the agent in one patient can compromise efficacy in another
An issue for Public Health!

40. Antibiotics and resistance……just the facts
Changes in use parallel changes in resistance
Patients with resistant infections more likely to have received prior antimicrobials
Hospital areas of highest resistance associated with highest antimicrobial use
Increased duration of therapy increases likeliness of colonization with resistant organisms
Shales DM, et al. Clin Infect Dis 1997; 25:

41. Antibiotics and resistance……just the facts
and……the patients are more likely to die!
Shales DM, et al. Clin Infect Dis 1997; 25:

42. Stewardship Decreases Resistance
Rate of Resistant Enterobacteriacae
Infections
Carney Hospital
Antimicrobial Use and Cost
Rate of VRE
Key Points:
A stewardship program was instituted in Carney Hospital, a community hospital in Boston.
They found that antibiotic use, rates of VRE and rates of resistant enterobacteraceae decreased.
This data shows that stewardship programs can work in non-academic medical centers as well.
MRSA rates stayed the same
Carling P et al. Infect Control Hosp Epidemiol. 2003;24:699.

43. Stewardship Decreases Costs
Strategy
Type of Institution
Annual Cost Savings
Pre-prescription approval
County teaching hospital
$803,910
Tertiary care hospital
$302,400
Post-prescription review
Decrease abx charge per patient ($1287 vs. $1873, p<0.04)
VA hospital
$145,942
Community hospital (175 beds)
$200, ,000
Community hospital (120 beds)
$177,000
Argentinean hospital (250 beds)
$913,236
Key Points:
Stewardship programs will save you money.
The average cost that a 500 bed hospital will save in the first 6 months is $500,000.
Stewardship programs reduce length of stay and increase patient welfare.
The challenge is to sustain evidence of value.
White AC et al. Clin Infect Dis. 1997;25: Fishman N. Am J Med. 2006;119:S53-S61.
Fraiser GL et al. Arch Intern Med. 1997;157: Gentry CA et al. Am J Health Syst Pharm. 2000;57:
LaRocco A. Clin Infect Dis. 2003;37:742-3; Bantar C et al. Clin Infect Dis. 2003;37:180-6.
Carling P et al. Infect Control Hosp Epidemiol. 2003;24:

44. Inpatient Stewardship Programs: Core Elements
Instructor Note:
This section introduces guidelines-based recommendations and real-world examples of core components of antimicrobial stewardship programs (ASP).

45. Antimicrobial Stewardship: A Spectrum of Activities
Comprehensive program led by ID trained physician and pharmacist
Individual interventions based on goals of institution led by individual (s) with interest
Key points:
There are a lot of different stewardship options that aren’t a comprehensive program led by an ID trained physician or pharmacist.
There are many choices, but they all require infrastructure.
The key is to assess resources and start small. Building over time can be more sustainable, than having a dedicated program. You will have more cross-stockholder buy-in, more strategic interventions, and an emphasis on proving value from the start.
Many approaches in between

47. Do Surveillance – and be truthful
Should be based on sound epidemiological and statistical principles
Designed in accordance with current recommended practices
Needs to be able to identify risk factors for infection
Adverse events
Implement risk-reduction measures
Monitor the effectiveness of intervention
Identify
Outbreaks
Emerging infectious diseases
Antibiotic-resistant organisms
Bioterrorist events

48. Consequences of HAI Reporting
There is marked variation and low inter-rater reliability in the interpretation of HAI criteria, even between experienced infection preventionists.
A recent survey of infectious disease specialists found that 70% of respondent infection prevention and control programs incorporated clinical judgment in the form of clinician veto or consensus adjudication into CLABSI assessments rather than strict adherence to NHSN criteria!
Klompas M. Interobserver variability in ventilator-associated pneumonia surveillance. Am J Infect Control. 2010; 38:237-9.
Lin MY, et al. Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates. JAMA. 2011; 304:
Mayer J, et al. Agreement in classifying bloodstream infections among multiple reviewers conducting surveillance. Clin Infect Dis. 2012; 55:
Beekman SE, et al. Diagnosing and reporting of central line-associated bloodstream infections. in press

49. Get Involved – Learn from Each Other
No need to “re-invent the wheel”
Engage with the “learning and action network”
Everyone learns – everyone contributes!
Obtain assistance with reporting and get resources and tools
Share your successes
Understand the evidence
Engage your leadership, stakeholders, and the patients you serve

50. There is Good News In
A 33% reduction in central line-associated bloodstream infections. This included a 35% reduction among critical care patients and a 26% reduction among non-critical care patients.
A 7% reduction in catheter-associated urinary tract infections throughout hospitals
A 10% reduction in surgical site infections
An 18% reduction in the number of people developing healthcare-associated invasive methicillin-resistant Staphylococcus aureus (MRSA) infections

51. Despite the improvements….
We have not eliminated healthcare-associated infections
We can’t measure all of the processes of care that influence rates of infection
No “bundle” that has resulted in elimination of HAIs
What are the most important components of bundles?
There is still a need for basic science (host factors, biological factors, healthcare factors)
Some factors that are known to influence infection rates are very difficult to measure and difficult to change

52. Can we prevent them all?
As many as 65%–70% of cases of CABSI and CAUTI and 55% of cases of VAP and SSI may be preventable with current evidence-based strategies. CAUTI may be the most preventable HAI. CABSI has the highest number of preventable deaths, followed by VAP….. Our findings suggest that 100% prevention of HAIs may not be attainable with current evidence-based prevention strategies; however, comprehensive implementation of such strategies could prevent hundreds of thousands of HAIs and save tens of thousands of lives and billions of dollars.
Umsheid CA, et al. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011; 32:

53. “Popularity is not leadership. Results are!” Peter Drucker