1. Methicillin Resistant Staphylococcus aureus (MRSA): Proposed Revision of ICD-9 Codes Rachel Gorwitz, MD, MPH Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

2. Staphylococcus aureus Common human colonizer Common cause of skin infections Potential to cause severe / invasive infections Transmission: Direct contact

3. Methicillin-Resistant Staphylococcus aureus (MRSA) Resistant to all currently available β-lactam antibiotics (penicillins, cephalosporins) Accounts for majority of S. aureus infections in healthcare settings – Associated with increased morbidity, mortality, and healthcare costs as compared to methicillin-susceptible S. aureus (MSSA) 1990s: Emerged as a community pathogen – Mainly skin infections – Occasionally severe / life-threatening

4. Public Interest in MRSA Increasing awareness of HAI preventability Increasing MRSA rates Controversy over control measures MRSA-specific legislation Media interest Reports of successful control in some facilities Congressional interest in MRSA Changes in virulence Emergence of community- associated MRSA Mandatory reporting of HAI HAI = healthcare-associated infection

5. Sources of MRSA Surveillance Data Active Bacterial Core Surveillance Project National Healthcare Safety Network (NHSN) National surveys using ICD-9 codes Specialized Projects – EMERGEncy ID Net – National Health and Nutrition Examination Survey

6. Active Bacterial Core Surveillance Areas (Invasive MRSA) Total Population: ~ 16.3 million Oregon California Colorado Tennessee Georgia Maryland Connecticut New York Minnesota

7. ABCs MRSA Case Categorization Healthcare-associated: – Hospital-onset: Cases with positive culture obtained >48 hrs after hospital admission (may also have risk factors) – Community-onset: Cases with at least 1 of the following risk factors: Invasive device at time of admission; h/o MRSA infection or colonization; h/o surgery, hospitalization, dialysis, or residence in a LTC facility in 12 mos preceding culture Community-associated: Cases with community-onset and none of above risk factors documented

8. Unique MRSA Patients Medical Record Review Methods of Invasive MRSA Surveillance MRSA + Isolates from invasive site Healthcare Risk Factors Healthcare-Associated Community-Associated

9. ABCs Invasive MRSA Surveillance 2005 Healthcare-Associated (community-onset) Community-Associated Klevens et al JAMA 2007;298:1763-71 14% 59% 28% Healthcare-Associated (hospital-onset) National estimates: 94,360 infections; 18,650 deaths

10. National Healthcare Safety Network (NHSN) Voluntary, confidential, internet-based system for monitoring healthcare-associated events and processes (including HAIs) Purposes: – Provide national estimates of magnitude of adverse events, trends – Provide risk-adjusted data for interfacility comparisons – Assist facilities in developing surveillance and analysis methods Facility-associated infection: – No evidence infection was present or incubating at time of admission (as assessed by trained infection control professional)

11. Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections Nationally representative surveys of hospitalizations and ambulatory care visits Utilize: – Specific S. aureus infection codes (038.11 septicemia, 482.41 pneumonia) – S. aureus organism code (041.11) – Codes for syndromes typical of S. aureus (e.g., 682 cellulitis and abscess) Methicillin resistance data from V codes (V09.0) or external data sources

12. Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections Kuehnert et al, Emerg Infect Dis 2005 – 291,542 annual hospital discharges with S. aureus infection-related diagnoses 1999-00 – 125,969 MRSA Klein et al, Emerg Infect Dis 2007 – 62%  in S. aureus-related hospitalizations 1999-2005; >2-fold  in MRSA-related hospitalizations McCaig et al, Emerg Infect Dis 2006 – 11.6 million annual ambulatory care visits for skin infections typical of S. aureus 2001-03

13. Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections: Challenges With exception of septicemia and pneumonia, S. aureus organism code not linked to clinical syndrome Resistance code (V09.0) not linked to clinical syndrome or S. aureus organism code (041.11) National surveys contain a limited number of ICD-9 fields → organism codes and resistance codes may be deleted Current resistance code (V09.0) not specific for S. aureus or for methicillin-resistance Currently no colonization code specific for S. aureus or MRSA (falls under V02.59 – Other specified bacterial diseases)

14. Proposal: Modification of ICD-9 Codes for MRSA Pages 17-18 of agenda

15. Acknowledgements Kate Ellingson Scott Fridkin Jeffery Hageman Michael Jhung John Jernigan Monina Klevens Cliff McDonald Cathy Rebmann Chesley Richards Melissa Schaefer Arjun Srinivasan

16. IL NY Jan-2007 MS OR ID MT NV AZ CO Jan-2008 NM OK Jul-2008 MO AR 2008 TX LA ND SD IA NE DC KY ME NJ Jan-2009? MD Jul-2008 TN Jan-2008 WY MI SC Jul-2007 FL HI AK MA Jul-2008 VT Feb-2007 WA Jul-2008 CA Jan-2008 WI PA Feb-2008 VA Jul-2008 NH AL GA UT KS MN OH NC RI DE Feb-2008 WV IN CT Jan-2008 * Mandates Public Reporting, Using NHSN Mandates Public Reporting Pending Legislation * Voluntary reporting using NHSN 2/13/2008 Legislative Activity for Public Reporting of Healthcare-Associated Infections