CNISP & CIHI MRSA infection rate comparison Preliminary results May 30 2017

What is the Canadian Nosocomial Infection Surveillance Program (CNISP) ? CNISP is as a collaboration between PHAC (CCDIC and NML)and sentinel hospitals across Canada who participate as members of the Canadian Hospital Epidemiology Committee (CHEC), a subcommittee of the Association of Medical Microbiology and Infectious Disease (AMMI) Canada. CNISP was established in 1994 as a hospital-based sentinel surveillance system Objective: Report on rates and trends in national and regional hospital-associated infections (HAIs) including antimicrobial resistant organisms (AROs), strain types and resistance patterns, some of which have been identified by FPTs (CIDSC) as priorities for AMR surveillance Currently CNISP collects surveillance data from 65 hospitals in 10 provinces network of hospitals that has worked in partnership with PHAC/NML since 1994 ONLY national surveillance system in Canada collecting epidemiologic and linked microbiology data regarding HAI and ARO infections

Current CNISP surveillance projects Methicillin Resistant Staphylococcus aureus (MRSA) infections Vancomycin Resistant Enterococci (VRE) infections Hospital-associated Clostridium difficile Infection (CDI) Central line associated bloodstream infections (CLABSI) (also collects antimicrobial resistance data) Carbapenem-Resistant Gram-Negative (CRGN) (Enterobacteriaceae & Acinetobacter) Three surgical site infection (SSI) surveillance projects – all collecting antimicrobial resistance data Hip & Knee SSI Pediatric Cardiac SSI Cerebrospinal fluid (CSF) shunt SSI Antimicrobial Utilization data (Hospital pharmacies) Periodic point-prevalence surveys of HAIs and antimicrobial utilization data – conducted in 2001, 2009 & 2017 Each CNISP surveillance project has a working group comprised of PHAC and CHEC members Working groups direct the development, implementation and prioritization of surveillance projects including the development of case definitions

How CNISP works CNISP surveillance follows a case identification process based on standardized case definitions, laboratory confirmation and chart review by infection control professionals. This method of surveillance is considered to be the gold standard in identifying cases of infection in any surveillance system. CNISP surveillance provides key information that informs the CARSS report and international reports (WHO) and also assists in the development of federal, provincial, territorial and local infection prevention and control programs and policies When carried out in a uniform manner, surveillance provides a measure of the burden of illness, establishes benchmark rates for internal and external comparison, identifies potential risk factors, and allows for the assessment of specific interventions

CNISP in Action contributes to scientific literature - since 1995, CNISP has produced > 260 publications (scientific articles, reports, conference abstracts) providing scientific evidence to inform public health action to reduce HAIs established and currently maintains only national surveillance system to determine epidemiology of HAI in Canadian hospitals and provides Canadian hospitals with “benchmark” data (national, regional and site-specific HAI rates, strain types and antimicrobial resistance and utilization data) provides evidence-based data for CARSS and Canadian infection prevention and control guideline preparation raises public awareness of important infection control issues relating to AROs and HAIs

2015-2016 CNISP/CIHI data comparison 59 CNISP hospitals participated in CNISP MRSA surveillance CNISP Québec hospitals (N = 6) excluded 7 of the CNISP hospitals compared are combined in the CIHI database Therefore comparison is on 46 hospitals Region N (%) Total patient days April 1 2015- March 31 2016 # MRSA infections (in-hospital only) Rate per 10,000 patient days p CNISP CIHI West n = 22 (47%) 3,181,564 2,725,461 457 190 1.44 0.70 <0.001 Central n = 14 (32%) 2299229 1,993,869 206 123 0.90 0.62 East n = 10 (21%) 879,000 709,261 121 44 1.38 National N = 46 6,359,793 5,428,591 784 357 1.23 0.66 West = BC, AB, SK, MB; Central = ON; East = NS, NB, NL, PEI

West Central East National Region # CNISP hospitals with Pt days > CIHI Pt days < CIHI Pt days = CIHI # infections > CIHI < CIHI = CIHI West n = 22 (%) 21 (95%) 1 (5%) 16 (72%) 3 (14%) Central n = 14 (%) 14 (93%) 0 (7%) 14 (100%) East n = 10 (%) 6 (60%) 4 (40%) 9 (90%) 1 (10%) National N = 46 41 (87%) 5 (13%) 39 (85%) 3 (6%) 4 (9%)

With the release of their data, CIHI has agreed to post on their website the following message: “The Public Health Agency of Canada (PHAC) produces healthcare-associated infection rates based on reporting from infection, prevention and control programs in 65 hospitals across Canada through the Canadian Nosocomial Infection Surveillance Program (CNISP). These rates are published at the regional (e.g. western, central, eastern) and national level. Comparisons of CIHI’s regional and national rates with CNISP rates of C. difficile and MRSA infection should be done with caution due to significant methodological differences: - CIHI’s indicator captures C. difficile and MRSA infections in patients identified after admission to hospital (most likely hospital acquired); it is risk-adjusted using standardized diagnostic criteria. - CNISP captures healthcare-associated C. difficile and MRSA infections (further categorized as healthcare or community associated) on all hospitalized patients using laboratory confirmation and standardized surveillance case definitions. - CIHI's C. difficile and MRSA infections indicator is based on physician documentation of an active infection on patient charts, captured through ICD-10-CA codes in administrative data following the direction in the Canadian Coding Standards. Incomplete documentation of the type of infection in a patient chart may lead to an underestimation of infections within CIHI’s indicator. - CNISP follows a case identification process based on standardized case definitions, laboratory confirmation and chart review by infection control professionals and constitutes active prospective surveillance.”