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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
Healthcare-Associated Infection (HAI) Types
Picture courtesy S Schraghttp://www.lightstalkers.org/images/show/305512http://www.featurepics.com/FI/Thumb300/20090428/Foley-Bag-1166380.jpg
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
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
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
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
Stakeholder Landscape: Increasing Demands, Need for Coordination
Fed
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cie
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pro
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Socie
ties,
org
an
izati
on
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itia
tives
State Public Health Labs
State Hospital Associations
State QIO
State Health Department
State survey and certification
Local Universities
Local APIC Chapters
Vision: Coordinated Public Health ApproachIn
frastr
uctu
re
Surveillance
Prevention Collaborative Coordination
Standardized Metrics
HAI expertiseOutbreak responseSurvey/CertPH Lab
Other Non-Governmental Initiatives
CDC’s DHQP: www.cdc.gov/hai
Response
Surveillance
Prevention Local Capacity
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
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 2007.Allegranzi et al Lancet 2011.
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. 2012.
Similar amount of device use in INICC units as in US hospitals
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
Increase in Incidence and Prevalence of ESRD
Internationally
USRDS 2009 Report. Published 2011.
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
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Any listed
Nu
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of
Dis
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es
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 2008. Agency for Healthcare Research and Quality, Rockville, MD. And unpublished data http://www.hcup-us.ahrq.gov/reports/statbriefs/sb50.pdf
Primary
Gram Negative Pathogens Reported to NHSN Jan 2006-
Sept 2007Overall percentage (rank)
CLABSI CAUTI VAP SSI
E. coli 10% (5) 3% 21% 5% 10%
P. aeruginosa 8% (6) 3% 10% 16% 6%
K. pneumoniae 6% (7) 5% 8% 18% 3%
A. baumannii 3% (9) 2% 1% 8% .6%
Hidron A, et al. Infect Control Hosp Epidemiol 2008; 29: 996-1011
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.
Mortality-associated with Resistance
Patel et al. Infect Control Hosp Epidemiol 2008;29:1099-1106
OR 3.71 (1.97-7.01) OR 4.5 (2.16-9.35)
Geographic Distribution of KPC-Producers: 2006
Patel, Rasheed, Kitchel. 2009. Clin Micro NewsMMWR MMWR Morb Mortal Wkly Rep. 2010 Jun 25;59(24):750.MMWR Morb Mortal Wkly Rep. 2010 Sep 24;59(37):1212.CDC, unpublished data
Geographic Distribution of KPC-Producers: 2010
Patel, Rasheed, Kitchel. 2009. Clin Micro NewsMMWR MMWR Morb Mortal Wkly Rep. 2010 Jun 25;59(24):750.MMWR Morb Mortal Wkly Rep. 2010 Sep 24;59(37):1212.CDC, unpublished data
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.
Patel, Rasheed, Kitchel. 2009. Clin Micro NewsMMWR MMWR Morb Mortal Wkly Rep. 2010 Jun 25;59(24):750.MMWR Morb Mortal Wkly Rep. 2010 Sep 24;59(37):1212.CDC, unpublished data
Geographic Distribution of KPC-Producers: 2012
KPC
KPC, NDM
KPC, NDM, VIM, IMP
KPC, NDM, VIM
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
Worldwide Distribution of KPC
Walsh. 2010. International Journal of Antimicrobial Agents
http://www.cdc.gov/hai/organisms/cre/cre-toolkit/
Prevention
How Should we Approach HAIs Globally?
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
Egypt: Successfully Partnered International Agencies
2-year interagency agreement between USAID and NAMRU-3: “Promotion of Quality and Safety of Healthcare in Egypt”
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
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
Infection Control UnitGlobal 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
1st 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?
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
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
Training to Implement Surveillance
Surveillance training Epi & Surveillance Clinical practice in identifying
HAI Use of PDAs 583 people trained
Microbiology trainingstandardized lab techniques: Organism identification Antimicrobial susceptibility testing 40 lab people trained
System DescriptionSurveillance 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
Device-Associated Infection Rates, Selected ICU Types
HAI/1,000 device-days CLABSI VAP CAUTI ICU typeAdult Medical 1.07 6.23 0.95
Adult Surgical 0 9.71 0
Adult/Ped Surgical 0.70 13.25 3.70
NICU 1.57 5.59 NA
Pediatric Med/Surg 0.48 6.88 0
NHSN 2010 Annual Report. http://www.cdc.gov/nhsn/PDFs/dataStat/NHSN-Report_2010-Data-Summary.pdf
Pathogens Reported: All HAIsMost common pathogens reported for all HAI, N = 533*
RankPathogen 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 4 1
Candida spp. 61 12 5 7
Other 106 20
*More than one pathogen/HAI can be reported
NHSN unpublished data.
Antimicrobial Resistance for Isolates Received, Selected Pathogens (N=180)
0%
20%
40%
60%
80%
100%100%
71%
59% 62%
81%
Pro
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f is
ola
tes
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esi
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nce
Acinetobacter spp.
K. pneumonia
e
Pseudomonas
aeruginosa
S. aureus E. coli
Multidrug resistance
Extended-spectrum
β- lactamase
Multidrug resistance
Methicillin resistance
Extended-spectrum
β lactamase
N=39 N=42 N=27 N=21 N=11
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
Egypt-specific adaptation of VAP
prevention materials
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
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
Kenya: ABHR ProjectAdapt training materials to local
context
Use permanent ink to mark the 5-Litre water level.
Calibrate and Label 20-Litre Jerricanfor 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 ProjectAdapt 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).
Kenya: ABHR ProjectAdapt training materials to local
context
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
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
For more information, please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.gov
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
kellingson@cdc.gov
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion
http://www.cdc.gov/hai/organisms/cre/cre-toolkit/
Prevention
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)
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
Hand Hygiene
Proper protocols Available supplies (soap, towels, etc.) HCP education Adherence monitoring and feedback More information:
www.cdc.gov/handhygiene
HCP Education
Regular education about MDROs Proper use of CP Hand hygiene
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
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
Device Use
Minimize use of invasive devices Urinary catheters Central venous catheters
HICPAC recommendations for: Urinary catheters Central lines
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
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
Antimicrobial Stewardship
Programs to ensure: Antimicrobials used for proper indications and duration Appropriate spectrum
Link to Get Smart for Healthcare: http://www.cdc.gov/getsmart/healthcare
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
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
CRE Screening Used to identify unrecognized CRE
colonization among contacts of CRE patients Stool, rectal, peri-rectal Link to laboratory protocol
http://www.cdc.gov/ncidod/dhqp/pdf/ar/Klebsiella_or_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
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
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; 31:620-6Kochar et al. ICHE 2009; 30:447-52
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.
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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