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Healthcare-associated infection in VictoriaSurveillance report for 2016–17 and 2017–18

A joint venture between The University of Melbourne and The Royal Melbourne Hospital

The VICNISS Coordinating Centre is fully funded by the Department of Health and Human Services.

We thank the Department for their ongoing support of this program.

We thank the hospital executives and executive sponsors for their support.

We extend a special acknowledgment to all infection control nurses and staff who participate in the surveillance program. Their ongoing support and commitment make this project successful, and this report possible.

Acknowledgements

Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.

© State of Victoria, Department of Health and Human Services December 2018.

Where the term ‘Aboriginal’ is used it refers to both Aboriginal and Torres Strait Islander people. Indigenous is retained when it is part of the title of a report, program or quotation.

Available at http:www.vicniss.org.au

Healthcare-associated infection in Victoria | 3

Overview

The VICNISS Coordinating Centre (VICNISS) was established in 2002 with the aim of reducing the occurrence of healthcare associated infections (HAIs). This includes any infection associated with healthcare, primarily in hospital but also during periods of outpatient treatment such as haemodialysis or hospital in the home.

Patients undergoing medical treatment are at increased risk of contracting an infection for a number of reasons, including:

- Use of invasive medical equipment e.g. needles and intravenous devices

- Surgery and other wounds which breach skin integrity

- Diseases and treatments (e.g. chemotherapy) which suppress the immune system

Victoria has an advanced program for monitoring and reporting healthcare-associated infections, facilitated by VICNISS, that has been in place since 2002. The program collates data on both outcomes (infections) and processes (actions associated with reducing the risk of infections), and reports to participating health services, the Department of Health and Human Services, and national agencies such as the Australian Institute of Health and Welfare.

The major activity of the VICNISS Coordinating Centre is to collate, analyse and report on data and information from hospitals in Victoria. This information is used to monitor hospital infection rates and results for other quality measures. This information is fed back through both formal and informal processes to health service executives and others who are able to address issues of concern and instigate improvements. VICNISS also provides support to hospitals through provision of expert advice and tools for monitoring as well as assisting health services run quality improvement activities.

The HAI surveillance methodology used in Victoria is based on that developed at the Centers for Disease Control and Prevention (CDC) in the United States. This methodology is considered international best practice and is used in many parts of the world, including North and South America, Canada, Japan, United Kingdom and many European countries.

Infection surveillance should target activities with the highest risk and those where improvements can be made. In addition, there are national and (in some states) state requirements. All public hospitals in Australia are required to carry out continuous surveillance of Staphylococcus aureus bloodstream infections (SAB) and Clostridium difficile infections (CDI) and to participate in the national hand hygiene audits. In Victoria, all public hospitals are required to supply details of staff vaccination rates for seasonal influenza. Other activities, such as monitoring of infection rates following surgery and in intensive care, depend on the size and activity levels of the hospital.

Previous reports have contained data from five or more years. This report contains only data for the time period 1 July 2016 to 30 June 2018. Future reports will be annual and will contain annual updates only. Consequently, improvements in infection rates and related indicators which have been achieved over time may not be evident in data presented. Time series data and previous reports are available on the VICNISS website http://www.vicniss.org.au and other results including time series analyses have been published in peer reviewed literature.

4 | Healthcare-associated infection in Victoria

Executive summary

Victoria has continued to make progress in the area of HAIs, with falling infection rates overall and demonstrated improvements in processes to prevent infections. Collection, collation reporting of data through this program continues to provide incentive for improvement and allows us to observe improvements over time. This is a testament to the dedication and commitment of the many individuals and groups who contribute to the surveillance program.

The rate of central line-associated bloodstream infections (CLABSI) in intensive care units remains low at around 0.8 infections per 1000 line days in “large” hospitals (major metropolitan) and 0.5 in all other hospitals.

The rate of Staphylococcus aureus bloodstream infections in Victoria is also very low at 0.7 per 10,000 occupied bed days. Healthcare-associated Staphylococcus aureus bloodstream infections (SAB) are significant and largely preventable infections, with a mortality of up to 20 per cent.

Rates of surgical site infections have shown some, but not as significant a change over the past two years; however the long term trends are still downward which is encouraging.

Victoria remains a leader in both HAI surveillance and response to new and emerging problems. In collaboration with the Department and the Microbiological Diagnostic Unit (MDU), VICNISS continues to closely monitor the situation in Victoria with respect to Carbapenamase-Producing Enterobacteriaceae (CPE), collecting incident data and assisting hospitals with implementation of the Victorian CPE guideline.

Rates of antibiotic prophylaxis continue to be an area of interest and the focus has shifted to looking at aspects of compliance not so far examined. These include second dosing of beta-lactam antibiotics for prolonged procedures, and correct dosing. Further analysis of comparison of effectiveness of different regimens is also being examined.

From 1 July 2018 the Victorian Government, in response to the Targeting Zero recommendations, brought into effect the Health Legislation Amendment (Quality and Safety) Act 2017 (the amending Act). This Act, among other things, brings private hospitals into line with public hospitals with respect to requirements for quality and safety including reporting to VICNISS. As a result VICNISS will be working with the Department to incorporate all private hospitals into the surveillance system over the next 12-18 months with minimum requirements.

Clostridium difficile infections remain endemic but at much lower levels than seen in Europe and North America. Rates of severe disease are low. VICNISS continues to monitor this infection.

In 2016 and 2017 VICNISS partnered with DHHS to develop infection control indicators for Victoria’s Public Sector Residential Aged Care Services (PSRACS). Indicators include participation in the aged care National Antimicrobial Prescribing Survey (ac-NAPS) which is jointly managed by VICNISS and the National Centre for Antimicrobial Stewardship (NCAS). In addition VICNISS now collects data on seasonal influenza vaccination rates in both staff and residents in all PSRACS as well as herpes zoster and pneumococcal vaccinations in residents; infections such as C.difficile, SAB, MRSA and VRE are also monitored. This is an important step forward and integrates infection control indicators from aged care with acute care, reflecting the related nature of these services.


Bloodstream infections related to use of central lines in intensive care units

Where?All public hospitals with an ICU report these infections. Private hospitals report on a voluntary basis

Who?Of the infections reported in 2016/17 and 2017/18: 35% were females. The median age of affected patients was 57

35% Females

How Many?There were 51 infections in 2016/17 and 48 infections in 2017/18. There were 34 contributing ICUs in both years 51 Infections

2016/1748 Infections

2017/18

How does this compare to previous years?The risk for patients of acquiring one of these infections in Victoria has reduced significantly by around 26% per year since surveillance commenced (from 2.5 to 0.7 infections per 1000 central line days). Over the period 2016/18 the rate in larger hospitals was slightly higher than the previous years at 0.9.


Infections in patients with intravenous lines

IntroductionPatients who have intravenous (IV) lines inserted are at a higher risk of infection due to having an invasive device inserted into a vein. Some types of devices and some groups of patients have a higher risk than others.

This section includes the results from surveillance of patients who have intravenous lines inserted in a variety of different care settings. In particular:

- patients in intensive care units (ICU)

- babies in neonatal ICU

- outpatient haemodialysis patients.

- It describes the results of:

- rates of bloodstream infections (BSIs) in these patients

- types of organisms causing these infections

- monitoring the insertion of intravenous lines for compliance with recommended practices.

1. Centres for Disease Control and Prevention United States, Dialysis safety, www.cdc.gov/dialysis, accessed 11 December 2012 2. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C 2006, ‘An intervention to decrease catheter-related bloodstream infections in the ICU’, N Engl J Med., vol. 355, no. 26, pp. 2725–32; and Stuart RL, Cameron DR, Scott C, Kotsanas D, Grayson ML, Korman TM, Gillespie EE, Johnson PD 2013, ‘Peripheral intravenous catheter-associated Staphylococcus aureus bacteraemia: more than 5 years of prospective data from two tertiary health services’, Med J Aust,.vol. 198, no. 10, pp. 551–53.

Rationale for surveillanceInfections can occur in patients who have a central or peripheral line inserted as part of their care.

Central lines are catheters inserted in a large vein in the neck, chest or groin and used to administer intravenous fluids and medications, obtain blood samples or take measurements.

Peripheral lines are catheters inserted into a peripheral vein, usually in a limb, generally used to administer intravenous fluids and medications.

Adult or paediatric patients in intensive care units (ICUs) or babies in neonatal ICU are at high risk for central line-associated blood stream infections (CLABSI) or peripheral line-associated blood stream infections (PLABSI).

Haemodialysis patients are at a high risk of infection because the process of haemodialysis requires frequent use of catheters or insertion of needles to access the bloodstream. Haemodialysis patients also have weakened immune systems, which increase their risk of infection, and they require frequent hospitalisations and surgery which exposes them to additional risk.1

A high proportion of intravenous line-associated infections are thought to be preventable with good practices and processes for line insertion and care.2


2016-17 2017-18

Major teaching hospitals

All other hospitals

0.90.83

0.480.42

Infections associated with central lines in ICU settingsScopeCentral line associated bloodstream infection (CLABSI) surveillance data was collected for adult and paediatric patients in ICUs who had central lines inserted and where the infections were considered to be associated with the central line.

Participating organisationsIn Victoria, ICUs are located only in the larger metropolitan, regional, and teaching hospitals. There are 26 public hospitals with adult and/or paediatric ICUs.

Participation in CLABSI surveillance is mandatory for Victorian public hospitals with ICUs. For more information see the Victorian Health Service Performance Monitoring Framework www.health.vic.gov.au/hospital-performance/.

In 2016–17 and 2017–18, ten private hospitals also participated in surveillance for ICU CLABSI.

MethodSurveillance of central line-associated infection was conducted in accordance with VICNISS surveillance module: central line-associated bloodstream infection (CLABSI) or peripheral line-associated bloodstream infection (PLABSI) (ICU/NNL) – protocol. This is based on the US Centres for Disease Control (CDC) National Healthcare Safety Network (NHSN) surveillance program. Hospitals with ICUs monitor and collect data on a continuous basis for this measure.

Observations on the surveillance data

Figure 1: Central line associated bloodstream infection rates in intensive care units (CLABSI per 1000 central line days) Figure 1 displays the annual ICU CLABSI rates with results presented in two groups: major teaching hospitals (A1 hospitals) and ‘other’ hospitals (less specialised hospitals). The A1 hospital group comprises seven public and four private hospitals. The ‘other’ hospital group comprises 19 public and six private hospitals.


Infections associated with central and peripheral lines in neonatal ICUScopeSurveillance data were collected for babies in level 3 neonatal ICUs who had a central or peripheral line inserted and where bloodstream infections were considered to be associated with those lines.

ParticipationIn Victoria, four public hospitals have level 3 neonatal ICUs. No private hospitals contribute data.

MethodSurveillance of central and peripheral line associated infections were conducted in accordance with VICNISS surveillance module (type 1) central line-associated bloodstream infection (CLABSI) or peripheral line-associated bloodstream infection (PLABSI) (ICU/NNL) – protocol. This is based on the US CDC NHSN surveillance program. Hospitals with level 3 neonatal ICUs monitor and collect data on a continuous basis for these measures.

Results are presented as rates per 1,000 central line or peripheral line days.


Observations on surveillance

Figure 2: Central line associated bloodstream infection rates in neonatal intensive care units (CLABSI per 1000 central line days, stratified by birthweight) Figure 2 displays the CLABSI rates stratified by birth weight for neonatal ICUs in Victoria for the years 2016–17 and 2017–18. These rates have particularly wide confidence intervals reflecting the small pool of data available to calculate infection rates.

<750g 751-1000g 1001-1500g 1501-2500g >2500g

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Figure 3: Peripheral line associated bloodstream infection rates in neonatal intensive care units (PLABSI per 1000 central line days, stratified by birthweight) Figure 3 displays the PLABSI rates stratified by birth weight for neonatal ICUs in Victoria for the years 2016–17 and 2017–18. These rates have particularly wide confidence intervals reflecting the small pool of data available to calculate infection rates.


Infections associated with outpatient haemodialysis settings PurposeAll same-day admission haemodialysis patients were monitored for any intravenous antibiotic start, positive blood culture or presence of pus, redness or swelling at the vascular access site.

In Victoria, all patients who attend hospital for haemodialysis are considered admitted patients. Same-day admission haemodialysis is the primary non-ICU setting for central-line surveillance.

Haemodialysis requires vascular access, which can either be a graft or an enlarged blood vessel that can be punctured to remove and replace blood. Patients who undergo dialysis treatment have an increased risk of a HAI. In the event of a suspected or actual infection, patients may receive antibiotics.

The infection may be superficial and restricted to the access site, be blood borne, or rely on clinical diagnosis only. Blood-borne infections and localised infections of the vascular access site are common in haemodialysis patients.3

Because of frequent hospitalisations and receipt of antimicrobial drugs, haemodialysis patients are also at high risk of infection with antimicrobial-resistant bacteria. However, this does not seem to be a significant problem in Victoria at present, where overall reported infection rates are low.

In addition to infections, patients starting antibiotics are also monitored, with vancomycin given particular attention.

3 VICNISS surveillance (type 1/2) module: haemodialysis event (HDE) – protocol 4 CDC United States, ‘Dialysis event protocol’, www.cdc.gov/nhsn/PDFs/pscManual/8pscDialysisEventcurrent.pdf, accessed 13 December 2012

ParticipationSurveillance of infections associated with same-day admission haemodialysis patients is voluntary. However, it has been enthusiastically adopted by many hospitals, with relatively consistent participation enabling conditional analysis of trends over time.

In 2016–17, 41 dialysis facilities participated in same-day admission haemodialysis surveillance.

In 2017–18, 39 dialysis facilities participated in same-day admission haemodialysis surveillance.

Currently only public haemodialysis units participate in surveillance.

MethodActive, patient-based prospective surveillance of infection was conducted in accordance with VICNISS surveillance (type 1/2) module: haemodialysis event (HDE) – protocol. This is based on the US CDC NHSN surveillance program.

Hospitals and other healthcare facilities that conduct same-day admission haemodialysis monitor and collect data on a continuous basis for this measure. Participating health services submitted data quarterly to VICNISS Coordinating Centre.

Observations on surveillanceThere are four main types of vascular access, which are listed below and ordered according to increased risk of infection. These are:4

- arteriovenous fistulas constructed from the patient’s own blood vessels

- arteriovenous grafts often constructed from synthetic materials

- tunnelled central lines (permanent line), a CVC that travels a distance under the skin from the point of insertion before terminating at or close to the heart or one of the great vessels.

- Non-tunnelled central lines (temporary line), a CVC that is fixed in place at the point of insertion and travels directly from the skin entry site to a vein and terminates close to the heart or one of the great vessels, typically intended for short-term use



The most common access type continues to be arteriovenous fistulas, followed by, arteriovenous grafts, then permanent central lines. Very few temporary central lines are used and data on these are not presented here.

Event types under surveillanceAntibiotic starts: Patients may be administered antibiotics if an infection is confirmed or suspected. If the infection is caused by Staphylococcus the haemodialysis patient may be administered the specific antibiotic, vancomycin.

Access related infection types:

- positive blood cultures – isolation of any microorganism from a blood culture where contamination as a source has been excluded

- access-related bloodstream infection (BSI) – positive blood culture with the suspected source identified as the vascular access site or uncertain, and where contamination as a source has been excluded

- local access infection – clinical symptoms of infection present but access-related BSI is not present

Figures 4-6 below display rates of events for 2016–17 to 2017–18 for patients with arteriovenous fistulas, arteriovenous grafts and permanent central lines respectively. Rates are reported per 100 patient months. As expected, the lowest rates of infection and infection-related events are seen in patients with AV-fistulas, followed by those with AV grafts and then permanent central lines.

Antibiotic Starts Vancomycin Starts Positive BloodCultures

Access AssociatedBSI

Local AccessInfections

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Figure 4: Rates of events for patients with arteriovenous fistulas– events per 100 patient months






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Figure 5: Rates of events for patients with arteriovenous grafts– events per 100 patient months

Figure 6: Rates of events for patients with permanent central lines– events per 100 patient months


Infections after surgery

Where?All 6 public hospitals performing bypass surgery participated in VICNISS surveillance. Three private hospital also participated

Who?High risk surgeries are monitored - for example cardiac bypass surgery. Between 1 July 2016 and 30 June 2017 79% of bypass patients were male. The median age of patients having bypass surgery was 70

How Many?Between 1 July 2016 and 30 June 2018, 166 patients were reported with an infection after bypass surgery; 49 of these were classified as ''deep or organ space" infections

How does this compare to previous years?For most surgery under surveillance the infection risk has fallen over the years. Currently the overall risk of an infection following bypass surgery remains stable at around 3.5% although this varies depending on individual patient risk.


Infections in patients undergoing surgery

Patients undergoing surgery are at risk of infection following their procedure, particularly if the surgery involved the use of an implanted device such as an artificial hip or knee.

IntroductionThis section consolidates the results from HAI surveillance of patients who have had specific types of surgery. The main surgical groups which are monitored are:

- coronary artery bypass surgery

- orthopaedic surgery (hip and knee replacement)

- caesarean section

- abdominal hysterectomy

- colorectal surgery

- other cardiac surgery.

It describes the:

- rates of surgical site infection (SSI) with stratification according to risk (type of surgery, patient factors)

- types of causative organisms associated with SSI

- monitoring of administration of surgical antibiotic prophylaxis.

Rationale for surveillanceType of surgerySome surgery carries a higher risk of infection. For example, surgery where an implant is used (such as a knee replacement) has a higher risk than some other types of surgery. ‘Dirty’ surgery, such as that involving opening the gastrointestinal tract, has a higher risk than ‘clean’ surgery. In general, HAIs are monitored and reported for those types of surgery with the greatest infection risk.

Risk stratificationSome patients will always be at greater risk of infection than others having the same type of surgery. A major determinant of risk is the patient’s general state of health. For basic risk stratification this is assessed via the Anaesthesiologist’s Society of America (ASA) score. In addition, different types of surgery carry different risk; and longer surgery generally carries a higher risk.

One method of accounting for some of these differences in risk is to allocate patients undergoing surgery to risk categories depending on their risk of acquiring an infection. The risk index currently used in Victoria is the same as that used by NHSN; and has categories ranging from –1 to 3. The risk index depends on the patients’ ASA score, the type of surgery (‘clean’/’dirty’) and the duration of the operation. It may be altered if a laparoscope is used for the operation.

This helps to ensure that infection rates are calculated on groups of patients with similar risk of contracting an infection. When calculating risk-stratified rates individual patients/procedures are excluded if a risk index cannot be determined; and risk indices are excluded where there are very small numbers of procedures.

Superficial or deep/organ space infectionsInfections are classified as superficial, deep or organ space. Superficial infections are generally less serious and can often be successfully treated with antibiotics alone. Deep or organ space infections often require rehospitalisation and sometimes reoperation. As well as being more serious for patients, they are considered the most reliable for investigating time trends or performing comparisons as they rarely go undetected – patients are usually readmitted to hospital. Superficial infections, on the other hand, may not be detected by surveillance as patients may be treated by a GP in the community.

Deep and organ space infections are often combined into a single category for reporting purposes.

Antibiotic prophylaxisAdministering a dose of antibiotic prior to surgical procedures has been shown to be effective in reducing infections following many types of surgery. However, to be effective, the type of antibiotic chosen must be appropriate, and it must be administered at an optimal time to allow it to be present in the patient’s tissues when the surgical incision is made.

MethodActive, patient-based prospective surveillance of SSI was conducted in accordance with VICNISS surveillance module: surgical site infection (SSI) – protocol. This is based on the US CDC NHSN surveillance program.

Surgical categories are classified as per the VICNISS procedure groups, using ICD10-AM and CMBS codes. Antibiotic prophylaxis compliance is assessed using the current version of the Therapeutic guidelines antibiotic and the guidelines from the National Surgical Infection Prevention Project in the United States.

The surgical procedures monitored by individual hospitals vary depending on:

- types of surgery performed

- requirements outlined in the department’s High-performing health services document

- local infection rates.

Data is submitted quarterly by participating health services to VICNISS Coordinating Centre.

Data are presented for 2016-17 and 2017-18. SSI results are presented as a rate per 100 procedures, stratified by risk index, and also by all infections or deep/organ space infections.

Rates of SSI by risk indexThe figures below display SSI rates by surgery type and risk index for 2016-17 and 2017-18. Higher rates of infection are usually seen in the higher risk indices (2–3). However the risk index is more predictive for some types of surgery than others. Some procedures are mandatory for all hospitals performing the procedures; others are voluntary, therefore time trends must be interpreted with caution.

Observations on surveillanceThe following figures depict the annual risk adjusted infection rates for surgical procedures for Victoria for 2016-17 and 2017-18. Results are presented for surgeries and risk indices where sufficient procedures were performed and more than one hospital contributed data. Figures are presented for total infections and also for complex infections (deep and organ space). The figure (‘n’) represents the number of procedures in the dataset for that year.



SSI – abdominal hysterectomyParticipation by Victorian public health services in SSI surveillance for this procedure is voluntary.

In 2016-17, and 2017-18 there were four hospitals monitoring and reporting SSIs for this procedure.


2016-17(n=295)

Low risk patients Higher risk patients Highest risk patients

2017-18(n=354)

2016-17(n=505)

2017-18(n=478)

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Figure 7: Surgical site infections following hysterectomy (total infections, rate per 100 procedures)

Figure 8: Surgical site infections following hysterectomy (deep/OS infections, rate per 100 procedures)


SSI – cardiac bypass graftsParticipation by Victorian public health services in SSI surveillance for this procedure is mandatory.

In 2016-17, and 2017-18 there were nine (6 public and 3 private) hospitals monitoring and reporting SSIs for this procedure.

2016-17(n=1674)

Low risk patients Higher risk patients

2017-18(n=1574)

2016-17(n=603)

2017-18(n=583)

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Figure 9: Surgical

Figure 10: Surgical site infections following cardiac bypass grafts (deep/OS infections, rate per 100 procedures)


SSI – Caesarean sectionsParticipation in SSI surveillance for caesarean section is mandatory for Mercy Health and The Royal Women’s Hospital. For more information see the Victorian Health Service Performance Monitoring Framework www.health.vic.gov.au/hospital-performance/.

Participation is voluntary for other Victorian public health services. In 2016-17, and 2017-18 there were 17 hospitals monitoring SSIs for C-sections, including one private hospital.


2016-17(n=5398)


2017-18(n=5384)

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Figure 11: Surgical site infections following Caesarean sections (total infections, rate per 100 procedures)

Figure 12: Surgical site infections following Caesarean sections (deep/OS infections, rate per 100 procedures)


SSI – Other Cardiac surgeryParticipation in SSI surveillance for cardiac surgery is voluntary. In 2016-17, and 2017-18 there were 4 hospitals monitoring SSIs for cardiac surgery.

2016-17(n=273)


2017-18(n=313)

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2017-18(n=170)

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Figure 13: Surgical site infections following other cardiac surgery (total infections, rate per 100 procedures)

Figure 14: Surgical site infections following other cardiac surgery (deep/OS infections, rate per 100 procedures)


SSI – Hip replacementsParticipation in SSI surveillance for hip replacements is mandatory for hospitals performing more than 50 procedures annually. In 2016-17, and 2017-18 there were

30 and 31 hospitals monitoring SSIs for hip replacements respectively, including 24 public hospitals.


2016-17(n=295)


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Figure 15: Surgical site infections following hip replacements (total infections, rate per 100 procedures)

Figure 16: Surgical site infections following hip replacements (deep/OS infections, rate per 100 procedures)


SSI – Knee replacementsParticipation in SSI surveillance for knee replacements is mandatory for hospitals performing more than 50 procedures annually. In 2016-17, and 2017-18 there were

28 and 31 hospitals monitoring SSIs for knee replacements respectively, including 24 public hospitals.

2016-17(n=1674)


2017-18(n=1574)

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2017-18(n=583)

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Figure 17: Surgical site infections following knee replacements (total infections, rate per 100 procedures)

Figure 18: Surgical site infections following knee replacements (deep/OS infections, rate per 100 procedures)



SSI – Colorectal surgeryParticipation in SSI surveillance for colorectal surgery is voluntary. In 2016-17, and 2017-18 there were 7 hospitals

monitoring SSIs for colorectal surgery respectively, all of them public hospitals.

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2016-17(n=90)

Lowest risk patients

2017-18(n=189)

2016-17(n=300)

2017-18(n=838)

2016-17(n=159)

2017-18(n=400)

5.6

3.22.6

3.7

7.0

5.1

10.8

15.7

20

18

16

14

12

10

8

6

4

2

02016-17(n=230)


2017-18(n=656)

2016-17(n=90)

Lowest risk patients

2017-18(n=189)

2016-17(n=300)

2017-18(n=838)

2016-17(n=159)

2017-18(n=400)

5.6

1.1 0.9

2.0 2.3 2.3

5.7

4.5

Figure 19: Surgical site infections following colorectal surgery (total infections, rate per 100 procedures)

Figure 20: Surgical site infections following colorectal surgery (deep/OS infections, rate per 100 procedures)


Causative organisms responsible for healthcare associated infections

Which organisms cause these infections?

Coagulase negative Staphylococcuswas the most common bacteria isolated from bloodstream infections in intensive care in both adults and neonates.

Staphylococcus aureus was the most common bacteria isolated for all major surgical groups monitored; and also haemodialysis related infections*

*Infections occurring between 1 July 2016 and 30 June 2018



Figure 21: Pathogens isolated in adult intensive care(CLABSI) 2016-2018

Figure 22: Pathogens isolated in neonatal intensive care (CLABSI/PLABSI) 2016-2018

Staphylococcus areas

Enterococcus faecium

Enterococcus faecailis

0 20 40 60 80 100

No. of patients with infections and organisms reported 117

No. of Infections with Organisms 118

No. of Distinct Pathogens 17

Coagulase Negative Staphylococcus (27%)

Staphylococcus aureus (17.5%)

Enterococcus faecalis (10.3%)

Escherichia coli (8.7%)

Klebsiella pneumoniae (8.7%)

Enterococcus faecium (7.1%)

Pseudomonas aeruginosa (4.8%)

Candida albicans (3.2%)

Acinetobacter spp. (3.2%)

Bacillus spp. (1.6%)

Citrobacter spp (1.6%)

Stenotrophomonas maltophilia (1.6%)

Serratia spp. (1.6%)

All Others (3.2%)

MRSA

MSSA

SA - Unkown

VRE

VSE

E - Uknown



0 20 40 60 80 100




Coagulase Negative Staphylococcus (35.3%)


Klebsiella pneumoniae (11.8%


Enterobacter spp (5.9%)


MRSA

MSSA

SA - Unkown

VRE

VSE

E - Uknown


Figure 23: Pathogens isolated from infections following cardiac bypass surgery 2016-2018

Figure 24: Pathogens isolated from infections following colorectal surgery 2016-2018




0 20 40 60 80 100








Proteus spp. (5.8%)





Klebsiella oxytoca (2.6%)



Morganella morganii (1.9%)

Streptococcus spp. (Group B) (1.6%)

Streptococcus spp. (Group C & G) (1.6%)

MRSA

MSSA

SA - Unkown

VRE

VSE

E - Uknown




0 20 40 60 80 100









Proteus spp. (3.3%)


Bacillus fragilis (3.3%)



MRSA

MSSA

SA - Unkown

VRE

VSE

E - Uknown



Figure 25: Pathogens isolated from infections following Casaerean section 2016-2018

Figure 26: Pathogens isolated from infections following hysterectomy 2016-2018


Enterococcus faecalis

0 20 40 60 80 100











Enterobacter spp. (2.1%)

Proteus spp. (2.1%)

Unidentified Gran begative bacillus (2.1%)

Bacteroides fragilis (2.1%)

MRSA

MSSA

SA - Unkown

VRE

VSE

E - Uknown






Streptococcus spp. (Group A) (33.3%)


Figure 27: Pathogens isolated from infections following haemodialysis infections 2016-2018



Enterococcus faecalis

0 20 40 60 80 100






Streptococcus pneumoniae (4.1%)

Enterobacter spp. (4.1%)



Proteus spp. (2.7%)

Clostridium perfringens (2.7%)

Klebsiella oxytoca (1.4%)

Stenotrophomonas maltophilia (1.4%)

Providencia rettgeru (1.4%)


Corynebacterium spp. (1.4%)

Streptococcus viridans (1.4%)

MRSA

MSSA

SA - Unkown

VRE

VSE

E - Uknown

Surveillance of specific organisms or types of organisms

Clostridium difficile infectionsPurposeCDI surveillance includes all patients presenting to a public hospital with a C. difficile toxin-positive specimen identified by a laboratory and confirmed by a suitably qualified healthcare worker. The infection is designated as healthcare-associated when the infection was considered to be associated with their episode of care.

ParticipationAt the department’s request, all Victorian public hospitals including (mental health facilities) must perform CDI surveillance.

MethodCDI surveillance was conducted in accordance with the VICNISS surveillance Clostridium difficile infection (CDI) – protocol. The definition is in accordance with the Australian Commission on Safety and Quality in Healthcare’s National definition and calculation of hospital identified Clostridium difficile infection. Hospitals collect data on a continuous basis for this measure. Participating health services submit quarterly data to VICNISS Coordinating Centre for collation and analysis. Results are presented each quarter as rates per 10,000 occupied bed days.

Observations on surveillanceSurveillance of CDI infections has now been carried out continuously in Victoria since late 2010. After an initial rise in reported infections, most likely explained by increased awareness and testing, the number of cases has been relatively stable, ranging from 1000 to 1400 cases classed as healthcare associated per year. All cases identified by healthcare facilities are reported, whether considered to be community or healthcare associated. In the case of CDI, it can be difficult to distinguish between community and healthcare associated infections.

Strains associated with particular ribotypes and which have caused outbreaks, and the majority of morbidity and mortality overseas are not being detected in appreciable numbers in Victoria. However, ribosome testing is performed on a relatively small proportion of isolated strains. Data is collected on markers of severity of illness and the proportions of severe disease in Victoria remain low. Severe disease is defined as cases admitted to intensive care, requiring surgery due to complications of CDI or where death occurs within 30 days of infection and is attributed to CDI. The percentage of cases with severe disease remains low at 1.5 per cent and 1.6 per cent in 2016–17 and 2017–18 respectively.



2000

1800

1600

1400

1200

1000

800

600

400

200

0Healthcareassociated

Community Indeterminate Unknown All HospitalIdentified

2017/18

2016/17

5

4.5

4

3.5

3

2.5

2

1.5

1

0.5

0

2.1

1.7

2017/18

2016/17

Figure 28: Numbers of Clostridium difficile infections by category including all hospital identified infections

Figure 29: Rate of hospital identified Clostridium difficile infections classified as healthcare associated (infections per 10,000 occupied bed days)


Staphylococcus aureus bacteraemiaPurposeSAB surveillance includes all patients admitted to a public hospital with a bacteraemia caused by either Methicillin-susceptible S.aureus (MSSA) or Methicillin-resistant S.aureus (MRSA) and where the infection was considered to be associated with their episode of care.

ParticipationParticipation in SAB surveillance is mandatory for Victorian public hospitals (including mental health facilities). For more information see the Victorian Health Service Performance Monitoring Framework: www.health.vic.gov.au/hospital-performance/.

All eligible Victorian public health services participate. Several private hospitals currently perform surveillance and submit data on SAB.

MethodSAB surveillance was conducted in accordance with the VICNISS surveillance module Staphylococcus aureus bacteraemia (SAB) – protocol. The definition is in accordance with the Australian Commission on Safety and Quality in

Healthcare’s National definition and calculation of hospital-identified Staphylococcus aureus infection.

Hospitals collect data on a continuous basis for this measure. Participating health services submit data quarterly to VICNISS Coordinating Centre. Rates of SAB are reported quarterly per 10,000 occupied bed days.

Observations on surveillance Figure 30 displays rates of SAB calculated using occupied bed days as the denominator, including the hospital bed days accrued by patients most at risk for SAB.

SAB rates in Victoria have decreased since the introduction of a coordinated surveillance program in 20109. A number of interventions have taken place in Victoria during this time that may have contributed to this decrease including the introduction of the VICNISS SAB surveillance program and the National Hand Hygiene Initiative.

The decrease in SAB rates in Victoria has been mirrored by national SAB rates, which have also declined since national data collation was introduced. More information on SAB rates in other states and territories as well as rates by hospital peer group is available on the Australian Institute of Health and Welfare website http://www.aihw.gov.au/

Surveillance of specific organisms or types of organisms

Total SAB rate MRSA SAB rate

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0.0

2017/18

2016/17

0.73

0.67

0.12 0.11

Figure 30: Healthcare associated Staphylococcus aureus bacteraemia rates (infections per 10,000 occupied bed days)


Carbapenamase producing Enterobacteriacea (CPE)PurposeCarbapenemase-producing Enterobacteriaceae are a group of bacteria that have developed resistanceto a number of front line antibiotics as well as carbapenems which are considered ‘last resort’ antibiotics for the treatment of serious infections. Carbapenemase genes encode enzymes that degrade carbapenem antibiotics. Enterobacteriaceae comprise the largest family of gram-negative bacteria causing human infection and includes common pathogens such as Escherichia coli, Klebsiella and Enterobacter species. These organisms are normal flora of the gastrointestinal tract but have the potential to cause infection and disseminate antimicrobial resistance.

ParticipationReporting of cases of CPE is mandatory in Victoria. A case of CPE is defined in the Victorian guidelines on carbapenamase producing Enterobacteriaceae for Victorian health services: https://www2.health.vic.gov.au/public-health/infectious-diseases/infection-control-guidelines/carbapenemase-producing-enterobacteriaceae-management

MethodThe department is the lead agency for the statewide response to CPE. The department has engaged several partner agencies, namely the Microbiological Diagnostic Unit Public Health Laboratory and the Victorian Healthcare Associated Infection Surveillance System to assist with the surveillance and response to CPE in Victoria.

Observations on surveillance Data collection on all cases of CPE commenced in January 2016. In addition, VICNISS developed online audit facilities through which hospitals were required to audit compliance with the first version of the CPE guidelines, plus a facility to collate data resulting from mandatory point prevalence surveys. Hospitals were also able to report the results of the audits and point prevalence surveys through the secure VICNISS portal.

Point prevalence surveys were mandated in areas considered to be high risk such as transplant and haematology wards and intensive care units. The prevalence of CPE was found to be almost zero from the surveys and the point prevalence surveys are no longer mandated in the second version of the guidelines.

Reports on CPE have been released and can be found at this link: https://www2.health.vic.gov.au/public-health/infectious-diseases/infectious-diseases-surveillance/interactive-infectious-disease-reports/state-wide-surveillance-report


IntroductionThis section contains the results from surveillance relating to healthcare workers in Victorian public health services. In particular:

- rates of vaccination of healthcare workers against seasonal influenza

- occupational exposures to blood and body fluids in smaller health services.

Purpose and rationale for surveillanceHealthcare workers are considered to be a group of special interest for influenza vaccination, since vulnerable patients who are exposed to a healthcare staff member with influenza can become infected. Additionally, reduction in healthcare staff numbers due to illness may adversely affect the care of vulnerable patients. The National Health and Medical Research Committee (NHMRC) recommends that all healthcare workers involved in direct patient care should be vaccinated.

The department provides seasonal influenza vaccination free of charge to Victorian health services for their healthcare workers.

Occupational exposures to blood and body fluids constitute a risk to healthcare workers and most are considered preventable with safe work practices and the use of safety engineered medical devices. It has been estimated that there are up to 18,000 sharps injuries in Australia each year and they are one of the most common causes of physical, pathological and psychological hazards for many healthcare workers. VICNISS collates data on these exposures in small health services; and in 2017 began collating these data from all health services from 2017.

Healthcare worker seasonal influenza vaccination PurposeTo identify the proportion of healthcare workers vaccinated against seasonal influenza.

ParticipationAll Victorian public health services can request from the department’s Immunisation Section the seasonal influenza vaccine to immunise their staff. For more information: www.health.vic.gov.au/immunisation.

All Victorian public health services contribute data for this measure.

MethodSurveillance was conducted in accordance with the VICNISS surveillance module: staff influenza vaccination protocol. Hospitals collect data for a finite period for this measure. Data is submitted annually by participating health services to VICNISS Coordinating Centre.

Results are presented as the proportion of staff known to be immunised by clinical category. Comparable data is available since 2005.

Observations on the surveillance dataFigure 31 displays the percentage of staff in Victorian public health services known to be vaccinated against seasonable influenza in 2016 and 2017. There was another slight increase in the total proportion of staff known to be vaccinated in 2017. Figure 32 has more detailed data by health care worker category.

HCW influenza vaccination and exposure to blood and body fluids


Healthcare worker immunisation against seasonal influenza

Vaccination of healthcare workers against seasonal influenza

The proportion of healthcare workers vaccinated in Victoria has doubled from 41% when data collection began in 2005 to 80% in 2017

How does this compare to previous years?A dramatic increase in proportions of staff vaccinated occurred in 2014 after a state target was introduced: the proportion increased from 59% to 72%. Currently it is stable at around 80%.

Proportion of vaccinated staff in intensive care units were very high (86% adult, 94 % paediatric, 86% neonatal) in 2018. ICU patients may be particularly vulnerable.

2010 2011 2012 2013 2014 2015 2016 2017

100

90

80

70

60

50

40

30

20

10

0


HCW influenza vaccination and exposure to blood and body fluids

2016 2017

100

90

80

70

60

50

40

30

20

10

0

79.9 80.1

Lab Sta� Medical Sta� Nursing Sta� Other Cat A&B Sta�

Category C Sta�

100

90

80

70

60

50

40

30

20

10

0

2016

2017

78.8

74.1

80.179.980.781.582.179.979.683.7

Figure 31: Percentage of eligible healthcare workers vaccinated

Figure 32: Percentage of healthcare workers vaccinated by major staff category


Occupational exposures to blood and body fluidsPurposeTransmissions of bloodborne pathogens through occupational exposures such as needle-stick injuries represent a significant risk to healthcare workers.

Occupational exposures to blood or body fluids in healthcare settings have the potential to transmit hepatitis B, hepatitis C or human immunodeficiency virus (HIV).

Participating organisationsParticipation by Victorian public health services in this surveillance is voluntary. This module has recently been redeveloped and earlier data may not be comparable. Larger health services are also now participating whereas in earlier years data were exclusively obtained from small health services.

Data collectionSurveillance was conducted in accordance with the VICNISS occupational exposure surveillance data collection form on an

as-required basis. This is based in part on the CDC Workbook for designing, implementing and evaluating a sharps injury prevention program and NSW Health Infection control program quality monitoring indicators user manual.

Health services submit data if an occupational exposure is reported. Results are presented annually as the number of exposures per 10,000 acute occupied bed days.

Observations on the surveillance dataThere are three key types of occupational exposures involving acute patient sources:

- percutaneous exposure – the piercing of skin with a contaminated sharp (any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes and exposed ends of dental wires)

- splash exposure – when blood or other potentially infectious materials makes contact with the eye, mouth, other mucous membrane or non-intact skin contact

- Bite/Assault

The results are displayed in Figure 33 below.

Percutaneous Splash Bite/Assault

6

5

4

3

2

1

0

2016

2017

0.10.1

0.90.9

4

4.7

Figure 33: Occupational exposures– exposures per 10,000 occupied bed days


Glossary

Term Definition

Antibiotic prophylaxis Use of antibiotics prior to surgery to prevent infections at the surgical site

ASA score American Society of Anaesthesiology score – designed to assess the patient’s physical status. Ranges from 1 for a healthy patient to 5 for a patient who is not expected to survive 24 hours without an operation.

Bloodstream infection (BSI) Presence of live pathogens in the blood, causing an infection

CDC Centers for Disease Control and Prevention (United States)

CDI Clostridium difficile infection

Central line / central venous catheter (CVC)

A catheter (tube) that is passed through a vein to end up in the thoracic (chest) portion of the vena cava (the large vein returning blood to the heart) or in the right atrium of the heart

Central line-associated bloodstream infection (CLABSI) A bloodstream infection thought to have been caused by the presence of a central line

Cholecystectomy A surgical procedure to remove the gallbladder

Coronary artery bypass graft surgery

A surgical procedure that creates new pathways around blocked or narrowed arteries to allow blood to reach the heart muscle again

Central line days The number of days for which an intravenous catheter or ventilator has been present in a patient

the department the Department of Health and Human Services

Healthcare-associated infection (HAI)

Any infection that occurs during or after hospitalisation that was not present or incubating at the time of the patient’s admission

Infection Invasion of pathogenic micro-organisms in a bodily part or tissue that may produce tissue injury and progress to disease

Intensive care unit (ICU) A hospital unit that usually treats very sick patients. Patients in intensive care units are at a higher risk of developing infections.

Methicillin-resistant Staphylococcus aureus (MRSA) A methicillin (antibiotic) resistant strain of Staphylococcus aureus

Neonatal A baby within the first four weeks of birth

NHSNThe National Healthcare Safety Network is a surveillance system that integrates patient and healthcare personnel safety surveillance systems managed by the Division of Healthcare Quality Promotion (DHQP) at CDC

Non-parenteral exposure Blood or other potentially infectious materials makes contact with the eye, mouth, other mucous membrane or non-intact skin contact

Occupied bed days (OBD) Number of days a patient is admitted to a hospital bed

Pathogen An agent of disease. The term pathogen is used most commonly to refer to infectious organisms such as bacteria, viruses and fungi

Parenteral exposure Piercing of skin with a contaminated sharp instrument

Peripheral-line associated bloodstream infection (PLASBI) A bloodstream infection thought to have been caused by the presence of a peripheral line

Risk index A means of stratifying patients according to their risk of infection, this then allows appropriate comparison of infection rates

SAB Staphylococcus aureus bacteraemia

Surgical site infection (SSI) An infection at the site of an operation (usually an incision) that is caused by the operation

Surveillance The ongoing systematic collection, analysis and interpretation of data

Type 1 hospitals Victorian hospitals with 100 beds or greater

Type 2 hospitals Victorian hospitals with less than 100 beds

VICNISS Advisory Committee

A committee providing stakeholder advice to the VICNISS Coordinating Centre on the implementation, development and deliverables of the VICNISS program

VICNISS Victorian healthcare-associated infection surveillance system


Appendix A: VICNISS Advisory Committee

PurposeThe VICNISS Advisory Committee provides stakeholder input and advice to the Coordinating Centre on the implementation, development and activities of VICNISS.

Members between 2016 and 2018

Member Representing

Mr Matthew Richards Infection control consultant –Public

Dr Cate Kelly Executive Director, Clinical Governance/Medical Services, Melbourne Health

Ms Sarah Gray Consumer

Dr Vij Sanjiv College of Intensive care Medicine of Australia & New Zealand, Australian and New Zealand Intensive Care Society

Ms Anne Lickliter Infection control consultant - Public

Ms Carol Rosevear Infection control consultant - Private

Prof Michael Richards VICNISS Coordinating Centre

Ms Pauline Woodburn Infection Control Consultant - Rural

Dr Rhonda Stuart Australian Society for Infectious Diseases

Mr David Love Royal Australasian College of Surgeons

Mr Lincoln Fowler Infection Control Consultant - Rural

Ms Leanne Houston Infection Control Consultant - Public

Mr Shane Thomas Consumer

Dr Sanjiv Vij College of Intensive Care Medicine, Australia and New Zealand

Dr Ann Bull VICNISS Coordinating Centre

Mr Jonathan Prescott Infection Prevention, Quality, Safety and Patient Experience, Department of Health and Human Services

Dr Andrew Stewardson Infectious Diseases Physician, Australian Society of Infectious Diseases

Ms Wendy Davis Accreditation and Projects (SJOG) Australasian College of Infection Prevention and Control

Mr Marinis Pirpiris Orthopaedic surgeon, Australian Orthopaedic Association

Ms Kelly Barton Infection Control Consultant – Rural

Ms Jenny Breen Infection Control Consultant – Metropolitan

Ms Elizabeth Orr Infection Control Consultant - Metropolitan


Appendix B: VICNISS Coordinating Centre staff

Staff 2016–2018Professor Michael Richards Director

Dr Ann Bull Operations Director

Simon Burrell, Database Manager

Roland Laguitan, Information technology

Dr Noleen Bennett Infection Control

Jennifer Bradford Infection Control

Judy Brett Infection Control

A/Prof Leon Worth, Infectious Diseases Physician

Ling Wang, Information technology

Beema Beegum, Information technology

Andrea Brebner, Administration

Chris Clark, Administration

Dr Tim Spelman, Statistician

Sandra Johnson, Epidemiologist

Dr Syed Nabeel Imam, Biostatistician/Epidemiologist

The Peter Doherty Institute for Infection and Immunity792 Elizabeth St, Melbourne Victoriawww.doherty.edu.au

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