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

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pro

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Socie

ties,

org

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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

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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)

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Acinetobacter spp.

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Pseudomonas

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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