NOREEN MOLLON, MSINFECTION PREVENTION CONSULTANT

Multi-Drug Resistant Organisms (MDROs) in

Michigan

www.michigan.gov/hai

Objectives

Describe MDROsMDRO surveillance and reporting

SHARP Prevention Initiatives Recent MDRO investigationsIP practices for MDROs

Describing MDROs

What is a MDRO?

Multidrug-Resistant Organisms (MDROs) are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents (HICPAC)

Deserve special attention in healthcare facilities– Healthcare-Associated Infections (HAIs)

Clinically significantAssociated with increased lengths of stay,

costs, and mortality

Types of MDROs

MRSAVISAVRSAVREC. DiffMDR GNB

Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii

ESBLs CRE

What is MRSA?

• MRSA:o Methicillino Resistanto Staphylococcuso aureus

• Staphylococcus aureus are Gram positive bacteria that can be transmitted from person-to-person in a healthcare facility or in the community

• MRSA is a staph infection that is resistant to β-lactam antibiotics (like methicillin, penicillin, and amoxicillin)

Methicillin-Resistant Staphylococcus aureus (MRSA)

MRSA >40% of US hospital-associated S. aureus

infections >50% of ICU-associated S. aureus infections

Increasing reports in non-healthcare settings Prisons Schools Day-care Workplace Other

Approximately 1% of the general population is colonized with MRSA

VISA

Vancomycin-intermediate Staphylococcus aureus

Vancomycin minimum inhibitory concentration (MIC) =4–8 µg/mL

Isolate must be confirmed at MDCH laboratory

Resistance mechanism is not transferrable to susceptible strains and is usually associated with vancomycin exposure

VRSA

Vancomycin-resistant Staphylococcus aureusVancomycin minimum inhibitory

concentration (MIC) 16 µg/mLIsolate must be confirmed at MDCH

laboratoryResistance is acquired from VRE and is

transferrable

VRE

Vancomycin-resistant Enterococcus

Can colonize the intestines and female genital tract

Can cause infections of the urinary tract, the bloodstream, or of wounds associated with catheters or surgical procedures

Clostridium difficile (C. diff)

Background Accounts for 15-25% antibiotic-associated

diarrhea 80% Clostridium difficile infection (CDI)

associated with healthcare Elderly and patients on antibiotics at highest

riskCurrent epidemiology

Increased rates nationwide Increased severity and mortality

Reasons Widespread use of antibiotics Changes in infection control practices New strain: NAP-1

MDR GNB

Multidrug-resistant gram-negative bacilliCan refer to various organisms:

Escherichia coli, Klebsiella pneumoniae,Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia, Burkholderia cepacia,and Ralstonia pickettii

MDR GNB

Grouped according to resistance Extended-spectrum β-Lactamases (ESBLs) Carbapenem-resistant Enterobacteriaceae (CREs)

Carbapenemase-producers (such as Klebsiella pneumoniae carbapenemase or KPC)

Metallo-beta-lactamase (MBL)-producers

Difficult to lab confirmWorrisome public health threat

What is a HAI?

Healthcare-Associated Infections (HAIs) are infections that patients acquire during the course of receiving healthcare treatment for other conditions that were not present at admission

HAIs are often MDROsAre frequently device-associated

HAIs

Approximately 1 out of every 20 hospitalized patients will contract an HAI

CDC estimated that 1.7 million HAIs occurred in US hospitals in 2002

HAIs are responsible for about 100,000 deaths in the US annually

The medical costs associated with these infections are approximated to be between $36-45 billion

Types of HAIs

Central Line-Associated Blood Stream Infections (CLABSI)

Catheter-Associated Urinary Tract Infections (CAUTI)

Ventilator-Associated Events (VAE)

Surgical Site Infections (SSI)

Clostridium difficile (C.diff) Infection

Methicillin-Resistant Staphylococcus aureus (MRSA)

Multidrug-Resistant Organisms (MDROs) – Acinetobacter, Klebsiella, Pseudomonas, Enterobacter, E.coli, etc.

Types of HAIs

Staphylococcus aureus

Subclavian central venous line

Mechanical ventilator

Surgical incision showing signs of infection

Clostridium difficile

Foley catheter insertion kit

SSI

CLABSI

VAE

CAUTI

CDI LabID

MRSA LabID

Costs of HAIs*

Meta-analysis results of top 5 HAIs

Infection Cost/Infection Attributed LOS(Days)

Total annual cost

($, billions)

Total annual cases

CLABSI $45,814 10.4 1.85 40,411

SSI $20,785 11.2 3.30 158.369

VAP $40,144 13.1 3.09 31,130

C. Diff $11,285 3.3 1.51 133,657

CAUTI $896 -- 0.28 77,079

* source: JAMAInternalMedicine, 9/2/2013

MDRO Surveillance and Reporting

33 states have laws requiring HAIs to be reported to state health departments, the majority of which publically release hospital HAI rates

Surveillance and Reportingwww.michigan.gov/hai

National Reporting Requirements

The Centers for Medicare and Medicaid Services (CMS) requires hospitals to report: CLABSI (effective January 2011) CAUTI (effective January 2012) SSI for Colon Surgeries and Abdominal

Hysterectomies (effective January 2012) MRSA Bacteremia LabID (effective January 2013) C. difficile LabID (effective January 2013)

Bureau of Disease Prevention, Control and Epidemiologywww.michigan.gov/epi

Division of Communicable Diseasewww.michigan.gov/mdch/0,1607,7-132-2945_5104-12219--,00.html

Surveillance and Infectious Disease Epidemiology Section (SIDE)

www.michigan.gov/cdinfo

Surveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit www.michigan.gov/hai

Education and Outbreak Response

SurveillancePrevention Initiatives

Carbapenem-Resistant Enterobacteriaceae (CRE) Prevention Collaborative

MRSA/CDI Prevention Collaborative

Collect HAI data from Michigan hospitals through the CDC’s web-based National Healthcare Safety Network (NHSN)

Provide general education and recommendations based on current best-practice, evidence-based guidelines

Authority of State and Local HDs

• Michigan is a “home rule” state, meaning local HDs have autonomy within their jurisdiction

• The MDCH operates independently from the local HDs

• The primary role of the MDCH in communicable disease control is to provide:\o Expert consultationo Reference level diagnostics laboratory serviceso Childhood vaccineso Support local HDs upon their requesto Maintenance and administration of the MDSS

• All communicable disease reports should be reported to your local HDs

Public Health Investigative Authority

State and local HD personnel are authorized to investigate reported diseases, including: Contacting health providers Conducting additional case-finding Conducting epidemiological studies Conducting specimen collection Gathering information on medical history, lab results,

diagnostic procedures, treatment, and health outcomes

The MDCH works collaboratively with the local HDs and participates in investigations when requested

Confidentiality, HIPAA, and PHI

Disclosure of protected health information (PHI) to health authorities without individual consent or authorization is permitted when disclosure is required by law or is authorized by law for a public health purpose (www.hhs.gov/ocr/hipaa/)

All information provided to public health authorities is kept confidential

Map of Michigan Local HDs

Communicable Disease Surveillance

Communicable disease reporting is required by Michigan law: Michigan Public Health Act No. 368 Communicable

Disease Rules: R 325.171-3, 333.5111 Rule revision allows the State the right to

periodically update the list of reportable diseases This reporting is expressly allowed under HIPAA

Hepatitis C Virus Neisseria meningitidis Histoplasma capsulatum Bordetella pertussis

Why Communicable Disease Surveillance is Important

To identify outbreaksTo assure treatment, preventive treatment

and/or educationTo evaluate prevention and control

programsTo help target prevention resourcesTo facilitate epidemiologic researchTo assist national and global surveillance

efforts

Salmonella sp.Influenza VirusChlamydia trachomatis Mycobacterium tuberculosis

Communicable Disease Reporting Entities

• Physicians*• Laboratories*• Hospital ICP• Private citizens• School systems*• Pharmacists• Veterinarians• Medical

Examiners

• Hospitals*• Child care

facilities• Long-term care

facilities*• Pre-hospital

emergency serviceso Policeo Fireo EMS

*Required to report

Communicable Disease “Brick Book”

The current 2012 version (electric crimson), provides a good summary of the communicable disease rules, requirements, and responsibilities

Michigan Reportable Diseases

~90 disease/conditions are reportable in Michigan

Also reportable are ‘unusual occurrences’, outbreaks and epidemics of any disease or condition (including healthcare-associated infections)

Specific reporting rules and definitions can be found at www.michigan.gov/cdinfo

Michigan Reportable MDROs and HAIs

Vancomycin-Intermediate Staphylococcus aureus (VISA) and Vancomycin-Resistant Staphylococcus aureus (VRSA) are required to be reported according to the communicable disease rules

Unusual occurrences and outbreaks of HAIs are also mandated by law to be reported

However, individual HAIs (like a CLABSI), are not required to be reported to state or local health departments

Surveillance of Healthcare Associated and Resistant Pathogens(SHARP) Activities

Surveillance and ReportingMDRO Prevention Initiatives Consulting/EducationOutbreak Response

Staphylococcus aureus

Clostridium difficileKlebsiella pneumoniae

www.michigan.gov/hai

www.michigan.gov/hai

SHARP Unit

Objectives of the SHARP Unit: Coordinate activities related to HAI surveillance

and prevention in Michigan Improve surveillance and detection of

antimicrobial-resistant pathogens and HAIs Identify and respond to disease outbreaks Use collected data to monitor trends Educate healthcare providers, state and local public

health partners, and the public on HAIs

In Michigan, hospitals can voluntarily report HAIs to MDCH SHARP via the National Healthcare Safety Network (NHSN)

NHSN is a web-based surveillance program designed by CDC: Uses standardized HAI surveillance definitions Users can enter and analyze HAI data

The data sent to SHARP from Michigan hospitals are de-identified and the numbers aggregated for the purposes of producing state-wide HAI surveillance reports

NHSN Surveillance Initiative

www.michigan.gov/hai

HAIs tracked by MDCH SHARP surveillance: Central Line-Associated Blood Stream Infection

(CLABSI) Surgical Site Infection (SSI) Catheter-Associated Urinary Tract Infection (CAUTI) Ventilator-Associated Pneumonia (VAP) Clostridium difficile LabID surveillance MRSA LabID surveillance Antimicrobial resistance in select pathogens

NHSN Surveillancewww.michigan.gov/hai

SHARP releases state-wide HAI reports quarterly, semiannually, and annually which are posted at www.michigan.gov/hai All hospital data is de-identified and aggregated Individual hospital data is not made public

SHARP also compiles hospital specific HAI reports which are only shared with those individual hospitals

SHARP Surveillance Reportswww.michigan.gov/hai

SHARP Surveillance

Currently there are 83 Michigan hospitals sharing HAI data with SHARP, 82 hospitals releasing their data to the Michigan Health and Hospital Association MHA Keystone Center, and 13 hospitals releasing their NICU data to the Vermont Oxford Network (9/26/13).

www.michigan.gov/hai

0

10

20

30

40

50

60

70

80

90

Number of Acute Care Hospitals that have Signed a Data Use Agreement with MDCH SHARP

Master Agreement

MHA Data Release

VON Data Release

Nu

mber

of

Hosp

itals

SHARP HAI Data: MRSA Lab IDwww.michigan.gov/hai

2011 Q1 2011 Q2 2011 Q3 2011 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q40

1

2

3

4

5

6

MRSA LabID Rates

MR

SA

LabID

Rate

per

1,0

00 P

ati

ent

Days

SHARP HAI Data: CDI LabIDwww.michigan.gov/hai

2011 Q1 2011 Q2 2011 Q3 2011 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q40

5

10

15

20

25

C. diff LabID Rates

C.

diff

LabID

Rate

per

10,0

00 P

ati

ent

Days

SHARP HAI Data: SIRStandardized Infection Ratios (SIR)

2012 Quarter 4

Type of Infection

Number of Hospitals

Procedures Done

Device Days Observed1 Predicted2 MI SIR3

MI p-value

MI 95% CI4

CAUTI5 75 N/A 99,581 232 215.972 1.074 0.1456 0.940, 1.222CLABSI6 73 N/A 89,342 86 179.784 0.478 <0.0001 0.383, 0.591SSI7 72 11,954 N/A 233 267.056 0.872 0.0184 0.762, 0.994SSI COLO8 69 2,111 N/A 91 122.292 0.744 0.0019 0.596, 0.917SSI HYST9 67 2,109 N/A 35 39.824 0.879 0.2509 0.607, 1.230 MI Data US Data

Green Font: SIR demonstrates statistically significantly fewer infections than expectedRed Font: SIR demonstrates statistically significantly more infections than expected

1Observed: Number of infections (CAUTI, CLABSIs or SSIs) reported during the time frame.2Predicted: The number of CAUTIs or CLABSIs predicted based on the type of hospital unit(s) under surveillance, or the number of SSIs predicted based upon 2009 national SSI rates by procedure type. 3SIR: Standardized Infection Ratio: Ratio of observed events compared to the number of predicted events, accounting for unit type or procedure. An SIR of 1 can be interpreted as having the same number of events that were predicted. An SIR that is between 0 and 1 represents fewer events than predicted, while an SIR of greater than 1 represents more events than expected. 495% CI: 95% confidence interval around the SIR estimate. A 95% CI indicates that 95% of the time, the actual SIR will fall within this interval.5CAUTI: Catheter-Associated Urinary Tract Infection. CAUTIs are defined using symptomatic urinary tract infection (SUTI) criteria or Asymptomatic Bacteremic UTI (ABUTI) criteria. UTIs must be catheter-associated (i.e. patient had an indwelling urinary catheter at the time of or within 48 hours before onset of the event).6CLABSI: Central Line-Associated Blood Stream Infection. CLABSIs are laboratory-confirmed bloodstream infections (LCBI) that are not secondary to a community-acquired infection, or an HAI meeting CDC/NHSN criteria at another body site. BSIs must be central line associated (i.e., a central line or umbilical catheter was in place at the time of, or within 48 hours before, onset of the event).7SSI: Surgical Site Infection. Includes any superficial incisional, deep incisional, or organ/space SSI.8SSI COLO: Colon surgeries9SSI HYST: Abdominal Hysterectomies17.

www.michigan.gov/hai

2009-2010 Annual Report 2010-2011 Semi-Annual Report0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

CLABSI Rates from Data Shared with MDCH SHARP through NHSN (MI vs. US)

MI CLABSI

US CLABSI

Time Period

CL

AB

SI R

ate

SHARP HAI Data: CLABSIwww.michigan.gov/hai

SHARP HAI Data: CAUTIwww.michigan.gov/hai

2011Q1 2011Q2 2011Q3 2011Q4 2012Q1 2012Q2 2012Q3 2012Q4 2013Q10

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Michigan Overall CAUTI SIR

SIR

2011Q1 2011Q2 2011Q3 2011Q4 2012Q1 2012Q2 2012Q3 2012Q4 2013Q10

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Michigan Original 25 Hospitals CAUTI SIR

SIR

SHARP HAI Data: CAUTIwww.michigan.gov/hai

MRSA/C. DIFFCRE

MDCH Prevention Initiatives

MDRO Prevention Initiatives

SHARP also has started two prevention initiatives aimed to reduce the incidence and prevalence of MDROs in healthcare facilities in Michigan:

Methicillin-Resistant Staphylococcus aureus (MRSA) and Clostridium difficile (CDI) prevention initiative

Carbapenem-Resistant Enterobacteriaceae (CRE) surveillance and prevention initiative

Enterobacter cloacaeCitrobacter freundii Klebsiella pneumoniaeEscherichia coli

Staphylococcus aureus

SHARP recruited facilities into the two initiatives

Both will measure the baseline prevalence and incidence of their respective organisms

Then there will be a period of measurement during which facilities are encouraged to begin implementing infection prevention interventions to reduce the transmission of these organisms

MDRO Prevention Initiatives

Planning Stage Baseline Stage

Intervention Stage

www.michigan.gov/hai

MDRO Prevention Initiativeswww.michigan.gov/hai

MRSA/CDI Contact- Gail Denkins DenkinsG@michigan.gov

CRE Contact- Brenda Brennan BrennanB@michigan.gov

MRSA/CDI Prevention Collaborative

Established September 28, 2011 and includes representation from:• MDCH • Michigan Society for Infection Prevention and

Control (MSIPC)• Michigan Health and Hospital

Association(MHA) Keystone Center for Patient Safety and Quality

• MPRO (Michigan's Quality Improvement Organization)

• Long Term Care• Michigan Association of Local Public Health

(MALPH)

MRSA/CDI Prevention Collaborative

The Collaborative works to integrate evidence based best practices along the continuum of care to reduce and eliminate the occurrence of MRSA and CDI among Michigan citizens

The Initiative Focus

• Acute care and skilled nursing care facilities can work together to reduce MRSA and CDI among patients that share the health care services provided within their regions

• Recognize the benefits of improving transfer of care communication

• Build collaborative community relationships with focus on sharing best practices to prevent and reduce MRSA and CDI infections

MRSA/CDI Prevention Initiative

• Design of the program was formed by the MRSA/CDI Collaborative

• Facilities submitted formal applications• 13 hospital and 12 skilled nursing facilities

were chosen by the MRSA/CDI Collaborative committee

• Facilities were provided MSIPC scholarships to attend conferences and training

• Facilities are required to submit a formal action plan, submit monthly MRSA/CDI event data

Cost Analysis

• Healthcare-associated infections (HAIs) in acute care hospitals and long term care facilities impose significant economic consequences on the healthcare system.

• The overall annual direct medical cost of HAIs to U.S. hospitals ranges from $35.7 to $45 billion (in 2007 dollars).

• This report utilizes published results from medical and epidemiological literature to provide a healthcare cost estimate for treating methicillin-resistant Staphylococcus aureus and Clostridium difficile Infection (MRSA/CDI) in Michigan.

MRSA Results

Facility Type Healthcare Onset Cost

Total Cost

Acute Care $ 9,245,800 $ 24,627,400

Skilled Nursing Facility

$ 381,900 $ 445,300

* Data represents 14 months of data collection at enrolled facilities

C.Diff Results

Facility Type Healthcare Onset Cost

Total Cost

Acute Care $ 7,595,100 $ 17,878,500

Skilled Nursing Facility

$ 452,400 $ 522,000

* Data represents 14 months of data collection at enrolled facilities

CRE Surveillance and Prevention Initiative

Develop a practical reporting mechanism for CRE, enroll acute care and LTAC facilities to participate, and identify best-practice recommendations that can be applied across the healthcare continuum. The overall goal is to build a regional, public health model to

reduce the spread of CRE in Michigan. Twenty one facilities (17 acute care and 4 long-term acute care

facilities) enrolled into the Initiative. Facilities are distributed across the state, with the greatest

concentration in SE and West Michigan. Facilities voluntarily report cases of CRE (per our surveillance

definition) and submit monthly denominator reports. Facilities developed CRE Prevention Plans designed for the specific

needs of their facility. These plans were implemented in March 2013.

More information about the CRE Surveillance and Prevention Initiative is available online at www.michigan.gov/hai under MDCH Prevention Initiatives.

Data HighlightsSeptember 2012 – September 2013

CRE Patient Demographics

• Total of 191 cases reported• Age

– Median: 66 y/o– Range: 21-96 y/o

• Sex– 50% Female

• Patient Type– Inpatient ICU: 40%– Inpatient Non-ICU: 50%– Outpatient: 9%– Referral patient: 1%

CRE Incidence in Michigan

CRE Laboratory Testing and Micro

Organism Klebsiella pneumoniae: 88% Escherichia coli: 12%

Specimen Type Clinical culture: 98% Surveillance Culture or screen: 2%

CRE Contact Precautions

Time from Antimicrobial Susceptibility Results to placing the patient into isolation/contact precautions: Paired dates for 133 (of 191) acute care patients

130 (98%) of patients were placed in CP within 24 hours Range: 0-11 days, Mean: 3.6 hours

The MDCH SHARP staff are available to offer our services and expertise in healthcare-associated outbreak investigations

MDCH can help facilities coordinate molecular testing with the MDCH Bureau of Laboratories to identify genetic-relatedness between patient isolates (at no cost)

Outbreak Response

Acinetobacter baumannii

www.michigan.gov/hai

Recent MDRO Investigations

VRSA in the United States

Case No. State Date1 Michigan June 2002

2 Pennsylvania September 2002

3 New York March 2004

4–6 Michigan February, October & December 2005

7 Michigan October 2006

8, 9 Michigan October & December 2007

10 Michigan December 2009

11, 12 Delaware April & August 2010

Most have had a history of:

Underlying health conditions including: diabetes, hemodialysis, heart disease, obesity, osteomyelitis

Recurrent MRSA infections and non-healing wounds

Catheters and indwelling medical devices

Recent hospitalizations or stays in LTC/rehab facilities

Recent and frequent exposure to vancomycin and other antimicrobials

VISA/VRSA Cases

CRE- Early 2013

BOL received a short-term grant from APHL to perform confirmatory testing of CRE isolates

This testing yielded Increased communications with hospitals improvements in communications between lab and IP

One facility implemented pre-emptive isolation of patients from a particular LTC after identifying a high rate of CRE positivity among those patients

Fungal Infections Associated with Contaminated Methylprednisolone Acetate in

Michigan, 2012-2013

September 26th, 2012 – NECC voluntarily recalls three lots of MPA (05212012, 06292012, and 08102012)

September 28th, 2012 – Growing evidence of connection between meningitis cases and NECC MPA shared on multi-state call with CDC

October 1st, 2012 –NECC customer invoice list shared with the Michigan Department of Community Health (MDCH) Bureau of Epidemiology

October 2nd, 2012 – MDCH begins contacting Michigan clinics who were recipients of recalled lots of NECC MPA

68

Case Count (as of June 3rd, 2013 - http://

www.cdc.gov/hai/outbreaks/meningitis-map-large.html)

Contributions from MDCH

MDCH dedicated ~4,000 hours during the first three months of the outbreak (equivalent of two FTEs)

Case report form completion – over 10,000 pages of hospitalization information from fungal cases abstracted from medical records sent to CDC: 264 case report forms, each a minimum of 27 pages

in length – totaling ~7,128 pages 277 additional admission case report forms, each a

minimum of 12 pages in length – totaling ~3,324 pages

Sharing information to help inform national guidelines and recommendations

IP Practices

Preventing Transmission of MDROs

Who is responsible for infection prevention?

All of us!We are each responsible for maintaining a safe

environment for our patients, staff, visitors, everyone!

We are each responsible for our own hands

Standard Precautions

All blood, body fluids, secretions (except sweat), nonintact skin, and mucus membranes assumed infectious

Includes hand hygiene, appropriate gloves/gown/mask/face shield when necessary, and safe injection practices

Because colonization with MDROs is often unrecognized, standard precautions have an ESSENTIAL role in preventing MDRO transmission in ALL healthcare settings

Preventing Transmission of MDROs

Promote compliance with CDC hand hygiene recommendations

Use Contact Precautions for all MDRO patients (colonized and infected)

Ensure cleaning and disinfection of both equipment and environment

Educate HCWs about MDROsEducate and engage patients and families

about MDROsMonitor compliance-personal accountability

Contact Precautions

Contact Precautions are intended to prevent transmission of organisms (MDROs) that are spread by direct or indirect contact with a patient or a patient's environment

A single patient room is preferred for patients who require Contact Precautions When a single-patient room is not available,

consultation with infection prevention personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate)

Contact Precautions

Requires putting on gown and gloves Perform hand hygiene before putting on gloves Gown must be tied at the waist and neck

Remove gown and gloves before leaving the room

Perform hand hygiene immediately after removing gown and gloves

Acknowledgements

SHARP Unit Jennie Finks Brenda Brennan Bryan Buckley Gail Denkins Allie Murad Judy Weber

Viral Hepatitis Unit Joe Coyle

Resources

www.cdc.gov/haiwww.michigan.gov/hai

Surveillance Initiative Prevention Initiatives

MRSA/CDI TTT

www.michigan.gov/cdinfohttp://www.apic.org/For-Consumers/Materials

-for-healthcare-facilities

Thank you

www.michigan.gov/hai