11/22/2016. Hospital-acquired Infections Update Disclosures. Outline. No conflicts of interest to disclose. Hot topics:

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1 Hospital-acquired Infections Update 2016 APIC-CI Conference November 17 th, 2016 Jay R. McDonald, MD Chief, ID Section VA St. Louis Health Care System Assistant Professor of medicine Washington University School of Medicine Disclosures No conflicts of interest to disclose Outline Hot topics: CDC s 2016 National and State Healthcare-Associated Infections Progress Report (HAI Progress Report) December 2015 CDC Antibiotic Resistance Atlas Carbapenem-resistant Enterobacteriaciae expanding threat? Antimicrobial stewardship teaser 1

2 Most common HAI s in the US Record review of 11,292 patients at 183 US hospitals in HAI among 452 patients (4.0%) Extrapolated results suggest 721,800 HAI in US hospitals in 2011 Magill SS et al. Multistate Point-Prevalence Survey of Health Care-associated Infections. N Engl J Med 2014;370: Cost of HAI s In the US, about $30 billion is spent annually on the care of HAI HAI s cost Medicare $300 million per month Loss of productivity Quality of life Mortality 2016 HAI Progress Report Previous reports included data from acute care hospitals only For the first time, this report includes national data from two additional facility types: CLABSI and CAUTI data from long-term acute care hospitals (LTACH) CAUTI data from inpatient rehabilitation facilities (IRFs), which include hospitals, or part of a hospital, that provide intensive rehabilitation services National and state factsheets include infectionspecific SIRs and progress in reducing HAIs 2

3 2016 HAI Progress Report: National results summary Significant reductions reported at the national level in 2014 for nearly all infection types when compared to the baseline data CLABSI and abdominal hysterectomy SSI show the greatest reductions Among 29 surgery types, SSI rates increased in only 2 surgery types: appendix surgery and breast surgery Some progress is shown in reducing both hospital-onset MRSA bacteremia and hospital-onset C difficile infections The previous two reports showed an increase in CAUTI from the prior year, signaling a strong need for additional prevention efforts CAUTI did decrease from 2013 to 2014, but continued prevention efforts are essential The only numerical goal (set in 2009) that was reached was a 50% reduction in CLABSI 2016 HAI Progress Report: National results 2016 HAI Progress Report: National SSI 3

4 CDC s 2016 National and State Healthcare-Associated Infections Progress Report (HAI Progress Report) LTACHs reported a 9 percent decrease in CLABSI and an 11 percent decrease in CAUTI between 2013 (baseline) and 2014 IRFs reported a 14 percent decrease in CAUTI between 2013 (baseline) and HAI Progress Report: Illinois CLABSI: 57% reduction (vs. 50% nationally) CAUTI: 13% reduction (vs. 0% nationally) MRSA bacteremia: 29% reduction (vs. 13% nationally) SSI abdominal hysterectomy: 24% reduction (vs. 17% nationally) SSI colon surgery: 11% reduction (vs. 2% nationally) CDI: 0% change (vs. 8% reduction nationally) DHHS 2016 National Action Plan to Prevent Health Care- Associated Infections: Road Map to Elimination In October 2016, the U.S. Department of Health and Human Services (HHS) announced new targets for the national acute care hospital metrics for the National Action Plan to Prevent Health Care- Associated Infections: Road Map to Elimination (HAI Action Plan). The targets use data from calendar year 2015 as a baseline 4

5 HHS goals for 2020 (baseline 2015) Measure (and data source) CLABSI (NHSN) CAUTI (NHSN) Invasive MRSA (NHSN) Facility-onset MRSA (NHSN) CDI (NHSN) SSI (NHSN) Clostridium difficile hospitalizations (HCUP) 2020 Target (from 2015 baseline) 50% reduction 25% reduction 50% reduction 50% reduction 30% reduction 30% reduction 30% reduction CDC s Antibiotic Resistance Patient Safety Atlas Updated December 2015, includes data reported to NHSN from acute hospitals, LTACHs, and IRFs Includes resistance data for CLABSI, CAUTI, and SSI 31 different bug-drug profiles (aka phenotypes), for example: MRSA CRE MDRO Pseudomonas Primary measure is Percent resistant Antibiotic resistance atlas: National results Among HAI s caused by.. Enterobacteriaciae, 3.5% nationally were CRE States ranged from 0-27% Higher rates in Northeast US E. coli, 13.4% were ESBL Klebsiella, 20.0% were ESBL Enterobacter, 28.5% were ESBL S. aureus, 46.4% were MRSA Higher rates in the Southeast US P. aeruginosa, 14.2% were MDRO (resistant to antibiotics from at least 3 classes) Acinetobacter, 54.8% were MDRO Enterococcus faecium, 77.3% were VRE Enterococcus faecalis, 6.9% were VRE 5

6 Antibiotic resistance atlas: Illinois Among HAI s caused by.. Enterobacteriaciae, 3.6% were CRE (national: 3.5%) E. coli, 14.7% were ESBL (national: 13.4%) Klebsiella, 22.0% were ESBL (national: 20.0%) Enterobacter, 27.4% were ESBL (national: 28.5%) S. aureus, 45.4% were MRSA (national: 46.4%) P. aeruginosa, 15.2% were MDRO (resistant to antibiotics from at least 3 classes) (national: 14.2%) Acinetobacter, 76.2% were MDRO (national: 54.8%) Enterococcus faecium, 80.4% were VRE (national: 77.3%) Enterococcus faecalis, 11.6% were VRE (national: 6.9%) Carbapenem-resistant Enterobacteriaciae (CRE) CRE are the result of several different resistance genes in 70 different genera of bacteria, with the common feature of carbapenem resistance Current CDC definition is both phenotypic and genotypic: Resistance to imi, mero, dori, or ertapenem OR documentation that the bacteria contains a carbapenemase Most labs do not routinely test for specific genetic resistance mechanisms such as KPC, NDM, OXA-48, and VIM, though the availability of such testing is increasing as PCR-based technologies are expanding Testing for resistance mechanism may shed light on local transmission patterns, and may eventually become relevant to clinical decision making, though currently the clinical utility of such testing is limited Prior CDC definition was purely phenotypic: non-susceptible to imi, mero, or dori, AND resistant to all 3 rd generation cephalosporins tested CRE trends and surveillance CRE were rare in the US prior to There has been no comprehensive systematic surveillance of CRE in the US, but incidence in the US appears to be slowly increasing over time, though rates are stable nationally First identified in North Carolina in 1996, but limited spread in the US until the past 10 years In 2006, only 14 states were known to have CRE. In 2015, all states except Idaho and Maine are known to have CRE CDC now tracking CRE through NHSN and the Emerging Infection Program s Multi-site Gram-negative Bacilli Surveillance Initiative (MuGSI) 6

7 CRE rates by state CRE by state Nationally: 3.5% Illinois: 3.6% Missouri: 1.7% New Jersey: 9.6% Nevada: 11.7% Puerto Rico: 27.9% CRE transmission Passed through person-to-person contact with skin Primary sites of colonization are GI tract and wounds Many can persist in sinks and plumbing in biofilms Increased attention due to outbreak associated with duodenoscopes with elevator mechanisms (ERCP scopes) Antibiotic options can be extremely limited (aminoglycosides, colistin, Very high associated mortality (up to 50%) 7

8 CRE Infection Prevention Healthcare personnel and facilities should: Practice hand hygiene Clean & disinfect patient rooms and medical equipment Don PPE before entering patient room Doff PPE and wash hands before exiting patient room Keep colonized or infected patient in a single room on Contact Precautions Dedicate equipment and staff Only prescribe antibiotics when necessary Remove temporary medical devices Consider active surveillance for CRE Consider screening epidemiologic contacts for CRE Improve interfacility communication regarding resistant organisms including CRE 2012 CRE toolkit: Consider 2% chlorhexidine bathing in outbreak settings CDC Updated CRE Toolkit 2015 Should facilities implement surveillance for CRE? While active-surveillance-driven initiation of isolation precautions for MDRO control is a controversial topic in infection control circles, the literature suggests that active screening programs can effectively control MDRO prevalence when they rapidly identify colonized patients and place them into contact isolation precautions Although patients can be colonized at any anatomic location (e.g., asymptomatic bacteruria, chronic wounds, etc.), previous studies have documented that a peri-anal swab sample will detect all colonized patients. Cotton-tipped swabs in use at the institution will suffice. Active surveillance should be considered when clinical cultures begin to appear at your institution, or at another health care facility in your geographic area. Surveillance approaches might include periodic prevalence surveys involving a representative sample of inpatients, including both geriatric and intensive care unit (ICU) patients, such that every third inpatient is sampled during a 1- to 2-week period. CRE and duodenoscopes Investigation published in JAMA in January 2014 described an outbreak of CRE (specifically New Dehli Metallo-betalactamase producing CRE) was described among patients after ERCP in northeastern Illinois Among 91 patients exposed to a contaminated scope, 50 had rectal swabs and 23 were colonized After changing from automated high-level disinfection to gas sterilization, no further cases were detected At the time, this cluster represented 44 of the known 69 patients in the US who had been found to have NDM CRE In early 2015, there were 7 new colonizations and 2 deaths associated with contaminated scopes at UCLA, leading to revision of the CDC s CRE toolkit and new recommendations for duodenoscope reprocessing 8

9 CDC 2015 Interim Protocol for Healthcare Facilities Regarding Surveillance for Bacterial Contamination of Duodenoscopes after Reprocessing Careful cleaning and inspection of elevator mechanism Thorough drying of channels prior to storage Consider routine culturing of endoscopes After reprocessing after each use? Every 4 weeks? Annually? No firm recommendation Culture methods are described Goal: No high-concern organisms (Gram negatives, S. aureus, Enterococci) and <10 CFU s of lowconcern microbes Antimicrobial stewardship Definition: Coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal drug regimen including dosing, duration of therapy, and route of administration (Infect Control Hosp Epidemiol 2012;33:322-7) Antimicrobial stewardship has been around for a long time, but new concerns about rising antimicrobial resistance and limited pipeline of new antibiotics to deal with this problem has brought stewardship to the forefront. Antimicrobial stewardship can help prevent the development and spread of MDROs, reduce unnecessary drug use and costs associated with expensive, broad-spectrum therapies used to treat HAIs, and improve patient safety. Antimicrobial stewardship in 2016 In June 2015, White House forum on Antibiotic Stewardship was held In April 2016, IDSA and SHEA published a joint guideline titled Implementing an Antibiotic Stewardship Program: Guidelines by the IDSA and SHEA in Clinical Infectious Disease (DOI: /cid/ciw118) In July 2016, Healthcare Infection Control Practices Advisory Committee (HICPAC) provided guidance for the first time to professional organizations on incorporating antibiotic stewardship principles into treatment guidelines In mid-2016, JCAHO announced a new Medication Management (MM) standard, MM : The hospital has an antimicrobial stewardship program based on current scientific literature In the Federal Register June 16 th 2016, Center for Medicare and Medicaid Services proposed 5 new conditions for participation, one of which is Requirements for antibiotic stewardship programs to help reduce inappropriate antibiotic use and antimicrobial resistance." I ll discuss elements of an effective stewardship program next hour 9

10 Thank you! Questions? 10

11/22/2016. Antimicrobial Stewardship Update Disclosures. Outline. No conflicts of interest to disclose

11/22/2016. Antimicrobial Stewardship Update Disclosures. Outline. No conflicts of interest to disclose Antimicrobial Stewardship Update 2016 APIC-CI Conference November 17 th, 2016 Jay R. McDonald, MD Chief, ID Section VA St. Louis Health Care System Assistant Professor of medicine Washington University

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