New Mexico Health Resources 21 st Annual Health Provider Retreat June 21, 2013 Joan Baumbach, MD, MPH, MS NM Department of Health

New Mexico Health Resources 21 st Annual Health Provider Retreat June 21, 2013 Joan Baumbach, MD, MPH, MS NM Department of Health

Provide overview of NM healthcare-associated infections (HAI) surveillance & prevention initiatives Review select examples of HAI outbreaks from medical & dental settings in New Mexico Understand role of medical & dental healthcare personnel in antimicrobial stewardship Edward Hopper (1882 1967) Drug Store (1927) (detail) Oil on canvas (73.6 cm 101.9 cm) The Museum of Fine Arts, Boston, Massachusetts, USA Bequest of John T. Spaulding, 48.564

Mandated by state regulation Developed by New Mexico Department of Health (NMDOH) Last updated February 29, 2012 List of diseases/conditions tracked statewide Communicable diseases: human and animal Occupational injury and illness Health conditions related to environmental exposures and certain injuries Adverse vaccine reactions Healthcare-associated infections Cancer Human papilloma virus Birth defects Genetic and congenital hearing screening

Anthrax* Haemophilus influenzae invasive infections* Rubella (including congenital) Avian or novel influenza* Measles Severe Acute Respiratory Syndrome (SARS)* Bordetella species* Meningococcal infections, invasive* Smallpox* Botulism (any type)* Plague* Tularemia* Cholera* Poliomyelitis, paralytic and non-paralytic Typhoid fever* Diphtheria* Rabies Yellow fever * Clinical specimens required to be sent to NM Dept. of Health Scientific Laboratory Division

Brucellosis Campylobacter infections* Clostridium difficile* Coccidioidomycosis Colorado tick fever Cryptosporidiosis Cysticercosis Cyclosporiasis Dengue E. coli 0157:H7 infections* E. coli, shiga-toxin producing (STEC) infections* Encephalitis, other Giardiasis Group A streptococcal invasive infections* Group B streptococcal invasive infections* Hantavirus pulmonary syndrome Hemolytic uremic syndrome Hepatitis A, acute Hepatitis B, acute or chronic Hepatitis C, acute or chronic Hepatitis E, acute Influenza-associated pediatric death Influenza, lab-confirmed hospitalization Legionnaires disease Leptospirosis Listeriosis* Lyme disease Malaria Mumps Necrotizing fasciitis* Psittacosis Q fever Relapsing fever Rocky Mountain spotted fever Salmonellosis* Shigellosis* St. Louis encephalitis infections Streptococcus pneumoniae invasive infections* Tetanus Trichinellosis Toxic shock syndrome Varicella Vibrio infections* West Nile Virus infections Western equine encephalitis infections Yersinia infections*

Newly reportable (2012) Central line-associated bloodstream infections in acute care hospital intensive care units Clostridium difficile infection Population-based surveillance Bernalillo County Facility-based laboratory reports into the National Healthcare Safety Network (NHSN) Voluntary reporting Healthcare personnel influenza vaccinations HAI-associated outbreaks

2005 Transmission of hepatitis B in oral surgery 2007 Transmission of Pseudomonas in urology clinic 2008 Transmission of group A Streptococcus in acute long-term care facility 2012 Lots of norovirus in healthcare facilities

Suspected source patient 1 st case Index patient 4 th case Hepatitis B surface antigen from both was type A/subtype adw2 Preliminary match led to contact other patients who had surgery same week/offer testing DNA base-pair sequence of two cases also matched

Modern, clean, anesthetic No re-use of needles or improper use of multi-dose vials Appropriate infection control practices Ideal 6-handed rather than 4-handed Floater in and out of sterile field Touching objects in sterile field (e.g., bloody gauze) and objects outside of sterile field (e.g., handle on sink, sterile water bottle) Sprayed and wiped surfaces after surgery No breakdown of procedure to account for transmission

HBV vaccination Apply standard precautions rather than universal precautions: Guidelines for Infection Control in Dental Health- Care Settings --- 2003 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr52 17a1.htm Establish a routine and don t vary from it

Guidelines have changed over time Studies between 1950-2006 showed no benefit of antibiotic prophylaxis, except in highest risk patients* Prosthetic heart valve, valve repair with prosthetic material, prior hx of infective endocarditis, many congenital heart abnormalities * Wilson W. et al., Prevention of infective endocarditis: guidelines from the American Heart Association. Circulation 2007; 116:1736.

CASES DEFINITIONS Patient admitted to or discharged from facility Oct. 1, 2007 - Feb. 3, 2008 Confirmed: GAS isolated from a usually sterile site Probable: GAS isolated from non-sterile site with clinically compatible syndrome when GAS was the predominant bacteria isolated CASES IDENTIFIED 10 cases 8 confirmed 7 bloodstream 1 bone/tissue 2 probable 2 deaths 1 bloodstream 1 wound

Confirmed Case Probable Case Number of case-patients 5 4 3 2 1 0 2007-Oct Nov Dec 2008-Jan Feb Universal Contact Precautions Instituted

# Cases 4 3 n = 23 Urologist temporarily ceased cystoscopies Urine Blood Both 2 1 0 7 14 21 28 4 11 18 25 4 11 18 25 1 8 15 22 29 6 13 20 27 Jan Feb Mar Apr May Date of Diagnosis by Week, 2007

Patients Environmental Samples from 4 cystoscoped patients matched PFGE patterns from environmental samples 1 2 3 A B A= 1 st rinse through cystoscope B = Isolate from cleaning brush

Responsible for ~ ½ of known foodborne illness outbreaks in U.S. 2006-2010 Important to identify outbreaks early 24 NM norovirus outbreaks identified in 2012 >50% in long-term care facilities Apply specific environmental and clinical prevention guidelines http://www.cdc.gov/norovirus/ Do not prescribe antibiotics

# Cases Norovirus Outbreak at Facility X, NM, 2012 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 A pts B pts C pts D pts E pts F pts G pts H pts I pts

HAI are major public health problem Preventing HAIs is priority of CDC, other federal agencies, and states Until recently, last full-scale estimate of magnitude of HAIs was from 1970 s CDC s Study on the Efficacy of Nosocomial Infection Control (SENIC) 5.23% of hospitalized patients acquired HAI

Estimate HAI prevalence among inpatients in acute healthcare facilities Determine distribution of HAI by pathogen & major infection site Estimate prevalence & describe rationale for antimicrobial use in acute healthcare facilities

3 phases to survey Phase 1: single-city pilot, 2009 Phase 2: limited roll-out, 2010 Phase 3: full-scale survey, 2011

10 Emerging Infections Program (EIP) states engaged up to 25 facilities based on 3 strata of bed size Survey conducted on single day at each facility during May-August 2011 Eligible patients Acute care inpatients of any age Randomly selected beds on survey morning Up to 100 patients/beds sampled depending on bed size strata Findings HAI prevalence & antimicrobial use varies between states Final analyses pending details will be disseminated

20 general acute care facilities participated 892 patient records were surveyed Mean age 52.6 yrs, median 58.0 yrs Range 0-96 yrs 53.5% female, 46.5% male 44.3% White, 39.0% Hispanic, 9.4% American Indian

218 patients (24.4%) had urinary catheter 32 patients (3.6%) receiving mechanical ventilation 159 (17.8%) had a central line Among those with a central line 70 patients (44.0%) had PICC line 3 patients (1.9%) had femoral line 87 patients (54.7%) had other central line 3 patients (1.9%) had unknown line type

25 HAI detected among 22 patients At patient level, 2.5% (95% CI 1.6 3.7) HAI prevalence 54.6% female, 45.5% male Mean age 61.5 yrs, median 70.5 yrs, (range 0.08-90.0 yrs) 10 HAI attributed to critical care locations, 13 attributed to ward locations

HAI Major Type Frequency (n=25) Percent (%) Urinary tract infection 7 (4/7 CAUTI) 28.0 Pneumonia 6 (4/6 VAP) 24.0 Gastrointestinal tract infection 3 12.0 Lower respiratory tract infection 3 12.0 Surgical site infection 2 8.0 Skin/soft tissue infection 2 8.0 Bloodstream infection 1 (1/1 CLABSI) 4.0 Eye, ear, nose, throat infection 1 4.0

443 patients (49.7%, 95% CI 46.4-52.9) reported to be on or scheduled for antimicrobials on survey day or day prior to survey day 433 patients (48.5%, 95% CI 45.3-51.8) determined to actually have received antimicrobials 768 antimicrobials given (includes same antimicrobial given by different routes) Antimicrobials per patient: mean 1.8, median 2.0, range 1-8

Rationale Frequency (n=768) Percent (%) Treatment of active infection 629 81.9 Surgical prophylaxis 105 13.7 Medical prophylaxis 16 2.1 Non-infectious 4 0.5 None documented 22 2.9

Top 5 Therapeutic Sites Frequency (n=629) Percent (%) Lower respiratory tract infection 209 33.2 Urinary tract infection 126 20.0 Skin/soft tissue infection 106 16.9 Gastrointestinal tract infection 80 12.7 Bloodstream infection 79 12.6

Location of Infection Onset Frequency (n=629) Percent (%) Community 538 85.5 Survey hospital 60 9.5 Other healthcare facility 35 5.6 Unknown 1 0.2

Top 1-10 Antimicrobials Frequency (n=768) Percent (%) Vancomycin 91 11.8 Cefazolin 89 11.6 Ceftriaxone 78 10.2 Piperacillin/tazobactam 74 9.6 Ciprofloxacin 58 7.6 Metronidazole 55 7.2 Clindamycin 33 4.5 Azithromycin 32 4.2 Levofloxacin 28 3.6 Moxifloxacin 25 3.3

Point prevalence, one day in time Voluntary participation Only acute care general hospitals, may not be representative of all facilities Following NHSN definitions, clinical and surveillance definitions may vary Limited to documentation in medical records

Almost ½ of surveyed patients on antimicrobials Most antimicrobials being used for treatment of active infections Most active infections had community onset Small percent of HAI but variety of HAI types and organisms present

Overuse use of antibiotics/more MDROs Complex healthcare delivery systems Increasingly sick patients/patient transfers Increased environmental contamination risk Increased MDRO colonization pressure Increasing risk of transmission Lack of resources/institutional will to enforce recommendations Suboptimal infection control Controlling MDROs requires a multifaceted and multi-disciplinary effort

Nature Reviews: Drug Discovery. 2007: 6; 8-12.

New antibacterial agents approved in the United States, 1983 2002, per 5-year period From: Spellberg et al. Trends in Antimicrobial Drug Development: Implications for the Future CID 2004:38 (1 May)

Extendingthecure.org, Policy Brief #6. 2008

Coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration Seeks to achieve optimal clinical outcomes related to antimicrobial use, minimize toxicity and other adverse events, reduce the costs of health care for infections, and limit the selection for antimicrobial resistant strains Across all healthcare settings

Right drug - check cultures for drug-bug mismatch Right reason - following published guidelines Right dose - renal and/or weight-adjusted Right formulation - consider switch to p.o. when ready Right timing - correct dosing interval or prophylactic timing Right duration - following published guidelines Right follow-up - monitor the patient Right consultation - know when you need help All without adverse consequences for the patient

Summarized in Patel D, et al. Antimicrobial Stewardship Programs: Interventions and Associated Outcomes. Expert Reviews of Anti-Infective Therapy http://www.expertreviews.com/doi/abs/10.1586/14787210.6.2.209 33 studies demonstrating cost savings or cost neutrality of programs 22 studies examining antimicrobial resistance and C. difficile outcomes 14 were able to demonstrate reduction in gramnegative resistance and/or C. difficile

Position statement of the Society for Healthcare Epidemiology of America (SHEA), IDSA, and the Pediatric Infectious Diseases Society of America (PIDS) http://www.sheaonline.org/policy/positionsstatements.aspx Infectious Diseases Society of America (IDSA) practice and stewardship guidelines http://www.idsociety.org/antimicrobial_agents/#antimicrobial Stewardship Centers for Disease Control and Prevention (CDC) online CME modules http://www.cdc.gov/getsmart/healthcare/learn-fromothers/cme/antimicrobial-stewardship.html and other tools: http://www.cdc.gov/getsmart/healthcare/

Various definitions in the literature Resistance to > 1 antibiotics Resistance to > 1 class of antibiotics Resistance to all but one antibiotic or class Resistance to all antibiotics or classes Definitions influence how magnitude of the problems and outcomes are presented

Prevalence varies temporally, geographically, and by healthcare setting Antimicrobial resistance rates are strongly correlated with hospital size, tertiary-level care, and facility type MDROs in U.S. hospitals and medical centers have increased steadily last several decades Methicillin-resistant Staphylococcus aureus (MRSA) was first isolated in the United States in 1968 Other identified and increasing over time: Vancomycinresistant Enterococcus (VRE); multi-drug resistant tuberculosis (MDR-TB); Acinetobacter; Clostridium difficile; extended spectrum beta-lactamase [ESBL]-producing or intrinsically resistant gram-negative bacilli

Options for treatment are relatively limited Worse outcomes have been shown for VRE, Pseudomonas, Acinetobacter, Enterobacter, E. coli, K. pneumoniae MDROs associated with Increased morbidity and mortality Increased lengths of stay Increased cost

KPC is a class A β-lactamase Confers resistance to all β-lactams including extendedspectrum cephalosporins & carbapenems During past decade in US, KPC established in Enterobacteriaceae Most commonly in Klebsiella pneumoniae Healthcare and community acquired Felt by many to be more virulent than Acinetobacter or Pseudomonas

Pharmacology plays large role FDA safety labeling revisions in Dec. 2007 for antimicrobials to warn of the risk for CDAD Hypertoxin-producing strains of C. difficile can be refractory to antimicrobial therapy Associated with increased morbidity & mortality May require colectomy, can cause death Opportunities to initiate/lead/join antimicrobial stewardship initiatives

4% 1% 10% 5% 53% One Two Three 27% Four Five Six One person each had 7, 8, or 9 different antibiotics *2011 2012 data; 2 weeks (2011) or 12 weeks (2012) prior to CDI diagnosis 2012 data are preliminary

30% 25% 20% 15% 10% 5% 0% *2011 2012 data; 2 weeks (2011) or 12 weeks (2012) prior to CDI diagnosis 2012 data are preliminary

Project goals Decrease Clostridium difficile infections (CDI) & CDI-related hospitalizations Increase CDI prevention best practices & antimicrobial stewardship practices Project partners Hospitals, community providers, nursing homes, dialysis centers, home health agencies, clinical labs, public health, healthcare quality improvement organization

Common Enterobacteriaceae include Klebsiella species and Escherichia coli (E. coli) CRE infections are most commonly seen in people with exposure to healthcare settings Some CRE bacteria have become resistant to almost all available antibiotics and can be deadly Among prevention approaches, important to only prescribe antibiotics when necessary

NMDOH is conducting active, populationbased CRE surveillance in Bernalillo County as part of national network Determine the extent of CRE Identify people most at risk for illness Measure trends in infections over time 2012 CDC CRE toolkit to assist healthcare facilities in preventing and controlling CRE: http://www.cdc.gov/hai/pdfs/cre/creguidance-508.pdf

View Farmington project antimicrobial stewardship webinars at: http://www.nmmra.org/providers/patientsafety_hais_drug s4bugs.php Antimicrobial stewardship webinars will run again from Oct 2013 through April 2014 Project ECHO (Extension for Community Health Outcomes: weekly TeleECHO clinics) will be offering infectious disease management, infection control, antimicrobial stewardship to interested hospitals Send your hospital name and designated clinician contact to jboyle@salud.unm.edu (Jeannie Boyle, RN) if you wish to join

24/7/365 505-827-0006 Joan Baumbach 827-0011 joan.baumbach@state.nm.us