2016 EPS Training Event Martin E. Evans, MD Director, VHA MDRO Program National Infectious Diseases Service Lexington, KY & Cincinnati, OH Infection Control of Emerging Diseases 2016 EPS Training Event
Outline Review the VHA methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative and successes in acute care, spinal cord injury, and the CLCs Review Clostridium difficile and the VHA C. difficile infection (CDI) Prevention Initiative and initial VA data Review the carbapenem-resistant Enterobacteriaceae (CRE) Prevention Initiative 2
Dr. Rajiv Jain Dr. Gary Roselle 3
Pittsburgh Demonstration Project, 2001 VA Pittsburgh Healthcare System, Pittsburgh Regional Health Initiative, CDC Eliminate MRSA healthcare-associated infections (HAIs) Using a Bundle based on Society for Healthcare Epidemiology of America (SHEA) guidelines.
VA MRSA Bundle 1) Active surveillance for all admissions, inhospital unit-to-unit transfers, and discharges 2) Contact Precautions for all patients/residents colonized or infected with MRSA 3) Hand hygiene 4) Culture change where Infection Control becomes everyone s responsibility
January 2007 Success at Pittsburgh VA 2002-2006 Importance of preventing MRSA HAIs for all Veterans Department of Veterans Affairs, issued VHA Directive 2007-002, Methicillin-resistant Staphylococcus aureus (MRSA) Initiative Implemented a nationwide program to reduce MRSA HAIs in all acute care VA hospitals
153 Acute Care Medical Centers
MRSA Prevention Coordinator (MPC) Dedicated person at each facility who: Oversees implementation of the Initiative at their facility Collects and reports data on their program Provides feedback to front-line healthcare workers Deals with local challenges
MRSA Data Reporting Beginning October, 2007 each facility submitted data monthly to the VA Inpatient Evaluation Center (IPEC) in Cincinnati. Aggregate data reported by unit or facility (no patient-specific information)
Definitions Healthcare-associated infection (HAI) MRSA infection occurring >48 hours after admission Follows CDC/NHSN definitions with minor adaptations Transmission (Tx) Patients have nasal swabs done on admission, unitto-unit transfer, and discharge (active surveillance) Converting from MRSA negative to MRSA positive is considered a transmission
April 14, 2011 Data from Oct 07 Jun 10 13
Data from Oct 07 Jun 11 15
Data from Jul 09 Dec12 17
Conclusion A program of universal surveillance, contact precautions, hand hygiene, and culture change was associated with a decrease in MRSA transmissions and HAIs in acute care, spinal cord injury, and long-term care settings in a large healthcare system.
Outline Review the VHA methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative and successes in acute care, spinal cord injury, and the CLCs Review Clostridium difficile and the VHA C. difficile infection (CDI) Prevention Initiative and initial VA data Review the carbapenem-resistant Enterobacteriaceae (CRE) Prevention Initiative 20
Clostridium difficile
Infections and Deaths United States, 2005 # Infections # Deaths Streptococcus pneumoniae 41,839 ~5,000 MRSA 94,360 18,650 HIV / AIDS 56,300 17,011 C. difficile >250,000 15,000-30,000 Active Bacterial Core Surveillance www.cdc.gov/abcs *www.cdc.gov/hiv/topics/surveillance/basic.htm#def
CDI Rates Among Hospitalized Patients Aged 65, 1996-2009 MMWR 2011;60:1171
Burden of CDI Recurrence rate quite high ~20% risk of recurrence after the initial episode of CDI ~40% risk of a second relapse 60% risk of a third relapse Approximately 15,000 to 30,000 deaths in the United States each year attributable to CDI 24
Risk Factors for CDI Antimicrobial exposure Acquisition of C. difficile Advanced age Underlying illness Immunosuppression Tube feeds? Gastric acid suppression 25
Patient Skin (A) and Examiner s Glove (B) Contamination with C. difficile Skin Contamination Glove Contamination Bobulsky, GS. Clin Infect Dis 2008:46;447
Glove Contamination After Touching a Patient with CDI Bobulsky, GS. Clin Infect Dis 2008:46;447
Environmental Contamination with C. difficile Riggs, MM. Clin Infect Dis 2007:45;992
Prevention Strategies: Core Contact Precautions for duration of diarrhea Hand hygiene in compliance with CDC/WHO Soap and water for hand hygiene before exiting room of a patient with CDI Cleaning and disinfection of equipment and environment Educate HCWs, housekeeping, administration, patients, & families about CDI 29
Rationale for extending isolation beyond duration of diarrhea Bobulsky et al. Clin Infect Dis 2008;46:447-50.
VHA CDI Bundle Environmental Management Hand Hygiene Contact Precautions Cultural Transformation
Outline Review the VHA methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative and successes in acute care, spinal cord injury, and the CLCs Review Clostridium difficile and the VHA C. difficile infection (CDI) Prevention Initiative and initial VA data Review the carbapenem-resistant Enterobacteriaceae (CRE) Prevention Initiative 33
What are Enterobacteriaceae? E. coli, Enterobacter (cloacae, aerogenes, agglomerans), Serratia marscescens, Citrobacter freundii, Klebsiella (pneumoniae, oxytoca) Sometimes cause community acquired (UTI, pneumonia) Often cause HAIs (central line bloodstream infection, catheterassociated urinary tract infection, ventilator-associated pneumonia, hospital acquired pneumonia, etc.)
Susceptibility Profile of CarbapenemaseProducing K. pneumoniae Antimicrobial Interpretation Antimicrobial Interpretation Amikacin I Chloramphenicol R Amox/clav R Ciprofloxacin R Ampicillin R Ertapenem R Aztreonam R Gentamicin R Cefazolin R Imipenem R Cefpodoxime R Meropenem R Cefotaxime R Pipercillin/Tazo R Cetotetan R Tobramycin R Cefoxitin R Trimeth/Sulfa R Ceftazidime R Polymyxin B MIC >4 g/ml Ceftriaxone R Colistin MIC >4 g/ml Cefepime R Tigecycline S
Mortality p<0.001 p<0.001 48 20 38 12 OR 3.71 (1.97-7.01) OR 4.5 (2.16-9.35)
First clinical use of penicillin 1942 First clinical use of ampicillin 1962 1949 Osteomyelitis due to penicillinase producing S. aureus 1966 Appearance of TEM βlactamase First clinical use of cefotaxime 1979 First Imipenem use 1985 1985 First ESBL (SHV-2) 1993 First carbapenemase 1990 CTX-M described Adapted from Rice, LB. Mayo Clin Proc 2012:87;198-208
IDSA. CID 2011:52 (Suppl 5);S397-428
Clinical Infectious Diseases 2009:48;1-12
Consequences of Resistance Longer hospital stays and more expense Higher morbidity and mortality when resistance is initially unrecognized Inability to treat sick patients as we run out of efficacious antimicrobials Aggressive cancer chemotherapy Hematopoietic stem-cell transplantation Solid organ transplantation Other aggressive immunosuppressive therapy Prosthetic joint placement Routine clean/clean contaminated surgery
CRE Vital Signs: Key Points CRE are increasing 1% to 4% overall Over 10% of Klebsiella are CRE Most hospitals do not see CRE regularly 4% of hospitals 18% of LTACHs Most CRE are still healthcare-associated 41
Carbapenemase-Resistant Enterobacteriaceae 2013 DC KPC KPC, NDM HI AK PR Patel, Rasheed, Kitchel. 2009. Clin Micro News MMWR 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 KPC, NDM, OXA KPC, NDM, VIM, OXA KPC, NDM, VIM, IMP, OXA
CRE Summary Unrivalled broad-spectrum resistance profile Susceptible to very few antibiotics Clinical data for treatment regimens is very limited Control involves: Antimicrobial stewardship Infection control Good environmental management 44
Infection Prevention & Control Preventing CRE/CPE Optimal Laboratory Use Antimicrobial Stewardship
Outline Review the VHA MRSA Prevention Initiative and successes in acute care, spinal cord injury, and the CLCs Review Clostridium difficile and the VHA CDI Prevention Initiative Review the carbapenem-resistant Enterobacteriaceae (CRE) Prevention Initiative 46
For more information, please visit the MDRO Website at vaww.mrsa.va.gov/ 47
Questions/Feedback/Input 48