Antimicrobial Stewardship: an HAI response activity in Connecticut

Richard Melchreit, MDHAI Program Coordinator

National Metrics and 5-Year TargetsMetric Source

National 5-year Prevention Target

Base/Target year On Track?

Bloodstream infections NHSN 50% reduction 2006-8/2013 Yes

Clostridium difficile (hospital discharges)

HCUP 30% reduction 2008/2013 No

Clostridium difficile infections NHSN 30% reduction 2010-11/2015 Data not yet available

Urinary tract infections NHSN 25% reduction 2006-8/2013 Yes

MRSA invasive infections (population)

EIP 50% reduction 2007-8/2013 Yes

MRSA bacteremia (hospital) NHSN 25% reduction 2010-11/2015 Data not yet available

Surgical site infections NHSN 25% reduction 2006-8/2013 Yes

Source: http://www.hhs.gov/ash/initiatives/hai/nationaltargets/index.html#table1

CMS Reporting Requirements: sorted by year

Year HAI Event Facility type/location

2011 CLABSI ACH/ICUs

2012 CAUTI ACH/ICUs

SSI:COLO, SSI:HYST ACH/all inpatient

DE Outpatient Dialysis

2013 MRSA bacteremia LabID, CDI LabID ACH/all inpatient

HCW vaccination ACH

CLABSI, CAUTI LTACH/all inpatient

CAUTI IRF/adult, pediatric wards

2015 CLABSI, CAUTI ACH/wards

HCW vaccination ACH/outpatient; LTACH, IRF, ASC

MRSA bacteremia LabID, CDI LabID LTACH/all inpatient

CSTE recommendation: CDI reporting (NHSN) to public health departments

Organism/ specimen

Type of facility Type of location

Time frame Exceptions

2013 2014 2015 2016

C. difficile Infection LabID Event

Acute Care Hospitals

All inpatient X NICUs, well baby nurseries

LTACH All inpatient X

CHA All inpatient X

IRF All inpatient X

Other non IQR All inpatient X

LTCFs* All residents x

* Will require enough facilities to develop the infrastructure and skills necessary to effectively use NHSN.

CSTE recommendation: MRSA Bacteremia reporting (NHSN) to public health departments

Organism/ specimen

Type of facility Type of location

Time frame Exceptions*

2013 2014 2015 2016

MRSA Bacteremia LabID Event

Acute Care Hospitals

All inpatient X None

LTACH All inpatient X

CAH All inpatient X

IRF All inpatient X

Other non IQR All inpatient X

LTCFs* All residents x

* Will require enough facilities to develop the infrastructure and skills necessary to effectively use NHSN.

Community-Associated (CA-MRSA)

No HACO risk factors

Medical Record Review

Invasive (sterile site) MRSA isolates reported from labs statewide

Health Care-Associated Community-Onset

(HACO-MRSA) -Central venous line at time of culture-Hospitalization, surgery, dialysis, or LTCF residence in year before culture

Hospital-Onset(HO-MRSA)

Isolate collected >2 days after hospital admission

Methods and Case Definitions

Incidence of MRSA by Place of Onset and Year, Connecticut, 2001-2011

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

5

10

15

20

25

30All MRSA HO HACO CA

Year

Rate

per

100

,000

pop

ulati

on

p<0.01a

aChi-square for trend

p<0.01a

p<0.01a

p<0.01a

Revised Annualized National Estimates, ABCs MRSA 2005-2010

(updated Nov, 2012)

2005 2006 2007 2008 2009 2010 20110

20,000

40,000

60,000

80,000

100,000

120,000

OverallCAHOHACO

Estim

ated

No.

Infe

ction

s, U

.S.

Revisions include:Adjustment for dialysis; incorporation of interval estimates (not included);enhanced case finding (TN) and resolved data transmission error (2006-2007). Data accessed (frozen) November 2012.

Revised Annualized National Estimates, ABCs MRSA 2005-2010

(updated Nov, 2012)

2005 2006 2007 2008 2009 2010 20110

20,000

40,000

60,000

80,000

100,000

120,000

OverallCAHOHACO

Estim

ated

No.

Infe

ction

s, U

.S.

Revisions include:Adjustment for dialysis; incorporation of interval estimates (not included);enhanced case finding (TN) and resolved data transmission error (2006-2007). Data accessed (frozen) November 2012.

~27% were outpatient dialysis patients

~50% were dischargedfrom acute care in previous 3 months

Vancomycin-resistant Enterococci (VRE) Connecticut: 2000-2010

VRE Incidence by Hospital Staffed Bed Size

VRE Incidence by Age

Percent of CLABSI organisms that were VRE or MRSA: 2009-2012

2009 2010 2011 20120.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

VRE Linear (VRE ) MRSA Linear (MRSA)

Perc

ent

Percent of CAUTI and SSI organisms that were VRE or MRSA 2012

Type of Infection

Total number of pathogens

isolated

Number (Percent)

VRE

Number (Percent)

MRSA

CAUTI 543 23 (4.2) 1( .2)

SSIs related to colon surgeries

191 7 (3.7) 13 (6.8)

Emerging Infections Program HAI prevalence survey CT 2011

EIP Antimicrobial Use Survey CT 2011

Carbapenem-resistant Enterobacteriacea

• Two KPC isolates from CT hospitals confirmed by CDC

• One NDM• NHSN has reporting

capability• Laboratories report CREs

in some other states• Laboratory Reportable

Condition 2014

CRE Laboratory Reporting Algorithm

No Yes

No

Yes

Is the organism I or R to Doripenem, Imipenem, or Meropenem ? Is the organism R

Is the specimen a clinical isolatefrom a sterile site, sputum, or urine?1

# of carbepenems (DOR, IMI, MERO) that are (I or R) plus Ertapenem (only if R)

I or R to any and all 3rd generation cephalosporins

Is isolate Proteus, Morganella, or Providencia?

I or R to Imipenem?

Go to

STOPdo not report

STOPdo not report

1 2 or more

No

Yes

Yes

Intermediate Resistant

≥ 30 days since last clinical isolate

No

Yes

Is this a new genus/species or a new

resistance profile compared to previous

Report isolate via OL-15C

Yes

Report isolate via OL-15C

No

1If more than one clinical isolate is collected on the same, first date of collection- report only the isolate from the most invasive source: CSF>Blood/Body Fluid>Sputum>Urine; 2 If within 30 calendar days a second, more invasive isolate is collected additional reporting is not required.

National Center for Emerging and Zoonotic Infectious DiseasesDivision of Healthcare Quality Promotion

Fair Haven Community Health Center HCHC project

• AMS in the outpatient setting (70% of patients are Latino)

• Assessment of AMS (facility level)• Provider and patient knowledge, attitude,

practices assessment• Provider, patient education (Get Smart

materials)• Chart reviews to assess prescribing

Upcoming DPH activities• Commissioner’s Call to Action for

antimicrobial stewardship• Antimicrobial stewardship survey of acute care

hospitals• Posting of hospital-specific 2012 CLABSI,

CAUTI, and SSI (COLO, HYST) data on DPH website

• Emerging Infections Program: antimicrobial use paper (descriptive) and new appropriateness survey