Methicillin Resistant Staphylococcus aureus (MRSA):

Proposed Revision of ICD-9 Codes

Rachel Gorwitz, MD, MPHDivision of Healthcare Quality Promotion

Centers for Disease Control and Prevention

Staphylococcus aureus Common human colonizer Common cause of skin infections Potential to cause severe / invasive

infections Transmission: Direct contact

Methicillin-Resistant Staphylococcus aureus (MRSA)

Resistant to all currently available β-lactam antibiotics (penicillins, cephalosporins)

Accounts for majority of S. aureus infections in healthcare settings– Associated with increased morbidity,

mortality, and healthcare costs as compared to methicillin-susceptible S. aureus (MSSA)

1990s: Emerged as a community pathogen– Mainly skin infections– Occasionally severe / life-threatening

Mandatoryreporting of HAI

Emergenceof community-

associated MRSA

Changes invirulence

Congressionalinterest in MRSA

Reports ofsuccessful controlin some facilities

Mediainterest

MRSA-specificlegislation

Controversy overcontrol measures

IncreasingMRSA rates

Increasing awarenessof HAI preventability

Public Interestin MRSA

HAI = healthcare-associated infection

Sources of MRSA Surveillance Data

Active Bacterial Core Surveillance Project National Healthcare Safety Network (NHSN) National surveys using ICD-9 codes Specialized Projects

– EMERGEncy ID Net– National Health and Nutrition Examination Survey

Active Bacterial Core Surveillance Areas (Invasive MRSA)

Total Population: ~ 16.3 million

Oregon

CaliforniaColorado

Tennessee

Georgia

Maryland

Connecticut

New YorkMinnesota

ABCs MRSA Case Categorization Healthcare-associated:

– Hospital-onset: Cases with positive culture obtained >48 hrs after hospital admission (may also have risk factors)

– Community-onset: Cases with at least 1 of the following risk factors:

• Invasive device at time of admission; h/o MRSA infection or colonization; h/o surgery, hospitalization, dialysis, or residence in a LTC facility in 12 mos preceding culture

Community-associated: Cases with community-onset and none of above risk factors documented

Unique MRSA Patients

Medical Record Review

Methods of Invasive MRSA Surveillance

MRSA + Isolates from invasive site

Healthcare Risk Factors

Healthcare-Associated Community-Associated

ABCs Invasive MRSA Surveillance 2005

Healthcare-Associated (community-onset)

Community-Associated

Klevens et al JAMA 2007;298:1763-71

14% 59%

28%

Healthcare-Associated (hospital-onset)

National estimates:94,360 infections; 18,650 deaths

National Healthcare Safety Network (NHSN)

Voluntary, confidential, internet-based system for monitoring healthcare-associated events and processes (including HAIs)

Purposes:– Provide national estimates of magnitude of adverse

events, trends– Provide risk-adjusted data for interfacility comparisons– Assist facilities in developing surveillance and analysis

methods Facility-associated infection:

– No evidence infection was present or incubating at time of admission (as assessed by trained infection control professional)

Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections

Nationally representative surveys of hospitalizations and ambulatory care visits

Utilize:– Specific S. aureus infection codes (038.11

septicemia, 482.41 pneumonia)– S. aureus organism code (041.11)– Codes for syndromes typical of S. aureus (e.g.,

682 cellulitis and abscess) Methicillin resistance data from V codes

(V09.0) or external data sources

Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections

Kuehnert et al, Emerg Infect Dis 2005– 291,542 annual hospital discharges with S.

aureus infection-related diagnoses 1999-00– 125,969 MRSA

Klein et al, Emerg Infect Dis 2007– 62% in S. aureus-related hospitalizations

1999-2005; >2-fold in MRSA-related hospitalizations

McCaig et al, Emerg Infect Dis 2006– 11.6 million annual ambulatory care visits for

skin infections typical of S. aureus 2001-03

Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections:

Challenges With exception of septicemia and pneumonia, S.

aureus organism code not linked to clinical syndrome Resistance code (V09.0) not linked to clinical

syndrome or S. aureus organism code (041.11) National surveys contain a limited number of ICD-9

fields → organism codes and resistance codes may be deleted

Current resistance code (V09.0) not specific for S. aureus or for methicillin-resistance

Currently no colonization code specific for S. aureus or MRSA (falls under V02.59 – Other specified bacterial diseases)

Proposal: Modification of ICD-9 Codes for MRSA

Pages 17-18 of agenda

Acknowledgements Kate Ellingson Scott Fridkin Jeffery Hageman Michael Jhung John Jernigan Monina Klevens Cliff McDonald Cathy Rebmann Chesley Richards Melissa Schaefer Arjun Srinivasan

IL

NYJan-2007

MS

OR

ID

MT

NV

AZ

COJan-2008

NMOK

Jul-2008

MO

AR2008

TXLA

ND

SD

IANE

DC

KY

ME

NJ Jan-2009?

MD Jul-2008

TNJan-2008

WYMI

SCJul-2007

FL

HI

AK

MA Jul-2008

VTFeb-2007

WAJul-2008

CAJan-2008

WI

PAFeb-2008

VAJul-2008

NH

AL GA

UT

KS

MN

OH

NC

RI

DE Feb-2008

WV

IN

CT Jan-2008

*Mandates Public Reporting,Using NHSN

Mandates Public Reporting

Pending Legislation

* Voluntary reporting using NHSN2/13/2008

Legislative Activity for Public Reporting of Healthcare-Associated

Infections