Multidrug-Resistant Hospital-Acquired Infections:

Reducing Risk ThroughQuality Improvement

Hospital-Acquired Infections• Associated with significant morbidity and mortality• High economic cost• Frequent sites of HAIs

– Surgical wound– Urinary tract– Lower respiratory tract– Bloodstream

• Highest prevalence– ICUs– Acute surgical and orthopedic wards

• Pathogens can be transmitted to community by patients, staff, visitors

HAI=hospital-acquired infections; ICU=intensive care unit.World Health Organization, 2002. Available at: http://www.who.int/csr/resources/publications/whocdscsreph200212.pdf. Accessed February 24, 2009.

Impact of Multidrug Resistance on HAIs• Many HAIs are caused by MDR organisms1

– For example, MRSA, VRE, ESBL producers

• ESKAPE pathogens cause majority of US hospital infections2

– Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp

• Widespread use of antibiotics in hospitals suppresses normal flora; allows MDR bacteria to flourish1

• Colonized or infected patients spread MDR pathogens to hospital environment, staff, and other patients1

• Resistant pathogens can transfer resistance genes and virulence factors to other types of bacteria1

ESBL=extended-spectrum β-lactamase; MDR=multidrug-resistant; MRSA=methicillin-resistant Staphylococcus aureus; VRE=vancomycin-resistant enterococci.1. Gould IM. J Antimicrob Chemother. 2008;61:763-765. 2. Boucher HW et al. Clin Infect Dis. 2009;48:1-12.

Infection Control and Quality Assurance for HAIs

• Infection control was once surveillance oriented; now it is prevention oriented

• Financial pressures from CMS and others• Promotion of prevention

– From CMS; JC; IHI; VHA; Premier, Inc.; and others• Public reporting• Patient safety movement• Antimicrobial stewardship• Performance improvement movement

– Focus on system-wide change

CMS=Centers for Medicare & Medicaid Services; IHI=Institute for Healthcare Improvement; JC=The Joint Commission; VHA=Veterans Health Administration.

Forces Driving the Quality Movement

H

TransparencyGovernment

BusinessConsumerDemand

National Quality Organizations

(IOM, media reports, Web sites)

(CMS, CDC, VHA,legislative mandates)

(Pay for performance, The Leapfrog Group)

(JC, NQF, AHRQ, IHI)

Hospital(Internal

commitment to patient safety and quality)

AHRQ=Agency for Healthcare Research and Quality; CDC=Centers for Disease Control and Prevention; IOM=Institute of Medicine; NHQ=National Quality Forum.

Antibiotic-Resistant Gram-Positive Bacteria• Resistance among Gram-positives is increasing• Streptococcus pneumoniae1

• VRE1

• MRSA– HA-MRSA

• Agents that may be effective: vancomycin, quinupristin-dalfopristin, minocycline, linezolid, daptomycin, and tigecycline1

• Vancomycin-resistant S aureus has been reported2

– CA-MRSA resistant to β-lactams3

• Agents that may be effective: clindamycin, doxycycline, and TMP/SMX1

1. Cunha BA. Med Clin N Am. 2006;90:1165-1182. 2. Sievert DM et al. MMWR. 2002;51:565-567. 3. Gordon RJ, Lowy FD. Clin Infect Dis 2008;46(suppl 5):S350-S359.

CA-MRSA=community-associated MRSA; HA-MRSA=healthcare-associated MRSA;TMP/SMX=trimethoprim/sulfamethoxazole.

Proportion of MRSA and VRE in Hospitalized Patients, 1995-2007 (NNIS/NHSN)

NHSN=National Healthcare Safety Network; NNIS=National Nosocomial Infections Surveillance System.1. Methicillin (oxacillin)-resistant Staphylococcus aureus (MRSA) among ICU patients, 1995-2004. Available at: http://www.cdc.gov/ncidod/ dhqp/pdf/ar/ICU_RESTrend1995-2004.pdf. Accessed March 3, 2009. 2. Vancomycin-resistant Enterococci among ICU patients, 1995-2004. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/ar/ICU_RESTrend1995-2004.pdf. Accessed March 3, 2009. 3. Hidron AI et al. Infect Control Hosp Epidemiol. 2008;29:996-1011.

70%

Res

ista

nce

60%

50%

40%

30%

20%

10%

0%1995 1996 1997 1998 1999

ICU Patients

2001 2002 2003 20042000

MRSA1

VRE2

2006–2007

56.2%

33.3%

MRSA3

VRE3

Device-Associated

HAIs

Higher Mortality Associated With MRSA Than MSSA Bacteremia

MSSA=methicillin-susceptible S aureus.1. Cosgrove SE et al. Clin Infect Dis. 2003;36:53-59. 2. Whitby M et al. Med J Aust. 2001;175:264-267.

23%

12%

29%

36%

0%

5%

10%

15%

20%

25%

30%

35%

40%

1980-2000 1990-2000

MSSA

N=39631 N=22092

MRSA

Economic Impact of MRSA Bacteremia

Adjusted Hospital Costs After S aureus BacteremiaAnalysis of Covariance (n=353)

$21,577

$11,668

Fixed direct costs are costs such as administration, clerical support, and building overhead; fixed indirect costs are costs such as hotel costs, utilities, maintenance, and housekeeping; variable direct costs are costs such as nursing staff and medications.Lodise TP et al. Diagn Microbiol Infect Dis. 2005;52:113-122.

$0

$5000

$10,000

$15,000

$20,000

$25,000

MRSA MSSA

Fixed direct costsVariable direct costsFixed indirect costs

MDR, Panresistant, and XDR Gram-Negative Bacteria

• MDR strains may be defined as those resistant to ³2 classes of normally active antibiotics1

– Classes: antipseudomonal cephalosporins, antipseudomonal carbapenems, β-lactam/β-lactamase inhibitor combinations, antipseudomonal fluoroquinolones, aminoglycosides

• Panresistant strains are not susceptible to all of the following2

– Antipseudomonal cephalosporins, antipseudomonal carbapenems, piperacillin/tazobactam, ciprofloxacin, levofloxacin

• Extremely drug-resistant (XDR) strains are not susceptible to all of the following2

– Antipseudomonal cephalosporins, antipseudomonal carbapenems, piperacillin/tazobactam, ticarcillin/clavulanate, ampicillin/sulbactam, ciprofloxacin, levofloxacin, aminoglycosides, tigecycline, polymyxins

1. Paterson DL. Clin Infect Dis. 2006;43(suppl 2):S43-S48. 2. Paterson DL et al. Clin Infect Dis. 2007;45:1179-81.

MDR P aeruginosa and A baumannii Isolates in US ICUs,1986-2003 (NNIS)1-3

For imipenem, ceftazidime, and amikacin, results of Cochran-Armitage χ2 tests for trend were significant (P<0.001).Upper graph adapted from Gaynes R et al. Clin Infect Dis. 2005;41:848-854.Lower graph reproduced with permission from Gaynes R, Edwards JR, and the NNIS System. Clin Infect Dis. 2005;41:848-854.1. Gaynes R, Edwards JR, NNIS System. Clin Infect Dis. 2005;41:848-854. 2. Fridkin SK, Gaynes RP. Clin Chest Med. 1999;20:303-316. 3. NNIS System. Fluoroquinolone-resistant P aeruginosa among ICU patients, 1995-2004. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/ar/ICU_RESTrend1995-2004.pdf. Accessed March 3, 2009.

1986Prop

ortio

n of

Res

ista

ntP

aeru

gino

saIs

olat

es

Year

2520151050

1988 1990 1992 1994 1996 1998 2000 2002

ImipenemCeftazidime

2004

Fluoroquinolone

3530

1986Prop

ortio

n of

Res

ista

ntA

baum

anni

iIso

late

s 706050403020100

1988 1990 1992 1994 1996 1998 2000 2002

ImipenemCeftazidime

Amikacin

Year

Costs of Gram-Negative Resistance• University hospital surgical ICU and ward• 604 surgical patients with GNR infections

– 467 sensitive and 137 resistant* GNR infections

*Resistance was defined as resistance to all drugs in ≥1 of these antibiotic classes: aminoglycosides, cephalosporins, carbapenems, and fluoroquinolones.GNR=Gram-negative rod.Evans HL et al. Crit Care Med. 2007;35:89-95.

P<0.0001

P<0.0001

P<0.0001

13

1

29

13

0 5 10 15 20 25 30 35

ICU Length ofStay (Days)

Length of Stay(Days)

Resistant GNR infectionsSensitive GNR infections

$29,604

$80,500

$0

$20,000

$40,000

$60,000

$80,000

$100,000

Hospital Costs

Mortality Associated With Initial Inappropriate* Antimicrobial Therapy

0 20 40 60 80 100

Luna (1997) – VAP†1

Ibrahim (2000) – BSI‡4

Kollef (1998) – VAP†3

Harbarth (2003) –Severe sepsis†5

Rello (1997) – VAP‡2

Initial appropriatetherapyInitial inappropriatetherapy

Mortality (%)

Vallés (2003) – BSI†6

91%

37%

38%

15.6%

33.3%60.8%

28.4%61.9%

24%39%

69.4%37%

1. Luna CM et al. Chest. 1997;111:676-685. 2. Rello J et al. Am J Respir Crit Care Med. 1997;156:196-200. 3. Kollef MH et al. Chest. 1998;113:412-420. 4. Ibrahim EH at al. Chest. 2000;118:146-155. 5. Harbarth S et al. Am J Med. 2003;115:529-535. 6. Vallés J et al. Chest. 2003;123:1615-1624.

*Based on the 2005 American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) guidelines for hospital-acquired pneumonia (HAP)/VAP/healthcare-associated pneumonia (HCAP) (Am J Respir Crit Care Med. 2005;171:388-416), “inappropriate” would be the term used to refer to the inadequate therapy noted on this slide. †Crude (overall) mortality; ‡Infection-related mortalityBSI=bloodstream infection; VAP=ventilator-associated pneumonia..

Critically Ill Patients With VAP or BSI

Resistance as a Risk Factor for Inadequate Therapy and Mortality in VAP

Reproduced with permission from Teixeira PJZ et al. J Hosp Infect. 2007;65:361-367.

OR=odds ratio.

• 151 patients with VAP: 82 received adequate therapy; 69, inadequate therapy• Risk factors for inadequate treatment of VAP: MDR bacteria (OR=3.07),

polymicrobial infection (OR=3.67), and late-onset VAP (OR=2.93)

0

1.0

0.8

0.6

0.4

0.2

0

Cum

ulat

ive

Surv

ival Adequate (n=82)

Inadequate (n=69)

7 14 21 28Time After VAP Onset (days)

Pneumonia Definitions• HAP: pneumonia occurring ≥48 hours after admission1

– Not incubating at time of admission• VAP: pneumonia arising >48 to 72 hours after endotracheal intubation1

• HCAP: includes patients1

– Hospitalized in acute care hospital for ≥2 days within 90 days of infection

– Residing in nursing home or long-term care facility– Receiving intravenous antibiotic therapy, chemotherapy, or wound

care within 30 days of infection – Attending a hospital or hemodialysis clinic

• CAP: pneumonia occurring outside the hospital setting in patients not meeting HCAP criteria2,3

1. ATS/IDSA. Am J Respir Crit Care Med. 2005;171:388-416. 2. Micek ST et al. Antimicrob Agents Chemother. 2007;51:3568-3573.3. Mandell LA et al. Clin Infect Dis. 2007;44(suppl 2):S27-S72.

CAP=community-acquired pneumonia.

Type of ICU 20041 20062 20073

Burn 12.0 12.3 10.7Cardiothoracic 7.2 5.7 4.7Coronary 4.4 2.8 2.5Medical 4.9 3.1 2.5Medical-surgical

Major teaching 5.4 3.6 3.3All others 5.1 2.7 2.3

Neurosurgical 11.2 7.0 6.5Pediatric 2.9 2.5 2.1Surgical 9.3 5.2 5.3Trauma 15.2 10.2 9.3

Pooled Means

1. NNIS. Am J Infect Control. 2004;32:470-485. 2. Edwards JR et al. Am J Infect Control. 2007;35:290-301. 3. Edwards JR et al. Am J Infect Control. 2008;36:609-626.

Recent Decline in VAP Rates per 1000 Ventilator Days in the US (NHSN)

Pathogens Associated With VAP in US Hospitals, 2006-2007 (NHSN)

Hidron AI et al. Infect Control Hosp Epidemiol. 2008;29:996-1011.

spp

• 54.4% of S aureus isolates were MRSA

24.4

16.3

8.4 8.4 7.5

0

5

10

15

20

25

30

(n=5960)

Path

ogen

ic Is

olat

es (%

)

S aureusP aeruginosaA baumanniiEnterobacterK pneumoniae

Risk Factors for MDR Pathogens Causing HAP, HCAP, and VAP

• Antimicrobial therapy in preceding 90 days• Current hospitalization of ≥5 days• High frequency of antibiotic resistance in community or in specific hospital unit

• Immunosuppressive disease and/or therapy• Presence of risk factors for HCAP

– Including recent hospitalization or residence in a nursing home or extended-care facility

Adapted with permission from ATS/IDSA. Am J Respir Crit Care Med. 2005;171:388-416.

MRSA CAP Pneumonia, 2006-2007• 51 S aureus CAP cases referred to the CDC in 2006-2007

– From 19 states– Median age 16 years– 44% had no underlying comorbidities– 33% had positive influenza test; 91% of these died– Of 47 patients with reported outcome, 51% died– Median time from symptoms onset to death: 4 days

• 37 of the 51 cases were due to MRSA– 48% died– Only 43% received MRSA coverage (linezolid or vancomycin)

empirically

Kallen AJ et al. Ann Emerg Med. 2009;53:358-365.

Initial Empiric Therapy for HAP: Late-Onset Disease or Risk Factors for MDR Pathogens

Potential PathogensPotential pathogens for patients without risk factors andMDR pathogens

P aeruginosaK pneumoniae (ESBL+)*Acinetobacter spp*

Initial Broad-Spectrum Combination Antibiotic Therapy

Antipseudomonal cephalosporinor

Antipseudomonal carbapenemor

β-lactam/β-lactamase inhibitor plus

Antipseudomonal fluoroquinolone*or

Aminoglycosideplus

Linezolid or vancomycin†

*If an ESBL strain, such as K pneumoniae or an Acinetobacter spp is suspected, a carbapenem is a reliable choice. If L pneumophila is suspected, thecombination antibiotic regimen should include a macrolide (eg, azithromycin), or a fluoroquinolone (eg, ciprofloxacin or levofloxacin) should be used rather than an aminoglycoside.†If MRSA risk factors are present or there is a high incidence locally.Adapted with permission from ATS/IDSA. Am J Respir Crit Care Med. 2005;171:388-416.

MRSALegionella pneumophila*

Deescalation of Antibiotic Therapy• Approach to deescalation/streamlining

– Initially treat with broad-spectrum antibiotics1,2

– Discontinue antibiotic therapy if no evidence of infection3

– Narrow the spectrum of activity based on culture findings, when possible1,2

– Shorten course of therapy, based on culture findings and clinical course4

• Exceptions to general approach– Do not discontinue antibiotics in a patient who is decompensating– Patients may be ill and require therapy, notwithstanding negative

culture results

1. Weber DJ. Int J Infect Dis. 2006;10(suppl 2):S17-S24. 2. Höffken G, Niederman MS. Chest. 2002;122:2183-2196. 3. ATS/IDSA. Am J Respir Crit Care Med. 2005;171:388-416. 4. Singh N et al. Am J Respir Crit Care Med. 2000;162:505-511.

Microbiology of Intraabdominal Infection

Enterobacteriaceae(Gram-negative rods)

Anaerobic bacteria (including Bacteroides fragilis,

Enterococcus spp)

Enterobacteriaceae (Gram-negative rods including

Escherichia coli, Klebsiella spp)S pneumoniae

Enterococcus faecalis

Secondary (Bowel Perforation);Complicated Intraabdominal Infection1Primary1

E coli (38% of intraabdominal infections) and B fragilis (24%) are the 2 most commonly isolated bacteria in intraabdominal infections2

1. Volles DF, Branan TN. Emerg Med Clin N Am 2008;26:813-834. 2. Wittman DH, Condon RE. In: Gorbach SL et al, eds. Infectious Diseases.3rd ed. 2004:714-723.

B fragilisE coli

© Custom Medical Stock Photo. © Custom Medical Stock Photo.

Worldwide Antimicrobial Resistancein E coli Isolates Causing cIAI

• SMART study (17 countries)1

– 3134 Gram-negative bacilli from intraabdominal infections– E coli (45%) and Klebsiella spp (17%) most common– 56% of 1403 E coli isolates susceptible to ampicillin/sulbactam

• Germany2

– 425 patients with community-acquired cIAI– Pathogens isolated within 2 days of surgery– 47% of isolates E coli– 32 of 147 E coli isolates resistant to antimicrobial agents (not further

specified)

cIAI=complicated intraabdominal infection; SMART=Study for Monitoring Antimicrobial Resistance Trends.1. Chow JW, et al. Surg Infect. 2005;6:439-448. 2. Krobot K et al. Eur J Clin Microbiol Infect Dis. 2004;23:682-687.

Recommended Regimens for cIAI in High-Risk Patients

IDSA Guidelines1 SIS Guidelines2

High-Severity Infections High-Risk Patients

Single agents1. Piperacillin/tazobactam

2. Imipenem/cilastatin

3. Meropenem

1. Piperacillin/tazobactam

2. Imipenem/cilastatin

3. Meropenem

Combinations1. Third-/fourth-generation cephalosporin

+ metronidazole

2. Aztreonam + metronidazole

3. Ciprofloxacin + metronidazole

1. Ciprofloxacin + metronidazole

2. Aminoglycoside + antianaerobe

3. Aztreonam + clindamycin

4. Third-/fourth-generation cephalosporin + antianaerobe

SIS=Surgical Infection Society.1. Adapted with permission from Solomkin JS et al. Clin Infect Dis. 2003;37:997-1005. 2. Adapted with permission from Mazuski JE et al.Surg Infect (Larchmt). 2002;3:161-173.

Pathogens Producing Hospitalized SSTIs(SENTRY, North America)

• In 1998, 26.2% of S aureus isolates were MRSA• In 2004, 47.4% of S aureus isolates were MRSA

1998 2004

SENTRY=SENTRY Antimicrobial Surveillance Program; SSTI=skin and soft tissue infection.Moet GJ et al. SENTRY data. Diagn Microbiol Infect Dis. 2007;57:7-13.

βStreptococcus5%

Other18%

Klebsiella spp3%

Enterobacter spp4%

E coli7%

Enterococcus spp8%

P aeruginosa13%

S aureus43%

βStreptococcus5%

Other10%

Klebsiella spp4%

Enterobacter spp4%

E coli7%

Enterococcus spp10%

P aeruginosa8%

S aureus52%

Prevalence of MRSA Among 422 ED Patients With SSTI, 2004

7/13 (54%)

24/47 (51%)

18/30 (60%)

25/42 (60%)

46/69 (67%)

43/58 (74%)

11/28 (39%)3/20 (15%)

32/58 (55%)

17/25 (68%)

23/32 (72%)

MSSA 17%

59%

ED=emergency department.Moran GJ et al. New Engl J Med. 2006;355:666-674.

Pathogens Associated With Surgical Site Infection in US Hospitals, 2006-2007 (NHSN)

CoNS= coagulase-negative staphylococci.Hidron AI et al. Infect Control Hosp Epidemiol. 2008;29:996-1011.

spp

13.711.2

9.6

5.6

30.0

0

5

10

15

20

25

30

35

(n=7025)

Path

ogen

ic Is

olat

es (%

)

S aureusCoNSEnterococcusE coliP aeruginosa

Catheter-Related BSIs• ICU patients are at increased risk for CR-BSIs

– 48% of ICU patients have indwelling CVCs– This accounts for 15 million CVC days per year in US ICUs

• As many as 28,000 ICU patients die of CR-BSIs annually in the United States

– Assuming average CR-BSI rate of 5.3 per 1000 catheter days and attributable mortality of 18% (0% to 35%)

• Most CR-BSIs are preventable• Therefore, efforts to decrease CR-BSIs are paramount

CR-BSI=catheter-related bloodstream infection; CVC=central venous catheter.Berenholtz SM et al. Crit Care Med. 2004;32:2014-2020.

Type of ICU 20041 20062 20073

Burn 7.0 6.8 5.6Cardiothoracic 2.7 1.6 1.4Coronary 3.5 2.8 2.1Medical 5.0 2.9 2.4Medical-Surgical

Major Teaching 4.0 2.4 2.0All Others 3.2 2.2 1.5

Neurosurgical 4.6 3.5 2.5Pediatric 6.6 5.3 2.9Surgical 4.6 2.7 2.3Trauma 7.4 4.6 4.0

Pooled Means

1. NNIS. Am J Infect Control. 2004;32:470-485. 2. Edwards JR et al. Am J Infect Control. 2007;35:290-301. 3. Edwards JR et al. Am J Infect Control. 2008;36:609-626.

Recent Decline in Central Line–Associated BSI Rates per 1000 Central Line Days (NHSN)

Pathogens Associated With Central Line–Associated BSI in US Hospitals, 2006-2007 (NHSN)

spp

Hidron AI et al. Infect Control Hosp Epidemiol. 2008;29:996-1011.

spp

11.79.9

4.9

34.1

16.0

0

5

10

15

20

25

30

35

40

(n=11,428)

Path

ogen

ic Is

olat

es (%

)

CoNSEnterococcusCandidaS aureusK pneumoniae

Collateral Damage: Selection ofDrug-Resistant Organisms

• Cephalosporin use has been linked to subsequent infection with

– VRE– ESBL-producing K pneumoniae– β-Lactam–resistant Acinetobacter spp– Clostridium difficile

• Quinolone use has been linked to– Infection with MRSA– Infection with ESBL-producing Klebsiella spp and E coli– Quinolone resistance in Gram-negative bacilli, such as P aeruginosa

Paterson DL. Clin Infect Dis. 2004;38(suppl 4):S341-S345.

C difficile–Associated Disease:a Reemerging Problem

Reproduced with permission from Kelly CP, LaMont JT. N Engl J Med. 2008;359:1932-1940. ©2008 Massachusetts Medical Society. All rights reserved.

2002 2003

880860

200180160

140120100806040200

Ann

ual I

ncid

ence

per

100

,000

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Age (years)≤1718-64≥65Total

Annual Incidence of C difficile Infection per 100,000 Population in Sherbrooke, Quebec, Canada, 1991-2003

New Treatment Options for MDR Pathogens• Gram-negative activity

– Tigecycline– Doripenem– Others ≥5 years to patients– Reintroduction of old therapy

(eg, colistin)

• Gram-positive activity– Linezolid – Daptomycin– Tigecycline– Telavancin– Dalbavancin– Oritavancin– Iclaprim– Ceftobiprole– Ceftaroline

Adapted from Boucher HW et al. Clin Infect Dis. 2009;48:1-12.

Agents in orange are FDA approved.

Antibacterial Agents in Clinical Development

Agent Manufacturer ClassDevelopment

Status

Ceftobiprole Basilea/J&J Cephalosporin Phase 3

Ceftaroline Cerexa/Forest Cephalosporin Phase 3

Telavancin Theravance Lipoglycopeptide Phase 3

Dalbavancin Pfizer Lipoglycopeptide Approvable letter/Phase 3

Oritavancin The Medicines Company Glycopeptide Phase 3

Iclaprim Arpida Diaminopyrimidine Phase 2/3

J&J=Johnson & Johnson.Talbot GH et al. Clin Infect Dis. 2006;42:657-668; Boucher HW et al. Clin Infect Dis. 2009;48:1-12.

CMS Preventable Hospital-Acquired Conditions

• These conditions, if not present at the time of admission, are not taken into account in calculating payments to hospitals

US Department of Health and Human Services. Federal Register. 2008;73:48433-49084.

• HAIs no longer reimbursed as of October 1, 2008

– Catheter-associated urinary tract infections

– Vascular catheter-associated BSIs

– SSIs following elective surgery (certain orthopedic procedures or bariatric surgeries)

– Mediastinitis after coronary bypass surgery

• HAIs being considered for nonreimbursement

– VAP– S aureus septicemia– MRSA– C difficile–associated disease– Legionnaires’ disease

Role of Hospital Administration:CMS Regulations

• CMS conditions of participation: quality assessment and performance improvement program

• Executive responsibilities– Maintain ongoing quality improvement program– Maintain ongoing patient safety program, including reduction of

medical errors– Ensure hospital-wide quality assessment and performance

improvements address priorities for improved quality of careand patient safety

– Establish clear expectations for safety– Must provide adequate resources for measuring, assessing,

improving, and sustaining performance and reducing riskfor patients

CMS. Section 482.21. Available at: http://edocket.access.gpo.gov/cfr_2003/octqtr/pdf/42cfr482.21.pdf. Accessed March 3, 2009.

World Health Organization: Hand Hygiene in Healthcare

“Hand hygiene, a very simple action, remains the primary measure to reduce health care–associated infection and the spread of antimicrobial resistance, enhancing patient safety across all settings.

Yet compliance with hand hygiene is very low throughout the world…”1

WHO=World Health Organization.1. WHO. Available at: http://www.who.int/patientsafety/events/05/HH_en.pdf. Accessed April 15, 2009. 2. WHO. Available at: http://www.who.int/gpsc/tools/5momentsHandHygiene_A3.pdf. Accessed April 15, 2009.

2

Surgical Care Improvement Project• Sponsored by CMS

– Partners include AHA, CDC, IHI, and JC• Goal: reduce postoperative complications by 25% by the year 2010

• Initiatives in 4 categories– Infection– Venous thromboembolism– Cardiac events surrounding surgery– Respiratory events

AHA=American Hospital Association.Premier. Available at: http://www.premierinc.com/safety/topics/scip/index.jsp. Accessed March 13, 2009. American Hospital Association. Introduction to SCIP and SCIP Measures. Available at: http://www.aha.org/aha/issues/Quality-and-Patient-Safety/scip.html. Accessed February 27, 2009.

Changes in National Performance on Antibiotics Administration

*National sample of 39,000 Medicare patients undergoing surgery in US hospitals during 2001.

Bratzler DW et al. Arch Surg. 2005;140:174-182. Additional data provided by D Bratzler, MD (2009).

55.7

91.692.6 95.8

40.7

87.7

0

20

40

60

80

100

120

2001

*

Q1 200

2

Q2 200

2

Q3 200

2

Q4 200

2

Q1 200

3

Q2 200

3

Q3 200

3

Q4 200

3

Q1 200

4

Q2 200

4

Q3 200

4

Q4 200

4

Q1 200

5

Q2 200

5

Q3 200

5

Q4 200

5

Q1 200

6

Q2 200

6

Q3 200

6

Q4 200

6

Q1 200

7

Q2 200

7

Q3 200

7

Q4 200

7

Q1 200

8

Q2 200

8

Perc

ent

Antibiotics within 60 minGuideline antibioticsAntibiotics discontinued

Medicare Modernization Act

Deficit Reduction Act and Society of Thoracic Surgeons recommendation of antibiotics for up to 48 hours for cardiac surgery

Data source changed from independently abstracted to hospital self-collected.

Medicare Modernization Act

Compendium of Strategies to Prevent HAIs in Acute Care Hospitals

• Implementation focused; not intended to replace detailed guidelines in each area

• Collaboration of several organizations– SHEA* – IDSA*– Association for Professionals in Infection Control and Epidemiology– AHA– JC

*Appointed task force.SHEA=Society of Healthcare Epidemiology in America.Yokoe DS et al. Infect Control Hosp Epidemiol. 2008;29(suppl 1):S12-S21.

Care Bundles (JC)• Bundle: collection of interventions that improve patient care outcomes when combined

• Included practices must be backed by excellent research• Excellent starting point for improving patient care

– Can easily score whether all elements of bundle were performed• All components must be performed to maximize success• Several types of bundles, including ventilator care, central line care, and sepsis management

– Example: central line bundle stipulates hand hygiene, chlorhexidine, maximal barrier precautions, subclavian insertion, daily evaluation of insertion site, and need for central line

JC. Joint Commission Perspectives on Patient Safety. 2006;6:5-6.

IHI 5 Million Lives Campaign• Continuation of 100K Lives campaign• SSIs1

– Appropriate use of antibiotics, appropriate hair removal, perioperative glucose control, and perioperative normothermia

• VAP2

– Elevation of head of bed (30°-45°), daily “sedation vacation,” and daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, and deep vein thrombosis prophylaxis

• Central line infections3

– Hand hygiene, maximum barrier precautions, chlorhexidine, optimal catheter site selection (ideally subclavian vein), daily review of line necessity, and prompt removal of unnecessary lines

1. IHI. Available at: http://www.ihi.org/NR/rdonlyres/17764BD1-B191-40D2-A91D-C8E421C47491/0/ssi.pdf. Accessed March 4, 2009.2. IHI. Available at: http://www.ihi.org/NR/rdonlyres/35B687FE-D4D0-44E5-A671-E76D74BB8D9F/0/vap.pdf. Accessed March 4, 2009.3. IHI. Available at: http://www.ihi.org/NR/rdonlyres/01E7F0ED-EEDE-41BA-ABB0-982405602158/0/cli.pdf Accessed March 4, 2009.

CDC/HICPAC Interventions forControl of MDROs

• Administrative (eg, dedicated staff for infection control)• MDRO education (eg, hand hygiene, antimicrobial prescribing patterns)

• Antimicrobial stewardship (eg, limited third-generation cephalosporins)

• MDRO surveillance (antibiogram)• Contact precautions (eg, gown and gloves)• Environmental measures (eg, decontamination and adherence to recommended cleaning practices)

• Decolonization (not routinely recommended)

HICPAC=Healthcare Infection Control Practices Advisory Committee; MDRO=multidrug-resistant organism.Siegel JD et al. Am J Infect Control. 2007;35(suppl 2):S165-S193.

SHEA/APIC Position Statement on Active Surveillance for MRSA

• SHEA/APIC do not support legislation to mandate use of active surveillance cultures

– Considerable evidence supports active surveillance cultures during outbreaks or in high-risk patients

– Not enough evidence to support mandatory surveillance of all hospitalized patients

• SHEA/APIC support development of validated, efficacious, and cost-effective strategies to prevent infections

– Support ongoing research on effectiveness of active surveillance culturing

– Support stronger collaboration between local health authorities and institutional infection control experts

APIC=Association for Professionals in Infection Control and Epidemiology.Weber SG et al. Infect Control Hosp Epi. 2007;28:249-260.

Infection Control and Education toLower Rates of Unit-Acquired MRSA

• Education for MRSA, contactprecautions, isolation,antibiotic use

• For the on-unit group, lowerMRSA infection rates for blood(1.1%–0.2%, P=0.014),sternal wound (2.6%–1.4%,P=0.057), and leg wound(1.5%–0.7%, P=0.141)sites were noted

Ward acquisition of MRSA was defined as the isolation of MRSA from any site more than 72 hours after admission by patients who had no history of MRSA infection or colonization.

Schelenz S et al. J Hosp Infect. 2005;60:104-110.

16 months prior to implementing control policies16 months after implementing control policies

Patie

nts

(%)

P=0.003 NS

Prevalence of MRSA Colonization

n=1036 n=921 n=1075 n=956

3.73.64.0

1.5

0

1

2

3

4

5

Study Unit Control Unit

Reproduced with permission from Urban C et al. Clin Infect Dis. 2003;36:1268-1274.

Antibiotic Control for MDRGram-Negative Agents

Multidrug-resistant, ceftazidime-susceptibleA baumannii (chromosomal)

Ceftazidime-resistantA baumannii

(chromosomal)1988

Ceftazidime use

Ceftazidime-resistantK pneumoniae

(plasmid-mediated)1993

Imipenemuse

Cephamycinand

ceftazidimeuseCeftazidime-imipenem-resistant

A baumannii (chromosomal)1991–1992

Ceftazidime-cephamycin-imipenem-resistant K pneumoniae (chromosomal

and plasmid-mediated) 1995

Contact isolation;patient cohorting;local polymyxin

Class restrictionof cephalosporinsand cephamycins

Imipenen-resistantP aeruginosa (chromosomal)

1996

Contact isolation;local polymyxin

OngoingElimination of imipenem

resistance, 1999

Reduction ofceftazidimeresistance;

44% hospital-wide,87% in ICUs

Reproduced with permission from Apisarnthanarak A et al. Clin Infect Dis. 2008;47:760-767.

Multifaceted Interventions to ReduceA baumannii Infections in the ICU

• 3 ICUs in tertiary center • Period 1: preintervention • Period 2: intervention• Period 3: follow-up• Interventions

– Hand hygiene– Contact precautions– Surveillance cohorting of

colonized and infected patients– Environmental cleaning with

sodium hypochlorite (1:100)

• Rates: 66% reduction in period 2 and 76% in period 3

54.5

43.5

32.5

21.5

10.5

0No. o

f Cas

es p

er 1

000

Patie

nt-D

ays

2005 2006 2007

Period 1 Period 2 Period 3

Replace sodium hypochlorite solutionby detergent/phenolic compounds

Interventioninitiated

Control of CRE (CDC and HICPAC)• CRKP is the most commonly encountered CRE

– In 2007, 8% of Klebsiella isolates were CRKP (<1% in 2000)– Resistant to almost all available antimicrobials– Some CRE strains are within the susceptible range for

carbapenems, making identification difficult• Infection control

– Implement CLSI guidelines for susceptibility testing and detection of carbapenemase production

– Manage CRE patients with contact precautions– If CRE or carbapenemase-producing strains are identified,

investigate facility for possible transmission

CLSI=Clinical and Laboratory Standards Institute; CRE=carbapenem-resistant Enterobacteriaceae; CRKP=carbapenem-resistant K pneumoniae. CDC. MMWR Morb Mortal Wkly Rep. 2009;58:256-260.

VAP Prevention• Oral decontamination

– Chlorhexidine 2%1

– Chlorhexidine 0.12%2,3

• Bed position4-6

• Suctioning6,7

• Humidification8

• Tracheotomy9

• Education and surveillance10

• Bundle11

1. Koemann M et al. Am J Respir Crit Care Med. 2006;173:1348-1355. 2. Segers P et al. JAMA. 2006;296:2460-2466.3. Chlebicki MP et al. Crit Care Med. 2007;35:595-602. 4. Van Nieuwehnoven CA, et al. Crit Care Med. 2006;34:396-402. 5. Delaney A. Crit Care.2006;10:R70. 6. Muscedere J et al. J Crit Care. 2008;23:126-137. 7. Vonberg RP, et al. Intensive Care Med. 2006;32:1329-1335. 8. Lorente L et al. Crit Care. 2006;10:R116. 9. Barquist ES, et al. J Trauma. 2006;60:91-97. 10. Rosenthal VD et al. Am J Infect Control. 2006;34:58-63. 11. Cocanour CS et al. J Trauma. 2006;61:122-130.

Intervention to Decrease CR-BSIs in the ICU• 108 ICUs in Michigan

– 1981 ICU months– 375,757 catheter-days

• 5 evidence-based procedures

– Hand washing– Full barrier precautions

during CVC insertion– Chlorhexidine prep– Avoidance of femoral

site– Removal of

unnecessary CVCs

Pronovost P et al. N Engl J Med. 2006;355:2725-2732.

2.7

0 0

7.7

2.31.4

0

1

2

3

4

5

6

7

8

9

Baseline 0-3 Months After Implementation

18 Months After Implementation

Median CR-BSI RateMean CR-BSI Rate

CR-B

SI R

ate

per 1

000

Cath

eter

-Day

s

Conclusions•MDROs are increasing in prevalence

– Both Gram-negative and Gram-positive– In HAP/VAP, cIAI, BSI, and SSI/cSSTI

•Limited availability of antimicrobials for treatment of MDR Gram-negative pathogens necessitates better use of current agents

•New Gram-positive agents are in development•All efforts for prevention of hospital-acquired MDRO infections are necessary