Healthcare-Associated Infections, Multidrug-Resistant Organisms,

and Infection Control

Timothy H. Dellit, MDthdellit@u.washington.edu

Infection Control and Antimicrobial ManagementHarborview Medical Center

Patient Safety and Infection Control• Prevention, monitoring, and feedback

– Healthcare-associated infections• Catheter-related bloodstream infections• Ventilator-associated pneumonia• Surgical site infections• Catheter-related UTI

– Transmission of multidrug-resistant/marker organisms• MRSA• VRE• Carbapenem-resistant Acinetobacter• ESBL-producing organisms• C. difficile• Aspergillus in burn and immunocompromised populations• Tuberculosis

Increasing Regulation and Reporting

• CMS and “medical errors”– FY2008

• Catheter-associated urinary tract infection• Vascular catheter-associated infections• Mediastinitis after CABG

– FY2009• SSI following select orthopedic procedures

– Spinal fusion– Elbow and shoulder arthroplasty

• SSI following bariatric surgery• Mandatory reporting of healthcare-associated infections (HB 1106)

– Central line infections in ICU: July 2008– Ventilator-associated pneumonia: January 2009– Selected surgical site infections: January 2010

• Cardiac surgery• Total hip and knee arthroplasty• Hysterectomy

Not selectedVAPS. aureus septicemia/ MRSAC. difficileLegionnaires’

“MDRO Bundle”

• Hand Hygiene• Contact precautions• Minimize shared equipment• Environmental cleaning• Healthcare-Associated

Infections Preventive Bundles– Catheter-associated BSI– Ventilator-associated

pneumonia– Catheter-associated UTI

• Active surveillance cultures • Chlorhexidine baths• Antimicrobial stewardship

Increased Hand Hygiene Associated with Decreased MRSA Transmission

0

10

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50

60

70

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1994 1998

Han

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Lancet 2000;356:1307-12

0 20 40 60 80 100

Room Door Handle

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Bath Door Handle

Side Rails

BP Cuff

Overbed Table

Patient Gown

Bed Linen

Percent of Surfaces Positive for MRSA

Infect Control Hosp Epidemiol 1997;18:622-627

Role of Environmental Contamination

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Gowns Gloves

Contact with patient

Contact with environment

Contact Contamination

Per

cent

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To Survey or Not to Survey?

• Interventions over 9 yr– Sterile CVC placement– Alcohol-based hand

hygiene– Hand hygiene campaign– ICU surveillance for

MRSA (16 months)• 29% of newly detected

MRSA carriers develop infection within 18 months

Surveillance Cultures Reduce MRSA Bacteremia

Reduced ICU transmission by 47%• 43 vs. 23 cases per 1000 at risk patientsClin Infect Dis 2003;36:281-5

Clin Infect Dis 2006;43:971-8

0

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Arch Intern Med 2006; 166:306-12

Chlorhexidine Body Wash in the ICU

Arch Intern med 2007;167:2073-79

Decreased Acquisition of VREBefore and after, compared with soap and water

Decreased Bloodstream InfectionsCross-over, compared with soap and water

6.4 vs. 16.8 BSI per 1000 catheter-days

Antimicrobial Stewardship• Includes the appropriate selection, dosing, and

duration of therapy– 50% of antimicrobial therapy is inappropriate

• Primary goal is to optimize clinical outcomes while minimizing unintended consequences– Toxicity, drug-drug interactions– Emergence of resistance– Clostridium difficile

• Secondary goal is to reduce healthcare costs without adversely impacting quality of care

Clin Infect Dis 2007;44:159-77

Catheter-Related BSI

• ICU CVC utilization 0.48 – 0.73 catheters/pt– 15 million catheter-days per year in US

• ICU rate 2.7 to 6.8 per 1000 catheter-days (2006 NHSN)– 80,000 CR-BSI annually in US ICUs– Attributable mortality 0-35%

• Healthcare cost $296 million to $2.3 billion– Attributable cost $15,000-$56,000– Prolonged ICU and hospital LOS

Clin Infect Dis 2002;35:1281-307

NHSN CLA-BSI Pathogens

1986-1989 1992-1999 2006-2007

Pathogen (%) (%) (%) Coag-negative staphylococci 27 37 34Staphylococcus aureus 16 13 10*Enterococcus 8 13 16Candida sp. 8 8 12Enterobacter 5 5Pseudomonas aeruginosa 4 4Klebsiella pneumoniae 4 3

E. Coli 6 2

Clin Infect Dis 2002;35:1281-307

Am J Infect Control 2008;36:609-26*MRSA 5.6%, MSSA 4.3%

Prevention of Catheter-Associated BSI

• IHI “Central Line Bundle”– Hand hygiene– Chlorhexidine skin prep– Maximal barriers

• Full drape• Mask, hair cover, sterile gown, sterile gloves

– Optimal catheter site selection– Daily review of line necessity

• Implementation AND documentation

Institute for Healthcare Improvement

Bundle in Action

Reduction in mean rate from 7.7 to 1.4 per 1000 catheter-days

N Engl J Med 2006;355:2725-32

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Baseline 0-3 4-6 7-9 10-12 13-15 16-18

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Teaching Hospital

Non-teaching Hospital

< 200 beds

> 200 beds

Months After Implementation

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Key Performance Measure Hospital Performance

Patient Level% of cases

median range

Central Venous Catheter Placed in the Subclavian Vein 44.2% 14.3 – 73.3%

Evidence of Maximal Barrier Precautions for Insertion 0.0% 0.0 – 8.2%

Hand Washing 0.0% 0.0 – 39.0%

Full Body Drape 3.0% 0.0 – 46.3%

Sterile Gloves and Gown 1.9% 0.0 – 39.0%

Cap and Mask 0.0% 0.0 – 13.6%

Chlorhexidine Skin Prep for Insertion 1.9% 0.0 – 98.1%

Daily Dressing Inspection 97.5% 25.1 – 100%

Daily Assessment of Medical Necessity to Continue CVC 16.4% 0.0 – 100%

Operational Yes % (n) Site #

Best Practice* CVC Insertion Policy 11.8% (2) 29, 89

Mandated Use of a CVC Insertion Checklist 11.8% (2) 84, 87

UHC Benchmark of Key Performance Measures

* Necessary elements: CVC insertion policy, mandated compliance policy, policy includes: qualification requirements for individuals inserting the central line, optimal site selection, hand hygiene, chlorhexidine skin antisepsis, and maximal barrier precautions

There is work to be done!

Infect Control Hosp Epidemiol 2008;29:440-2

National Reduction in CLA-BSI

JAMA 2009;301:727-36

MRSA Central Line-Associate BSI

JAMA 2009;301:727-36

50% reduction in MRSA CLA-BSI (0.43 vs 0.21 per 1000 catheter-days)

Hospital-Acquired UTI

Survey of Hospital Monitoring

• 40% of healthcare-associated infections• 80% due to indwelling urethral catheter

Potential Strategies

• Insertion/care• Catheter reminders/ automatic stop orders• Bladder US scanners• Condom catheters• Antimicrobial catheters

Aymptomatic bacteriuria vs.

Symptomatic UTI in patients without localizing GU symptoms

Clin Infect Dis 2008;46:243-50

No

mo

nito

ring

(%

)

UTI Pathogens in ICU Patients (N = 47,502)

11%

18%

6%6% 15%

25%

14%2%3%

Coag-negative Staphylococcus

S. aureus

Clinics Chest Med 1999;20:303-16

National Nosocomial Infections Surveillance System January 1989 - June 1998

Enterococcus

Other

CandidaEnterobacter

Pseudomonas

Klebsiella

E. coli

Catheter-related UTI

• Duration of catheterization is primary risk

• Providers unaware of catheter status– Students 21%– Interns 22%– Residents 27%– Attendings 38%

• Daily assessment of need, especially when transferred from ICU to floor

Am J Med 2000;109:476-80

Ventilator-Associated Pneumonia• Rate 2.8 – 12.3 per 1000 ventilator days (NHSN 2006)

– 10-30% of intubated patients– Incidence increases with duration of MV

• Day 1-5: 3% risk per day• Day 6-10: 2% risk per day• > 10 days: 1% risk per day

• Attributable mortality rate 33-50%• Increased LOS 7-9 days• Cost of $40,000 per patient• Accounts for 50% of ICU antimicrobials• Clinical vs. microbiologic definitions

– Poor external quality measure

Am J Respir Crit Care Med 2005;171:388-416

BICU: Burn PICU: Pediatric med/surgCICU: Coronary NICU: NeurosurgeryCT ICU: Cardiothoracic SICU: SurgicalMICU: Medical TICU: Trauma

Rat

e pe

r 10

00 v

ent-

days

NHSN Mean VAP by Unit2006-2007

Am J Infect Control 2008;36:609-26

“Ventilator Bundle”

• Head of bed elevation > 30 degrees*

• Daily “sedation vacation” and assessment of readiness to extubate*

• Oral care (chlorhexidine)

• Peptic ulcer disease prophylaxis*

• Deep vein thrombosis prophylaxis*

*Institute for Healthcare Improvement

Reduction in VAP from 6.6 to 2.7 (59%) per 1000 ventilator-days with > 95% compliance (Jt Comm J Qual Patient Saf 2005;31(5):243-8)

Policy to Implementation

J Trauma 2006;61:122-130

Ventilator BundleDaily compliance and

weekly feedbackCompliance audit and feedback

Which of the following has been demonstrated to reduce surgical site infections and is

currently part of national recommendations?

A. Peri-operative prophylactic antibiotics should be given within 60 minutes after incision

B. Peri-operative prophylactic antibiotics should be given within 60 minutes before incision and discontinued within 24 hours

C. Peri-operative antibiotics should be continued until the drains are out

D. Nasal carriage of S. aureus should be eradicated prior to surgery

E. Pre-surgical bath with chlorhexidine

Surgical Infection Prevention Project

• Implemented by CDC and Centers for Medicare and Medicaid Services in 2002

• Nationally included procedures– Cardiothoracic, vascular, colon, hip or knee arthroplasty, vaginal or

abdominal hysterectomy

• Performance measures (Baseline of 34,133 medicare patients in 2001)– Antimicrobial prophylaxis within 1 hr of incision (55.7%)– Antimicrobial agent c/w current guidelines (92.6%)– Discontinuation within 24 hours after surgery (40.7%)

• Role of MRSA screening?

Arch Surg 2005;140:174-82

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≤-3 -2 -1 0 1 2 3 4 ≥5

N Engl J Med 1992;326:281-6

Perioperative Prophylactic AntibioticsTiming of Administration

Infe

ctio

ns (

%)

Hours From Incision

14/369

5/699

5/1009

2/180

1/81

1/411/47

15/441

Society of Thoracic Surgeons

• Rationale– Unique patient risks

• Cardiopulmonary bypass, systemic hypothermia

– Devastating sequelae of mediastinitis (7-20% mortality)– No randomized studies < 48 hrs in CT surgery

• Major Recommendations1. Postoperative prophylactic antibiotics are given for 48 hours or

less2. Duration not dependent on chest tube removal3. If risk for MRSA, then vancomycin AND cefazolin4. Routine mupirocin administration for all patients in the absence

of documented negative testing for staphylococcal colonization

Ann Thorac Surg 2006;81:397-404Ann Thorac Surg 2006;83:1569-76

Is Vancomycin Alone Adequate?

S. aureus, 40%

Anaerobes, 1%Fungi, 1%

Enterococcus, 3%

Other Gram-positives, 4%

Gram-negative Bacilli, 20%

Coagulase-negative

Staphylococci, 21%

No Pathogen, 4%

Unknown, 7%Acceptable for cardiac, vascular, or orthopedic surgery:

• Beta-lactam allergy

• Documented rationale

Pathogens causing deep SSI following CABG, Hip and Knee Arthroplasty

NNIS 1994-2003

Meta-analysis of Seven Randomized Studies: Glycopeptide vs. β-Lactam for Prevention of Surgical Site Infection after Cardiac Surgery

Clin Infect Dis 2004;38:1357-63

MSSA more frequent in vancomycin group 3.7% vs. 1.3%(J Thorac Cardiovasc Surg 2002;123:326-32)

Intranasal Mupirocin and Surgical Site Infections

• Nasal carriage of S. aureus and risk of surgical site infection– Orthopedic surgery with prosthetic implants in 272 patients, RR 8.9

(Infect Control Hosp Epidemiol 2000;21:319-323)– Cardiothoracic surgery in 1980 patients, OR 9.6 (J

Infect Dis 1995;171:216-9)• 10/10 pre- and post-surgical pairs identical by phage typing

• Randomized, double-blind, placebo-controlled trial of pre-surgical mupirocin in 3864 patients (N Eng J Med 2002;346:1871-7)

– No difference in nosocomial infections, nosocomial S. aureus infections, or S. aureus surgical site infections

– S. aureus carriers (N=891)• 4.5 fold increase in S. aureus SSI• Significant reduction in S. aureus nosocomial infections (4.0 vs. 7.7)• Trend towards decreased S. aureus SSI (3.7 vs. 5.9, 37%, P=0.15)• Same strain in nares and site of infection in 85%

Universal Screening of Surgical Patients?JAMA 2008;299:1149-57

• Prospective, cross-over study of 21,754 surgical patients– 87% on admission– MRSA colonization 5.1%

• Standard practices for all patients with MRSA– Contact precautions– Adjustment of pre-op prophylaxis– Intranasal mupirocin and chlorhexidine body wash

• No difference in MRSA SSI (0.99 vs. 1.14 per 100)– 34% of MRSA carriers did not receive appropriate pre-op

prophylaxis– None identified through outpatient screening developed MRSA

infection

MRSA Screening and SSI

• Evanston Northwestern– Universal screening upon hospital

admission– Decolonization with mupirocin and CHG– MRSA SSI 2.83 to 1.63 per 10,000 pt-

days (P=0.008)• University College London Hospitals

– Screening upon admission or pre-admission clinics

– Decolonization with mupirocin and CHG– MRSA SSI 1.44 to 1.25 per 1000 pt-days

(P=0.021)• Pitt County Memorial Hospital (NC)

Ann Intern Med 2008;148:409-18Br J Surg 2008;95:381-6J Am Coll Surg 2009;208:981-8

MRSA SSI 0.23% to 0.09%

Mupirocin for S. aureus Colonization

RR

Nosocomial S. aureus infection 0.55 (0.43 to 0.70)

Nosocomial S. aureus infection (surgical pts) 0.55 (0.34 to 0.89)

S. aureus surgical site infections 0.63 (0.38 to 1.04)

Cochrane Review of nine randomized trials with 3,396 patients

Cochrane Database Syst Rev. 2008, Issue 4:CD006216. Review

Pre-operative Chlorhexidine Baths

RR

Chlorhexidine vs. placebo 0.91 (0.80 to 1.04)

Chlorhexidine vs. bar soap 1.02 (0.57 to 1.84)

Chlorhexidine vs. no washing 0.36 (0.17 to 0.79)

Cochrane Review of six randomized trials with 10,007 patients

Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004985. Review

It’s a small world…

A 60 year old Vietnamese woman presents to the ED with 4 day history of fever 39 C, cough, shortness of breath, and severe myalgias.

Upon further questioning, you discover that she returned from Vietnam four weeks ago after a two month visit with her family. She did not visit any open air markets or handle live poultry. Her CXR did not demonstrate any infiltrates or effusions, but she was admitted to the hospital for observation and poor PO intake.

And getting smaller….

26 y o medical student returns April 20, 2009 from an international elective in Mexico. On April 27 she presents to ED with 4 day h/o fever 39 C, cough, HA, myalgias, and diarrhea. That same day you hear reports of a novel Influenza A virus H1N1 associated with increased mortality in Mexico.

Which of the following is MOST correct regarding influenza?

A. No special precautions are necessary for patients with suspected influenza since it is not very transmissible.

B. The woman from Vietnam should be placed in Airborne Precautions with use of PAPR or N-95 respirator due to concern for avian influenza.

C. Patients admitted to the hospital with influenza after 48 hours of symptom onset should not be treated with antivirals as there is no benefit in symptom resolution.

D. Influenza vaccination of healthcare workers does not have an impact on patients.

E. Influenza is primarily transmitted by large droplets (> 5 microns), therefore healthcare workers should use Droplet Precautions with a surgical mask with eye protection for routine care to prevent contamination of mouth, nose, and conjunctiva.

Annual Impact of Influenza

• Infects 5-20% of US population annually– Attack rates highest in young– Mortality highest among older adults– Droplet transmission (> 5 microns)

• 3 lost days of work or school• 226,000 hospitalizations per year 1979-2001• 36,000 deaths annually

– Post influenza MRSA pneumonia

JAMA 2005;292;1333-40, JAMA 2003;289:179-186

World Distribution of H5N1 (Avian Flu)

Through May 22, 2009433 Cases262 Deaths (61%)

2009Egypt (27)China (7)Vietnam (4)

Primarily contact with infected birds; very rare reports of possible human to human transmission

H1N1 (Swine Flu)(June 26, 2009)

• Most cases mild - 27,717 cases in US

-127 deaths - estimated 1,000,000 - 588 cases in WA - 70% age < 19• Emphasize basics -Wash your hands! -Cover your cough -Stay home if sick

Rapid worldwide spread!

Zoonotic Influenza

Wild Aquatic Birds

HumansDomestic Birds

Swine

N Engl J Med 2009;361 on line May 7

Novel Influenza and Infection Control

• Hand hygiene• Respiratory hygiene/cough etiquette• Influenza vaccination• Evolving case definitions

– Avian Influenza• Travel to affected area with direct poultry contact within 10 days of

symptom onset– H1N1 (Swine Flu)

• Mexico to everywhere

• Droplet vs. airborne transmission?– Seasonal influenza: droplet precautions– Novel influenza (sporadic): airborne precautions– Pandemic influenza: CONTROVERSY!

Influenza and Antiviral Resistance• Adamantanes (amantadine and rimantadine)

• High rate of resistance (91%) among H3N2 during 2005-2006 influenza season

• Retained activity against seasonal H1N1

• Neurominidase inhibitors (oseltamavir and zanamavir)– Emergence of oseltamivir resistance

• 11% resistance among H1N1 in US 2007-2008• 99% resistance among H1N1 in US 2008-2009

Treatment of seasonal influenza with zanamavir OR (oseltamavir and rimantadine)

H1N1 (S-OIV) currently susceptible to oseltamavir, but will resistance emerge with increased oseltamavir use?

Summary

• Healthcare-associated infections associated with significant patient morbidity and mortality

• Increasing resistance with a paucity of new antimicrobials in the pipe line

• Infection control and antimicrobial use involves all of us and is a patient safety issue

• Wash your hands!