U.S. Healthcare-Associated Infections and Antimicrobial Use Prevalence Surveys:

Plans for 2015

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion

Shelley S. Magill, MD, PhD

Division of Healthcare Quality Promotion

U.S. Centers for Disease Control and Prevention

February 12, 2015

Overview

Healthcare-associated infection (and antimicrobial use) surveillance in the United States, then and now

Key results from the first U.S. HAI and antimicrobial use prevalence survey in 2011

How the data have been used, and reasons for repeating the survey in 2015

Overview of objectives and methods for the 2015 HAI and antimicrobial use prevalence survey—what’s new

U.S. HAI SURVEILLANCE SYSTEMS

www.cdc.gov/nhsn

National Healthcare Safety Network (NHSN)

“Most widely used healthcare-associated infection (HAI) tracking system” in the United States

Facilities use standard NHSN surveillance protocols to track infections and report data using the NHSN application

NHSN data are used by healthcare facilities, state health departments, federal agencies, and the public to: “Identify infection prevention problems by facility, state, or specific

quality improvement project

Benchmark progress of infection prevention efforts

Comply with state and federal public reporting mandates, and ultimately,

Drive national progress toward elimination of HAIs.”

www.cdc.gov/nhsn

http://www.cdc.gov/hai/eip/index.html

Emerging Infections Program (EIP)

Network of 10 state health departments and academic partners established in 1995 Assess public health impact and evaluate approaches to prevention

and control of emerging infectious diseases

HAI-related work established as formal EIP activity in 2009

Core EIP work is active, population- and laboratory-based infection surveillance with isolate collection Basis for epidemiological and laboratory analyses and special projects

performed at CDC and in EIP states

Data are collected by trained EIP site staff working with a variety of CDC programs across the agency

Data are primarily used by CDC and other federal agencies to inform national infection prevention and control strategies and policies

Then (2010-2011): National Healthcare Safety Network

Data reported from 2400 – 4500+ healthcare facilities Mostly acute care hospitals Most reporting from intensive care units (ICUs) Focus on reporting of device- and procedure-associated

infections HAI reporting driven by state reporting mandates and in

2011 by reporting programs of the federal Centers for Medicare & Medicaid Services (CMS) CMS incorporated ICU CLABSI into its Hospital Inpatient Quality

Reporting (IQR) Program with data collection beginning Jan 1, 2011

Little to no reporting of antimicrobial use NHSN Antimicrobial Use and Resistance (AUR) Module launched in

2011

Then (2010-2011): Rationale for HAI and AU Prevalence Survey

Redefine HAI burden (i.e., to update the oft-quoted “1.7 million HAIs per year” from analysis of 1990s-2002 data*)

Describe the full spectrum of HAIs across acute care inpatient populations to identify areas in need of prevention attention Complements focused reporting of selected HAIs to NHSN

Describe patient-level epidemiology of antimicrobial use in acute care hospitals to identify high-impact targets for stewardship Complements consumption data gathered electronically through

reporting to AUR Module

*Klevens M, et al. Public Health Reports 2007;122:160-6.

Now (2015): National Healthcare Safety Network

Approximately 13,000 healthcare facilities Expansion of HAI reporting beyond acute care hospitals:

Long term acute care, nursing homes, dialysis centers, inpatient rehab, ambulatory surgery centers

Expansion of reporting within acute care hospitals: Outside the ICU Most reporting still focused on device and procedure-associated HAIs All HAI definitions have been revised as of January 2015

Multiple infection types now part of CMS Hospital IQR: Central line-associated bloodstream infection (CLABSI)

All ICU and medical and surgical wards (adult and pediatric)

Catheter-associated urinary tract infections (CAUTI) Non-neonatal ICU and medical and surgical wards (adult and pediatric)

Surgical site infections (SSI), colon and hysterectomy procedures Hospital-onset MRSA bacteremia (facility wide) Hospital-onset Clostridium difficile infection (CDI) (facility wide)

Now (2015): Rationale for HAI and AU Prevalence Survey

Is there still a role for a periodic, large-scale prevalence survey in U.S. acute care hospitals?

What is the role?

U.S. HAI and AU Prevalence Surveys

Pilot HAI survey

• 1 city

• 9 hospitals

• 855 patients

Limited roll-out HAI and AU survey

• 10 states

• 22 hospitals

• 2015 patients

Full-scale HAI and AU survey

• 10 states

• 183 hospitals

• 11,282 patients

Full-scale HAI and AU survey

• 10 states

• ~180 hospitals

• ~11,300 patients

2009 2010 2011 2015

Emerging Infections Program Survey Participation, 2011

GA: 22 hospitals,

1395 patients TN: 25 hospitals,

1486 patients

MD: 21 hospitals,

1372 patients

MN: 24 hospitals,

1358 patients

NY: 23 hospitals,

1545 patients

CT: 13 hospitals, 945

patients

OR: 15 hospitals, 898

patients

CA: 8 hospitals, 514

patients

CO: 12 hospitals, 877

patients

NM: 20 hospitals, 892

patients

Key Prevalence Survey Results, 2011: HAIs

1 in 25 hospital inpatients (4%) had at least one HAI

Estimated national burden of 722,000 HAIs in 648,000 patients in 2011

~75,000 patients with HAIs died during their hospitalizations

Magill SS, et al. NEJM 2014;370:1198-208.

HAI Distribution, 2011

PNEU, 110 (22%)

VAP, 43 (39% of PNEU)

Other, 83 (16%)

UTI, 65 (13%)

CAUTI, 44 (68% of UTI)

GI, 86 (17%)

BSI, 50 (10%) CLABSI, 42

(84% of BSI)

SSI, 110 (22%)

PNEU

VAP

Other

UTI

CAUTI

GI

BSI

CLABSI

SSI

#1 (tie) #1 (tie)

#3 #4

#5

Proportion of HAIs Detected in the Survey that are Commonly Reported to NHSN, 2015

0%

20%

40%

60%

80%

100%

69%

31%

CLABSI and CAUTI (all locations), hospital-onset CDI, MRSA bacteremia, SSIs associated with common procedures

Based on prevalence survey data: what proportion of HAIs are routinely reported to NHSN for the CMS

Hospital IQR Program?

0%

20%

40%

60%

80%

100%

2011 2015

97%

71%

3%

29%

HAIs not included in CMS

reporting

HAIs included in CMS reporting

Where are HAIs occurring?

Critical care locations, 34%

Wards and other non-ICU

locations, 66%

HAI Take-Home Messages, 2011 Survey

Survey helped us describe the full spectrum of HAIs in hospitals— beyond those systematically tracked by NHSN.

Survey data show what new challenges are likely to require increased attention and prevention efforts moving forward (e.g., PNEU).

Bottom line: Progress is being made, but there is much more work to be done to prevent the wide spectrum of infections still common in hospitals.

Key Prevalence Survey Results, 2011: Antimicrobial Use

50% of patients were on antimicrobials at the time of the survey

Of patients getting antimicrobials, half were getting ≥2 drugs

Few differences in treatment given to patients inside and outside of ICUs, for community and healthcare infections

Magill SS, et al. JAMA 2014;312:1438-46.

Antimicrobial Drug Use Prevalence and Distribution

5635 patients on antimicrobial drugs (50%, 95% CI 49 to 51%)

1388, 14.1%

1213, 12.3%

1081, 11.0%

1037, 10.5%

0 200 400 600 800 1000 1200 1400

Fluoroquinolones

Glycopeptides

Penicillincombinations

Third generationcephalosporins

Number of Drugs (N=9865)

Antimicrobial Treatment

Vancomycin IV, ceftriaxone, piperacillin-tazobactam, levofloxacin,

45%

Everything else (79 other

drugs), 55%

Antimicrobial Use Take-Home Messages, 2011 Survey

Lots of antimicrobials are being used in acute care hospitals—and mostly broad spectrum drugs and drugs used to treat resistant pathogens Even in patients who are not in the intensive care unit and patients

who do not have HAIs

Survey data suggest high impact areas for national stewardship efforts Treatment for lower respiratory, urinary tract, and skin and soft tissue

infections, and use of 4 specific drugs (vancomycin, pip/tazo, ceftriaxone and levofloxacin)—covers about 50% of all antimicrobial use in hospitals.

How Prevalence Survey Data Have Been Used

Used to generate national burden estimates for CDC’s report on “Antimicrobial Resistance Threats in the United States” Puts the burden in context for the public and for policy makers

Prompted initiation of efforts to describe clinical events detected by pneumonia and lower respiratory infection definitions

Highlighted the potential for improving prescribing in U.S. hospitals (CDC “Vital Signs” report) Justified the need for policy changes outlined in the National Strategy

to expand antibiotic stewardship programs to all U.S. hospitals

Prompted additional work on approaches to describing quality of antimicrobial prescribing

Why repeat the survey in 2015?

Maintain awareness of all HAIs affecting hospital patients Only system right now providing “comprehensive” view of acute care

HAIs; complements NHSN

New targets, changes over time

Update national burden estimates Estimates can be used to validate estimates generated using other

systems (e.g., National Healthcare Safety Network, NHSN)

Might be able to provide inpatient AU burden estimate, too (in 2015)

Describe antimicrobial prescribing in hospitals at the patient level Only system right now that can provide patient-level use and

prescribing quality data from acute care setting

Emerging Infections Program Survey Anticipated Participation, 2015

GA: 22 hospitals?

TN: 25 hospitals?

MD: 21 hospitals?

MN: 24 hospitals?

NY: 23 hospitals?

CT: 13 hospitals?

OR: 20 hospitals?

CA: 20 hospitals?

CO: 20 hospitals?

NM: 20 hospitals?

Hospital and Patient Selection

Hospitals Sites will seek to engage same hospitals that participated in 2011

Site with <20 hospitals in 2011 will try to recruit additional hospitals through stratified random sampling scheme based on hospital bed size

Patients Random sample of acute care inpatients on morning of survey

Patients selected through use of random sort of acute care bed numbers done prior to survey

100 patients in large hospitals, 75 in small and medium hospitals (or all acute care inpatients if <75)

Hospital-Level Data Collection

NEW in 2015—Healthcare Facility Assessment Administered once to each participating hospital

During month prior to survey date

Hospital characteristics

Infection control resources, policies, practices

Stewardship resources, policies, practices

EIP team will also collect certain hospital characteristics using public data sources Urban vs. rural hospitals

Teaching vs. non-teaching

2015 Patient Data Collection: Antimicrobial Use

All patients

• Demographics, payer information

• Devices, body mass index

• On antimicrobials or not at time of survey

• Hospital admission and discharge dates and outcome

50% of patients

• Drug name and route

• First and last dates, total days of treatment (dose optional)

• Rationale for use

• Sites of infection and infection onset location

26% of patients

• Allergies and underlying conditions

• Infection syndromes, severity of illness

• Microbiology and laboratory data

NEW: Prescribing quality assessment

If on antimicrobials, then

If treatment with IV vancomycin, FQs, or for CAP or UTI, then

Antimicrobial Quality Assessment (AQUA) Forms

Case eligibility form (excludes infants, children for FQs, and patients with risk factors for healthcare-associated pneumonia)

Patient assessment (underlying conditions, etc.)

Event-specific forms (microbiology and other lab data, clinical signs and symptoms of UTI, pneumonia, etc.)

2015 Patient Data Collection: HAIs

All patients

• Demographics, payer information

• Devices, body mass index

• On antimicrobials or not at time of survey

• Hospital admission and discharge dates and outcome

50% of patients

• Drug name and route

• First and last dates, total days of treatment (dose optional)

• Rationale for use

• Sites of infection and infection onset location

36% of patients

• HAIs, 2011 and 2015 NHSN definitions

• Onset and treatment start dates

• Pathogens and susceptibility

NEW: Two sets of HAI definitions

If on antimicrobials, then

If patient got antimicrobials for treatment or no reason

HAI Form

HAI Form

Timeline for Data Collection and Management

Primary Team in each hospital

collects demographic,

device, and limited antimicrobial data

EIP Team reviews medical records to

collect antimicrobial drugs (ADs), rationale,

infection sites and onset locations; HAI

determinations, antimicrobial use

quality assessment; enters into web-based

data management system

1-day surveys (May-Sept 2015)

5-18 mos after surveys (Dec 2016)

1-12 mos after surveys (June 2016)

EIP Teams work with CDC to clean data,

begin analysis

Challenges

Hospital recruitment Ebola activities have stretched hospital and state health department

resources; EIP sites are concerned this may impact hospitals’ willingness to engage in the survey

Antimicrobial use data collection Quality assessment forms are complex and time-consuming to

complete; also these are the newest forms, and sites have the least experience with them

HAI data collection Taking into account use of both 2011 and 2015 definitions, sites will be

applying 68 different HAI definitions

… and Opportunities

Largest U.S. experience assessing prescribing quality

Opportunity to see what changes have occurred over time and refine burden estimation process

Experience will help inform decision making about whether to conduct surveys in other healthcare settings E.g., nursing homes—pilot survey in 9 nursing homes completed in

2014, discussions underway for possible scale-up in 2016-2017

Acknowledgments

Participating hospitals and personnel

EIP site teams

EIP Healthcare-Associated Infections/Community Interface Steering Group

Phase 1 prevalence survey participants

ECDC and EU prevalence survey colleagues

U.S. CDC colleagues

Many others …

The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348

E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for

Disease Control and Prevention.

Thank you!

smagill@cdc.gov

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion