Infection Control of Emerging Diseases...Infection Control of Emerging Diseases . 2016 EPS Training Event . VETERANS HEALTH ADMINISTRATION Outline 2 • Review the VHA methicillin-resistant

2016 EPS Training Event Martin E. Evans, MD Director, VHA MDRO Program National Infectious Diseases Service Lexington, KY & Cincinnati, OH

Infection Control of Emerging Diseases

2016 EPS Training Event

VETERANS HEALTH ADMINISTRATION

Outline

2

• Review the VHA methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative and successes in acute care, spinal cord injury, and the CLCs

• Review Clostridium difficile and the VHA C. difficile infection (CDI) Prevention Initiative and initial VA data

• Review the carbapenem-resistant Enterobacteriaceae (CRE) Prevention Initiative


Dr. Rajiv Jain Dr. Gary Roselle

3


Pittsburgh Demonstration Project, 2001

• VA Pittsburgh Healthcare System, Pittsburgh Regional Health Initiative, CDC

• Eliminate MRSA healthcare-associated infections (HAIs)

• Using a “Bundle” based on Society for Healthcare Epidemiology of America (SHEA) guidelines.


VA MRSA “Bundle” 1) Active surveillance for all admissions, in-

hospital unit-to-unit transfers, and discharges 2) Contact Precautions for all patients/residents

colonized or infected with MRSA 3) Hand hygiene 4) Culture change where Infection Control

becomes everyone’s responsibility


January 2007

• Success at Pittsburgh VA 2002-2006 • Importance of preventing MRSA HAIs for all

Veterans • Department of Veterans Affairs, issued VHA

Directive 2007-002, “Methicillin-resistant Staphylococcus aureus (MRSA) Initiative”

• Implemented a nationwide program to reduce MRSA HAIs in all acute care VA hospitals


153 Acute Care Medical Centers


MRSA Prevention Coordinator (MPC) • Dedicated person at each facility who:

– Oversees implementation of the Initiative at their facility

– Collects and reports data on their program – Provides feedback to front-line healthcare workers – Deals with local challenges


MRSA Data Reporting

• Beginning October, 2007 each facility submitted data monthly to the VA Inpatient Evaluation Center (IPEC) in Cincinnati.

• Aggregate data reported by unit or facility (no patient-specific information)


Definitions

• Healthcare-associated infection (HAI) – MRSA infection occurring >48 hours after admission – Follows CDC/NHSN definitions with minor

adaptations • Transmission (Tx)

– Patients have nasal swabs done on admission, unit-to-unit transfer, and discharge (active surveillance)

– Converting from MRSA negative to MRSA positive is considered a transmission


April 14, 2011

13 Data from Oct 07 – Jun 10

VETERANS HEALTH ADMINISTRATION 15 Data from Oct 07 – Jun 11


17 Data from Jul 09 – Dec12


Conclusion

• A program of universal surveillance, contact precautions, hand hygiene, and culture change was associated with a decrease in MRSA transmissions and HAIs in acute care, spinal cord injury, and long-term care settings in a large healthcare system.


Outline

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Clostridium difficile


Infections and Deaths United States, 2005

# Infections # Deaths Streptococcus pneumoniae 41,839 ~5,000

MRSA 94,360 18,650

HIV / AIDS 56,300 17,011

C. difficile >250,000 15,000-30,000 Active Bacterial Core Surveillance www.cdc.gov/abcs *www.cdc.gov/hiv/topics/surveillance/basic.htm#def

http://www.cdc.gov/abcs


CDI Rates Among Hospitalized Patients Aged ≥65, 1996-2009

MMWR 2011;60:1171


Burden of CDI

• Recurrence rate quite high – ~20% risk of recurrence after the initial episode of

CDI – ~40% risk of a second relapse – ≥60% risk of a third relapse

• Approximately 15,000 to 30,000 deaths in the United States each year attributable to CDI

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Risk Factors for CDI

• Antimicrobial exposure • Acquisition of C. difficile • Advanced age • Underlying illness • Immunosuppression • Tube feeds • ? Gastric acid suppression

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Patient Skin (A) and Examiner’s Glove (B) Contamination with C. difficile

Bobulsky, GS. Clin Infect Dis 2008:46;447

Skin Contamination

Glove Contamination


Glove Contamination After Touching a Patient with CDI

Bobulsky, GS. Clin Infect Dis 2008:46;447


Environmental Contamination with C. difficile

Riggs, MM. Clin Infect Dis 2007:45;992


Prevention Strategies: Core

• Contact Precautions for duration of diarrhea • Hand hygiene in compliance with CDC/WHO

– Soap and water for hand hygiene before exiting room of a patient with CDI

• Cleaning and disinfection of equipment and environment

• Educate HCWs, housekeeping, administration, patients, & families about CDI

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Rationale for extending isolation beyond duration of diarrhea

Bobulsky et al. Clin Infect Dis 2008;46:447-50.


VHA CDI Bundle

• Environmental Management • Hand Hygiene • Contact Precautions • Cultural Transformation


Outline

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What are Enterobacteriaceae? E. coli, Enterobacter (cloacae, aerogenes, agglomerans), Serratia marscescens, Citrobacter freundii, Klebsiella (pneumoniae, oxytoca)

Sometimes cause community acquired (UTI, pneumonia)

Often cause HAIs (central line bloodstream infection, catheter-associated urinary tract infection, ventilator-associated pneumonia, hospital acquired pneumonia, etc.)

Susceptibility Profile of Carbapenemase-Producing K. pneumoniae Antimicrobial Interpretation Antimicrobial Interpretation Amikacin I Chloramphenicol R Amox/clav R Ciprofloxacin R Ampicillin R Ertapenem R Aztreonam R Gentamicin R Cefazolin R Imipenem R Cefpodoxime R Meropenem R Cefotaxime R Pipercillin/Tazo R Cetotetan R Tobramycin R Cefoxitin R Trimeth/Sulfa R Ceftazidime R Polymyxin B MIC >4µg/ml Ceftriaxone R Colistin MIC >4µg/ml Cefepime R Tigecycline S

Mortality

0

10

20

30

40

50

60

Overall Mortality AttributableMortality

Per

cent

of s

ubje

cts CRKP

CSKPp<0.001

p<0.001

20 48 12 38

OR 3.71 (1.97-7.01) OR 4.5 (2.16-9.35)

First clinical use

of penicillin

1942

1949 Osteomyelitis

due to penicillinase producing S.

aureus

Adapted from Rice, LB. Mayo Clin Proc 2012:87;198-208

First clinical use of

ampicillin 1962

1966 Appearance

of TEM β-lactamase

First clinical use of

cefotaxime 1979

1985 First ESBL (SHV-2)

First Imipenem

use 1985

1990 CTX-M described

1993 First carbapenemase

IDSA. CID 2011:52 (Suppl 5);S397-428

New Molecular Entity Systemic Antibiotics Approved in the US

0 4 8 12 16

2008-20122003-20071998-20021993-19971988-19921983-1987

Clinical Infectious Diseases 2009:48;1-12


Consequences of Resistance • Longer hospital stays and more expense • Higher morbidity and mortality when resistance is

initially unrecognized • Inability to treat sick patients as we run out of

efficacious antimicrobials – Aggressive cancer chemotherapy – Hematopoietic stem-cell transplantation – Solid organ transplantation – Other aggressive immunosuppressive therapy – Prosthetic joint placement – Routine clean/clean contaminated surgery

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CRE Vital Signs: Key Points CRE are increasing

1% to 4% overall Over 10% of Klebsiella are

CRE

Most hospitals do not see CRE regularly 4% of hospitals 18% of LTACHs

Most CRE are still healthcare-associated

Patel, Rasheed, Kitchel. 2009. Clin Micro News MMWR MMWR Morb Mortal Wkly Rep. 2010 Jun 25;59(24):750. MMWR Morb Mortal Wkly Rep. 2010 Sep 24;59(37):1212. CDC, unpublished data

DC

PR AK

HI

Carbapenemase-Resistant Enterobacteriaceae 2013

KPC

KPC, NDM

KPC, NDM, VIM, IMP, OXA

KPC, NDM, VIM, OXA

KPC, NDM, OXA


CRE Summary

• Unrivalled broad-spectrum resistance profile • Susceptible to very few antibiotics • Clinical data for treatment regimens is very

limited • Control involves:

– Antimicrobial stewardship – Infection control – Good environmental management

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Infection Prevention &

Control

Antimicrobial Stewardship

Optimal Laboratory

Use

Preventing CRE/CPE


Outline

46

• Review the VHA MRSA Prevention Initiative and successes in acute care, spinal cord injury, and the CLCs

• Review Clostridium difficile and the VHA CDI Prevention Initiative



For more information, please visit the MDRO Website at vaww.mrsa.va.gov/

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Questions/Feedback/Input

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Infection Control of Emerging Diseases...Infection Control of Emerging Diseases . 2016 EPS Training Event . VETERANS HEALTH ADMINISTRATION Outline 2 • Review the VHA methicillin-resistant