Lab ID Events MRSA Bloodstream Infection and C. Clostridium difficile C. difficile infections continue

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  • Lab ID Events MRSA Bloodstream Infection

    and C. difficile

  • MDRO and CDI Module • Methicillin-resistant Staphylococcus (MRSA), Vancomycin-

    resistant Enterococcus(VRE), certain gram negative bacilli, Clostridium difficile have increased in prevalence in U.S. hospitals over the last three decades

    • Limited treatment options become concern

    • Increased length of stay

    • HICPAC has approved guidelines for the control of MDROs.

    • The MDRO and CDI modules of the NHSN can provide a tool to assist facilities in meeting some of the criteria outlined in the guidelines.

    • This presentation will focus on MRSA Bacteremia and C difficile reporting.

  • LabID Core Reporting • Option 1: Laboratory-Identified (LabID) Event Reporting

    1A: MDRO LabID Event Reporting (MRSA Bloodstream Infection)

    1B: Clostridium difficile (C. difficile) LabID Event Reporting

    • Option 2: Infection Surveillance Reporting

    2A: MDRO Infection Surveillance Reporting

    2B: C. difficile Infection Surveillance Reporting

    All reporting depends on your facility objectives and required reporting by state and regulatory agencies.

    NOTE: LabID Event reporting and Infection Surveillance reporting are two separate and independent reporting options. See Appendix 3: Differentiating Between LabID Event and Infection Surveillance for key differences between the two

    options.

  • LabID Reporting

    • Uses lab data without clinical evaluation of patient

    • Less labor-intensive

    • Provide proxy measures for MDRO and C difficile

    • Collecting and tracking positive lab results collected for clinical purposes

    • Active Surveillance Cultures not included

    • Two reporting options

  • Background MRSA Bacteremia

    • 30% of the population has MRSA colonized in their nose or on their skin.

    • Of the 609 infection related, Staphylococcus aureus isolates reported through TxHSN in 2012, 55% tested sensitive to oxacillin/methicillin.

    • The incidence of S. aureus bacteremia and its complications has increased sharply in recent years.

    • Urgent need for improved strategies and better antibiotics to prevent and treat S. aureus bacteremia.

    • Increased hospital stay and the treatment costs associated with MRSA bacteremia.

  • Background

    • Increased frequency of invasive procedures

    • Increased numbers of immunocompromised patients

    • Increased resistance of S. aureus strains to available antibiotics

  • Health.gov • Reduce the incidence of invasive health

    care-associated MRSA infections.

    • Baseline 27.08 infections per 100,000 persons(2007-2008)

    • 2012 Progress 31% overall reduction or 18.6 infections per 100,000 persons

    • 2013 Target 50% reduction or 13.5 infections per 100,000 persons

    • Proposed 2020 Target: 75% reduction from 2007-2008 baseline.

  • MRSA NHSN Defintion

    Includes S. aureus cultured from any specimen that tests oxacillin-resistant, cefoxitin-resistant, or methicillin- resistant by standard susceptibility testing methods, or by a laboratory test that is FDA-approved for MRSA detection from isolated colonies; these methods may also include a positive result by any FDA-approved test for MRSA detection from specific sources.

  • NHSN: MRSA Positive Blood Isolate

    Any blood specimen obtained for clinical decision making for MRSA

    Excludes tests related to active surveillance testing.

  • MRSA Bacteremia LabID Event

    MRSA positive blood specimen for a patient in a location with no prior MRSA positive blood specimen result collected within 14 days for the patient and location.

    Duplicate MRSA Bacteremia LabID Event

    Any MRSA blood isolate from the same patient and same location, following a previous positive MRSA blood laboratory result within the past 14 days.

  • Choose at least 1 reporting method Method Numerator Data Reporting Denominator Data Reporting

    Facility-wide by location (All Specimens)

    Enter each MDRO LabID Event from all locations seperately

    Report separate denominators for each location in the facility as specified in the NHSN Monthly Reporting Plan

    Selected locations (All Specimens)

    Ener each MDRO LabID Event from all inpatient locations seperately

    Report separate denominators for each location monitored as specified in the NHSN Monthly Reporting Plan

    Overall Facility-wide Inpatient (FacWideIN), All Specimens

    Enter each MDRO LabID Event from all inpatient locations seperately

    Report only one denominator for the entire facility (admissions, patient days)

    Overall Facility -wide Outpatient (FacWideOUT)

    Enter each MDRO LabID Event from all outpatient locations seperately

    Report only one denominator for all outpatient locations (total number of encounters)

    Overall Facility-wide Inpatient, Blood Specimens Only

    Enter each MDRO LabID Blood Specimen Event from all inpatient locations seperately

    Report only one denominator for the entire facility (admissions, patient days)

    Overall Facility-wide Outpatient, Blood Specimens Only

    Enter each MDRO LabID Blood Specimen Event from all outpatient locations seperately

    Report only one denominator for all outpatient locations (total number of encounters)

  • Clostridium difficile

     C. difficile infections continue to rise

     C. difficile infections linked to about 14,000 deaths each year.

     CDC Vital Signs

    • Emerging Infections Program 2010

    • 94% CDI were health care associated

    • 75% had onset not currently hospitalized

    • 52% POA but largely health-care related.

     Antibiotic use and healthcare exposure greatest risk factors.

  • C. difficile risk factors.

    • Antimicrobial exposure

    • Acquisition of C. difficile 1st

    two main modifiable.

    • Advanced age

    • Underlying illness

    • Immunosuppression

    • Tube feeds

    • Gastric acid suppression

  • Infection Control Strategies • Hand hygiene

    • Contact precautions

    • Identify cases within hospital (appropriate hand hygiene and room disinfection)

    • Environmental disinfection

    • Appropriate use of antibiotics

    • Laboratory-based alert system for immediate notification of positive test results

    • Educate about CDI: HCP, housekeeping, administration, patients, families

    Attention to surface cleaning and use of contact precautions when treating those known to be infected can reduce spread by 20%

  • Supplemental Infection Control Strategies

    • Extend use of Contact Precautions beyond duration of diarrhea (e.g., 48 hours)*

    • Presumptive isolation for symptomatic patients pending confirmation of CDI

    • Evaluate and optimize testing for CDI

    • Implement soap and water for hand hygiene before exiting room of a patient with CDI

    • Implement universal glove use on units with high CDI rates*

    • Use sodium hypochlorite (bleach) – containing agents for environmental cleaning

    • Implement an antimicrobial stewardship program

  • Health.gov

    • Reduce facility-onset Clostridium difficile infections in facility-wide health care

    • Baseline: 1.0 SIR (2010-2011)

    • 2012 Progress: 2% reduction or 0.98 SIR

    • 2013 Target: 30% reduction or 0.70 SIR

    • Proposed 2020 Target: 30% reduction from 2015 baseline.

  • NHSN Definition Clostridium difficile

    A positive laboratory test result for C. difficile toxin A and/or B, (includes molecular assays (PCR) and/or toxin assays)

    OR

    A toxin producing C. difficile organism detected by culture or other laboratory means performed on a stool sample.

  • Choose one or more reporting choices

    Method Numerator Data

    Reporting Denominator Data

    Reporting

    Facility-wide by location

    Enter each CDI LabID Event from all locations seperately

    Report separate denominators for each location in the facility

    Selected locations Enter each CDI LabID Event from selected locations seperately.

    Report separate denominators for each location monitored as specified in the NHSN Monthly Reporting Plan

    Overall Facility-wide Inpatient (FacWideIN)

    Enter each CDI LabID Event from all inpatient locations seperately

    Report only one denominator for the entire facility (e.g., total number admissions and total number of patient days)

    Overall Facility-wide Outpatient (FacWideOUT)

    Enter each CDI LabID Event from all outpatient locations seperately

    Report only one denominator for all outpatient locations (e.g., total number of encounters)

  • C. difficile Surveillance NOT performed in

    • NICU

    • Specialty Care Nurseries

    • Babies in LDRP

    • Well baby nurseries

  • C. Difficile Laboratory- Identified (LabID) Event

    All non-duplicate C. difficile toxin-positive laboratory results. Can include specimens collected in the Emerg