Lab ID EventsMRSA 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 aureusisolates 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. aureusbacteremia.

• 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 methodMethod 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 DefinitionClostridium difficile

A positive laboratory test result for C. difficiletoxin 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

MethodNumerator Data

ReportingDenominator 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 locationsEnter each CDI LabIDEvent 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 Emergency Department of the admitting facility or other affiliated outpatient location, if collected same calendar day as patient admission.

CDI Data AnalysisCommunity Onset

Positve cultures obtained on day 1 (admission date), day 2, and day 3 of admission.

Hospital Onset

Positive cultures obtained on or after day 4

Community-Onset Healthcare Facility-Associated

Positive culture collected from a patient discharged from the facility < 4 weeks prior to current date of stool specimen collection.

Duplicate C. difficile test

Any C. difficile toxin-positive laboratory result from the same patient and location, following a previous C. difficile toxin-positive laboratory result within the past two weeks (14 days) (even across calendar months).

There should be 14 days with no C. difficile toxin-positive laboratory result for the patient and location, before another C. difficile LabID Event is entered into NHSN for the patient and location.

The date of specimen collection is considered Day 1.

CDI Standardized Infection Ratio (SIR)

The SIR is calculated by dividing the number of observed events by the number of predicted events.

The number of predicted events is calculated using LabID probabilities estimated from NHSN data during a baseline time period.

SIR=Observed (O) HAIs

Expected (E) HAIs

Calculated for FacWideIN surveillance only.

C. difficile rates

• C. difficile rates are typically computed at a rate per 10,000 patient days using this formula:

# of C. difficile infections x 10,000 = C. difficile

rate per 10,000 patient days

MRSA blood isolate / C. difficile specimen per patient and location

Yes

LabID Event

No Duplicate MRSA

Bloodstream isolate / C. difficile test

Not a LabIDEvent

Prior (+) MRSA from blood / C.

difficile in <2 weeks from

same patient and location

(including across

calendar months)

MRSA Bloodstream and C. difficile Test Result Algorithm for LabID Events

Case Study #1Mr. Smith had been in the hospital with pneumonia for 10 days. He was discharged on antibiotics. Twenty-four hours after discharge, he was seen in the emergency department complaining of watery diarrhea every 1-2 hours. His stool specimen from the ED was C difficile toxin positive. He was treated with IV fluids and Flagyl and sent home to follow up with his primary physician. He returns to the hospital one week later.

Admission C difficile tests are positive.

What is reported?

A: The re-admission CDI.

CMS reporting requirements include only inpatient LabID reporting. Positive C. difficile tests must be reported from inpatients and from ED patients if admitted to the hospital the same calendar day. The CDI positive lab obtained in the ED 24-hours after the first hospital discharge is not reported because the patient was not admitted. The CDI-positive lab obtained on readmission must be reported.

Case Study #1

Case Study #2A 70 year-old man with no significant past medical history admitted via the ED goes to the OR for a fractured hip from a fall. On post-op day 3, the orthopedic surgeon discharged him to home with a 10-day antibiotic prescription since he developed pneumonia after surgery. He had no fever or dyspneaat discharge. The patient returned to the ED after being home for a week complaining of weakness and diarrhea for over 24 hours. A stool specimen was collected at 10 pm in the ED and and then admitted to the medical/surgical floor at 12:15 AM for diarrhea and dehydration. The stool is positive for Clostridium difficile.

Q: Should this positive stool specimen be reported as a CDI LabID event?

Case Study #2

A: No.

The specimen date was prior to the date of admission and would not be included in CDI inpatient LabIDreporting.

If the patient would have been admitted at 11:59 pm the same day, then it would have been reported as CDI LabID event.

Case Study #3

On January 1st , Mr. Smith was readmitted to the Intensive Care Unit with redness, pain and purulent drainage at the peripheral IV catheter site. Blood cultures were drawn. Fluid cultures were obtained aseptically. January 2nd, one of the blood cultures was reported to have grown Staph aureus resistant to oxicillan.

Is this an MRSA bacteremia?

Case Study #3YES

It must be reported by your hospitals as a MRSA BSI LabId event. It would be attributed to the Intensive Care Unit.

For the blood culture positive for MRSA, a LabID event must be reported whether it’s a primary or secondary BSI are reported if the pathogen is MRSA.

LabID Event calculator

QUESTIONS?

References

NHSN MDRO/CDI Module Protocol and supporting documents

Health.gov

CDC vital signs