can we beat the bug? infection control: a primer for ... · (& antimicrobial stewardship) a...
TRANSCRIPT
1/31/2017
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Can We Beat the Bug? Infection Control
(& Antimicrobial Stewardship) A Primer
Sorabh Dhar MD
Associate Professor of Medicine WSU
Corporate Medical Director of Antimicrobial Stewardship DMC, JDDVAMC
Medical Director of Infection Prevention and Hospital Epidemiology JDDVAMC
No Financial Disclosures
Objectives
• Describe Infection Control Programs (their development, structure, scope, and goals)
• Discuss Infection Control Practices and their importance in decreasing the spread of antimicrobial resistance pathogens/infections
• Review the current regulatory and reporting requirements for Infection Control ( & their effect on Antimicrobial Stewardship)
• Understand the role of pharmacists and nursing in Infection Control (How pharmacy and infection control interface/collaborate)
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Infection Prevention Protection from the Plague Doktor Schnabel von Rome
Nohl (note 3). Pp 94-95
Townsend, G. L. (1965). "THE PLAGUE DOCTOR; AN ENGRAVING BY GERHART ALTZENBACH (17TH CENTURY).
NEW HAVEN, YALE MEDICAL LIBRARY, CLEMENTS C. FRY COLLECTION." J Hist Med Allied Sci 20: 276.
Antibiotics - Boon for Infection Treatment
“ But I would like to sound one note of warning… it is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body.
The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.”
Sir Alexander Fleming 1945
Or Bane for Infection Treatment ?
Antibiotic Resistance Threats in the US, 2013 http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf
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Antibiotic Resistance Threats in the US, 2013 http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf
PDR
Infections, Antibiotics, and Resistance
• Healthcare Associated Infections (HAIs) • 2-10% of hospitalized patients
• Approximately 2 million patients acquire HAI each year in the US • 99,000 deaths annually in US
• ~ 5 billion dollars/year in attributable cost
• Regulatory – Medicare reimbursements
• Media – Public reporting of hospital infections
• Up to 50% of all antibiotics in the US are unnecessary or inappropriate
• Multidrug Resistant Organisms • Increased Mortality, LOS, Admissions to ICU, surgical procedures
• 50% of persons in LTCF are colonized • 26% > 1 MDRO
Increases in Outbreaks of Multidrug Resistant Organisms (MDROs)
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Infection Prevention & Hospital Epidemiology
• Multifaceted program to prevent the spread of infection & improve hospital safety and quality.
• Study of distributions and determinants of health related states or events (disease)
Education
Process & Policy
Surveillance
Feedback
Safety Quality
History of National HAI Surveillance Initiatives
Yokoe DS and Classen D. Improving patient safety through infection control: a new healthcare imperative. Infect Control Hosp Epidemiol 2008;29 Suppl 1:S3-11.
The Game Changer
• Institute of Medicine report on medical errors and patient safety (1999)
• 44,000-98,000 deaths per year due to preventable medical errors.
• Errors are often caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.
Institute of Medicine. To Err is Human. 1999
Call to Action for Change
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A complex web of stakeholders influence hospital infection control programs.
Weinstein R A et al. Clin Infect Dis. 2008;46:1746-1750 © 2008 by the Infectious Diseases Society of America
The Landscape of Infection Prevention
How it All Fits Together
Value of Infection Prevention Program: Study on the Efficacy of Nosocomial Infection Control (SENIC)
• Establishment of an “effective” infection control program was associated with a 32% reduction in infection rates.
• Very few hospitals had established such programs.
• Only 6% of infections were being prevented.
• Noted that prevention of approximately 6 % of HAIs offset the cost of a program in a 250-bed hospital
Haley RW. Am J Epidemiol 1985:121:182-205 Harbarth S. J Hosp Infect. 2013;83:173-84.
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The Cost of Infections & Savings from Infection Prevention
Costs
Savings
• CLABSI: $5,734 - $22,939
• VAP: $11,897 - $25,072
• CAUTI: $589 - $758
• SSI: $10,443 - $24,546
• CDI: $5,042 - $7,179
catheterout.org
Making a Business Case for Infection Prevention Cost & Savings of Contact Precautions
Hospitalizations Costs
• Antibiotics
• Excess Length of Stay
• ICU Stay
• Patient Costs & Outcomes
• Mortality
• Morbidity
• Infections
Intervention Costs
- Test Costs
- Gown and Glove Cost
- Nurse and Physician Time
- Isolation Room
Perencevich EN, et al. Infect Control Hosp Epidemiol 2007;28: 1121-33
Puzniak LA, et al. Infect Control Hosp Epidemiol 2004;25:418-24.
$493,341
$73,995
= $419, 349
Goals of Infection Prevention Program
• Lower Infection Rates
• Decreased Mortality & Morbidity
• Improved Education
Protect the patient
• Isolation Practices
• Exposure Investigations
• Immunizations & BBFE Reductions
Protect the healthcare worker, visitors, and others
in the healthcare environment
• Costs of Prevention vs. Financial Cost of the Infection
• Monetary & Non-monetary costs
Accomplish the previous two goals in a cost-
effective manner
Scheckler et al.. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals:
a consensus panel report. Society for Healthcare Epidemiology of America. ICHE 1998;19:114-24.
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Infection Prevention Committee
Infe
ctio
n P
reve
nti
on
Co
re
• Infection Prevention Chair – Hospital Epidemiologist
• Infection Control Preventionists
• Quality Personnel
• Program Support
• Data Analyst
Clin
ical
Sta
ff
• Pharmacy
• Physicians
• Nursing • Employee Health
• Operating Room Personnel
• Critical Care & ED
• Trainees
• PICC Team N
on
-Clin
ical
• Hospital Administration
• Environmental Services/House Keeping
• Microbiology Laboratory
• Central Supply and Sterilization
• Emergency Preparedness
• Union • Kitchen/Dietary
• Others
Pathogenesis of Hospital Acquired Infections (HAI)
• Usually bacterial infection
• Colonization usually precedes infection • Both colonized and infected patients are
contagious
• Bugs are spread from patient to patient by healthcare workers
• Hands, equipment (eg stethoscope)
• Transient colonization most common
• Role of environment
Pathogenesis of HAI
• Major risks: • Indwelling devices
• Debilitated state
• More frequent contact with Healthcare Workers
• Prevention: • Hand hygiene
• Isolation precautions
• Cohorting
• Example • Methicillin-resistant Staphylococcus aureus (MRSA), ESBL,
CRE.
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Colonized or Infected: What is the Difference?
• People who carry bacteria without evidence of infection (fever, increased white blood cell count) are colonized
• If an infection develops, it is usually from bacteria that colonize patients
• Bacteria that colonize patients can be transmitted from one patient to another by the hands of healthcare workers
~ Bacteria can be transmitted even if the patient is not infected ~
The Iceberg Effect
Infected
Colonized
Uncovering Colonization
Infected
Colonized
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Epidemiologically Important Pathogens
Infectious agents that have one or more of the following characteristics:
1. A propensity for transmission within healthcare facilities based on published reports and the occurrence of temporal or geographic clusters of > 2 patients
2. Antimicrobial resistance implications
3. Associated with serious clinical disease, increased morbidity and mortality
4. A newly discovered or reemerging pathogen
Siegel, J. D., E. Rhinehart, M. Jackson, L. Chiarello and C. Healthcare Infection Control Practices
Advisory (2007). "Management of multidrug-resistant organisms in health care settings, 2006." Am J
Infect Control 35(10 Suppl 2): S165-193.
MRSA
The Inanimate Environment Can
Facilitate Transmission
~ Contaminated surfaces increase cross-transmission ~
Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.
X represents VRE culture positive sites
Role of the Environment in Transmission
Otter, J. A., S. Yezli, J. A. Salkeld and G. L. French (2013). "Evidence that contaminated surfaces contribute to the transmission of hospital
pathogens and an overview of strategies to address contaminated surfaces in hospital settings." Am J Infect Control 41(5 Suppl): S6-11.
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Evidence for Environmental Transmission to Patients
Otter, J. A., S. Yezli, J. A. Salkeld and G. L. French (2013). "Evidence that contaminated surfaces contribute to the
transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital
settings." Am J Infect Control 41(5 Suppl): S6-11.
Putting it all Together
Prevention of Infections Pearls
• Hand hygiene for all patients: before and after patient contact • Soap and water vs waterless (alcohol based) hand rub
• Standard Precautions (Universal Precautions), contact precautions, airborne precautions
• Gloves, gowns, masks, eye protection when contaminated fluid/blood exposure is anticipated
• Transmission Based Precautions • Droplet, contact, Airborne Precautions
• Limit duration of indwelling devices • Limit antibiotic exposures • Facilitate Discharge • Immunizations
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So Why All the Fuss About Hand Hygiene?
• Most common mode of transmission of microbes is via hands !
• Spread of Antimicrobial Resistance !!
Ignaz Semmelweis, 1815-1865
• 1840’s: General Hospital of Vienna
• Divided into two clinics, alternating admissions every 24 hours:
• First Clinic: Doctors and medical students
• Second Clinic: Midwives 0
2
4
6
8
10
12
14
16
Ma
tern
al m
ort
alit
y, 1
84
2
First Clinic SecondClinic
The Intervention:
Hand scrub with chlorinated lime solution
Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847.
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Hand Hygiene: Not a New Concept
Maternal Mortality due to Postpartum Infection General Hospital, Vienna, Austria,
0
2
4
6
8
10
12
14
16
18
1841 1842 1843 1844 1845 1946 1847 1848 1849 1850
Ma
tern
al M
ort
alit
y (%
)
MDs Midwives
Semmelweis’ Hand Hygiene Intervention
~ Hand antisepsis reduces the frequency of patient infections ~
Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.
Better hand hygiene reduces nosocomial infection rates
Pittet D. Lancet 2000; 356:1307-12
Hand Hygiene Adherence in Hospitals
1. Gould D, J Hosp Infect 1994;28:15-30. 2. Larson E, J Hosp Infect 1995;30:88-106. 3. Slaughter S, Ann Intern Med 1996;3:360-365. 4. Watanakunakorn C, Infect Control Hosp Epidemiol 1998;19:858-860. 5. Pittet D, Lancet 2000:356;1307-1312.
Year of Study Adherence Rate Hospital Area
1994 (1) 29% General and ICU
1995 (2) 41% General
1996 (3) 41% ICU
1998 (4) 30% General
2000 (5) 48% General
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Self-Reported Factors for Poor Adherence with Hand Hygiene
Handwashing agents cause irritation and dryness
Sinks are inconveniently located/lack of sinks
Lack of soap and paper towels
Too busy/insufficient time
Understaffing/overcrowding
Patient needs take priority
Low risk of acquiring infection from patients
Adapted from Pittet D, Infect Control Hosp Epidemiol 2000;21:381-386.
The Problem
• Up to 50% of all antibiotics in the US are unnecessary or inappropriate
• Antibiotic Related Adverse Consequences
Dellit TH, et al. Clin Infect Dis . 2007;44:159-77.
Adverse Drug Events and Toxicity
C. difficile Infection
Antibiotic Resistant
Pathogens
Excess Mortality and Costs
Inappropriate Antibiotic Use
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The Solution • 2006 CDC guideline “Management of Multi-Drug Resistant Organisms in
Healthcare Settings” • Control of multi-drug resistant organisms in healthcare “must include attention to
judicious antimicrobial use”
• 2009 CDC launched the “Get Smart for Healthcare Campaign” • Promote improved use of antibiotics in acute care hospitals
• CDC’s Top Ten: 5 Health Achievements in 2013 and 5 Health Threats in 2014 • Improving the use of antibiotics is an important patient safety and public health issue
as well as a national priority
• 2014 CDC recommended that all acute care hospitals implement Antibiotic Stewardship Programs
Antimicrobial Stewardship
• Appropriate use of antimicrobials
• The right agent, dose, timing, duration, route
• Optimize clinical outcomes
• Optimize time to effective therapy
• Limit drug-related adverse events
• Minimize risk of unintentional consequences
• Help reduce antimicrobial resistance
• The combination of effective antimicrobial stewardship and infection control has been shown to
limit the emergence of antimicrobial-resistant bacteria
Dellit TH et al. Clin Infect Dis. 2007;44(2):159–177; . Drew RH. J Manag Care Pharm. 2009;15(2 Suppl):S18–S23; Drew RH et al. Pharmacotherapy. 2009;29(5):593–607; Barlam
et al, Clin Infect Dis, 2016, epub
Key Members of the Stewardship Team
Exp
erts
an
d H
osp
ital
Le
ader
ship
• Infectious Diseases Physician(s) (compensated)
• ID Pharmacist (compensated)
• Microbiology
• Administration (support, agree with metrics and goals)
• Informatics support
Key
Stak
e H
old
ers
• Critical Care
• Emergency Medicine
• Infection Prevention/Control
• Nursing
• Clinical pharmacy
• Hospitalists
• P and T
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ASP Multidisciplinary Team Roles
Clin Infect Dis. 2016 Jan 1;62(1):84-9
Antimicrobial Stewardship Reporting and Structure
• Antimicrobial stewardship committees usually report/serve as a subcommittee to Pharmacy and Therapeutics
• Key members include Infectious Diseases physician, Infectious Diseases pharmacist
• Often support and collaborate with Infection Control
• Communication and collaboration with ID, pharmacy, P and T and clinicians critical for success
Core Elements of Stewardship
• Accountability
• Drug expertise
–Appointing a single pharmacist leader
• Action
–Implementing one or more of the following
• Antibiotic time-out
• Prospective audit
• Restriction
• Tracking
• Reporting
• Education
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National Action Plan to Combat Antibiotic-Resistant Bacteria (CARB)
• Published March, 2015 by President Obama
• Goals include:
• To make antimicrobial stewardship a condition of participation from CMS in line
with CDC Core Elements of Hospital Antibiotic Stewardship Programs
• Establishment of antibiotic stewardship programs in all acute care hospitals and
improved antibiotic stewardship across all healthcare settings by 2020.
• Reduction of inappropriate antibiotic use by 50% in outpatient settings and by
20% in inpatient settings by 2020.
https://www.whitehouse.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-national- action-plan-combat-ant
Joint Commission and Antimicrobial Resistance
• Surgical Care Improvement Project Core Measure Set
• Increasing focus and interest related to antimicrobial resistance
• Expect more (and more) regulation in the near future https://www.jointcommission.org/assets/1/6/2016_NPSG_HAP.pdf
Note: CLABSI, CAUTI and SSI are other NPSGs
https://www.jointcommission.org/assets/1/6/HAP-CAH_Antimicrobial_Prepub.pdf
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Stewardship Standard Elements of Performance
1. Leaders establish Stewardship as a priority
2. Education of staff involved in antimicrobial ordering, dispensing, administration, and monitoring [on Resistance & Stewardship Practices]
3. Education of patients and families regarding antimicrobial use
4. Multi-disciplinary antimicrobial stewardship team
5. Follow the CDC’s core elements
6. Program uses multi-disciplinary protocols for interventions
7. Collects, analyze, and report data on the program
8. Take action on improvement opportunities identified
• Proposing revision to §482.42 …. that would require a hospital to develop and maintain an antibiotics stewardship program as an effective means to improve hospital antibiotics – prescribing practices and curb patient risk for possibly deadly CDI as well as other future & potentially life – threatening antibiotic resistant infections
• Proposing a new requirement that hospitals demonstrate adherence to nationally recognized infection prevention & control guidelines, as well as best practice for improving antibiotic use … for reducing the development and transmission of HAIs and antibiotic- resistant organisms
https://www.federalregister.gov/articles/2016/06/16/2016-13925/medicare-and-
medicaid-programs-hospital-and-critical-access-hospital-changes-to-promote-innovation
Infection Control – Antimicrobial Stewardship Collaboration Opportunities
Device-related infections Abx resistance/C. diff
Operative care Bloodborne fluid exposures
Influenza/emerging infections
Regulatory/accreditation QI/Patient Safety
Ambulatory care Communicable diseases
Tuberculosis Environment
HAC/CMS
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Several Outcome Measures Used in Both VBP and HAC Payment Programs
Measure Date Reporting
Began
VBP Program
(1st fiscal year)
HAC Reduction
Program
(1st fiscal year)
CLABSI 2011 Q1 2015 2015
CAUTI 2012 Q1 2015 2015
SSI 2012 Q1 2016 2016
MRSA 2013 Q1 2017
2017
C.diff 2013 Q1 2017
AHRQ
Composite (“PSI
90”)
(CMS calculates) 2015 2015
Performance Periods 2015 VBP = CY 2013 2016 VBP = CY 2014 2017 VBP = CY 2015 2018 VBP = CY 2016
Opportunities from CMS LabID Events
• MRSA • Preventions
• Antimicrobial interventions (eg eliminating unnecessary fluoroquinolone use)
• Pre-operative screening, decolonization, antimicrobial prophylaxis
• Rapid Diagnostics
• Treatment • Guidelines & Pathways
• C. difficile infection • Diagnostics
• Avoiding antimicrobial overuse
• Treatment Pathways
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Other CMS-Related Collaborative Opportunities • Pneumonia core measures
• Blood cultures
• Appropriate antimicrobials
• Readmissions (Pneumonia)
• SCIP – antimicrobial prophylaxis
• Central-line associated bloodstream infection
• Appropriate culturing – avoiding cultures drawn through the catheter, avoiding unnecessary blood cultures
• Catheter-associated urinary tract infection
• Avoiding unnecessary cultures of urine
• Avoiding unnecessary treatment of asymptomatic bacteruria
• Vaccination of patients and healthcare providers
Opportunities in Decreasing Antimicrobial Resistance
• Minimizing unnecessary antimicrobial use can prevent the emergence and spread of multi-drug resistant (MDR) Gram-negative bacilli
• ESBL-producers
• Carbapenem-resistant enterobacteriaceae
• MDR Pseudomonas aeruginosa
• MDR Acinetobacter baumannii
• Methods • Treatment guidelines and protocols
• De-escalation
• Short durations of therapy
Dellit TH et al. Clin Infect Dis. 2007;44:159-177; Paterson DL et al. Clin Infect Dis. 2008;47(suppl 1):S14-20; Craven DE et al. Shorter course antibiotic
therapy. In: Owens and Lautenbach, eds. Antimicrobial Resistance. Informa Healthcare, NY; 2008; File T. Clin Infect Dis. 2004;39(Suppl 3):S159-164;. Marchaim,
Infect Control Hosp Epidemiol. 2012;33(8):817-30
Effect of Stewardship in Reducing Resistance
Yearly percentage of ciprofloxacin-susceptibility among ESBL-producing bacteria (right y-axis) vs. average yearly use of ciprofloxacin (DDDs/1000 bed days, left y-axis). Ciprofloxacin use ( );Ciprofloxacin-susceptibility (%) (__)
Time Series Analysis following Fluoroquinolone restriction in January 2008 (P <0.001).
Aldeyab MA, Harbarth S, Vernaz N, et al. The impact of antibiotic use on the incidence and resistance pattern of extended-spectrum beta-lactamase-producing bacteria in primary and secondary healthcare settings. British journal of clinical pharmacology. 2012;74(1):171-179.
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Risk for Overall Antimicrobial Exposures and CRE It’s Not Just Carbapenems!
CRE vs Uninfected OR (95% CI)
CRE vs ESBL OR (95% CI)
CRE vs Susceptible OR (95% CI)
CRE vs all controls combined OR (95% CI)
Antibiotic exposure in previous 3 months
11.4 (2-64.3)
5.2 (1.4 19.4)
12.3 (3.3-45)
7.1 (1.9-25.8)
Marchaim D, et.al. Infect Control Hosp Epidemiol. 2012;8: 817-30
91 unique patients with CRE were included. Exposure to
antibiotics within 3 months was an independent predictor that
characterized patients with CRE isolation in all analyses
Opportunities in Improved Operative Care
• Prevention of surgical site infection • Orthopedic (implant) surgeries (HPRO, KPRO)
• CABG
• Bariatric surgery
• Prevention of surgical site infection due to MRSA
• Role of antimicrobial stewardship team • Appropriate antimicrobial prophylaxis dosing (and re-
dosing)
• Pre-operative screening for S. aureus and decolonization/changes in antimicrobial prophylaxis
Prevention of Infection Due to S. aureus in Surgery Involving Implants
• Complex, multi-step process • Screening patients in timely, pre-operative fashion
• Follow-up on results
• Prescription and education re: decolonization with mupirocin and chlorhexidine
• Appropriate changes in pre-operative antimicrobial prophylaxis (ie for MRSA carriers)
• Infection control, surgeons can use help in establishing and executing these processes!
Bode, NEJM, 2010, vol 362, p 9-17
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Antibiotic Stewardship & Infection Control Competing Principles ?
Early Initiation of Appropriate Antibiotics
Reduction of Antibiotics to avoid unnecessary use, adverse effects,
resistance
Increased Resistance (MDROs)
Decreased Resistance (MDROs)
Antibiotic Stewardship & Infection Control Competing? Complementary Principles
Early Initiation of Appropriate Antibiotics
Diagnostic Evaluation, Cultures & Source
Control
Discontinuation or Optimization of Antimicrobials
Optimal Infection Control Practices
Decreased Resistance
Conclusions
• Infection control is well established in hospital culture and infrastructure • Antimicrobial stewardship is emerging and increasingly recognized and valued
• Many opportunities for fruitful collaborations and interactions between infection control and antimicrobial stewardship
• Antimicrobial resistance and C. difficile
• Operative care
• CMS reporting and VBP
• Antimicrobial stewardship can learn much from infection control with regards to navigating the political healthcare landscape
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Questions ??