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20180313-MDRO-SCC-12.pdf

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This document discusses multi-drug resistant organisms (MDROs) such as MRSA, C. difficile, and CRE. It notes that at least 2 million Americans get infected with antibiotic-resistant bacteria each year, resulting in 23,000 deaths. The direct medical costs of these healthcare-associated infections range from $35.7-45 billion annually. While screening and isolation precautions can help control the spread of certain MDROs like MRSA, antibiotic overuse in medicine and agriculture continues to drive resistance. Comprehensive tracking of MDROs is needed to fully understand and address the growing crisis of antimicrobial resistance.

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Multi-Drug Resistant Organisms March 13, 2018 KevinT. Kavanagh, MD, MS Health Watch USA Somerset Community College
Multi-Drug Resistant Organisms Bacteria which are resistant to three or more classes of antibiotics Aminoglycosides (gentamycin, tobramycin), β-lactams (cephalosporins, penicillin, methicillin), Carbapenems, Fluoroquinolones (ciprofloxacillin, levofloxacin) and Tetracyclines
LectureTopics • Incidence & Cost of MDRO Infections • Antibiotic Overutilization • Agricultural Usage of Antibiotics • Types of Organisms -- MRSA -- Incidence -- Prevention -- C. Diff -- Incidence -- Prevention -- CRE -- Incidence -- Prevention • Facility and Health Department Coordination Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections. -- Association for Professionals in Infection Control and Epidemiology http://cqrcengage.com/apic/antibioticresistance
These infections will transform healthcare and not in a good way. Once treatable disease will become death sentences. Patients Needing OrganTransplantation. Chemotherapy for Cancer. Immunosuppression for Autoimmune Disease & Asthma. Immunocompromised Patients Such as Diabetics. Even SurgeriesWill Have Much Greater Risk of Complications. Incidence & Cost
Cost of Antibiotic Resistant Infections The Direct Medical costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Author – R. Douglas Scott II, Economist Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention March 2009 https://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf • March 2009: “…the overall annual direct medical costs of HAI to U.S. hospitals ranges from ….. $35.7 billion to $45 billion (after adjusting to 2007 dollars using the CPI for inpatient hospital services).
Source: Antimicrobial Resistance:Tackling a crisis for the health and wealth of nations. The Review on Antimicrobial Resistance, HM Government, WelcomeTrust.Chaired by Jim O’Neill “For countries in the OECD, the cumulative (multi-year) loss of economic output by 2050 will amount to between USD 20 and 35 trillion”
Incidence & Cost • The damaging effects of antimicrobial resistance (AMR) are already manifesting themselves across the world. Antimicrobial-resistant infections currently claim at least 50,000 lives each year across Europe and the US alone, with many hundreds of thousands more dying in other areas of the world. But reliable estimates of the true burden are scarce. Antimicrobial Resistance:Tackling a crisis for the health and wealth of nations. HM Government, WelcomeTrust. The Review on Antimicrobial Resistance, Chaired by Jim O’Neill. Dec. 2014 https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20- %20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20 of%20nations_1.pdf
Nursing Homes - HAI A large proportion of Healthcare Associated Infections (HAI) are Drug Resistant. • “…there are between 1.6 and 3.8 million HAIs [health care- acquired infections] in nursing homes every year. Annually, these infections result in an estimated 150,000 hospitalizations, 388,000 deaths, and between $673 million and $2 billion dollars in additional healthcare costs (Castle, et al. Nursing home deficiency citations for infection control, American Journal of Infection Control, May 2011; 39, 4).” Proposed CMS Nursing Home Regulations: Docket ID: CMS-2015-0083. Agency: Centers for Medicare Medicaid Services (CMS)
Antimicrobial Resistance: Tackling a crisis for the health and wealth of nations. The Review on Antimicrobial Resistance, Chaired by Jim O’Neill
Yearly Deaths to AMR by 2050 Antimicrobial Resistance:Tackling a crisis for the health and wealth of nations. HM Government,Welcome Trust. The Review on Antimicrobial Resistance, Chaired by Jim O’Neill https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20- %20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf
20180313-MDRO-SCC-12.pdf
Antibiotic Usage – United States The Center For Disease Dynamics, Economics & Policy (CDDEP): https://resistancemap.cddep.org/AntibioticUse.php
Antibiotic Usage – United States
Antibiotic Usage – Kentucky The Center For Disease Dynamics, Economics & Policy https://resistancemap.cddep.org/CountryPageSub.php?countryId= 38&country=United+States
Antibiotic Usage - Kentucky
Colistin,The last line of Defense Same mechanism of resistance: 1) Polymyxin B 2) Polymyxin D (Colistin)
20180313-MDRO-SCC-12.pdf
Agriculture Usage of Antibiotics 70% of antibiotics used in the United States are Used in Agriculture. 95% are used in the food and water of animals. Approximately 96% are sold over the counter. U.S. Food and DrugAdministration, 2014 Summary Report onAntimicrobials Sold or Distributed for Use in Food-ProducingAnimals (2015), http://www.fda.gov/downloads/ForIndustry/UserFees/AnimalDrugUserFeeActADUFA/UCM476258.pdf . Antibiotics andAnimalAgriculture: A Primer. Why are antibiotics used in animal agriculture, and what can be done to ensure their appropriate use? A fact sheet from the PEW charitable trusts. Jan. 2017 http://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/12/antibiotics-and-animal- agriculture-a-primer
Agriculture – MDRO Spread Importance in Human Infections. Spread to the environment. On food processed, for example chicken chicken contaminated with Salmonella and/or Campylobacter. Mounting evidence of direct spread of MDROs from animals to humans. However, the percentage of human infections caused by this source has not been determined. Consumer Union:The Overuse of Antibiotics in Food AnimalsThreatens Public Health. http://consumersunion.org/news/the-overuse-of-antibiotics-in-food- animals-threatens-public-health-2/
20180313-MDRO-SCC-12.pdf
• Methicillin-resistant Staphylococcus aureus (MRSA) -- Administration and Hospital Staff Dependent. Environmental Staff & Nursing. • Clostridium difficile (C. Diff.) -- Physician Dependent, Antibiotic Stewardship can prevent activation. -- Screening has also been found to be beneficial. • Carbapenem-resistant Enterobacteriaceae (CRE) -- Screening all contacts in both hospital and community. Coordinated approach with Health Dept. of Paramount Importance. Epidemiology and Control Are Different Depending Upon the Organism
Epidemiology and Control Are Different Depending Upon the Organism
Mechanisms of Resistance Produces EnzymeTo Breakdown Antibiotics. Multi-Drug Efflux Pumps Wall Barriers to Penetration.
20180313-MDRO-SCC-12.pdf
• MRSA causes all too common skin and soft tissue infection. MRSA inThe United States
MRSA inThe United States Kavanagh KT, et. al.The incidence of MRSA infections in the United States. Is a more comprehensive tracking system needed? Antimicrobial Resistance and Infection Control. April 7, 2017.
MRSA in Kentucky – CDC - HAI CDC: .
MRSA in Kentucky – NHSN - HAI Ranking State Measure Name Measure ID SIR Score 44 NV MRSA HAI_5_SIR 1.115 45 KY MRSA HAI_5_SIR 1.173 46 DC MRSA HAI_5_SIR 1.183 47 WV MRSA HAI_5_SIR 1.199 48 OK MRSA HAI_5_SIR 1.254 49 AR MRSA HAI_5_SIR 1.264 50 TN MRSA HAI_5_SIR 1.267 51 LA MRSA HAI_5_SIR 1.385 State Rankings MRSA Bloodstream Infections – Hospital Associated NHSN Data for Acquisition Dates: 4/1/2016 3/31/2017
MRSA in Kentucky – NHSN - HAI KY Hospital Rankings MRSA Bloodstream Infections – HAI  27 of 92 hospitals had calculated SIR Scores.  One hospital was statistically better than the National Benchmark (NB).  Four hospitals were statistically worse than the National Benchmark (NB). NHSN Data for Acquisition Dates: 4/1/2016 3/31/2017 Rank Hospital Measure ID SIR Score 4 BAPTIST HEALTH LOUISVILLE LOUISVILLE MRSA HAI_5_SIR 0.268 Better Than NB 18 UNIVERSITY OF KENTUCKY HOSPITAL LEXINGTON MRSA HAI_5_SIR 1.378 Worse than NB 20 NORTON HOSPITAL / NORTON HEALTHCARE PAVILION / NOR LOUISVILLE MRSA HAI_5_SIR 1.639 Worse than NB 21 UNIVERSITY OF LOUISVILLE HOSPITAL LOUISVILLE MRSA HAI_5_SIR 1.703 Worse than NB 26 LAKE CUMBERLAND REGIONAL HOSPITAL SOMERSET MRSA HAI_5_SIR 2.541 Worse than NB
WillThe Epidemic Reverse • Denmark Experience – In Beginning EasierTo Reverse “The frequency of MRSA rose to 15% in the years 1967 through 1971 but decreased to 0.2% in 1984. Since 1984, only 0.2% of the Danish S aureus population has been MRSA, and imported MRSA strains have been prevented from spreading. “ RosdahlVT, Knudsen AM. The decline of methicillin resistance among Danish Staphylococcus aureus strains. Infect Control Hosp Epidemiol. 1991 Feb;12(2):83-8.
MRSA Prevention Two Methodologies are in Use Surveillance and Screening Unit or Facility Wide Daily Bathing with Chlorhexidine Reuters News Service: “In 2009, the federal government launched a campaign to reduce bloodstream infections by the notorious superbug methicillin-resistant Staphylococcus aureus (MRSA) in hospital patients 25 percent by 2013.That failed. The new goal: Halve infection rates by 2020. “ Nelson DJ, McNeill R. Money from infection-control industry muddies research into beating back superbugs Reuters News Service. Apr. 7, 2017. http://www.reuters.com/investigates/special- report/usa-superbugs-research/
MRSA Prevention Surveillance and Screening The U.S.Veterans Administration The United Kingdom
MRSA Prevention -VA Kavanagh KT, Abusalem S, Calderon LE. The incidence of MRSA infections in the United States. Is a more comprehensive tracking system needed? Antimicrobial Resistance and Infection Control. April 7, 2017. 6:34 DOI: 10.1186/s13756-017-0193-0 https://aricjournal.biomedcentral.com/articles/10.1186/s13756-017-0193-0 • TheVA has also seen a dramatic reduction in MRSA infections in 127 reporting acute care hospitals. From October 2007 to October 2015, healthcare-associated MRSA infection rates dropped 87.0% in ICUs and 80.1% in non-ICU patient areas, achieving an incidence of 0.147 and 0.090 infections per 1,000 patient days, respectively. In long term care facilities theVA reports MRSA infection reductions of 49.4% from July 2009 to September 2015.12
MRSA Prevention -VA Kavanagh KT, Abusalem S, Calderon LE. The incidence of MRSA infections in the United States. Is a more comprehensive tracking system needed? Antimicrobial Resistance and Infection Control. April 7, 2017. 6:34 DOI: 10.1186/s13756-017-0193-0 https://aricjournal.biomedcentral.com/articles/10.1186/s13756-017-0193-0
Even a Large Scale Epidemic Can Be Reversed. The English Experience Otter J. The English MRSA Miracle. Micro Blog. Your window to the world of healthcare microbiology and epidemiology; by Jon Otter and SaberYezli Mar. 8, 2015 from https://reflectionsipc.com/2015/03/03/the-english-mrsa-miracle/ MRSA Prevention – United Kingdom
MRSA Prevention – United Kingdom Screening of High Risk Patients All elective surgical patients All emergency admissions Critical care (including intensive care and high-dependency units) Pre-operative patients in certain surgical specialties Emergency orthopaedic and trauma admissions Renal medicine All patients previously known to be MRSA positive Oncology/chemotherapy inpatients Patients admitted from high-risk settings Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation: A strategy for NHS trusts: a summary of best practice. 2006 (Archived Jan 23, 2013) http://webarchive.nationalarchives.gov.uk/20130123191323/http://www.dh.gov.uk/prod_ consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_063187.pdf
MRSA Prevention – United Kingdom • The logical conclusion of risk factor assessments and the results of modelling studies is that the most appropriate approach to the reduction in MRSA carriage in the population, and resultant MRSA infections, is the universal screening of all admissions to hospital (either at pre-admission clinics for elective admissions or immediately on admission for emergency admissions). Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation: A strategy for NHS trusts: a summary of best practice. 2006 (Archived Jan 23, 2013) http://webarchive.nationalarchives.gov.uk/20130123191323/http://www.dh.gov.uk/prod_ consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_063187.pdf
MRSA - Chlorohexidine Bathing Popularized by the Reduce MRSA Study. Research Integrity Questions Regarding: Spinning of Data Changing of Metrics Use of Surrogate Endpoints Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013; 368(24):2255-65. doi: 10.1056/NEJMoa1207290. Epub 2013 May 29
Spinning of Data – REDUCE MRSA Study Abstract: “In routine ICU practice, universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen.” But “any pathogen” refers to a composite category which was added after the trial completion date (registered on clinical trials.gov) and whose effects were largely based onYeast and Consensual Bacteria. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013; 368(24):2255-65. doi: 10.1056/NEJMoa1207290. Epub 2013 May 29
Chlorhexidine – Health Watch USA  Kavanagh KT, Saman DM,YuY. A Perspective on How the United States Fell behind Northern Europe in the Battle against Methicillin-Resistant Staphylococcus aureus. AntimicrobAgents Chemother. 2013 Dec;57(12):5789-91. doi: 10.1128/AAC.01839-13. Epub 2013 Oct 7. PMID: 24100502 http://aac.asm.org/content/57/12/5789.long  Kavanagh KT, Calderon LE, Saman DM, Abusalem SK. The use of surveillance and preventative measures for methicillin-resistant staphylococcus aureus infections in surgical patients. Antimicrob Resist Infect Control. 2014 May 14;3:18. eCollection 2014. PMID: 24847437 http://www.aricjournal.com/content/3/1/18  Kavanagh KT, Calderon LE and Saman DM Viewpoint: a response to “Screening and isolation to control methicillin-resistant Staphylococcus aureus: sense, nonsense, and evidence” Antimicrobial Resistance and Infection Control 2015, 4:4 (5 February 2015) http://www.aricjournal.com/content/4/1/4  Kavanagh KT,Tower SS, Saman DM. A perspective on the principles of integrity in infectious disease research. Journal of Patient Safety. Published Online Mar. 24, 2016. PMID 27010326 http://journals.lww.com/journalpatientsafety/Fulltext/2016/06000/A_Perspective _on_the_Principles_of_Integrity_in.1.aspx
MRSA - Chlorhexidine Bathing Reuters News Service: “Since then, Sage has provided funding and millions of dollars in wipes for studies byWeinstein and his colleagues.And in that time,Weinstein and his colleagues have published 11 articles on six trials that endorse daily washing of patients with Sage’s patented wipes — an “off-label” use, as the U.S. Food and Drug Administration (FDA) has approved the wipes only for cleaning patients before surgery.”
MRSA - Chlorhexidine Bathing Reuters News Service: “….a $1 million donation from the family foundation of Sage’s founder,Vincent W. Foglia.The money was earmarked for research by the senior scientist on the study, Dr Robert A. Weinstein, an infectious-disease specialist at Rush..”
MRSA - Chlorhexidine Bathing Helio Infectious Disease News: “We found that, in general units outside the ICU, only patients with central lines and other medical devices derived a benefit from chlorhexidine bathing, researcher Susan S. Huang, MD, MPH,.” Oct. 7, 2017: https://www.healio.com/infectious- disease/mrsa/news/online/{91bded5c-d4c7-426d-97f7-b42169472618}/daily- chlorhexidine-does-not-reduce-mrsa-vre-in-lower-risk-patients
MRSA - Chlorhexidine Bathing LATimes: “Dr. Susan Huang, the hospital’s infection control expert, had a plan. The strategy — which she had promoted so successfully that most U.S. hospitals now use it — included bathing all infants in the ICU with a powerful disinfectant, and swabbing inside their noses with an antibiotic. But this time, the plan failed..” Peterson M. LATimes May 16, 2017 http://www.latimes.com/business/la-fi-uci-infant-outbreak- 20170515-story.html
MRSA - Chlorhexidine Bathing May be fueling the epidemic of CRE by stimulation of Multi-Drug Efflux Pumps
20180313-MDRO-SCC-12.pdf
Clostridium difficile • C. Diff can cause a severe and life threatening GI infection. • Forms Spores –Very hard to treat and infections return 20% of the time. • 95% of infections are linked to medical care (hospitals 25%, nursing homes, outpatient care 75%). https://www.cdc.gov/HAI/organism s/cdiff/Cdiff_infect.html https://www.cdc.gov/hai/organisms /cdiff/cdiff-patient.html
Clostridium difficile • C. difficile – was estimated to cause almost half a million infections in the United States in 2011, and 29,000 died within 30 days of the initial diagnosis. • Cost estimated to be 1 billion dollars annually. • Rates increased 4X between 2000 and 2007. NOT GOING DOWN https://www.cdc.gov/HAI/organism s/cdiff/Cdiff_infect.html https://www.cdc.gov/hai/organisms /cdiff/cdiff-patient.html
Clostridium difficile – PA Hospitals • In FY 2017, 17,495 admissions for CDI—relatively steady since FY 2008. 20% developed the condition in the hospital. • Mortality Declining. “In-hospital mortality dropped 42% (from 9.7% to 5.7% • Readmission rates dropped 14%, from 32.9% to 28.2%.” • Patients admitted with CDI had a 5% mortality. Acquired CDI in the hospital was associated with a 8.5 mortality. Ref: PHC4 http://www.phc4.org/reports/rese archbriefs/cdi/17/nr030118.htm
Clostridium difficile in KY– CDC - HAI CDC: .
Clostridium difficile in KY – NHSN - HAI State Rankings Clostridium Difficile Infections – Hospital Associated NHSN Data for Acquisition Dates: 4/1/2016 3/31/2017 Ranking State Measure Name Measure ID SIR Score 1 AL C. Difficile HAI_6_SIR 0.623 2 ME C. Difficile HAI_6_SIR 0.68 3 ID C. Difficile HAI_6_SIR 0.692 4 MS C. Difficile HAI_6_SIR 0.718 5 FL C. Difficile HAI_6_SIR 0.769 6 SC C. Difficile HAI_6_SIR 0.77 7 HI C. Difficile HAI_6_SIR 0.779 8 AR C. Difficile HAI_6_SIR 0.786 9 KY C. Difficile HAI_6_SIR 0.799
Clostridium difficile in KY– NHSN - HAI NHSN Data for Acquisition Dates: 4/1/2016 3/31/2017 Rank Hospital Measure ID SIR Score 1 WHITESBURG ARH HOSPITAL WHITESBURG C. Diff HAI_6_SIR 0 Better than NB 8 GREENVIEW REGIONAL HOSPITAL BOWLING GREEN C. Diff HAI_6_SIR 0.149 Better than NB 11 METHODIST HOSPITAL HENDERSON C. Diff HAI_6_SIR 0.289 Better than NB 12 HAZARD ARH REGIONAL MEDICAL CENTER HAZARD C. Diff HAI_6_SIR 0.291 Better than NB 14 HIGHLANDS REGIONAL MEDICAL CENTER PRESTONSBURG C. Diff HAI_6_SIR 0.332 Better than NB 16 HARDIN MEMORIAL HOSPITAL ELIZABETHTOWN C. Diff HAI_6_SIR 0.453 Better than NB 17 BAPTIST HEALTH PADUCAH PADUCAH C. Diff HAI_6_SIR 0.467 Better than NB 19 OUR LADY OF BELLEFONTE HOSPITAL ASHLAND C. Diff HAI_6_SIR 0.473 Better than NB 21 OWENSBORO HEALTH REGIONAL HOSPITAL OWENSBORO C. Diff HAI_6_SIR 0.503 Better than NB 24 LOURDES HOSPITAL PADUCAH C. Diff HAI_6_SIR 0.536 Better than NB 26 BAPTIST HEALTH MADISONVILLE MADISONVILLE C. Diff HAI_6_SIR 0.611 Better than NB 28 KING'S DAUGHTERS' MEDICAL CENTER ASHLAND C. Diff HAI_6_SIR 0.639 Better than NB 29 THE MEDICAL CENTER AT BOWLING GREEN BOWLING GREEN C. Diff HAI_6_SIR 0.652 Better than NB 30 UNIVERSITY OF KENTUCKY HOSPITAL LEXINGTON C. Diff HAI_6_SIR 0.766 Better than NB 31 ST ELIZABETH MEDICAL CENTER NORTH EDGEWOOD C. Diff HAI_6_SIR 0.77 Better than NB 57 EPHRAIM MCDOWELL REGIONAL MED. CTR. DANVILLE C. Diff HAI_6_SIR 1.482 Worse than NB 59 OWENSBORO HEALTH MUHLENBERG COMMUNITY HOSPITAL GREENVILLE C. Diff HAI_6_SIR 2.722 Worse than NB 60 FLAGET MEMORIAL HOSPITAL BARDSTOWN C. Diff HAI_6_SIR 3.529 Worse than NB  60 of 92 hospitals had calculated SIR Scores.  15 hospitals was statistically better than the National Benchmark.  3 hospitals were statistically worse than the National Benchmark.
Antibiotic Overutilzation • Fluoroquinolones FDA: “The U.S. Food and Drug Administration is advising that the serious side effects associated with fluoroquinolone antibacterial drugs generally outweigh the benefits for patients with acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections who have other treatment options. For patients with these conditions, fluoroquinolones should be reserved for those who do not have alternative treatment options.” July 26, 2016. https://www.fda.gov/Drugs/DrugSaf ety/ucm500143.htm
Antibiotic Usage – Kentucky The Center For Disease Dynamics, Economics & Policy https://resistancemap.cddep.org/CountryPageSub.php?countryId= 38&country=United+States
20180313-MDRO-SCC-12.pdf
Carbapenem-resistant Enterobacteriaceae • Severe GI Infections with a 50% fatality rate if enters the blood. • Colistin –Very toxic antibiotic is the last line of defense. • However, becoming resistant to this antibiotic. Ref: CDC
Carbapenem-resistant Enterobacteriaceae • There is no National Reporting System • Possible to reduce CRE infections by 70% over 5 years if facilities coordinate to protect patients – CDC.
CRE - Prevention Ref: Carbapenem-Resistant Enterobacteriaceae (CRE) Control and Prevention Toolkit. - AHRQ http://www.ahrq.gov/cretoolkit “Each institution will need to carefully choose among the available screening methodologies to support their active surveillance program, and lack of ability to implement molecular testing should not otherwise prevent pursuit of aggressiveCRE control efforts using existing culture techniques.”
• Identification of all epidemiologically related contacts (screening). • Contact Isolation for carriers and those with infections.
CRE are nightmare bacteria CRE in 2002 to 2012: “During the first six months of 2012 4.6% of hospitals reported one or more infections. 3.9% in short stay hospitals and 17.8% long term facilities.2 CRE Klebsiella cultures positive forCRE increased from 0.1% to 4.5% between 2002 and 2010.4 Vital Signs: Carbapenem-Resistant Enterobacteriaceae. MMWR Morbidity and Mortality Weekly Report. March 5, 2013. Vol. 62 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w CDC News Release. Tuesday, March 5th, 2013. http://www.cdc.gov/media/releases/2013/p0305_deadly_bacteria.html Braykov NP, Eber MR, Klein EY, Morgan DJ, Laxminarayan R. Trends in resistance to carbapenems and third-generation cephalosporins among clinical isolates of Klebsiella pneumoniae in the United States, 1999-2010. Infect Control Hosp Epidemiol. 2013 Mar;34(3):259-68. doi: 10.1086/669523. Epub 2013 Jan 23. http://www.ncbi.nlm.nih.gov/pubmed/23388360
CRE in 2001 to 2013 • “Nationally, the CDC issued warnings last year about CRE, saying the bacteria spread from one medical facility in 2001 to numerous facilities in 46 states in 2013. CDC Director Tom Frieden said, "Our strongest antibiotics don't work, and patients are left with potentially untreatable infections.“ Unger L. Doctors fear growing hospital superbug. Courier Journal. Aug. 5, 2014. https://www.courier-journal.com/story/life/wellness/health/2014/08/04/doctors-fear- growing-hospital-superbug/13569933/
CRE Outbreak in Louisville, KY - 2013 • “Kavanagh said it’s important that outbreaks be made public, partly because patients often go from one health care location to another “This is a huge problem,” he said. “It’s not something one hospital can control. In Kentucky, health care sites must report “outbreaks” of greater-than-expected numbers of cases, leaving it to them to interpret what that means. But Kavanagh and state Rep.Tom Burch, D-Louisville, are calling for a new rule that hospitals report all CRE cases to the state. Burch says he plans to introduce a bill on mandatory public reporting in next year’s General Assembly.” Ungar L. Kindred had 40 CRE cases. Courier Journal, April 16, 2013.
CRE in 2012 to 2013 • Study finds an incidence of 2.93 CRE cases per 100,000 people over a two year period. Equates to 4500 People a Year. Data acquisition dates 2012-2013. Guh AY, Bulens SN, MuY, Jacob JT, et al. Epidemiology of Carbapenem-Resistant Enterobacteriaceae in 7 US Communities, 2012-2013. JAMA. 2015 Oct 5:1479-1487. doi: 10.1001/jama.2015.12480. [Epub ahead of print]
CRE in 2014 - Kentucky Kentucky Deptartment for Public Health
CRE in 2016 – HARP-DC
CRE in 2016 HARP-DC
Dangerous CRE Outbreak In Kentucky. Health Department Working With Healthcare Facilities • A rare form of resistance found in 8 patients, in 4 different types of bacteria, in two different wards. • Demonstrates that the transmission of resistance between different types of bacteria is clinically important. • No patient developed an infection.
Dangerous CRE Outbreak In Kentucky. Health Department Working With Healthcare Facilities • A rare form of resistance found in 8 patients, in 4 different types of bacteria, in two different wards. • Demonstrates that the transmission of resistance between different types of bacteria is clinically important. • No patient developed an infection. Bacterial Conjugation
Dangerous CRE Outbreak In Kentucky. "On August 11, 2016, two Klebsiella pneumoniae carbapenemase (KPC)– producing CP-CRE isolates from clinical cultures were reported from patients hospitalized at a rural, community hospital in Kentucky; CRE had not been identified previously at this facility. During the next 4 months, an additional 21 CRE isolates were identified from facility patients, resulting in a total of 23 isolates, including 17 K. pneumoniae, five Escherichia coli, and one Enterobacter cloacae isolate. Seventeen (74%) of these isolates were identified through patient screening cultures; the rest were from clinical cultures." We hear about it over a year later.
20180313-MDRO-SCC-12.pdf
Kentucky – MDRO Reporting Regulation  Defines an Outbreak “HAI Outbreak” means (a)The occurrence of two (2) or more HAIs that are epidemiologically linked or connected by person, place, or time; or (b) A single case of an HAI not commonly diagnosed such as a postsurgical groupA Streptococcus infection or healthcare-associated Legionella infection.  Covers AllTypes of Facilities ““Health facility” means: (a) A facility licensed under 902 KAR Chapter 20 and required by the Centers for Medicare and Medicaid Services (CMS) to report an HAI event or healthcare personnel influenza vaccination information to CMS using the National Healthcare Safety Network; or (b) A facility licensed under KRS Chapter 216B.” Healthcare associated infection surveillance KAR 902.20
Kentucky – MDRO Reporting Regulation  Following diseases shall be electronically reported to the Kentucky Department for Public within five (5) business days: (a)Vancomycin-intermediate Staphylococcus aureus (VISA), (b)Vancomycin-resistant Staphylococcus aureus (VRSA) (c) Methicillin-resistant Staphylococcus aureus (MRSA) (d)Vancomycin-resistant Enterococcus species (VRE) (e) Clostridium difficile (C. difficile) identified from a positive laboratory test result for a C. difficile toxinA or B, (f) Carbapenem-resistant Enterobacteriaceae (CRE) (g) Extended–spectrum beta-lactamaseGram negative organisms (ESBL); (h) Multidrug-resistant – Acinetobacter - Non-susceptibility (resistant or intermediate) to at least one (1) agent in at least three (3) antimicrobial classes. Healthcare associated infection surveillance KAR 902.20
• No single facility or facility type can solve this problem. It takes a coordinated approach.
CDC: What Is Needed • Independent Approach – Not Enough • Coordinated Approach –What is Needed. Facilities and public health authorities share information and implement shared infection control actions to stop spread of germs from facility to facility. Vital Signs. Aug. 4, 2015 Center for Disease Control and Prevention
Vital Signs. Aug. 4, 2015 Center for Disease Control and Prevention
20180313-MDRO-SCC-12.pdf

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20180313-MDRO-SCC-12.pdf

  • 1. Multi-Drug Resistant Organisms March 13, 2018 KevinT. Kavanagh, MD, MS Health Watch USA Somerset Community College
  • 2. Multi-Drug Resistant Organisms Bacteria which are resistant to three or more classes of antibiotics Aminoglycosides (gentamycin, tobramycin), β-lactams (cephalosporins, penicillin, methicillin), Carbapenems, Fluoroquinolones (ciprofloxacillin, levofloxacin) and Tetracyclines
  • 3. LectureTopics • Incidence & Cost of MDRO Infections • Antibiotic Overutilization • Agricultural Usage of Antibiotics • Types of Organisms -- MRSA -- Incidence -- Prevention -- C. Diff -- Incidence -- Prevention -- CRE -- Incidence -- Prevention • Facility and Health Department Coordination Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections. -- Association for Professionals in Infection Control and Epidemiology http://cqrcengage.com/apic/antibioticresistance
  • 4. These infections will transform healthcare and not in a good way. Once treatable disease will become death sentences. Patients Needing OrganTransplantation. Chemotherapy for Cancer. Immunosuppression for Autoimmune Disease & Asthma. Immunocompromised Patients Such as Diabetics. Even SurgeriesWill Have Much Greater Risk of Complications. Incidence & Cost
  • 5. Cost of Antibiotic Resistant Infections The Direct Medical costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Author – R. Douglas Scott II, Economist Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention March 2009 https://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf • March 2009: “…the overall annual direct medical costs of HAI to U.S. hospitals ranges from ….. $35.7 billion to $45 billion (after adjusting to 2007 dollars using the CPI for inpatient hospital services).
  • 6. Source: Antimicrobial Resistance:Tackling a crisis for the health and wealth of nations. The Review on Antimicrobial Resistance, HM Government, WelcomeTrust.Chaired by Jim O’Neill “For countries in the OECD, the cumulative (multi-year) loss of economic output by 2050 will amount to between USD 20 and 35 trillion”
  • 7. Incidence & Cost • The damaging effects of antimicrobial resistance (AMR) are already manifesting themselves across the world. Antimicrobial-resistant infections currently claim at least 50,000 lives each year across Europe and the US alone, with many hundreds of thousands more dying in other areas of the world. But reliable estimates of the true burden are scarce. Antimicrobial Resistance:Tackling a crisis for the health and wealth of nations. HM Government, WelcomeTrust. The Review on Antimicrobial Resistance, Chaired by Jim O’Neill. Dec. 2014 https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20- %20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20 of%20nations_1.pdf
  • 8. Nursing Homes - HAI A large proportion of Healthcare Associated Infections (HAI) are Drug Resistant. • “…there are between 1.6 and 3.8 million HAIs [health care- acquired infections] in nursing homes every year. Annually, these infections result in an estimated 150,000 hospitalizations, 388,000 deaths, and between $673 million and $2 billion dollars in additional healthcare costs (Castle, et al. Nursing home deficiency citations for infection control, American Journal of Infection Control, May 2011; 39, 4).” Proposed CMS Nursing Home Regulations: Docket ID: CMS-2015-0083. Agency: Centers for Medicare Medicaid Services (CMS)
  • 9. Antimicrobial Resistance: Tackling a crisis for the health and wealth of nations. The Review on Antimicrobial Resistance, Chaired by Jim O’Neill
  • 10. Yearly Deaths to AMR by 2050 Antimicrobial Resistance:Tackling a crisis for the health and wealth of nations. HM Government,Welcome Trust. The Review on Antimicrobial Resistance, Chaired by Jim O’Neill https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20- %20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf
  • 12. Antibiotic Usage – United States The Center For Disease Dynamics, Economics & Policy (CDDEP): https://resistancemap.cddep.org/AntibioticUse.php
  • 13. Antibiotic Usage – United States
  • 14. Antibiotic Usage – Kentucky The Center For Disease Dynamics, Economics & Policy https://resistancemap.cddep.org/CountryPageSub.php?countryId= 38&country=United+States
  • 15. Antibiotic Usage - Kentucky
  • 16. Colistin,The last line of Defense Same mechanism of resistance: 1) Polymyxin B 2) Polymyxin D (Colistin)
  • 18. Agriculture Usage of Antibiotics 70% of antibiotics used in the United States are Used in Agriculture. 95% are used in the food and water of animals. Approximately 96% are sold over the counter. U.S. Food and DrugAdministration, 2014 Summary Report onAntimicrobials Sold or Distributed for Use in Food-ProducingAnimals (2015), http://www.fda.gov/downloads/ForIndustry/UserFees/AnimalDrugUserFeeActADUFA/UCM476258.pdf . Antibiotics andAnimalAgriculture: A Primer. Why are antibiotics used in animal agriculture, and what can be done to ensure their appropriate use? A fact sheet from the PEW charitable trusts. Jan. 2017 http://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/12/antibiotics-and-animal- agriculture-a-primer
  • 19. Agriculture – MDRO Spread Importance in Human Infections. Spread to the environment. On food processed, for example chicken chicken contaminated with Salmonella and/or Campylobacter. Mounting evidence of direct spread of MDROs from animals to humans. However, the percentage of human infections caused by this source has not been determined. Consumer Union:The Overuse of Antibiotics in Food AnimalsThreatens Public Health. http://consumersunion.org/news/the-overuse-of-antibiotics-in-food- animals-threatens-public-health-2/
  • 21. • Methicillin-resistant Staphylococcus aureus (MRSA) -- Administration and Hospital Staff Dependent. Environmental Staff & Nursing. • Clostridium difficile (C. Diff.) -- Physician Dependent, Antibiotic Stewardship can prevent activation. -- Screening has also been found to be beneficial. • Carbapenem-resistant Enterobacteriaceae (CRE) -- Screening all contacts in both hospital and community. Coordinated approach with Health Dept. of Paramount Importance. Epidemiology and Control Are Different Depending Upon the Organism
  • 22. Epidemiology and Control Are Different Depending Upon the Organism
  • 23. Mechanisms of Resistance Produces EnzymeTo Breakdown Antibiotics. Multi-Drug Efflux Pumps Wall Barriers to Penetration.
  • 25. • MRSA causes all too common skin and soft tissue infection. MRSA inThe United States
  • 26. MRSA inThe United States Kavanagh KT, et. al.The incidence of MRSA infections in the United States. Is a more comprehensive tracking system needed? Antimicrobial Resistance and Infection Control. April 7, 2017.
  • 27. MRSA in Kentucky – CDC - HAI CDC: .
  • 28. MRSA in Kentucky – NHSN - HAI Ranking State Measure Name Measure ID SIR Score 44 NV MRSA HAI_5_SIR 1.115 45 KY MRSA HAI_5_SIR 1.173 46 DC MRSA HAI_5_SIR 1.183 47 WV MRSA HAI_5_SIR 1.199 48 OK MRSA HAI_5_SIR 1.254 49 AR MRSA HAI_5_SIR 1.264 50 TN MRSA HAI_5_SIR 1.267 51 LA MRSA HAI_5_SIR 1.385 State Rankings MRSA Bloodstream Infections – Hospital Associated NHSN Data for Acquisition Dates: 4/1/2016 3/31/2017
  • 29. MRSA in Kentucky – NHSN - HAI KY Hospital Rankings MRSA Bloodstream Infections – HAI  27 of 92 hospitals had calculated SIR Scores.  One hospital was statistically better than the National Benchmark (NB).  Four hospitals were statistically worse than the National Benchmark (NB). NHSN Data for Acquisition Dates: 4/1/2016 3/31/2017 Rank Hospital Measure ID SIR Score 4 BAPTIST HEALTH LOUISVILLE LOUISVILLE MRSA HAI_5_SIR 0.268 Better Than NB 18 UNIVERSITY OF KENTUCKY HOSPITAL LEXINGTON MRSA HAI_5_SIR 1.378 Worse than NB 20 NORTON HOSPITAL / NORTON HEALTHCARE PAVILION / NOR LOUISVILLE MRSA HAI_5_SIR 1.639 Worse than NB 21 UNIVERSITY OF LOUISVILLE HOSPITAL LOUISVILLE MRSA HAI_5_SIR 1.703 Worse than NB 26 LAKE CUMBERLAND REGIONAL HOSPITAL SOMERSET MRSA HAI_5_SIR 2.541 Worse than NB
  • 30. WillThe Epidemic Reverse • Denmark Experience – In Beginning EasierTo Reverse “The frequency of MRSA rose to 15% in the years 1967 through 1971 but decreased to 0.2% in 1984. Since 1984, only 0.2% of the Danish S aureus population has been MRSA, and imported MRSA strains have been prevented from spreading. “ RosdahlVT, Knudsen AM. The decline of methicillin resistance among Danish Staphylococcus aureus strains. Infect Control Hosp Epidemiol. 1991 Feb;12(2):83-8.
  • 31. MRSA Prevention Two Methodologies are in Use Surveillance and Screening Unit or Facility Wide Daily Bathing with Chlorhexidine Reuters News Service: “In 2009, the federal government launched a campaign to reduce bloodstream infections by the notorious superbug methicillin-resistant Staphylococcus aureus (MRSA) in hospital patients 25 percent by 2013.That failed. The new goal: Halve infection rates by 2020. “ Nelson DJ, McNeill R. Money from infection-control industry muddies research into beating back superbugs Reuters News Service. Apr. 7, 2017. http://www.reuters.com/investigates/special- report/usa-superbugs-research/
  • 32. MRSA Prevention Surveillance and Screening The U.S.Veterans Administration The United Kingdom
  • 33. MRSA Prevention -VA Kavanagh KT, Abusalem S, Calderon LE. The incidence of MRSA infections in the United States. Is a more comprehensive tracking system needed? Antimicrobial Resistance and Infection Control. April 7, 2017. 6:34 DOI: 10.1186/s13756-017-0193-0 https://aricjournal.biomedcentral.com/articles/10.1186/s13756-017-0193-0 • TheVA has also seen a dramatic reduction in MRSA infections in 127 reporting acute care hospitals. From October 2007 to October 2015, healthcare-associated MRSA infection rates dropped 87.0% in ICUs and 80.1% in non-ICU patient areas, achieving an incidence of 0.147 and 0.090 infections per 1,000 patient days, respectively. In long term care facilities theVA reports MRSA infection reductions of 49.4% from July 2009 to September 2015.12
  • 34. MRSA Prevention -VA Kavanagh KT, Abusalem S, Calderon LE. The incidence of MRSA infections in the United States. Is a more comprehensive tracking system needed? Antimicrobial Resistance and Infection Control. April 7, 2017. 6:34 DOI: 10.1186/s13756-017-0193-0 https://aricjournal.biomedcentral.com/articles/10.1186/s13756-017-0193-0
  • 35. Even a Large Scale Epidemic Can Be Reversed. The English Experience Otter J. The English MRSA Miracle. Micro Blog. Your window to the world of healthcare microbiology and epidemiology; by Jon Otter and SaberYezli Mar. 8, 2015 from https://reflectionsipc.com/2015/03/03/the-english-mrsa-miracle/ MRSA Prevention – United Kingdom
  • 36. MRSA Prevention – United Kingdom Screening of High Risk Patients All elective surgical patients All emergency admissions Critical care (including intensive care and high-dependency units) Pre-operative patients in certain surgical specialties Emergency orthopaedic and trauma admissions Renal medicine All patients previously known to be MRSA positive Oncology/chemotherapy inpatients Patients admitted from high-risk settings Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation: A strategy for NHS trusts: a summary of best practice. 2006 (Archived Jan 23, 2013) http://webarchive.nationalarchives.gov.uk/20130123191323/http://www.dh.gov.uk/prod_ consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_063187.pdf
  • 37. MRSA Prevention – United Kingdom • The logical conclusion of risk factor assessments and the results of modelling studies is that the most appropriate approach to the reduction in MRSA carriage in the population, and resultant MRSA infections, is the universal screening of all admissions to hospital (either at pre-admission clinics for elective admissions or immediately on admission for emergency admissions). Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation: A strategy for NHS trusts: a summary of best practice. 2006 (Archived Jan 23, 2013) http://webarchive.nationalarchives.gov.uk/20130123191323/http://www.dh.gov.uk/prod_ consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_063187.pdf
  • 38. MRSA - Chlorohexidine Bathing Popularized by the Reduce MRSA Study. Research Integrity Questions Regarding: Spinning of Data Changing of Metrics Use of Surrogate Endpoints Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013; 368(24):2255-65. doi: 10.1056/NEJMoa1207290. Epub 2013 May 29
  • 39. Spinning of Data – REDUCE MRSA Study Abstract: “In routine ICU practice, universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen.” But “any pathogen” refers to a composite category which was added after the trial completion date (registered on clinical trials.gov) and whose effects were largely based onYeast and Consensual Bacteria. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013; 368(24):2255-65. doi: 10.1056/NEJMoa1207290. Epub 2013 May 29
  • 40. Chlorhexidine – Health Watch USA  Kavanagh KT, Saman DM,YuY. A Perspective on How the United States Fell behind Northern Europe in the Battle against Methicillin-Resistant Staphylococcus aureus. AntimicrobAgents Chemother. 2013 Dec;57(12):5789-91. doi: 10.1128/AAC.01839-13. Epub 2013 Oct 7. PMID: 24100502 http://aac.asm.org/content/57/12/5789.long  Kavanagh KT, Calderon LE, Saman DM, Abusalem SK. The use of surveillance and preventative measures for methicillin-resistant staphylococcus aureus infections in surgical patients. Antimicrob Resist Infect Control. 2014 May 14;3:18. eCollection 2014. PMID: 24847437 http://www.aricjournal.com/content/3/1/18  Kavanagh KT, Calderon LE and Saman DM Viewpoint: a response to “Screening and isolation to control methicillin-resistant Staphylococcus aureus: sense, nonsense, and evidence” Antimicrobial Resistance and Infection Control 2015, 4:4 (5 February 2015) http://www.aricjournal.com/content/4/1/4  Kavanagh KT,Tower SS, Saman DM. A perspective on the principles of integrity in infectious disease research. Journal of Patient Safety. Published Online Mar. 24, 2016. PMID 27010326 http://journals.lww.com/journalpatientsafety/Fulltext/2016/06000/A_Perspective _on_the_Principles_of_Integrity_in.1.aspx
  • 41. MRSA - Chlorhexidine Bathing Reuters News Service: “Since then, Sage has provided funding and millions of dollars in wipes for studies byWeinstein and his colleagues.And in that time,Weinstein and his colleagues have published 11 articles on six trials that endorse daily washing of patients with Sage’s patented wipes — an “off-label” use, as the U.S. Food and Drug Administration (FDA) has approved the wipes only for cleaning patients before surgery.”
  • 42. MRSA - Chlorhexidine Bathing Reuters News Service: “….a $1 million donation from the family foundation of Sage’s founder,Vincent W. Foglia.The money was earmarked for research by the senior scientist on the study, Dr Robert A. Weinstein, an infectious-disease specialist at Rush..”
  • 43. MRSA - Chlorhexidine Bathing Helio Infectious Disease News: “We found that, in general units outside the ICU, only patients with central lines and other medical devices derived a benefit from chlorhexidine bathing, researcher Susan S. Huang, MD, MPH,.” Oct. 7, 2017: https://www.healio.com/infectious- disease/mrsa/news/online/{91bded5c-d4c7-426d-97f7-b42169472618}/daily- chlorhexidine-does-not-reduce-mrsa-vre-in-lower-risk-patients
  • 44. MRSA - Chlorhexidine Bathing LATimes: “Dr. Susan Huang, the hospital’s infection control expert, had a plan. The strategy — which she had promoted so successfully that most U.S. hospitals now use it — included bathing all infants in the ICU with a powerful disinfectant, and swabbing inside their noses with an antibiotic. But this time, the plan failed..” Peterson M. LATimes May 16, 2017 http://www.latimes.com/business/la-fi-uci-infant-outbreak- 20170515-story.html
  • 45. MRSA - Chlorhexidine Bathing May be fueling the epidemic of CRE by stimulation of Multi-Drug Efflux Pumps
  • 47. Clostridium difficile • C. Diff can cause a severe and life threatening GI infection. • Forms Spores –Very hard to treat and infections return 20% of the time. • 95% of infections are linked to medical care (hospitals 25%, nursing homes, outpatient care 75%). https://www.cdc.gov/HAI/organism s/cdiff/Cdiff_infect.html https://www.cdc.gov/hai/organisms /cdiff/cdiff-patient.html
  • 48. Clostridium difficile • C. difficile – was estimated to cause almost half a million infections in the United States in 2011, and 29,000 died within 30 days of the initial diagnosis. • Cost estimated to be 1 billion dollars annually. • Rates increased 4X between 2000 and 2007. NOT GOING DOWN https://www.cdc.gov/HAI/organism s/cdiff/Cdiff_infect.html https://www.cdc.gov/hai/organisms /cdiff/cdiff-patient.html
  • 49. Clostridium difficile – PA Hospitals • In FY 2017, 17,495 admissions for CDI—relatively steady since FY 2008. 20% developed the condition in the hospital. • Mortality Declining. “In-hospital mortality dropped 42% (from 9.7% to 5.7% • Readmission rates dropped 14%, from 32.9% to 28.2%.” • Patients admitted with CDI had a 5% mortality. Acquired CDI in the hospital was associated with a 8.5 mortality. Ref: PHC4 http://www.phc4.org/reports/rese archbriefs/cdi/17/nr030118.htm
  • 50. Clostridium difficile in KY– CDC - HAI CDC: .
  • 51. Clostridium difficile in KY – NHSN - HAI State Rankings Clostridium Difficile Infections – Hospital Associated NHSN Data for Acquisition Dates: 4/1/2016 3/31/2017 Ranking State Measure Name Measure ID SIR Score 1 AL C. Difficile HAI_6_SIR 0.623 2 ME C. Difficile HAI_6_SIR 0.68 3 ID C. Difficile HAI_6_SIR 0.692 4 MS C. Difficile HAI_6_SIR 0.718 5 FL C. Difficile HAI_6_SIR 0.769 6 SC C. Difficile HAI_6_SIR 0.77 7 HI C. Difficile HAI_6_SIR 0.779 8 AR C. Difficile HAI_6_SIR 0.786 9 KY C. Difficile HAI_6_SIR 0.799
  • 52. Clostridium difficile in KY– NHSN - HAI NHSN Data for Acquisition Dates: 4/1/2016 3/31/2017 Rank Hospital Measure ID SIR Score 1 WHITESBURG ARH HOSPITAL WHITESBURG C. Diff HAI_6_SIR 0 Better than NB 8 GREENVIEW REGIONAL HOSPITAL BOWLING GREEN C. Diff HAI_6_SIR 0.149 Better than NB 11 METHODIST HOSPITAL HENDERSON C. Diff HAI_6_SIR 0.289 Better than NB 12 HAZARD ARH REGIONAL MEDICAL CENTER HAZARD C. Diff HAI_6_SIR 0.291 Better than NB 14 HIGHLANDS REGIONAL MEDICAL CENTER PRESTONSBURG C. Diff HAI_6_SIR 0.332 Better than NB 16 HARDIN MEMORIAL HOSPITAL ELIZABETHTOWN C. Diff HAI_6_SIR 0.453 Better than NB 17 BAPTIST HEALTH PADUCAH PADUCAH C. Diff HAI_6_SIR 0.467 Better than NB 19 OUR LADY OF BELLEFONTE HOSPITAL ASHLAND C. Diff HAI_6_SIR 0.473 Better than NB 21 OWENSBORO HEALTH REGIONAL HOSPITAL OWENSBORO C. Diff HAI_6_SIR 0.503 Better than NB 24 LOURDES HOSPITAL PADUCAH C. Diff HAI_6_SIR 0.536 Better than NB 26 BAPTIST HEALTH MADISONVILLE MADISONVILLE C. Diff HAI_6_SIR 0.611 Better than NB 28 KING'S DAUGHTERS' MEDICAL CENTER ASHLAND C. Diff HAI_6_SIR 0.639 Better than NB 29 THE MEDICAL CENTER AT BOWLING GREEN BOWLING GREEN C. Diff HAI_6_SIR 0.652 Better than NB 30 UNIVERSITY OF KENTUCKY HOSPITAL LEXINGTON C. Diff HAI_6_SIR 0.766 Better than NB 31 ST ELIZABETH MEDICAL CENTER NORTH EDGEWOOD C. Diff HAI_6_SIR 0.77 Better than NB 57 EPHRAIM MCDOWELL REGIONAL MED. CTR. DANVILLE C. Diff HAI_6_SIR 1.482 Worse than NB 59 OWENSBORO HEALTH MUHLENBERG COMMUNITY HOSPITAL GREENVILLE C. Diff HAI_6_SIR 2.722 Worse than NB 60 FLAGET MEMORIAL HOSPITAL BARDSTOWN C. Diff HAI_6_SIR 3.529 Worse than NB  60 of 92 hospitals had calculated SIR Scores.  15 hospitals was statistically better than the National Benchmark.  3 hospitals were statistically worse than the National Benchmark.
  • 53. Antibiotic Overutilzation • Fluoroquinolones FDA: “The U.S. Food and Drug Administration is advising that the serious side effects associated with fluoroquinolone antibacterial drugs generally outweigh the benefits for patients with acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections who have other treatment options. For patients with these conditions, fluoroquinolones should be reserved for those who do not have alternative treatment options.” July 26, 2016. https://www.fda.gov/Drugs/DrugSaf ety/ucm500143.htm
  • 54. Antibiotic Usage – Kentucky The Center For Disease Dynamics, Economics & Policy https://resistancemap.cddep.org/CountryPageSub.php?countryId= 38&country=United+States
  • 56. Carbapenem-resistant Enterobacteriaceae • Severe GI Infections with a 50% fatality rate if enters the blood. • Colistin –Very toxic antibiotic is the last line of defense. • However, becoming resistant to this antibiotic. Ref: CDC
  • 57. Carbapenem-resistant Enterobacteriaceae • There is no National Reporting System • Possible to reduce CRE infections by 70% over 5 years if facilities coordinate to protect patients – CDC.
  • 58. CRE - Prevention Ref: Carbapenem-Resistant Enterobacteriaceae (CRE) Control and Prevention Toolkit. - AHRQ http://www.ahrq.gov/cretoolkit “Each institution will need to carefully choose among the available screening methodologies to support their active surveillance program, and lack of ability to implement molecular testing should not otherwise prevent pursuit of aggressiveCRE control efforts using existing culture techniques.”
  • 59. • Identification of all epidemiologically related contacts (screening). • Contact Isolation for carriers and those with infections.
  • 60. CRE are nightmare bacteria CRE in 2002 to 2012: “During the first six months of 2012 4.6% of hospitals reported one or more infections. 3.9% in short stay hospitals and 17.8% long term facilities.2 CRE Klebsiella cultures positive forCRE increased from 0.1% to 4.5% between 2002 and 2010.4 Vital Signs: Carbapenem-Resistant Enterobacteriaceae. MMWR Morbidity and Mortality Weekly Report. March 5, 2013. Vol. 62 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w CDC News Release. Tuesday, March 5th, 2013. http://www.cdc.gov/media/releases/2013/p0305_deadly_bacteria.html Braykov NP, Eber MR, Klein EY, Morgan DJ, Laxminarayan R. Trends in resistance to carbapenems and third-generation cephalosporins among clinical isolates of Klebsiella pneumoniae in the United States, 1999-2010. Infect Control Hosp Epidemiol. 2013 Mar;34(3):259-68. doi: 10.1086/669523. Epub 2013 Jan 23. http://www.ncbi.nlm.nih.gov/pubmed/23388360
  • 61. CRE in 2001 to 2013 • “Nationally, the CDC issued warnings last year about CRE, saying the bacteria spread from one medical facility in 2001 to numerous facilities in 46 states in 2013. CDC Director Tom Frieden said, "Our strongest antibiotics don't work, and patients are left with potentially untreatable infections.“ Unger L. Doctors fear growing hospital superbug. Courier Journal. Aug. 5, 2014. https://www.courier-journal.com/story/life/wellness/health/2014/08/04/doctors-fear- growing-hospital-superbug/13569933/
  • 62. CRE Outbreak in Louisville, KY - 2013 • “Kavanagh said it’s important that outbreaks be made public, partly because patients often go from one health care location to another “This is a huge problem,” he said. “It’s not something one hospital can control. In Kentucky, health care sites must report “outbreaks” of greater-than-expected numbers of cases, leaving it to them to interpret what that means. But Kavanagh and state Rep.Tom Burch, D-Louisville, are calling for a new rule that hospitals report all CRE cases to the state. Burch says he plans to introduce a bill on mandatory public reporting in next year’s General Assembly.” Ungar L. Kindred had 40 CRE cases. Courier Journal, April 16, 2013.
  • 63. CRE in 2012 to 2013 • Study finds an incidence of 2.93 CRE cases per 100,000 people over a two year period. Equates to 4500 People a Year. Data acquisition dates 2012-2013. Guh AY, Bulens SN, MuY, Jacob JT, et al. Epidemiology of Carbapenem-Resistant Enterobacteriaceae in 7 US Communities, 2012-2013. JAMA. 2015 Oct 5:1479-1487. doi: 10.1001/jama.2015.12480. [Epub ahead of print]
  • 64. CRE in 2014 - Kentucky Kentucky Deptartment for Public Health
  • 65. CRE in 2016 – HARP-DC
  • 67. Dangerous CRE Outbreak In Kentucky. Health Department Working With Healthcare Facilities • A rare form of resistance found in 8 patients, in 4 different types of bacteria, in two different wards. • Demonstrates that the transmission of resistance between different types of bacteria is clinically important. • No patient developed an infection.
  • 68. Dangerous CRE Outbreak In Kentucky. Health Department Working With Healthcare Facilities • A rare form of resistance found in 8 patients, in 4 different types of bacteria, in two different wards. • Demonstrates that the transmission of resistance between different types of bacteria is clinically important. • No patient developed an infection. Bacterial Conjugation
  • 69. Dangerous CRE Outbreak In Kentucky. "On August 11, 2016, two Klebsiella pneumoniae carbapenemase (KPC)– producing CP-CRE isolates from clinical cultures were reported from patients hospitalized at a rural, community hospital in Kentucky; CRE had not been identified previously at this facility. During the next 4 months, an additional 21 CRE isolates were identified from facility patients, resulting in a total of 23 isolates, including 17 K. pneumoniae, five Escherichia coli, and one Enterobacter cloacae isolate. Seventeen (74%) of these isolates were identified through patient screening cultures; the rest were from clinical cultures." We hear about it over a year later.
  • 71. Kentucky – MDRO Reporting Regulation  Defines an Outbreak “HAI Outbreak” means (a)The occurrence of two (2) or more HAIs that are epidemiologically linked or connected by person, place, or time; or (b) A single case of an HAI not commonly diagnosed such as a postsurgical groupA Streptococcus infection or healthcare-associated Legionella infection.  Covers AllTypes of Facilities ““Health facility” means: (a) A facility licensed under 902 KAR Chapter 20 and required by the Centers for Medicare and Medicaid Services (CMS) to report an HAI event or healthcare personnel influenza vaccination information to CMS using the National Healthcare Safety Network; or (b) A facility licensed under KRS Chapter 216B.” Healthcare associated infection surveillance KAR 902.20
  • 72. Kentucky – MDRO Reporting Regulation  Following diseases shall be electronically reported to the Kentucky Department for Public within five (5) business days: (a)Vancomycin-intermediate Staphylococcus aureus (VISA), (b)Vancomycin-resistant Staphylococcus aureus (VRSA) (c) Methicillin-resistant Staphylococcus aureus (MRSA) (d)Vancomycin-resistant Enterococcus species (VRE) (e) Clostridium difficile (C. difficile) identified from a positive laboratory test result for a C. difficile toxinA or B, (f) Carbapenem-resistant Enterobacteriaceae (CRE) (g) Extended–spectrum beta-lactamaseGram negative organisms (ESBL); (h) Multidrug-resistant – Acinetobacter - Non-susceptibility (resistant or intermediate) to at least one (1) agent in at least three (3) antimicrobial classes. Healthcare associated infection surveillance KAR 902.20
  • 73. • No single facility or facility type can solve this problem. It takes a coordinated approach.
  • 74. CDC: What Is Needed • Independent Approach – Not Enough • Coordinated Approach –What is Needed. Facilities and public health authorities share information and implement shared infection control actions to stop spread of germs from facility to facility. Vital Signs. Aug. 4, 2015 Center for Disease Control and Prevention
  • 75. Vital Signs. Aug. 4, 2015 Center for Disease Control and Prevention