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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 ??