Identifying and Preventing Healthcare-Associated Infections: A Global Challenge

1. Identifying and Preventing Healthcare-Associated Infections: A Global Challenge Kate Ellingson, PhD Epidemiologist, Division of Healthcare Quality Promotion Centers for Disease Control and Prevention October 11, 2012 Division of Healthcare Quality Promotion

2. Healthcare-Associated Infection (HAI) Types HAI Pneumonia Urinary tract infection Bloodstream infection Surgical Site Infection Others Ventilator-associated (VAP) Catheter-associated (CAUTI) Central line-associated (CLABSI) Device-associated infections (subtypes) Target of many prevention efforts Picture courtesy S Schrag http://www.lightstalkers.org/images/show/305512 http://www.featurepics.com/FI/Thumb300/20090428/Foley-Bag-1166380.jpg

3. HAI: Pathogens • Reservoirs • Skin: Staphylococcus aureus • Water/environment: gram-negative organisms (e.g., Klebsiella spp., E. coli, Pseudomonas aeruginosa, Acinetobacter spp.) • Antimicrobial resistance • Severely limits treatment options • Methicillin-resistance • Extended-spectrum β lactamase production (E. coli, Klebsiella spp.) • Multidrug resistance

4. Objectives • Provide overview of the current national landscape of HAI activities • Provide justification for a global approach • Worldwide burden of HAIs • Global proliferation of invasive healthcare • Antimicrobial resistance • Describe examples of CDC’s international HAI efforts • Discuss key elements of a responsible global approach to HAI prevention moving forward

5. HAIs Under the National Spotlight • Paradigm shift in past decade: HAIs increasingly viewed as preventable • Prevention research demonstrates dramatic decreases in HAI rates with implementation of evidence-based practices • Consumers mobilized, demanding action and transparency • States begin to pass laws mandating reporting of HAIs • First HHS Action Plan finalized in 2009 • HAIs become CDC Winnable Battle • $39 million to state health departments to build local capacity for HAI surveillance and prevention • AHRQ funds national prevention efforts • CMS invokes payment non-reimbursement incentives for hospital-acquired conditions and incentives for reporting • Partnership for Patients established

6. Stakeholder Landscape: Increasing Demands, Need for Coordination Federal agencies and programs Societies, organizations, and initiatives State Health Department Local Universities State survey and certification State QIO State Hospital Associations Local APIC Chapters State Public Health Labs

7. Vision: Coordinated Public Health Approach Other Non-Governmental Initiatives Prevention Collaborative Coordination Surveillance Infrastructure HAI expertise Outbreak response Survey/Cert PH Lab Standardized Metrics

8. CDC’s DHQP: www.cdc.gov/hai Response Prevention Local Capacity Surveillance

9. Need for a Global Approach • Global burden: HAIs lead to excess morbidity, mortality, and healthcare costs worldwide • Proliferation of invasive healthcare internationally without commensurate infection prevention infrastructure • Antimicrobial resistance: everyone’s problem

10. Global Burden • Healthcare-associated infection (HAI) in the United States (2002) • 1/20 patients • 1.7 million HAIs • 99,000 deaths • Developing countries • Limited data from low income countries • Estimated prevalence: at least three times greater than United States Klevens et al Public Health Reports 2007. Allegranzi et al Lancet 2011.

11. International Nosocomial Infection Control Consortium • 422 ICUs in 36 countries in Latin America, Asia, Africa, and Europe used National Healthcare Safety Network (NHSN) definitions for device-associated infections • Similar amount of device use in INICC units as in US hospitals Rosenthal et al. Am. J. Infection Control. 2012 .

12. Why might there be more HAIs in middle- and low-income countries? • Less infection prevention and control infrastructure • Training lacking in general infection control • Improper use of equipment (e.g., reuse of single-use equipment) • Insufficient reprocessing • Less surveillance, awareness, and targeted prevention efforts • Proliferation of invasive medical care across the globe • Large dialysis organizations expanding across boarders • Increase in medical tourism

13. Increase in Incidence and Prevalence of ESRD Internationally USRDS 2009 Report. Published 2011 .

14. Antimicrobial Resistance • Studies suggest that approximately ½ of antimicrobial use in US healthcare settings is inappropriate • Rising resistance leads to decreasing treatment options and increasing cost • Inappropriate prescribing contributor to C. difficileepidemic

15. National Estimates of US Short-Stay Hospital Discharges with C. difficile,National Inpatient Sample Any listed Primary Number of Discharges Year Elixhauser, A. (AHRQ), and Jhung, MA. (Centers for Disease Control and Prevention). Clostridium Difficile-Associated Disease in U.S. Hospitals, 1993–2005. HCUP Statistical Brief #50. April 2008. Agency for Healthcare Research and Quality, Rockville, MD. And unpublished data http://www.hcup-us.ahrq.gov/reports/statbriefs/sb50.pdf

16. Gram Negative Pathogens Reported to NHSN Jan 2006- Sept 2007 Hidron A, et al. Infect Control Hosp Epidemiol 2008; 29: 996-1011

17. Klebsiella Pneumoniae Carbapenemase KPC confers resistance to all b-lactams including extended-spectrum cephalosporins and carbapenems Is the predominant mechanisms of carbapenem resistance in Enterobacteriaceae (CRE) in the US.

18. Mortality-associated with Resistance OR 3.71 (1.97-7.01) OR 4.5 (2.16-9.35) Patel et al. Infect Control Hosp Epidemiol 2008;29:1099-1106

19. Geographic Distribution of KPC-Producers: 2006 Patel, Rasheed, Kitchel. 2009. Clin Micro News MMWR MMWR Morb Mortal Wkly Rep. 2010 Jun 25;59(24):750. MMWR Morb Mortal Wkly Rep. 2010 Sep 24;59(37):1212. CDC, unpublished data

20. Geographic Distribution of KPC-Producers: 2010 Patel, Rasheed, Kitchel. 2009. Clin Micro News MMWR MMWR Morb Mortal Wkly Rep. 2010 Jun 25;59(24):750. MMWR Morb Mortal Wkly Rep. 2010 Sep 24;59(37):1212. CDC, unpublished data

21. Novel Mechanisms Conferring Carbapenem Resistance • Since 2009, in addition to KPC-producing Enterobacteriaceae, several different metallo-β-lactamase-producing strains have been identified • New Delhi metallo-β-lactamase (NDM) • Verona integron-encoded metallo-β-lactamase (VIM) • imipenemase(IMP) metallo-β-lactamase • Enzymes are more common in other areas of the world • In United States generally been found among patients who received medical care in countries where these organisms are known to be present.

22. Geographic Distribution of KPC-Producers: 2012 KPC KPC, NDM KPC, NDM, VIM KPC, NDM, VIM, IMP Patel, Rasheed, Kitchel. 2009. Clin Micro News MMWR MMWR Morb Mortal Wkly Rep. 2010 Jun 25;59(24):750. MMWR Morb Mortal Wkly Rep. 2010 Sep 24;59(37):1212. CDC, unpublished data

23. Novel Enzymes: Many Related to Healthcare Exposure Outside US • To date CDC has confirmed • 14 NDM-producing Enterobacteriaceae ( all but 1 had received care outside the U.S. • 3 IMP-producing Enterobacteriaceae • 3 VIM-producing Enterobacteriaceae (2/3 had received care outside the US) • 2 OXA-48 producing Enterobacteriaceae (both with healthcare exposure outside the US) • Spread of novel resistance mechanisms is bidirectional between US and other countries

24. Worldwide Distribution of KPC Walsh. 2010. International Journal of Antimicrobial Agents

25. Prevention http://www.cdc.gov/hai/organisms/cre/cre-toolkit/

26. How Should we Approach HAIs Globally?

27. International Efforts Abroad • Two case examples: • Surveillance and prevention in Egypt • Infection Control training and infrastructure building in Kenya • Both countries CDC International Emerging Infection Program Sites

28. Egypt: Successfully Partnered International Agencies 2-year interagency agreement between USAID and NAMRU-3: “Promotion of Quality and Safety of Healthcare in Egypt”

29. Egypt: Program Components

30. Challenges in Implementing Surveillance for HAIs and AMR in Egypt • Complexity of CDC case definitions • Limited Resources • Labor intensive • Staff not motivated • Limited financial and human capacities • Data management capabilities • Limited hospital laboratory capacities • Medical Records not well maintained • Political- confidentiality issues

31. Head IC specialists IC training coordinator Epidemiologists M &E specialists Pharmacist Health communication specialist Anthropologist Infection Control UnitGlobal Disease Detection & Response ProgramUS Naval Medical Research Unit No.3

32. What is the Best Strategy for Surveillance of HAIs and AMR in Egypt? • 1st Panel of experts: Jan, 2011 • Infection Control Unit • CDC/DHQP • WHO/HQ • Cornell University • MOH/University Reps

33. Proposed Surveillance Approach Panel of Experts - January 2011 • Phase I: (Pilot - 9 months) • Active prospective surveillance • CDC – NHSN case definitions • Select eligible hospitals • Only ICUs • All types of HAI monitored • Four pathogens reported by infection type • Regular monitoring to hospitals • Evaluation - 6 months after implementation

34. Egypt HAI Surveillance Timeline Phase 2 = limited roll-out Phase 3 = full-scale surveillance Phase 1 = pilot Oct/ 2012 Apr/2011 Oct/2011 Goal: Inform surveillance methodology for phase 2

35. Training to Implement Surveillance • Surveillance training • Epi & Surveillance • Clinical practice in identifying HAI • Use of PDAs • 583 people trained • Microbiology training • standardized lab techniques: • Organism identification • Antimicrobial susceptibility testing • 40 lab people trained

36. System Description Surveillance Coordinators attend ICU rounds Review Clinical, Lab, Radiology results Denominator data collected manually: - Pt days - Device days Request more investigations Suspect HAI? YES Enter in PDA Lab & x-rays results PDA confirms one of 43 HAIs coded

37. Device-Associated Infection Rates, Selected ICU Types NHSN 2010 Annual Report. http://www.cdc.gov/nhsn/PDFs/dataStat/NHSN-Report_2010-Data-Summary.pdf

38. Pathogens Reported: All HAIs NHSN unpublished data.

39. Antimicrobial Resistance for Isolates Received, Selected Pathogens (N=180)

40. Recommendations • HAI prevention should focus on: • Pneumonia (all ICUs) • CLABSI (NICUs) • Identify sources of multidrug-resistant organisms and implement measures to control transmission • Build laboratory capacity

41. Egypt-specific adaptation of VAP prevention materials

42. Kenya –Medical Education Partnership Initiative • Healthcare-associated infection “carve out” from PEPFAR funds • CDC guidance for infection prevention in resource-limited settings • Modules to be vetted and piloted in Kenya, then disseminated more broadly

43. Kenya- Local Production Project • iFund grant to improve HH in Kenyan hospitals through local production of ABHR • Production underway in 3 hospitals using WHO recipe for local production of ABHR • Mixed-methods evaluation underway

44. Kenya: ABHR ProjectAdapt training materials to local context Use permanent ink to mark the 5-Litre water level.

45. Kenya: ABHR ProjectAdapt training materials to local context Calibrate and Label 20-Litre Jerricanfor First Use (cont.) Repeat this process until the 20-Litre jerrican is marked with the 5 Litre, 7.5 Litre, and 10 Litre calibration marks

46. Kenya: ABHR ProjectAdapt training materials to local context Step 1: Add isopropyl alcohol • Pour a total of 7515 mL of 99.8% isopropyl alcohol into the 20L jerrican. (This can be done in three increments using the 5-litre container and a funnel).

47. CDC Kenya: Infrastructure Building • Production of ABHR occurring at 3 hospitals • Intervention staggered for intervention-control evaluation • Hand hygiene audit rates fed back to healthcare workers • Final report in 2013 to be sent to ministry for broader consideration • Other CDC-Kenya HAI-related efforts • Syndromicsurveillance for respiratory HAIs • Laboratory capacity building for MDRO surveillance • Integration of HAI training into medical school curriculums

48. Future Considerations Related to Global HAI Infrastructure, Surveillance, and Prevention • Raising awareness of HAI as a public health issue is key • Paradigm shift in United states mobilized action • Can learn from successes/failures of US approach • Basic training and infrastructure are the foundation of robust surveillance and prevention efforts • Before implementing surveillance • Focus on documentation and laboratory capacity • Understand local barriers • Multi-facility, infection-specific collaborative models have shown success globally • Prioritization and balance is key

49. Thank You! I look forward to further discussion kellingson@cdc.gov National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

50. Prevention http://www.cdc.gov/hai/organisms/cre/cre-toolkit/