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Methicillin Resistant Staphylococcus aureus (MRSA): Proposed Revision of ICD-9 Codes

This article proposes modifications to the ICD-9 codes for MRSA to improve monitoring and tracking of infections caused by this antibiotic-resistant bacteria. It discusses the current state of MRSA infections, the sources of surveillance data, and the challenges in using ICD-9 codes for monitoring MRSA infections. The article also highlights the need for more specific codes for MRSA and methicillin resistance.

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Methicillin Resistant Staphylococcus aureus (MRSA): Proposed Revision of ICD-9 Codes

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  1. Methicillin Resistant Staphylococcus aureus (MRSA): Proposed Revision of ICD-9 Codes Rachel Gorwitz, MD, MPH Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

  2. Staphylococcus aureus • Common human colonizer • Common cause of skin infections • Potential to cause severe / invasive infections • Transmission: Direct contact

  3. Methicillin-Resistant Staphylococcus aureus (MRSA) • Resistant to all currently available β-lactam antibiotics (penicillins, cephalosporins) • Accounts for majority of S. aureus infections in healthcare settings • Associated with increased morbidity, mortality, and healthcare costs as compared to methicillin-susceptible S. aureus (MSSA) • 1990s: Emerged as a community pathogen • Mainly skin infections • Occasionally severe / life-threatening

  4. HAI = healthcare-associated infection

  5. Sources of MRSA Surveillance Data • Active Bacterial Core Surveillance Project • National Healthcare Safety Network (NHSN) • National surveys using ICD-9 codes • Specialized Projects • EMERGEncy ID Net • National Health and Nutrition Examination Survey

  6. Active Bacterial Core Surveillance Areas (Invasive MRSA) Minnesota New York Oregon Connecticut California Maryland Colorado Tennessee Georgia Total Population: ~ 16.3 million

  7. ABCs MRSA Case Categorization • Healthcare-associated: • Hospital-onset: Cases with positive culture obtained >48 hrs after hospital admission (may also have risk factors) • Community-onset: Cases with at least 1 of the following risk factors: • Invasive device at time of admission; h/o MRSA infection or colonization; h/o surgery, hospitalization, dialysis, or residence in a LTC facility in 12 mos preceding culture • Community-associated: Cases with community-onset and none of above risk factors documented

  8. Methods of Invasive MRSA Surveillance MRSA + Isolates from invasive site Unique MRSA Patients Medical Record Review Healthcare Risk Factors Healthcare-Associated Community-Associated

  9. Healthcare-Associated (community-onset) Healthcare-Associated (hospital-onset) Community-Associated ABCs Invasive MRSA Surveillance 2005 National estimates: 94,360 infections; 18,650 deaths 28% 59% 14% Klevens et al JAMA 2007;298:1763-71

  10. National Healthcare Safety Network (NHSN) • Voluntary, confidential, internet-based system for monitoring healthcare-associated events and processes (including HAIs) • Purposes: • Provide national estimates of magnitude of adverse events, trends • Provide risk-adjusted data for interfacility comparisons • Assist facilities in developing surveillance and analysis methods • Facility-associated infection: • No evidence infection was present or incubating at time of admission (as assessed by trained infection control professional)

  11. Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections • Nationally representative surveys of hospitalizations and ambulatory care visits • Utilize: • Specific S. aureus infection codes (038.11 septicemia, 482.41 pneumonia) • S. aureus organism code (041.11) • Codes for syndromes typical of S. aureus (e.g., 682 cellulitis and abscess) • Methicillin resistance data from V codes (V09.0) or external data sources

  12. Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections • Kuehnert et al, Emerg Infect Dis 2005 • 291,542 annual hospital discharges with S. aureus infection-related diagnoses 1999-00 • 125,969 MRSA • Klein et al, Emerg Infect Dis 2007 • 62%  in S. aureus-related hospitalizations 1999-2005; >2-fold  in MRSA-related hospitalizations • McCaig et al, Emerg Infect Dis 2006 • 11.6 million annual ambulatory care visits for skin infections typical of S. aureus 2001-03

  13. Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections: Challenges • With exception of septicemia and pneumonia, S. aureus organism code not linked to clinical syndrome • Resistance code (V09.0) not linked to clinical syndrome or S. aureus organism code (041.11) • National surveys contain a limited number of ICD-9 fields → organism codes and resistance codes may be deleted • Current resistance code (V09.0) not specific for S. aureus or for methicillin-resistance • Currently no colonization code specific for S. aureus or MRSA (falls under V02.59 – Other specified bacterial diseases)

  14. Proposal: Modification of ICD-9 Codes for MRSA • Pages 17-18 of agenda

  15. Acknowledgements • Kate Ellingson • Scott Fridkin • Jeffery Hageman • Michael Jhung • John Jernigan • Monina Klevens • Cliff McDonald • Cathy Rebmann • Chesley Richards • Melissa Schaefer • Arjun Srinivasan

  16. Legislative Activity for Public Reporting of Healthcare-Associated Infections WA Jul-2008 VT Feb-2007 ME MT ND MN OR NH NY Jan-2007 ID SD WI MA Jul-2008 WY MI RI PA Feb-2008 CT Jan-2008 IA NE NJ Jan-2009? NV OH UT DE Feb-2008 IL IN DC CO Jan-2008 CA Jan-2008 MD Jul-2008 WV VA Jul-2008 KS MO KY NC TN Jan-2008 * OK Jul-2008 AZ SC Jul-2007 AR 2008 NM Mandates Public Reporting,Using NHSN GA AL MS Mandates Public Reporting TX LA Pending Legislation FL AK HI * Voluntary reporting using NHSN 2/13/2008

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