Antimicrobial Stewardship: an HAI
response activity in Connecticut
Richard Melchreit, MD
HAI Program Coordinator
National Metrics and 5-Year Targets
Metric
National 5-year
Base/Target
Source Prevention
year
Target
On Track?
Bloodstream
Yes
NHSN 50% reduction 2006-8/2013
infections
Clostridium
difficile (hospital HCUP 30% reduction 2008/2013
No
discharges)
Clostridium
Data not yet available
NHSN 30% reduction 2010-11/2015
difficile infections
Urinary tract
NHSN 25% reduction 2006-8/2013
Yes
infections
MRSA invasive
infections
EIP
50% reduction 2007-8/2013
Yes
(population)
MRSA bacteremia
Data not yet available
NHSN 25% reduction 2010-11/2015
(hospital)
Surgical site
Yes
NHSN 25% reduction 2006-8/2013
infections
Source: http://www.hhs.gov/ash/initiatives/hai/nationaltargets/index.html#table1
CMS Reporting Requirements:
sorted by year
Year
HAI Event
Facility type/location
2011
CLABSI
ACH/ICUs
2012
CAUTI
ACH/ICUs
SSI:COLO, SSI:HYST
ACH/all inpatient
DE
Outpatient Dialysis
MRSA bacteremia LabID, CDI LabID
ACH/all inpatient
HCW vaccination
ACH
CLABSI, CAUTI
LTACH/all inpatient
CAUTI
IRF/adult, pediatric wards
CLABSI, CAUTI
ACH/wards
HCW vaccination
ACH/outpatient; LTACH, IRF, ASC
MRSA bacteremia LabID, CDI LabID
LTACH/all inpatient
2013
2015
CSTE recommendation: CDI reporting (NHSN) to
public health departments
Organism/
specimen
Type of facility
Type of
location
Time frame
2013
C. difficile
Infection
LabID Event
2014
Acute Care
Hospitals
All inpatient
LTACH
All inpatient
X
CHA
All inpatient
X
IRF
All inpatient
X
Other non IQR
All inpatient
LTCFs*
All residents
2015
Exceptions
2016
X
NICUs, well
baby
nurseries
X
x
* Will require enough facilities to develop the infrastructure and skills necessary to
effectively use NHSN.
CSTE recommendation: MRSA Bacteremia
reporting (NHSN) to public health departments
Organism/
specimen
Type of facility
Type of
location
Time frame
2013
MRSA
Bacteremia
LabID Event
2014
Acute Care
Hospitals
All inpatient
LTACH
All inpatient
X
CAH
All inpatient
X
IRF
All inpatient
X
Other non IQR
All inpatient
LTCFs*
All residents
2015
Exceptions*
2016
X
None
X
x
* Will require enough facilities to develop the infrastructure and skills necessary to
effectively use NHSN.
Methods and Case Definitions
Invasive (sterile site) MRSA isolates
reported from labs statewide
Medical Record Review
Hospital-Onset
(HO-MRSA)
Isolate collected >2 days
after hospital admission
Community-Associated
(CA-MRSA)
No HACO risk factors
Health Care-Associated
Community-Onset
(HACO-MRSA)
-Central venous line at time of culture
-Hospitalization, surgery, dialysis, or
LTCF residence in year before culture
Incidence of MRSA by Place of Onset
and Year, Connecticut, 2001-2011
All MRSA
Rate per 100,000 population
30
HO
HACO
CA
25
p<0.01a
20
15
p<0.01a
10
p<0.01a
p<0.01a
5
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Year
aChi-square
for trend
Revised Annualized National
Estimates, ABCs MRSA 2005-2010
(updated Nov, 2012)
Estimated No. Infections, U.S.
120,000
100,000
80,000
60,000
Overall
CA
HO
40,000
HACO
20,000
0
2006 2007 2008 2009 2010 2011
Revisions include: 2005
Adjustment for dialysis; incorporation of interval estimates (not included);enhanced case finding (TN) and resolved data
transmission error (2006-2007). Data accessed (frozen) November 2012.
Revised Annualized National
Estimates, ABCs MRSA 2005-2010
(updated Nov, 2012)
Estimated No. Infections, U.S.
120,000
100,000
80,000
Overall
CA
60,000
HO
~50% were discharged
from acute care in
previous 3 months
40,000
20,000
HACO
~27% were outpatient
dialysis patients
0
2005
2006
2007
2008
2009
2010
2011
Revisions include:
Adjustment for dialysis; incorporation of interval estimates (not included);enhanced case finding (TN) and resolved data
transmission error (2006-2007). Data accessed (frozen) November 2012.
Vancomycin-resistant Enterococci
(VRE) Connecticut: 2000-2010
VRE Incidence by Age
VRE Incidence by Hospital Staffed Bed Size
Percent
Percent of CLABSI organisms that were
VRE or MRSA: 2009-2012
18.0
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
2009
2010
VRE
2011
MRSA
2012
Percent of CAUTI and SSI organisms
that were VRE or MRSA 2012
Type of
Infection
Total
number of
pathogens
isolated
Number
(Percent)
VRE
Number
(Percent)
MRSA
CAUTI
543
23 (4.2)
1( .2)
SSIs related
to colon
surgeries
191
7 (3.7)
13 (6.8)
Emerging Infections Program HAI
prevalence survey CT 2011
EIP Antimicrobial Use Survey CT 2011
Carbapenem-resistant
Enterobacteriacea
• Two KPC isolates from
CT hospitals confirmed
by CDC
• One NDM
• NHSN has reporting
capability
• Laboratories report
CREs in some other
states
• Laboratory Reportable
Condition 2014
CRE Laboratory Reporting Algorithm
Is the specimen a clinical isolatefrom a
sterile site, sputum, or urine?1
No
Yes
Is the organism I or R to Doripenem,
Imipenem, or Meropenem ? Is the organism R
STOP
do not
report
No
STOP
do not
report
Yes
# of carbepenems (DOR, IMI, MERO) that are (I
or R) plus Ertapenem (only if R)
2 or more
1
I or R to any and all 3rd
generation cephalosporins
≥ 30 days since last
clinical isolate
Yes
Yes
No
Is isolate Proteus,
Morganella, or
Providencia?
Report isolate
via OL-15C
Is this a new
genus/species or a new
resistance profile
compared to previous
Yes
I or R to
Imipenem?
Intermediate
Yes
Resistant
No
No
Report isolate
via OL-15C
Go to
1If more
than one clinical isolate is collected on the same, first date of collection - report only the isolate from the
most invasive source: CSF>Blood/Body Fluid>Sputum>Urine;
2 If within 30 calendar days a second, more invasive isolate is collected additional reporting is not required.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion
Fair Haven Community Health
Center HCHC project
• AMS in the outpatient setting (70% of patients
are Latino)
• Assessment of AMS (facility level)
• Provider and patient knowledge, attitude,
practices assessment
• Provider, patient education (Get Smart
materials)
• Chart reviews to assess prescribing
Upcoming DPH activities
• Commissioner’s Call to Action for
antimicrobial stewardship
• Antimicrobial stewardship survey of acute
care hospitals
• Posting of hospital-specific 2012 CLABSI,
CAUTI, and SSI (COLO, HYST) data on DPH
website
• Emerging Infections Program: antimicrobial
use paper (descriptive) and new
appropriateness survey