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
Healthcare-Associated Infection (HAI)
Types
HAI
Pneumonia
Deviceassociated
infections
(subtypes)
Ventilatorassociated
(VAP)
Urinary tract
infection
Bloodstream
infection
Catheterassociated
(CAUTI)
Central lineassociated
(CLABSI)
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
Surgical
Site
Infection
Others
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
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
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
Stakeholder Landscape:
Societies,
organizations,
and initiatives
Federal
agencies and
programs
Increasing Demands, Need for Coordination
State Health Department
Local Universities
State Hospital
Associations
State QIO
Local APIC
Chapters
State Public
Health Labs
State survey and
certification
Vision: Coordinated Public Health Approach
Infrastructure
Prevention
Collaborative
Coordination
Other NonGovernmental
Initiatives
Surveillance
HAI expertise
Outbreak response
Survey/Cert
PH Lab
Standardized
Metrics
CDC’s DHQP: www.cdc.gov/hai
Response
Prevention
Surveillance
Local Capacity
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
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.
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
.
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
Increase in Incidence and
Prevalence of ESRD Internationally
USRDS 2009 Report. Published 2011
.
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. difficile
epidemic
National Estimates of US Short-Stay Hospital
Discharges with C. difficile, National Inpatient
Sample
Number of Discharges
400,000
350,000
Any listed
300,000
Primary
250,000
200,000
150,000
100,000
50,000
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
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
Gram Negative Pathogens
Reported to NHSN Jan 2006- Sept
Overall 2007
CLABSI
CAUTI VAP SSI
percentage
(rank)
E. coli
10% (5)
3%
21%
5%
10%
P. aeruginosa
8% (6)
3%
10%
16%
6%
K. pneumoniae
6% (7)
5%
8%
18%
3%
A. baumannii
3% (9)
2%
1%
8%
.6%
Hidron A, et al. Infect Control Hosp Epidemiol 2008; 29: 996-1011
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.
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
Geographic Distribution of KPCProducers: 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
Geographic Distribution of KPCProducers: 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
Novel Mechanisms Conferring
Carbapenem Resistance

Since 2009, in addition to KPC-producing
Enterobacteriaceae, several different metallo-βlactamase-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.
Geographic Distribution of KPCProducers: 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
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
Worldwide Distribution of KPC
•
Walsh. 2010. International Journal of Antimicrobial Agents
Prevention
http://www.cdc.gov/hai/organisms/cre/cre-toolkit/
How Should we Approach HAIs
Globally?
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
Egypt: Successfully Partnered
International Agencies
• 2-year interagency agreement between USAID
and NAMRU-3: “Promotion of Quality and
Safety of Healthcare in Egypt”
Egypt: Program Components
1. Design, pilot & implement a surveillance
system to measure HAIs and AMR
2. Implement targeted IC prevention
strategies to reduce rates of HAIs
3. Optimize Antibiotic Use in Egypt
4. Strengthen/create hospital infection
control programs in Egypt
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
Infection Control Unit
Global Disease Detection & Response Program
US Naval Medical Research Unit No.3
 Head
 IC specialists
 IC training





coordinator
Epidemiologists
M &E specialists
Pharmacist
Health
communication
specialist
Anthropologist
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
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
Egypt HAI Surveillance Timeline
Phase 1 = pilot
Apr/2011
Goal: Inform surveillance
methodology for phase 2
Phase 2 = limited
roll-out
Oct/2011
Phase 3 = full-scale
surveillance
Oct/ 2012
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
System Description
Surveillance
Coordinators attend
ICU rounds
Review Clinical, Lab,
Radiology results
Denominator data
collected manually:
- Pt days
- Device days
Suspect HAI?
Request more
investigations
YES
Enter in PDA
PDA confirms one of
43 HAIs coded
Lab & x-rays
results
Device-Associated Infection Rates, Selected
ICU Types
CLABSI
HAI/1,000 device-days
VAP
CAUTI
ICU type
Adult Medical
1.07
6.23
0.95
Adult Surgical
0
9.71
0
Adult/Ped Surgical
0.70
13.25
3.70
NICU
1.57
5.59
NA
Pediatric Med/Surg
0.48
6.88
0
NHSN 2010 Annual Report. http://www.cdc.gov/nhsn/PDFs/dataStat/NHSN-Report_2010-Data-Summary.pdf
Pathogens Reported: All HAIs
Most common pathogens reported for all HAI, N = 533*
Pathogen
No. reported % of total isolates
Rank
Egypt US
Acinetobacter spp.
115
22
1
14
Klebsiella spp.
97
19
2
4
Pseudomonas aeruginosa
77
15
3
5
S. aureus
67
13
4
1
Candida spp.
61
12
5
7
Other
106
20
*More than one pathogen/HAI can be reported
NHSN unpublished data.
Proportion of isolates with resistance
Antimicrobial Resistance for Isolates Received,
Selected Pathogens (N=180)
100%
100%
81%
80%
71%
60%
59%
62%
40%
20%
0%
Acinetobacte
r spp.
K.
pneumoniae
Pseudomona
s aeruginosa
S. aureus
E. coli
Multidrug
resistance
Extendedspectrum βlactamase
Multidrug
resistance
Methicillin
resistance
Extendedspectrum β
lactamase
N=39
N=42
N=27
N=21
N=11
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
Egypt-specific adaptation of
VAP prevention materials
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
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
Kenya: ABHR Project
Adapt training materials to local
context
Use permanent ink to mark the 5-Litre water level.
Kenya: ABHR Project
Adapt training materials to local
context
Calibrate and Label 20-Litre Jerrican
for 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
Kenya: ABHR Project
Adapt 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).
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
 Syndromic surveillance for respiratory HAIs
 Laboratory capacity building for MDRO surveillance
 Integration of HAI training into medical school
curriculums
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
Thank You!
I look forward to further discussion
kellingson@cdc.gov
For more information, please contact Centers for Disease Control and
Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion
Prevention
http://www.cdc.gov/hai/organisms/cre/cre-toolkit/
Surveillance and Definitions



Facilities/Regions should have an awareness of the
prevalence of CRE in their Facility/Region
Could concentrate on Klebsiella and E. coli
CDC definition (based on 2012 CLSI definitions):
 Your lab might not be using these definitions
 NS to one of the carbapenems (doripenem, meropenem,
imipenem)
 Resistant to all 3rd generation cephalosporins tested
 Some Enterobacteriaceae are intrinsically resistant to imipenem
(Morganella, Providencia, Proteus)
Interventions

Core









Hand hygiene
Contact Precautions*
HCP education
Minimizing device use
Patient and Staff cohorting
Laboratory notification*
Antimicrobial stewardship
CRE Screening*
* Included in 2009 document
Supplemental
 Active surveillance cultures
 Chlorhexidine bathing
Hand Hygiene





Proper protocols
Available supplies (soap, towels, etc.)
HCP education
Adherence monitoring and feedback
More information: www.cdc.gov/handhygiene
HCP Education

Regular education about MDROs
 Proper use of CP
 Hand hygiene
Contact Precautions






CP for patients colonized or infected with CRE
Systems in place to identify patients at readmission
Duration of CP unclear
Education of HCP about use and rationale behind CP
Adherence monitoring
Consideration of pre-emptive CP in patients
transferred from high-risk settings
Contact Precautions in Long-Term Care

CP could be modified in these settings:
 CP should be used for residents with CRE who are at higher risk
for transmission
•
•
•
•
Dependent upon HCP for their activities of daily living
Ventilator-dependent
Incontinent of stool
Wounds with drainage that is difficult to control
 For other residents the requirement for Contact Precautions
might be relaxed
 Standard Precautions should still be observed
Device Use

Minimize use of invasive devices
 Urinary catheters
 Central venous catheters

HICPAC recommendations for:
 Urinary catheters
 Central lines
Patient and Staff Cohorting





CRE patients in single rooms (when available)
Cohorting (even when in single rooms)
Staff cohorting
Recommendation applies to both acute and longterm care settings
Preference for single rooms should be given to
patients at highest risk for transmission such as
patients with incontinence, medical devices, or
wounds with uncontrolled drainage
Laboratory Notification


Facilities should have protocols for timely
notification of appropriate staff when CRE isolated
from surveillance or clinical specimens
Facilities who send cultures to off-site laboratories
should ensure that protocols are established with
those labs
Antimicrobial Stewardship

Programs to ensure:
 Antimicrobials used for proper indications and duration
 Appropriate spectrum

Link to Get Smart for Healthcare:
 http://www.cdc.gov/getsmart/healthcare
Antimicrobial Stewardship and MDR GNRs

Antimicrobial
stewardship program in
Surgical/Trauma ICU
 Specific protocol for
therapeutic antibiotics
 Surgical antibiotic
prophylaxis protocols
 Quarterly rotation and
limitation of dual antibiotic
classes
•
Dortch et al Surgical Infections 2011; 12:15-25
Antimicrobial Stewardship and MDR GNRs



Proportion of MDR GNR pathogens decreased (37%
to 9%)
Rate of infections caused by MDR GNRs decreased
yearly by 0.78/ 1,000 patient days
Yearly decrease was for:
 MDR Pseudomonas (-0.14/1,000 pd),
 MDR Acinetobacter (-0.49/1,000 pd),
 MDR Enterobacteriaceae (-0.14/ 1,000 pd)
•
Dortch et al Surgical Infections 2011; 12:15-25
CRE Screening





Used to identify unrecognized CRE colonization
among contacts of CRE patients
Stool, rectal, peri-rectal
Link to laboratory protocol
http://www.cdc.gov/ncidod/dhqp/pdf/ar/Klebsiella_or
_E.coli.pdf
Applicable to both acute and long-term care settings
Description of types
 Point prevalence survey
• Rapid assessment of CRE Prevalence on particular wards/units
• Might be useful if lab review identifies one or more previously
unrecognized CRE patient on a particular unit
 Screening of epidemiologically linked patients
• Roommates
• Patients who shared primary HCP
Active Surveillance Cultures


Controversial
Studies suggest that only a minority of patients
colonized with CRE will have positive clinical
cultures
 CRKP Point prevalence study in Israel (5.4% prevalence rate);
fewer than 5/16 had a positive clinical culture for CRKP. (WeinerWell et al. J Hosp Infect 2010;74:344-9)
 A study of surveillance cultures at a US hospital found that they
identified a third of all positive CRKP patients. Placing these
patients in CP resulted in about 1400 days from unprotected
exposure. (Calfee et al. ICHE 2008;29:966-8.
• r
Active Surveillance Cultures

One study from Israel used surveillance cultures (ICU) admission and weekly; (non-ICU) patients with
epi-links to CRE patients
 Found a 4.7-fold reduction in in CRKP infection incidence

Kochar et al. used rectal surveillance cultures as
part of a multifaceted intervention in an ICU
 Found decrease in number of new patients per 1,000 patient
days per quarter that were positive for CRKP
Ben-David et al. ICHE 2010; 31:620-6
Kochar et al. ICHE 2009; 30:447-52
Active Surveillance Cultures

Potential considerations:
 Focus on patients admitted to certain high-risk settings (e.g.,
ICU) or specific populations (e.g., from LTCF/LTAC)
 Generally done at admission but can also be done periodically
during admission


Patients identified as positive on these surveillance
cultures should be treated as colonized
Applicable to both acute and long-term care settings.
Chlorhexidine Bathing

Reviews basics of this process
 Limited evidence for CRE
• Used effectively by Munoz-Price in outbreak in LTAC as part of a
package of interventions
 Applied to all patients regardless of CRE colonization status

In long-term care:
 Might be used on targeted high-risk residents (e.g., residents
that are totally dependent upon healthcare personnel for
activities of daily living, are ventilator-dependent, are incontinent
of stool, or have wounds whose drainage is difficult to control)
 Might be less frequent depending on the facility’s usual bathing
protocol.
Munoz-Price et al. ICHE 2010;31:341-7