Prevent Healthcare Associated Infections CDR Tammy Servies, MD, MPH Uniformed Services University of the Health Sciences 1 December 2016

Disclosures The presenter has no financial relationships to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. Neither PESG, AMSUS, nor any accrediting organization support or endorse any product or service mentioned in this activity. PESG and AMSUS staff has no financial interest to disclose. Commercial support was not received for this activity.

Disclaimer The content of this presentation is the sole responsibility of the author and does not necessarily reflect the views or policies of the Uniformed Services University of the Health Sciences (USUHS), the Department of Defense (DoD), or the Departments of the Army, Navy or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.

Learning Objectives Understand the nature of the problem and importance of this initiative List the 6|18 recommendations related to healthcare associated infections Supporting evidence for goals and recommendations Review current programs within the Military Health System (MHS) Explore potential programs and interventions

Definition An infection acquired in hospital by a patient who was admitted for a reason other than that infection An infection occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission. Infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility Nosocomial infections occur worldwide, and have a significant impact on both developed and resource poor countries. Infections acquired from within health care settings are a major cause of increased morbidity among hospitalized patients, and represent a significant social cost and public health burden. Prevention of hospital acquired infections, A practical guide. 2nd edition. World Health Organization, 2002

Categories & Impact Categories: Impact: Why is it important?* Central line associated blood stream infections (CLABSI) Catheter- associated urinary tract infections (CAUTI) Surgical site infections (SSI) Hospital onset Clostridium difficile infections Hospital onset methicillin resistant Staphylococcus aureus (MRSA) bacteremia Impact: Why is it important?* Healthcare associated infections are one of the most common sources of preventable harm Contributes to hospital readmissions, development of antibiotic resistance Most of such infections are preventable; represent opportunity to save lives and reduce cost Healthcare Associated Infections represent a significant problem; most of these cases are preventable- the implementation of prevention practices could lead up to a 70% reduction in many categories. (Healthypeople.gov) *HealthyPeople2020; Scott II, R.

Costs

HAI within the MHS All inpatient facilities participate in Partnership for Patients (https://partnershipforpatients.cms.gov/)* Data from CDC’s National Healthcare Safety Network indicate MHS hospitals are generally meeting national standards** Partnership for Patients is a nationwide public/private partnership initiative working to improve quality, safety, and affordability of health care for all Americans; its two primary goals are: making care safer and improving care transition ***Standardized infection ratio is a summary statistic that can be used to track healthcare associated infection prevention progress over time. Lower SIRs are better. About ½ of MHS hospitals do not have enough procedures for accurate data analysis *MHS Review Final Report **Health.mil Patient Safety Reports ***CDC HAI Progress report

6|18 Prevent Healthcare Associated Infections Require antibiotic stewardship programs in all hospitals and skilled nursing facilities Prevent hemodialysis-related infections through immediate (payer) coverage for insertion of permanent dialysis ports Recommendation: A study implementing the CDC Antibiotic Stewardship Guidelines resulted in 25% of antimicrobial orders being modified (86% resulted in less-expensive therapy, and 47% resulted in use of a drug with a narrower spectrum of activity), significantly increasing microbiologically based prescribing (63% vs. 27%). Stepwise implementation of an antimicrobial stewardship program demonstrated progressive decreases in antimicrobial consumption and savings of $913,236 over 18 months. A study of an intervention that led Canadian medical trainees to implement CDC-recommended antibiotic “time outs” reduced antibiotic costs on the unit from $149,743 (Canadian dollars) (January 2011 to January 2012) to $80,319 (January 2012 to January 2013), for a savings of $69,424 (46% reduction).3 A pharmacist records review of inpatients who were prescribed two or more antibiotics in order to identify redundant combinations identified 70% of combinations investigated were inappropriate. The pharmacist-stewardship intervention was projected to have saved $10,800 and 584 days of reduction in antibiotic combination days

Antibiotic Resistant Infections Over 2 million antibiotic resistant infections annually Over 23,000 deaths due to antibiotic resistance annually $20 billion in direct excess costs Additional $35 billion to society in lost productivity Annually, over 23 thousand fatalities, and over 2 million illnesses can be directly attributed to antibiotic resistant infections. In 2010, nearly a million cases of antibiotic resistant infections were reported; ----____ *CDC, 2013

Four Core Actions to Prevent Antibiotic Resistance Prevent infections, prevent the spread of resistance Tracking Improving antibiotic prescribing/stewardship Developing new drugs and diagnostic tests Preventing infections, preventing spread of disease: Preventing an initial infection reduces amount of antibiotics used, and reduces likelihood of resistance development. Multiple ways of avoiding infections: personal hygiene/hand washing, use of immunizations, and sanitary cooking/food handling practices are good examples. Tracking Centers for Disease Control (CDC) collect and evaluate data on antibiotic resistant medications, possible causes for resistance, and risk factors for infection/transmission. Improving Antibiotic prescribing /stewardship Behavioral and cultural change- over half of antibiotic usage is unnecessary and inappropriate. Stopping such unregulated use in livestock, and altering the frequency of antibiotic prescriptions would greatly reduce the spread of resistant bacteria. Developing new drugs and diagnostic tests Ongoing research is needed to continue to counteract natural microbial evolution

Antibiotic Stewardship Programs in US

DoD Initiatives and Ways Ahead Antibiotic stewardship programs in most hospitals Ensure hospitals and clinics are following guidelines: http://www.cdc.gov/getsmart/healthcare/pdfs/checklist.pdf DoD Combating Antibiotic Resistant Bacteria (CARB) program* Multi-drug Resistant Organism Repository and Surveillance Network (MRSN)* Located at WRAIR Sequenced mcr-1 transferrable gene from colistin-resistant E. coli Research on sepsis in deployed service members* Research on drug resistant malaria* *Levine, P. June 6, 2016 Letter

Scope of Hemodialysis Related Infections Incidence of sepsis in ESRD patients is 100 times as high as general population* Over 50% of ESRD patients in the US initiate dialysis with central venous catheter (CVC)* Delays blamed on slow referral process and slow catch up of Medicare for ESRD patients* Relative risk of infection of CVC vs. AV Fistula is 2.3** Reducing CVC use by 50% in ESRD patients will save $1 billion in Medicare costs*** *2013 DHHS **2006 National Kidney Foundation ***2011 Allon, et al.

DoD/MHS Hemodialysis When possible, permanent access is created prior to initiation of hemodialysis Exceptions are primarily in emergencies Tricare/Tricare for Life covers all-aspects of ESRD up until the fourth month of dialysis at which point the patient must be enrolled in Medicare

DoD/MHS Dialysis Way Ahead Capture/Evaluate data on CVC vs. permanent dialysis access Minimize use of CVC in ESRD patients Ensure adequate time is allowed for maturation of permanent access prior to use

Future endeavours (Ideas/suggestions) Risk management of communicable disease (MERS-CoV, Pandemic Influenza, Tuberculosis) Procedure for patient screening at point of entry into MHS (Urgent care, ER) Procedure for isolation, quarantine Patient/provider education Process improvement measures Identification of patients at greater risk for readmission

Summary DoD is leading the way in HAI initiatives MTFs should ensure good adherence to recommendations and move forward with future initiatives

References Centers for Disease Control and Prevention. (2013, April 23). Antibiotic Resistance Threats in the United States, 2013. Retrieved from http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf Levine, Peter. (2016, June 6). “Letter to Honorable Thad Cochran, Chairman, Subcommittee on Defense Committee on Appropriations.” Department of Health and Human Services. (2013, April). National Action Plan to Prevent Healthcare Associated Infections: Road Map to Elimination. Retrieved from https://health.gov/hcq/pdfs/hai-action-plan-esrd.pdf National Kidney Foundation KDOQI guidelines. Clinical Practice Guidelines and Clinical Practice Recommendations: 2006 Updates. New York: National Kidney Foundation; 2006. http://www2.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/ Allon, M., Dinwiddie, L., Lacson, E., Latos D.L., Lok, C.D., Steinman, T., et al. “Medicare reimbursement policies and hemodialysis vascular access outcomes: a need for change.” Journal of the American Society of Nephrology. 2011; 22(3): 426-30. Zimlichman, E. et al. “Health Care-Associated Infections: A Meta-analysis of Costs and Financial Impact on the US Health Care system.” JAMA Intern Med. 2013; 173(22):2039-2046 Scott II, R. “The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention.” Division of Healthcare Quality Promotion… Centers for Disease Control and Prevention, March 2009. Office of Disease Prevention and Health Promotion. (2016, September 06). Healthy People 2020: Healthcare-Associated Infections. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/healthcare-associated-infections

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Reserve slides

Risk Assessment Urgent threats: Serious threats C. Difficile, Carbapenem-resistant Enterobaceriaceae (CRE), Drug resistant Neisseria Gonorrhea (cephalosporin resistance) Serious threats Multi-drug resistant Acinetobacter, Drug resistant Campylobacter, Fluconazole resistant Candida, Extended spectrum B-lactamase producing Enterobacteraceae (ESBLs), Vancomycin-resistant Enterococcus (VRE), Multidrug resistant Pseudomonas aeruginosa, Drug resistant Non-typhoidal Salmonella, Drug resistant Salmonella Typhi, Drug resistant Shigella, Methicillin- resistant Staphylococcus aureus (MRSA), Drug resistant Streptococcus pneumonia, Drug resistant tuberculosis (MDR, XDR).