Antimicrobial Stewardship: an HAI response activity in Connecticut Richard Melchreit, MD HAI Program Coordinator

National Metrics and 5-Year Targets MetricSource National 5-year Prevention Target Base/Target year On Track? Bloodstream infections NHSN50% reduction2006-8/2013 Yes Clostridium difficile (hospital discharges) HCUP30% reduction2008/2013No Clostridium difficile infections NHSN30% reduction /2015 Data not yet available Urinary tract infections NHSN25% reduction2006-8/2013Yes MRSA invasive infections (population) EIP50% reduction2007-8/2013Yes MRSA bacteremia (hospital) NHSN25% reduction /2015 Data not yet available Surgical site infections NHSN25% reduction2006-8/2013 Yes Source:

CMS Reporting Requirements: sorted by year YearHAI EventFacility type/location 2011CLABSIACH/ICUs 2012CAUTIACH/ICUs SSI:COLO, SSI:HYSTACH/all inpatient DEOutpatient Dialysis 2013MRSA bacteremia LabID, CDI LabIDACH/all inpatient HCW vaccinationACH CLABSI, CAUTILTACH/all inpatient CAUTIIRF/adult, pediatric wards 2015CLABSI, CAUTIACH/wards HCW vaccinationACH/outpatient; LTACH, IRF, ASC MRSA bacteremia LabID, CDI LabIDLTACH/all inpatient

CSTE recommendation: CDI reporting (NHSN) to public health departments Organism/ specimen Type of facilityType of location Time frameExceptions C. difficile Infection LabID Event Acute Care Hospitals All inpatientXNICUs, well baby nurseries LTACHAll inpatientX CHAAll inpatientX IRFAll inpatientX Other non IQRAll inpatientX LTCFs*All residentsx * 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 facilityType of location Time frameExceptions* MRSA Bacteremia LabID Event Acute Care Hospitals All inpatientXNone LTACHAll inpatientX CAHAll inpatientX IRFAll inpatientX Other non IQRAll inpatientX LTCFs*All residentsx * Will require enough facilities to develop the infrastructure and skills necessary to effectively use NHSN.

Community-Associated (CA-MRSA) No HACO risk factors Medical Record Review Invasive (sterile site) MRSA isolates reported from labs statewide Health Care-Associated Community-Onset (HACO-MRSA) -Central venous line at time of culture -Hospitalization, surgery, dialysis, or LTCF residence in year before culture Hospital-Onset (HO-MRSA) Isolate collected >2 days after hospital admission Methods and Case Definitions

Incidence of MRSA by Place of Onset and Year, Connecticut, p<0.01 a a Chi-square for trend p<0.01 a

Revised Annualized National Estimates, ABCs MRSA (updated Nov, 2012) Revisions include: Adjustment for dialysis; incorporation of interval estimates (not included);enhanced case finding (TN) and resolved data transmission error ( ). Data accessed (frozen) November 2012.

Revised Annualized National Estimates, ABCs MRSA (updated Nov, 2012) Revisions include: Adjustment for dialysis; incorporation of interval estimates (not included);enhanced case finding (TN) and resolved data transmission error ( ). Data accessed (frozen) November ~ 27% were outpatient dialysis patients ~ 27% were outpatient dialysis patients ~ 50% were discharged from acute care in previous 3 months ~ 50% were discharged from acute care in previous 3 months

Vancomycin-resistant Enterococci (VRE) Connecticut: VRE Incidence by Hospital Staffed Bed Size VRE Incidence by Age

Percent of CLABSI organisms that were VRE or MRSA:

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 CAUTI54323 (4.2)1(.2) SSIs related to colon surgeries 1917 (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

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