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

2. 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.

3. 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.

4. 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

5. 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

6. 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.

7. Costs

8. HAI within the MHS
All inpatient facilities participate in Partnership for Patients (
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

9. 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

10. 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

11. 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

12. Antibiotic Stewardship Programs in US

13. DoD Initiatives and Ways Ahead
Antibiotic stewardship programs in most hospitals
Ensure hospitals and clinics are following guidelines:
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

14. 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.

15. 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

16. 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

17. 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

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

19. References
Centers for Disease Control and Prevention. (2013, April 23). Antibiotic Resistance Threats in the United States, Retrieved from
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
National Kidney Foundation KDOQI guidelines. Clinical Practice Guidelines and Clinical Practice Recommendations: Updates. New York: National Kidney Foundation;
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 ; 22(3):
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):
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

20. Obtaining CME/CE Credit
If you would like to receive continuing education credit for this activity, please visit:

21. Reserve slides

22. 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).