1. Healthcare-associated Infections and Antibiotic Resistance
Clifford McDonald, M.D.
Senior Adviser for Science and Integrity
Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion

2. Healthcare-associated Infections (HAIs)
Infections that patients acquire during the course of receiving treatment for other conditions within a healthcare setting
HAIs increase cost: $26-33 billion annually
CDC estimates 1 in 25 hospital patients has an infection, including
Central-line associated bloodstream infections
Catheter-associated urinary tract infections
Surgical site infections
Pneumonias - ventilator-associated and others
Clostridium difficile infections
Many infections are caused by resistant microorganisms
Carbapenem-resistant Enterobacteriaceae (CRE)
Methicillin-resistant Staphylococcus aureus (MRSA)
In hospitals settings, we estimate that one in twenty-five patients has an infection as a result of their hospital care.
HAIs include central-line associated bloodstream infections, catheter- associated UTI, surgical site infections and infections caused by organisms such as MRSA and Clostridium difficile. 5

3. CDC: Science and Data for Action
National Healthcare Safety Network (NHSN): real-time data system
Evidence-based guidelines; the standard of care to prevent HAIs
CDC supports healthcare facilities and health departments
to investigate and control outbreaks
CDC implements prevention strategies with public and private partners
CDC provides national and international laboratory expertise
CDC conducts applied research to inform prevention
CDC’s main contributions are providing the data for action and evidence- based prevention
Our flagship program is NHSN and I will talk about it in a minute.
CDC’s evidence based guidelines are the standard for HAI prevention
In addition, CDC supports health departments and healthcare facilities with laboratory and prevention expertise. 6

4. Eliminating Healthcare Associated Infections
Strengthening public health- healthcare collaboration
CDC infection prevention guidelines serve as the basis for checklists
CDC provides expertise for HHS HAI Action Plans
CDC provides data for tracking national progress
Healthcare Facilities
CDC guidelines drive the standard of care
CDC’s NHSN provides data for local improvement (e.g. HAI, antibiotic use)
CDC’s National Healthcare Safety Network is used to report infection data to CMS under pay for performance requirements
CDC infection prevention expertise helps populate surveyor checklists
CDC infection prevention expertise providing guidance on content and data collection
Healthcare facilities: For example, CDC delivers evidence-based guidelines so clinicians can improve the quality of care for all patients; and NHSN customized data so that healthcare facilities can monitor and prevent infections;
Health Departments: CDC’s expertise and laboratories are very important in outbreak responses related to HAI. NHSN data are used by state health departments to track and prevent HAIs in the states so that states can solve local healthcare quality problems;
CDC has partnerships with all HHS agencies engaged with HAI prevention.
We provide expertise to the HHS Action Plan and data to monitor national progress
We work with FDA in outbreak investigations that guide product recalls
CDC’s guidelines serve as the basis for checklists developed by AHRQ
Data from NHSN are used by CMS for IPPS and CDC guidelines, for promoting standard of care. We also provide technical expertise to CMS to promote infection prevention (QIO, survey and certification)
State Health Departments
CDC assists in outbreak responses
CDC releases state-specific progress reports
CDC serves as a reference laboratory
CDC guides prevention collaboratives
CDC outbreak investigations guide FDA product recalls

5. CDC’s National Healthcare Safety Network (NHSN)
NHSN is a national surveillance and quality improvement system
NHSN is used by
Facilities across healthcare to track HAIs and antimicrobial resistance, and direct prevention activities
States for public reporting and regional prevention
CMS for quality reporting and prevention initiatives
HHS to measure national progress
NHSN data are used by several partners including healthcare facilities, states, CMS, and HHS
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6. NHSN: Tracking infections in over 16,000 healthcare facilities nationwide*
HAI Event
Number of Facilities Enrolled In NHSN
Initial Target Number of Facilities
ACUTE CARE HOSPITALS
5,900
5,000
CLABSI - ICU†
3,450
3,400
CAUTI - ICU
CLABSI – Non-ICU
1,700
4,000
CAUTI – Non-ICU
2,250
SSI
3,900
MRSA Bacteremia
4,550
C. difficile LabID Event
4,600
DIALYSIS FACILITIES
6,750
5,600
LONG TERM ACUTE CARE FACILITIES (LTAC)
575
430
INPATIENT REHABILITATION FACILITIES (IRF)
1,250
1,200
AMBULATORY SURGICAL CENTERS (ASC)
3,150
5,300
NURSING HOMES/SKILLED NURSING FACILITIES
280
15,000
* - Data as of February 19, 2015

7. NHSN Data For Action Targeted Assessment For Prevention (TAP)
Over 4,800 hospitals currently reporting CAUTI, CLABSI, and C. difficile data
Target hospitals with highest number of excess infections
Target
AHRQ funded networks
CMS funded networks
Health Departments
Other partners
Partnering for Prevention

8. healthcare-associated infections: 2008-2013
Progress reducing
healthcare-associated infections:
Graphic showing decrease in three HAIs between 2008 and 2013: CLABSI, MRSA, and SSI.
*CLABSI: Central line-associated bloodstream infections
†MRSA: Methicillin-resistant Staphylococcus aureus

9. Healthcare and HAIs have moved beyond hospitals….
Ambulatory facilities
Long-term care
Dialysis facilities
~5,000
~5,000
~6,000
As I said before, more and more care is being delivered outside of the hospital.
Patients come and go from dialysis facilities and nursing homes, undergo surgical procedures without checking in to a hospital,
And in many cases today, most recovery occurs in a long-term care facility instead of a hospital. Many HAIs are being transmitted between health care facilities and to have a effective impact, HAI prevention has to be across healthcare settings. We recently highlighted the problem of Clostridium difficile in the Vital Signs (hand out). CDC is working with CMS, other federal agencies, health departments and other partners to continue to prevent HAIs and save lives across health care.
11 (103)
~16,000 9

10. Detect and Protect Regional prevention collaborative
Health Department
Provide situational awareness
CRE surveillance
(reporting of outbreaks)
Lab support
Outbreak response, technical guidance
Provide expertise, build capacity
Education and training H
Facilitate inter-facility communication L L H
Healthcare Facilities

11. Detect and Protect Antibiotic Use and Resistance (AUR) Module
FY2015 proposed President’s budget will support developing AUR Module of NHSN:
Collect data from healthcare facilities and improve antibiotic prescribing
Use real-time electronic AU and AR data from healthcare facilities allowing rapid analysis
Provide national benchmarks to compare antibiotic use and antibiotic resistance across facilities
Antibiotic Use Module
Provides data to assess and improve local and national appropriate antibiotic use
Lab, pharmacy data captured electronically
Addresses the need for standardized and accurate antibiotic use data
Provides essential data to prevent C.difficile through controlled antibiotic use
Antibiotic Resistance Module
Monitoring of local, regional, national
Resistance patterns in healthcare settings
Tracking of resistance patterns across and between facilities and within communities

12. Innovations to improve patient safety CDC prevention epicenters program
Unique research program in which CDC collaborates with academic investigators to conduct innovative infection control and prevention research
This collaboration protects patients by filling prevention knowledge gaps identified by CDC’s outbreak response and surveillance data

13. Emerging Infections Program (EIP) Early warning system for new and changing threats
CDC funded network of 10 state health departments collaborating with local health departments, academic institutions, other federal agencies, laboratories, infection preventionists, and healthcare providers
Conduct surveillance on infectious disease, foodborne disease, influenza, HAIs, and antibiotic resistance to estimate national burden numbers
Conduct applied research, e.g. risk factors and prevention strategies
EIP population (~44 million) representative of the U.S. (e.g. age, gender, race, population density, percent at or below poverty level)
Recently released 2011 HAI and Antimicrobial Use Prevalence Survey
Estimated 722,000 HAIs in US hospitals in 2011, or 1 in 25 patients
Estimated 75,000 patients with HAIs died during hospitalization

14. CDC’s Clinical and Environmental Microbiology Laboratory
Assist EIP surveillance by providing reference testing and diagnostic capacity of pathogens causing HAIs and antibiotic resistant infections
Serve as national and an international reference laboratory for antimicrobial susceptibility testing
Develop and evaluate methods to reliably detect emerging antimicrobial resistance
Conduct applied research on improved detection methods for HAIs
Provide environmental microbiology methods for measuring contamination of healthcare environment
Assist in Healthcare-associated outbreak investigations
Various settings, infection sources, and organisms
Culture medical devices, medications, environmental samples
Conduct typing of organisms

15. Antibiotic Resistance
Additional Slides
Antibiotic Resistance

16. Antimicrobial Resistance: The strategy
In 2013, CDC identified four core actions to help fight antibiotic resistance:

17. Antibiotic resistance in the US
Threat to economic stability
Modern medicine is at risk
Loss of effective antibiotic treatment could make routine infections deadly
Patients who receive specialized care will be at highest risk
Need to act now or even drugs of last resort will soon be ineffective

18. Detect and Protect – FY16 proposal
A down payment to improve our country’s ability
to start tackling our biggest drug-resistant threats
The FY 2016 President’s Budget requests $264M to
Slow development of resistant bacteria and prevent spread of resistant infections
Strengthen surveillance to track AR threats and measure impact
Advance development and use of rapid and innovative diagnostic tests
Accelerate research and development for new antibiotics, other therapies, and vaccines
Support partnerships for prevention, detection, control, and research

19. AR Initiative: key activities
CDC plans to award more than 85% of its FY 2016 AR initiative funding to States, communities, health care providers, universities, and other groups to:
Establish a “Detect” network of 7 regional labs to characterize emerging resistance and rapidly identify outbreaks of dangerous drug- resistant threats
Double number of Emerging Infection Program sites from 10 to 20 to expand our ability to track all urgent and serious threats for focused prevention
Establish State AR Prevention “Protect” Programs in 50 states and 10 large cities for health care to better track outbreaks, improve prescribing, and prevent infections
Improve antibiotic prescribing in hospitals and across health care settings and target community AR threats
Track how antibiotics affect the human microbiome and how the microbiome might protect humans from AR infections
Greatly scale up rapid detection of AR infections transmitted to humans through food and other pathways
Enhance collaboration and capacities to combat AR internationally
AR Initiative
The requested increase of $ million will provide support for full implementation of CDC’s surveillance, prevention, and stewardship activities outlined in the National Strategy to ensure we can reach the ambitious CARB prevention goals.
CDC plans to award more than 85% of the CARB funding to states, communities, healthcare providers, universities, and other groups to implement the National Strategy activities and to effectively address the AR threats facing our country.
CDC’s requested increase of $ million for the AR initiative will support work to achieve measurable results in three core areas – stop the spread of AR Pathogens, track AR threats and measure impact, and support for partnerships for prevention and detection.
The requested AR initiative increase will support CDC’s work in the following AR priority areas:
Establish a “Detect” network of seven regional labs to characterize emerging resistance and rapidly identify outbreaks of dangerous AR threats
Double the number of Emerging Infection Program sites from 10 to 20 to expand our ability to track all urgent and serious AR threats for focused prevention
Establish State AR Prevention “Protect” Programs in 50 states and 10 large cities for health care settings to better track outbreaks, improve prescribing, and prevent infections
These ”Protect” Programs will focus on reducing inappropriate inpatient antibiotic use by 20% and preventing the spread of AR threats most commonly transmitted in healthcare settings, including:
50% reduction in overall C. difficile
60% reduction in CRE
35% reduction in drug-resistant pseudomonas
At least 50% reduction in overall MRSA
Improve antibiotic prescribing in hospitals and across health care settings, and target community AR threats
Track how antibiotics affect the human microbiome and how the microbiome might protect humans from AR infections
Greatly scale up rapid detection of AR infections transmitted to humans through food and other pathways
Enhance collaboration and capacities to combat AR internationally

20. Antibiotic Resistance Initiative could reduce many infections
Support for CDC’s FY 2016 AR initiative will result in:
Nationwide implementation of CDC core elements of hospital antibiotic stewardship
Critical new interventions that transform public health response to antibiotic resistance
At least 10 times more drug susceptibility testing for high-priority pathogens

21. Attributable medical costs
Substantial Cost Savings from Aggressive AR Intervention Projected burden of healthcare-associated invasive MRSA, healthcare-associated CDI, healthcare-associated CRE, and hospital-onset MDR Pseudomonas infections
Attributable medical costs
($ in billions)
$1.0 Bn
$2.0 Bn
$3.0 Bn
$4.0 Bn
$5.0 Bn
Maintaining status quo
Aggressive multisectoral intervention $0