CIPARS INTEGRATED AMR RESULTS 2012 1 Epidemiology and Healthcare Associated Infection: What does the...
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Transcript of CIPARS INTEGRATED AMR RESULTS 2012 1 Epidemiology and Healthcare Associated Infection: What does the...
CIPARS INTEGRATED AMR RESULTS 2012 1
Epidemiology and Healthcare Associated Infection: What does the future hold?Denise Gravel, PhD(c) August 29, 2014University of OttawaDepartment of Epidemiology & Community MedicineSummer Institute 2014
OverviewReview of healthcare-associated infections
Antimicrobial resistant organisms: why are they important
Current research focus
Examples studies in healthcare epidemiology
IntroductionHealthcare-associated infections (HAI) are infections
that patients acquire while receiving treatment for medical or surgical conditions and are the most frequent adverse event during care delivery formerly « nosocomial » and/or « hospital acquired »
Burden remains unknown because of the difficulty in gathering reliable data surveillance is complex and requires the use of standardized
criteria availability of diagnostic facilities expertise to conduct it and interpret the results
Horan TC, Andrus M, Dudeck MA. Am J Infect Control.2008; 36(5):309–332.
Common HAI, in order of relative frequency
1. Urinary tract infections (UTI)• 80% Catheter-associated (CAUTI)• Prevalence 4.3%
2. Pneumonia (HAP)• 30% Ventilator-associated (VAP)• Prevalence 2.7%
3. Surgical site infections (SSI)• Prevalence 2.7%
4. Blood stream infections (BSI)• 40% Central venous catheter associated (CVC-BSI or CLBSI)
5. Clostridium difficile infection (CDI)• Prevalence 1.5%
Children, in addition to the above Necrotizing enterocolitis (NEC) Viral respiratory infections and gastroenteritis (VRI/VGE)
Gravel et al. Am J Infect Control.2009
Impact of HAI on healthcare deliveryLengthened hospital stays, Delays in new admissions Risk of wide propagation of infection & increased
mortalityUnits/facilities closed due to isolation/quarantine
policyIncreased use of diagnostic tests & expensive
treatmentsUndermining of governments efforts to improve
the healthcare system, e.g. access, quality, and wait times
Burden of illness of HAI
In Europe:16 million extra-days of hospital stay, 37 000 attributable deaths, and contribute to an
additional 110 000 every year. annual financial losses approximately € 7 billion,
direct costs only. In the USA,
approximately 99 000 deaths were attributed to HAI in 2009
annual economic impact was estimated at approximately US$ 6.5 billion in 2010.
Several studies showed that increased length of stay between 5 and 29 days.Stockholm,European Centre for Disease Prevention and
Control, 2012Klevens RM et al. Public Health Reports, 2007,122:160–166.Scott RD, Direct Medical Costs of HAI, CDC, 2009
What about Canada?
“Each year in Canada over 220,000+ HAIs result in 8,500-12,000 deaths…
rates are rising. HAI are the fourth leading cause of death in Canada.”
“One in eight patients hospitalized in Canada will developed a HAI. Deaths directly related to C.difficile have increased by 5 fold the past decade.”
The healthcare-associated methicillin-resistant Staphylococcus aureus infection rate increased more than 1,000% from 1995 to 2009.
About 80% of common infections are spread by healthcare workers, patients and visitors.
Direct medical costs associated with HAI exceeded $CDN200 million annually in 2009
Clostridium difficile infection (CDI) alone was CDN$46.1 million
MRSA was estimated at CDN$36.3 million
Surgical site infections (SSI) at CDN$24 millionZoutman et al, AJIC 2003; 31(5): 266-272CPHO 2013 ReportCPSI, The Economics of Patient Care, 2012
Estimated attributable per inpatient costs of HAI* Site Low estimate** High estimate Total infections Low adjusted
overall cost†High adjusted overall cost
CAUTI $862 $1,007 19,373 $16,700 $19,509
VAP $19,633 $28,508 4,561 $89,546 $130,025
SSI $11,874 $34,670 12,952 $153,792 $449,046
BSI $7,288 $29,156 3,829 $27,908 $103,980
CDI‡ $6,408 $9,124 6,758 $43,305 $61,660
$256,959 $508,423
*Based on US$ adjusted by 2007 CPI for inpatient services**Average attributable costs based on reported studies from 1997-2005†Increments of $1000‡Based on reported studies prior to the emergence of hypervirulent NAP1
Gravel, D. 2011 unpublished
Increasing Attention to AMR
Dame Sally Davies, Chief Medical Officer for England: 'Antibiotic resistance is like climate change in that we're doing it to ourselves. But there are no sceptics''as big a risk as terrorism’
Dr. Arjun Srinivasan, Associate Director Centers for Disease Control and Prevention: “There have been covers of magazines about the end of antibiotics, question mark; I would say you can change the title to the end of antibiotics, period”
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AMR now causes more deaths in US than all other infectious diseases combined. CDC
Source: CDC, Antibiotic Resistance Threats in the United States, 2013
The drivers of AMR
ANTIMICROBIAL RESISTANCE IN CANADA: WORKING TOWARDS A COMMON UNDERSTANDING
Demographic changesClimate changeHealthcare
Trade Globalization Travel
Human Behaviour
Agriculture and Veterinary Practices
Environmental Sources
Antimicrobial Resistance
Examples include:
• Salmonella heidelberg
Carbapenem-resistant Enterobacteriaceae (CRE) (e.g., NDM-1)
Methicillin-resistant Staphylococcus aureus (MRSA)
Vancomycin-resistant Enterococci (VRE)
Multidrug resistant tuberculosis (MDR-TB)
Neisseria gonorrhoeae
Escherichia coli (E.coli)
Clostridium difficile (C. difficile)
Candida spp. and Aspergillus
Why is AMR a global concern?1. AMR kills
Prolonged illness & greater risk of death.
2. AMR hampers the control of infectious diseases & healthcare gains Potential spread of resistant microorganisms to others.
3. AMR increases the cost of health care Need for more expensive & lengthy treatments in healthcare settings
4. AMR jeopardizes healthcare gains to society Without effective antimicrobials, the success of treatments such as organ
transplantation, cancer chemotherapy & major surgery would be compromised.
5. AMR threatens health security and damages economies & trade Global trade & travel – AMR organisms spread rapidly to distant countries &
continents.
6. AMR threatens a return to the pre-antibiotic era Health-related UN Millennium Development Goals set for 2015 in jeopardy. Source: http://www.who.int/mediacentre/factsheets/fs194/en/
Why is antimicrobial resistance a concern in Canada?• AMR is a global threat to the prevention and control of infectious diseases
It is complex and multi-faceted
• The loss of effective antibiotics will undermine our ability to fight infectious diseases
Increasing morbidity and mortality throughout world Less effective antimicrobials for treatment of infectious diseases Longer, more severe illnesses / complications in vulnerable populations Increasing costs to the health care system (i.e. hospitalization, wait time,
complex treatments)
• Investment in development of new antibiotics is decreasing Research, development and commercialization to bring a new antibiotic to
market is costly and may take years to develop.
• Potential return to a pre-antibiotic era treatment options for a number of resistant infections are running out (i.e. multi-drug resistant gonorrhea)
Only 5% of the drugs in the development pipeline are antibiotics
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Silver. 2011. Clin Micro Rev. 24:71-109
Penicillins
Carbapenems
Cephalosporins
The Beta-Lactam Antibiotics
TEM-1, SHV-1
ESBLsTEM/SHV-variantsCTX-M
Carbapenemases
Expended 1930s
Expended late 1970s
Expended in 1990s-2000s
Research Focus over the years1970s: establishing evidence for infection prevention
and control programs 1980s: focussed on risk factors for HAI
understanding device associated HAI
1990s: focussed on antimicrobial resistance outcomes research preventing infections in health-care personnel;
2000s: focussed on prevention in an era of increasing complexity of medical care preventing bloodstream infections, surgical site infections, and
pneumonia associated with healthcare infection prevention in special populations, pediatric, geriatric, and
immunocompromised patients; infection control in nonhospital settings, including long-term care,
home health care, and ambulatory care;
Research: Future Focus2010s: advancing healthcare epidemiology using
business cases, patient safety, and performance improvement methodscombatting ESKAPE pathogens —Enterococcus faecium,
Staphylococcus aureus, Klebsiella species, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species.
optimizing the implementation of infection control interventions that are known to be effective
modelling interventions: understanding what works and how
health care costs of HAI/AMRcost effectiveness studies
18
Source: INSPQ February 2006
The effect of hospital-acquired infection with C.difficile on length of stay in hospitalForster et al. CMAJ 2012 Retrospective observational cohort design using a hospital
administrative database: reviewed 136,877 admissions Association between C.difficile infection and time to discharge Kaplan-Meier and Cox proportional hazards regression models
controlling for baseline risk of death and accounting for time-varying effect of onset of CDI
Clostridium difficile: anaerobic, spore-forming, gram-positive bacillus, Resists disinfection, Persists in the environment
The effect of hospital-acquired infection with C.difficile on length of stay in hospitalForster et al. CMAJ 2012
A: Kaplein-Mayer curves adjustedB: with C.difficile as time-varyingD: with baseline risk of death
Surgical Mask vs N95 Respirator in preventing Flu in Healthcare WorkersLoeb et al. JAMA 2009 Randomized controlled trial of 446 nurses in ER, medical and
pediatric units from 8 acute care hospitals Non-inferiority of surgical mask to N95 respirator Primary outcome: lab-confirmed flu Non-inferiority was met if lower limit of 95%CI for reduction in
incidence was < -9%
Surgical Mask vs N95 Respirator in preventing Flu in HCWLoeb et al. JAMA 2009
Surgical Mask vs N95 Respirator in preventing Flu in HCWLoeb et al. JAMA 2009
An intervention to decrease catheter-related bloodstream infections in the ICUPronovost et al, NEJM 2006 Cohort study in 108 ICUs in Michigan, comparing BSI rates
before, during, and 18-months after implementing IPC interventions
Calculated rate per 100 catheter-days X 3months, adjusted using generalized linear latent and mixed model with Poisson distribution
Nested clustering for BSI within hospital, within geographic regions plus third level clustering potential ICU effectCatheter placed into a
large vein, tip is lodged in the right atrium
Sites of insertion: right and left subclavian, internal jugular and femoral veins
An intervention to decrease catheter-related bloodstream infections in the ICUPronovost et al, NEJM 2006procedure cart for central line insertionadherence to recommended guidelines
hand washing sterile gloves & gown mask and cap sterile drape (preferably full body drape) chlorhexidine-based skin prep maintenance of sterile field use of subclavian site and tunnelled, cuffed catheter
authorizing nurses to stop any procedure that did not follow catheter insertion guidelines
daily assessment of the need to continue central line use
An intervention to decrease catheter-related bloodstream infections in the ICUPronovost et al, NEJM 2006
Rates in Canada following implementation of “Safer Health Care Now!” initiative
2006 2009 2010 20110.00
0.50
1.00
1.50
2.00
2.50
3.00
National and Regional CVC-BSI rate per 1,000 days in Medical, Surgical, and Mixed Adult ICUs 2006, 2009-2011
West Central East Overall
Targeted vs Universal Decolonization to Prevent ICU InfectionHuang et al. NEJM 2013Cluster-randomized trial in 74 ICUs (43 hospitals) in
CaliforniaHospitals were assigned to: 1. MRSA screening and
isolation, 2. targeted decolonization, 3. universal colonization
Proportional hazards models were used to assess differences in infection rates, clustering to hospital
Decolonization: BID intranasal mupirocin x 5 days with daily bathing chlorhexidine
Targeted vs Universal Decolonization to Prevent ICU InfectionHuang et al. NEJM 2013
Universal decolonization was more effective than targeted decolonization or screening/isolation in reducing MRSA clinical infections and bloodstream infections from any pathogen
Question: Is it cost effective?
Questions? Comments?