Your Facility and Public Health: Partners in the Fight Against Multidrug-Resistant Organisms

October 29, 2013

Andrea Alvarez, MPHHealthcare-Associated Infections Program

CoordinatorDivision of Surveillance and Investigation

Virginia Department of Health

Objectives

• Review purposes of tracking infections in healthcare facilities

• Discuss recently published long-term care surveillance definitions and introduce the National Healthcare Safety Network

• Review disease reporting regulations, specifically as they pertain to long-term care and multidrug-resistant organisms

• Outline the role of the Virginia Department of Health in working with healthcare facilities, especially on MDRO investigations/outbreaks

• Discuss relevant prevention initiatives from CDC• Provide resources for more information

Long-term Care Facilities: Why the Risk?Medically fragile population

• Could have more severe disease, complications

Congregate setting• Germs easily transmitted over short distances

Close contact• Direct contact with staff members, other

patients/residents, family members/visitors

Cognitive changes/challenges• May not be able to communicate symptoms,

may not be aware of germ-spreading behavior

Surveillance

• Systematic and ongoing approach to monitoring illnesses of your residents and staff• Establish illness-specific baselines to define

what is normal in your facility• Track changes over time• Notice when diseases increase more quickly or

become more severe

• Helps to identify health problems early • Find common factors among the ill• Develop prevention measures to fit the

situation

Onset

Name of resident with respiratory illness Age Sex Ro

om N

umbe

rOnset Date Bo

dy a

ches

Chills

Coug

h

Feve

r

Head

ache

Sore

thro

at

Unu

sual

fatig

ue

High

est T

emp.

Dura

tion

of

Sym

ptom

s

Lab

Test

?

Result

Date of Flu

Vaccine Antiv

iral U

sed?

Name Yrs M/F MM/DD/YY (°) Hours Y/N Y/N MM/DD/YY Y/N MM/DD/YY MM/DD/YY Y/N

TOTALS:

Mark each with Y=yes, N=no

Hospitalized?If Yes, Date

Death?If Yes, Date

Resident Respiratory Illness Log

Facility Name:___________________________________ Total Residents Ill:______

Date Log Started:__________ Total Residents (ill and well):______

Identification Information Signs and Symptoms Lab Info Outcomes Prevent/Treat

Jan-Mar Apr-Jun Jul-Sept Oct-Dec0.00

2.00

4.00

6.00

8.00

10.00

12.00

Catheter-associated urinary tract infection rate (per 1000 catheter days)Urinary tract infection rate (per 1000 resident days)

CA

UT

I/U

TI

Rate

Long-Term Care Surveillance Tips

• In addition to infection-specific surveillance, helpful to keep track of:• Hospital transports• Hospital admissions• Deaths

• Look for common causes if/when an increase is observed

Surveillance: Outbreak/Cluster

• What is an outbreak?• More cases of a disease in a designated

population than usually occur for a given period of time• Every disease has an expected level of

activity, or a “baseline” number of cases that occur over a given time period

• For some diseases, one case is more than what is expected (e.g., hepatitis B virus)

Long-Term Care Surveillance Definitions• In 2012, McGeer definitions for infections in long-term

care (1991) updated (Stone et al. ICHE 2012;33(10):965-977)

• New definitions designed for use in skilled nursing facilities and long-term residential care environments that deliver nursing services

• Definitions are infection-specific, not organism-specific (usually)

• When is the infection “long-term care onset”?• No evidence of an incubating infection at the time of

admission to the facility• Onset of clinical manifestation occurs >2 calendar days after

admission

http://www.jstor.org/stable/10.1086/667743

What Types of Infections Should My Facility be Tracking?• Consider as routine surveillance

• Able to be transmitted in a healthcare setting• Viral respiratory infections (flu), viral gastroenteritis

(norovirus)• Strategies to prevent people from acquiring the

infection are available• Clinically significant cause of morbidity and

mortality• Urinary tract infections, GI infections (including C.

diff), skin and soft tissue infections• Pathogens that can cause serious outbreaks (i.e.,

one lab-confirmed case should prompt further investigation)• Invasive group A strep, acute viral hepatitis, scabies

What Types of Infections Should My Facility be Tracking?• Consider as routine surveillance

• Able to be transmitted in a healthcare setting• Viral respiratory infections (flu), viral gastroenteritis

(norovirus)• Strategies to prevent people from acquiring the

infection are available• Clinically significant cause of morbidity and

mortality• Urinary tract infections, GI infections (including C.

diff), skin and soft tissue infections• Pathogens that can cause serious outbreaks (i.e.,

one lab-confirmed case should prompt further investigation)• Invasive group A strep, acute viral hepatitis, scabies

Definitions• Changes to constitutional criteria (e.g., fever)• Respiratory tract infections

• Common cold, influenza-like illness, pneumonia, lower respiratory tract infections

• Urinary tract infections (with and without a catheter)

• Skin and soft tissue infections• Skin infections, scabies, fungal infections,

herpesvirus skin infections, conjunctivitis• Gastrointestinal infections

• Gastroenteritis, norovirus (*new*), C. difficile (*new*)

• Systemic infections (i.e., bloodstream infections, unexplained febrile episodes) (no change)

www.cdc.gov/nhsn/LTC/ index.html

NHSN Long-Term Care Component• Infection modules for:

• MDRO/C. difficile laboratory-identified events• Options: MRSA, MSSA, VRE, CRE (Klebsiella

spp. or E. coli), cephalosporin-resistant Klebsiella spp., multidrug-resistant Acinetobacter

• Urinary tract infections (with or without catheter)

• Benefits• Free to enroll, use software• Uses standardized definitions, forms• Analysis functionality• Technical support from CDC, state health

department

Communication is Key!

Transfer of patients/residents between healthcare settings demands streamlined communication between facilities

How does your facility give and receive information?

Model transfer form – one example (nursing facility to ED/hospital or ED/hospital to nursing facility)

• Demographics• At risk for communicable disease• Wounds• Urinary catheter use• Isolation precautions

www.vdh.virginia.gov/Epidemiology/Surveillance/HAI/documents/pdf/Virginia%20Model%20Transfer%20Form.pdf

When Should You Contact the Health Department?• Suspect or confirm

patient/resident has a reportable disease

• Suspect an outbreak may be occurring• Outbreak: greater than

expected level of disease activity

• Question about a disease-related topic

How to Contact the Local Health Department• Call local health department for city/county in

which the facility is located• www.vdh.virginia.gov/lhd• Roanoke/Alleghany Health Department:

District Epidemiologist – Hope White (540-283-5032 or hope.white@vdh.virginia.gov)

State Regulations: Long-Term Care12 VAC 5-371-180. Infection control.

C. The infection control program addressing the surveillance, prevention and control of facility wide infections shall include:1. Procedures to isolate the infecting organism;2. Access to handwashing equipment for staff;3. Training of staff in proper handwashing techniques, according to

accepted professional standards, to prevent cross contamination;4. Implementation of universal precautions by direct resident care

staff;5. Prohibiting employees with communicable diseases or infections

from direct contact with residents or their food, if direct contact will transmit disease;

6. Monitoring staff performance of infection control practices;7. Handling, storing, processing and transporting linens, supplies

and equipment in a manner that prevents the spread of infection;8. Handling, storing, processing and transporting regulated medical

waste in accordance with applicable regulations;9. Maintaining an effective pest control program; and10. Staff education regarding infection risk-reduction behavior.

State Regulations: Long-Term Care (cont’d)12 VAC 5-371-180. Infection control.

D. The nursing facility shall report promptly to its local health department diseases designated as “reportable” according to 12 VAC 5-90-80 when such cases are admitted to or are diagnosed in the facility and shall report any outbreak of infectious disease as required by 12 VAC 5-90. An outbreak is defined as an increase in incidence of any infectious disease above the usual incidence at the facility.

What’s Reportable?

• The Virginia Reportable Disease List outlines diseases and conditions (including outbreaks) that are reportable to the local health department

• Revised periodically• www.vdh.virginia.gov/

epidemiology/Regulations.htm

Who Reports?

• Physicians• Directors of medical care facilities (such as

nursing homes/long-term care facilities)• A person in charge of a medical care facility

may assume the reporting responsibility on behalf of the director of the laboratory operating within the facility

• Directors of laboratories• Directors of assisted living facilities are required

to report suspected/confirmed outbreaks only

Reporting – When? How?

• Reports shall be made within three days of the suspicion or confirmation of disease unless the disease in question requires reporting by most rapid means possible (e.g., outbreaks, unusual occurrence of public health concern) – see conditions in RED on list

• Reports may be by computer-generated printout, Epi-1 form, CDC surveillance form, or upon agreement with VDH, by means of secure electronic transmission.

Multidrug-Resistant Organisms and Reporting RequirementsWhat’s reportable:

• Invasive methicillin-resistant S. aureus (MRSA)• Tuberculosis (including drug-resistant TB)• Vancomycin-intermediate or vancomycin-resistant S.

aureus• Unusual occurrence of disease of public health concern

[includes carbapenem-resistant Enterobacteriaceae (CRE) with an “unusual” resistance mechanism]

• Outbreaks

What’s not:Individual cases of MRSA (non-invasive, such as skin and soft tissue infections), vancomycin-resistant Enterococci, C. difficile, CRE with “usual” resistance mechanisms (if not considered above the baseline level for your facility)

“Invasive” means the organism is affecting a normally sterile site, including but not limited to blood or cerebrospinal fluid.

CRE and Reporting to the Health Department• When to Call the Local Health Department

• Suspected/confirmed outbreaks of CRE (infection OR colonization)

• Individual cases of CRE suspected or confirmed to have an “unusual” resistance mechanism (e.g., NDM-1, OXA-48, VIM) – considered “unusual occurrence of disease of public health concern”• Note: unusual resistance mechanism suspected

in patients with CRE who have a history of recent inpatient stay (within 6 months) in a healthcare facility abroad. PCR testing is needed to confirm the resistance mechanism.

What is the Health Department Doing to Prevent the Transmission of MDROs?• Staff work with healthcare facilities, schools, etc.

during outbreak investigations• Help identify the source of the problem and

control the spread of disease• Collect information about ill and well persons• Coordinate specimen testing with state lab• Conduct site visit(s) to meet with staff, make

observations• Recommend steps to stop outbreak and reduce

the risk of disease

What is the Health Department Doing to Prevent the Transmission of MDROs?• Develop and disseminate

guidance and educational resources• Successful Strategies toolkit

(2011)• New HAI website (2012)• VDH HAI MDRO website

Tools and Resources CRE “Summary Recommendations for Acute and LTCF April 2013”

VDH Guidance on Prevention and Control of CRE• Guidance based on CDC CRE Toolkit

(2012)• For long-term care:

• Place CRE colonized or infected patients at high-risk [e.g., unable to perform hand hygiene, incontinent of stool, dependent on staff for activities of daily living (ADLs), draining wounds] for transmission on Contact Precautions

• For CRE colonized or infected patients at lower risk (e.g., able to perform hand hygiene, continent of stool, less dependent on staff for ADLs, no draining wounds) for transmission, Standard Precautions may be used

What is CDC Doing to Prevent the Spread of MDROs?• Supports systems to track infections,

antimicrobial resistance patterns• National Healthcare Safety Network• Emerging Infections Program• Quantifies morbidity and mortality

• Promotes antimicrobial stewardship• Get Smart campaign

• Publishes prevention guidance and recommendations• Participates on committees such as HICPAC

(Healthcare Infection Control Practices Advisory Committee)

Antibiotic Resistance Threats in the US

Urgent Threats Clostridium difficile Carbapenem-resistant Enterobacteriaceae (CRE) Drug-resistant Neisseria gonorrhoeae

Serious Threats Multidrug-resistant Acinetobacter Drug-resistant Campylobacter Fluconazole-resistant Candida (a fungus) Extended spectrum β-lactamase producing Enterobacteriaceae (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 pneumoniae Drug-resistant tuberculosis

Concerning Threats Vancomycin-resistant Staphylococcus aureus (VRSA) Erythromycin-resistant Group A Streptococcus Clindamycin-resistant Group B Streptococcus

www.cdc.gov/ drugresistance/ threat-report-2013/index.html

Four Core Actions to Help Fight Drug-Resistant Infections• Preventing infections and preventing the

spread of resistance

• Tracking resistant bacteria

• Improving the use of today’s antibiotics

• Promoting the development of new antibiotics and developing new diagnostic tests for resistant bacteria

Stewardship Resources for Long-Term Care

Need More Information?

• Local health department• www.vdh.virginia.gov/lhd for contact information

• VDH HAI Program website• HAI website - long-term care page:

www.vdh.virginia.gov/epidemiology/surveillance/hai/longterm.htm

• HAI website - MRSA and MDRO page: www.vdh.virginia.gov/epidemiology/surveillance/hai/MRSAandMDRO.htm

• Office of Licensure and Certification• Contact your local surveyor

More Resources (CDC)• Antibiotic resistance:

www.cdc.gov/drugresistance/index.html • Infection-specific sites

• MRSA: www.cdc.gov/mrsa • CRE: www.cdc.gov/HAI/organisms/cre/index.html

• CRE toolkit: www.cdc.gov/hai/organisms/cre/cre-toolkit/ index.html

• Get Smart campaign: www.cdc.gov/getsmart/healthcare• www.cdc.gov/getsmart/healthcare/learn-from-othe

rs/factsheets/nursing-homes.html• National Healthcare Safety Network

• www.cdc.gov/nhsn/LTC/index.html

Questions?

Andrea.Alvarez@vdh.virginia.govCall 804-864-8141 to speak to anyone on the HAI Program Team at the state health department

• April Achter: HAI/Influenza Epidemiologist• Carol Jamerson: Nurse Epidemiologist• Alyssa Parr: CSTE HAI Applied Epidemiology

Fellow

EXTRA SLIDES

What Types of Infections Could My Facility be Tracking?• Could be considered in surveillance

• Infections with limited transmissibility in a healthcare setting• Ear and sinus infections, fungal oral and skin

infections, and herpetic skin infections• Infections with limited preventability

• Other accepted definitions should be applied, but may only apply to specific at-risk residents• Surgical site infections• Central line-associated bloodstream infections• Ventilator-associated pneumonia

TB Drug Resistance is Man-made

• Always assure ingestion of TB medications by direct observation (DOT)

• Prescribe the correct drugs and/or dosages• 4 drug therapy

• Isoniazid• Rifampin• Pyrazinamide• Ethambutol

• More common in foreign-born

Infection Control and TB Drug Resistance

• Impact on contact investigations• Consult with your local health department

for recommendations• Follow-up of facility contacts remains the

same• Management of contacts is individualized

• Re-admission for medication management • Strict isolation – use of N95 respirators• Observation of ingestion of meds• Discharge only after all plans in place for

management at home (TB treatment/discharge plan)

CDC 12 Steps to Protect our Long-Term Care Residents

The CDC advocates these 4 basic groups of actions that we should take to prevent antimicrobial resistance in long-term care:

• Prevent infection• Diagnose and treat infection effectively• Use antimicrobials wisely• Prevent transmission

CDC 12 Steps: Prevent InfectionStep 1. Vaccinate

• Give influenza and pneumococcal vaccinations to residents

• Promote vaccination among all staffStep 2. Prevent conditions that lead to infection

• Prevent aspiration• Prevent pressure ulcers• Maintain hydration

Step 3. Get the unnecessary devices out• Insert catheters and devices only when essential

and minimize duration of exposure• Use proper insertion and catheter-care protocols• Reassess catheters regularly• Remove catheters and other devices when no

longer essential

CDC 12 Steps: Diagnose and Treat Infection Effectively

Step 4. Use established criteria for diagnosis of infection• Target empiric therapy to likely pathogens • Target definitive therapy to known pathogens• Obtain appropriate cultures and interpret results

with care• Consider C. difficile in residents with diarrhea

and antibiotic exposure

Step 5. Use local resources• Consult infectious disease experts for

complicated infections and potential outbreaks• Know your local and/or regional data• Get previous microbiology data for transfer

residents

Use Antimicrobials Wisely

“Studies conducted over the years indicate that antibiotic use is unnecessary or inappropriate in as many as 50% of cases”

“LTC antibiotic use patterns reveal that antibiotic prescriptions are written for an inappropriate dose, given for treatment of a viral infection, used needlessly for asymptomatic bacteriuria, or began in the absence of clinical evidence of infection.”

- Dr. Neil Fishman

CDC 12 Steps: Use Antimicrobials Wisely

Step 6. Know when to say “no”• Minimize use of broad-spectrum antibiotics• Avoid chronic or long-term antimicrobial

prophylaxis• Develop a system to monitor antibiotic use and

provide feedback to appropriate personnelStep 7. Treat infection, not colonization or

contamination• Perform proper antisepsis with culture collection• Re-evaluate the need for continued therapy after

48-72 hours• Do not treat asymptomatic bacteriuria

Step 8. Stop antimicrobial treatment• When cultures are negative and infection is

unlikely• When infection has resolved

CDC 12 Steps: Prevent Transmission

Step 9. Isolate the pathogen• Use Standard Precautions

• Contain infectious body fluids (use approved Contact and Droplet Precautions)

Step 10. Break the chain of contagion• Follow CDC recommendations for work

restrictions and stay home when sick• Cover your mouth when you cough or sneeze• Educate staff, residents, and families• Promote wellness in staff and residents

CDC 12 Steps: Prevent TransmissionStep 11. Perform hand hygiene

• Use alcohol-based hand rubs or wash your hands with soap and water

• Encourage staff and visitors

Step 12. Identify residents with multidrug-resistant organisms (MDROs)

• Identify both new admissions and existing residents with MDROs

• Follow standard recommendations for MDRO case management

Michigan Antibiotic Resistance Reduction Coalition’s Long-Term Care Toolkit (2010): www.mi-marr.org/LTC_toolkit.php