Multi-Drug Resistant Organisms (MDROs) in Michigan

1. Multi-Drug Resistant Organisms (MDROs) in Michigan Noreen Mollon, MS Infection Prevention Consultant www.michigan.gov/hai

2. Objectives • Describe MDROs • MDRO surveillance and reporting • SHARP Prevention Initiatives • Recent MDRO investigations • IP practices for MDROs

3. Describing MDROs

4. What is a MDRO? Multidrug-Resistant Organisms (MDROs) are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents (HICPAC) Deserve special attention in healthcare facilities– Healthcare-Associated Infections (HAIs) Clinically significant Associated with increased lengths of stay, costs, and mortality

5. Types of MDROs • MRSA • VISA • VRSA • VRE • C. Diff • MDR GNB • Escherichia coli, Klebsiellapneumoniae, Pseudomonas aeruginosa, Acinetobacterbaumannii • ESBLs • CRE

6. What is MRSA? • MRSA: • Methicillin • Resistant • Staphylococcus • aureus • Staphylococcus aureusare Gram positive bacteria that can be transmitted from person-to-person in a healthcare facility or in the community • MRSA is a staph infection that is resistant to β-lactam antibiotics (like methicillin, penicillin, and amoxicillin)

7. Methicillin-Resistant Staphylococcus aureus (MRSA) • MRSA • >40% of US hospital-associated S. aureus infections • >50% of ICU-associated S. aureus infections • Increasing reports in non-healthcare settings • Prisons • Schools • Day-care • Workplace • Other • Approximately 1% of the general population is colonized with MRSA

8. VISA • Vancomycin-intermediate Staphylococcus aureus • Vancomycin minimum inhibitory concentration (MIC) =4–8 µg/mL • Isolate must be confirmed at MDCH laboratory • Resistance mechanism is not transferrable to susceptible strains and is usually associated with vancomycin exposure

9. VRSA • Vancomycin-resistant Staphylococcus aureus • Vancomycin minimum inhibitory concentration (MIC) 16 µg/mL • Isolate must be confirmed at MDCH laboratory • Resistance is acquired from VRE and is transferrable

10. VRE Vancomycin-resistant Enterococcus Can colonize the intestines and female genital tract Can cause infections of the urinary tract, the bloodstream, or of wounds associated with catheters or surgical procedures

11. Clostridium difficile (C. diff) • Background • Accounts for 15-25% antibiotic-associated diarrhea • 80% Clostridium difficile infection (CDI) associated with healthcare • Elderly and patients on antibiotics at highest risk • Current epidemiology • Increased rates nationwide • Increased severity and mortality • Reasons • Widespread use of antibiotics • Changes in infection control practices • New strain: NAP-1

12. MDR GNB • Multidrug-resistant gram-negative bacilli • Can refer to various organisms: • Escherichia coli, Klebsiellapneumoniae,Pseudomonas aeruginosa, Acinetobacterbaumannii, Stenotrophomonasmaltophilia, Burkholderiacepacia,andRalstoniapickettii

13. MDR GNB • Grouped according to resistance • Extended-spectrum β-Lactamases (ESBLs) • Carbapenem-resistant Enterobacteriaceae (CREs) • Carbapenemase-producers (such as Klebsiellapneumoniaecarbapenemase or KPC) • Metallo-beta-lactamase (MBL)-producers • Difficult to lab confirm • Worrisome public health threat

14. What is a HAI? Healthcare-Associated Infections (HAIs) are infections that patients acquire during the course of receiving healthcare treatment for other conditions that were not present at admission HAIs are often MDROs Are frequently device-associated

15. HAIs Approximately 1 out of every 20 hospitalized patients will contract an HAI CDC estimated that 1.7 million HAIs occurred in US hospitals in 2002 HAIs are responsible for about 100,000 deaths in the US annually The medical costs associated with these infections are approximated to be between $36-45 billion

16. Types of HAIs Central Line-Associated Blood Stream Infections (CLABSI) Catheter-Associated Urinary Tract Infections (CAUTI) Ventilator-Associated Events (VAE) Surgical Site Infections (SSI) Clostridium difficile(C.diff) Infection Methicillin-Resistant Staphylococcus aureus(MRSA) Multidrug-Resistant Organisms (MDROs) – Acinetobacter, Klebsiella, Pseudomonas, Enterobacter, E.coli, etc.

17. Types of HAIs SSI CLABSI Surgical incision showing signs of infection Subclavian central venous line VAE CAUTI Foley catheter insertion kit Mechanical ventilator CDI LabID MRSA LabID Clostridium difficile Staphylococcus aureus

18. Costs of HAIs* *source: JAMAInternalMedicine, 9/2/2013

19. MDRO Surveillance and Reporting

20. Surveillance and Reporting 33 states have laws requiring HAIs to be reported to state health departments, the majority of which publically release hospital HAI rates www.michigan.gov/hai

21. National Reporting Requirements • The Centers for Medicare and Medicaid Services (CMS) requires hospitals to report: • CLABSI (effective January 2011) • CAUTI (effective January 2012) • SSI for Colon Surgeries and Abdominal Hysterectomies (effective January 2012) • MRSA BacteremiaLabID (effective January 2013) • C. difficileLabID (effective January 2013)

22. Bureau of Disease Prevention, Control and Epidemiologywww.michigan.gov/epiDivision of Communicable Diseasewww.michigan.gov/mdch/0,1607,7-132-2945_5104-12219--,00.htmlSurveillance and Infectious Disease Epidemiology Section (SIDE)www.michigan.gov/cdinfoSurveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit www.michigan.gov/hai Prevention Initiatives Surveillance Education and Outbreak Response MRSA/CDI Prevention Collaborative Collect HAI data from Michigan hospitals through the CDC’s web-based National Healthcare Safety Network (NHSN) Carbapenem-Resistant Enterobacteriaceae (CRE) Prevention Collaborative Provide general education and recommendations based on current best-practice, evidence-based guidelines

23. Authority of State and Local HDs • Michigan is a “home rule” state, meaning local HDs have autonomy within their jurisdiction • The MDCH operates independently from the local HDs • The primary role of the MDCH in communicable disease control is to provide:\ • Expert consultation • Reference level diagnostics laboratory services • Childhood vaccines • Support local HDs upon their request • Maintenance and administration of the MDSS • All communicable disease reports should be reported to your local HDs

24. Public Health Investigative Authority • State and local HD personnel are authorized to investigate reported diseases, including: • Contacting health providers • Conducting additional case-finding • Conducting epidemiological studies • Conducting specimen collection • Gathering information on medical history, lab results, diagnostic procedures, treatment, and health outcomes • The MDCH works collaboratively with the local HDs and participates in investigations when requested

25. Confidentiality, HIPAA, and PHI Disclosure of protected health information (PHI) to health authorities without individual consent or authorization is permitted when disclosure is required by law or is authorized by law for a public health purpose (www.hhs.gov/ocr/hipaa/) All information provided to public health authorities is kept confidential

26. Map of Michigan Local HDs

27. Communicable Disease Surveillance • Communicable disease reporting is required by Michigan law: • Michigan Public Health Act No. 368 Communicable Disease Rules: R 325.171-3, 333.5111 • Rule revision allows the State the right to periodically update the list of reportable diseases • This reporting is expressly allowed under HIPAA Bordetella pertussis Histoplasmacapsulatum Neisseria meningitidis Hepatitis C Virus

28. Why Communicable Disease Surveillance is Important To identify outbreaks To assure treatment, preventive treatment and/or education To evaluate prevention and control programs To help target prevention resources To facilitate epidemiologic research To assist national and global surveillance efforts Chlamydia trachomatis Mycobacterium tuberculosis Influenza Virus Salmonella sp.

29. Communicable Disease Reporting Entities • Physicians* • Laboratories* • Hospital ICP • Private citizens • School systems* • Pharmacists • Veterinarians • Medical Examiners • Hospitals* • Child care facilities • Long-term care facilities* • Pre-hospital emergency services • Police • Fire • EMS *Required to report

30. Communicable Disease “Brick Book” The current 2012 version (electric crimson), provides a good summary of the communicable disease rules, requirements, and responsibilities

31. Michigan Reportable Diseases • ~90 disease/conditions are reportable in Michigan • Also reportable are ‘unusual occurrences’, outbreaks and epidemics of any disease or condition (including healthcare-associated infections) • Specific reporting rules and definitions can be found at www.michigan.gov/cdinfo

32. Michigan Reportable MDROs and HAIs Vancomycin-Intermediate Staphylococcus aureus(VISA) and Vancomycin-Resistant Staphylococcus aureus (VRSA) are required to be reported according to the communicable disease rules Unusual occurrences and outbreaks of HAIs are also mandated by law to be reported However, individual HAIs (like a CLABSI), are not required to be reported to state or local health departments

33. Surveillance of Healthcare Associated and Resistant Pathogens(SHARP) Activities Surveillance and Reporting MDRO Prevention Initiatives Consulting/Education Outbreak Response www.michigan.gov/hai Staphylococcus aureus Klebsiella pneumoniae Clostridium difficile

34. SHARP Unit • Objectives of the SHARP Unit: • Coordinate activities related to HAI surveillance and prevention in Michigan • Improve surveillance and detection of antimicrobial-resistant pathogens and HAIs • Identify and respond to disease outbreaks • Use collected data to monitor trends • Educate healthcare providers, state and local public health partners, and the public on HAIs www.michigan.gov/hai

35. NHSN Surveillance Initiative • In Michigan, hospitals can voluntarily report HAIs to MDCH SHARP via the National Healthcare Safety Network (NHSN) • NHSN is a web-based surveillance program designed by CDC: • Uses standardized HAI surveillance definitions • Users can enter and analyze HAI data • The data sent to SHARP from Michigan hospitals are de-identified and the numbers aggregated for the purposes of producing state-wide HAI surveillance reports www.michigan.gov/hai

36. NHSN Surveillance • HAIs tracked by MDCH SHARP surveillance: • Central Line-Associated Blood Stream Infection (CLABSI) • Surgical Site Infection (SSI) • Catheter-Associated Urinary Tract Infection (CAUTI) • Ventilator-Associated Pneumonia (VAP) • Clostridium difficileLabID surveillance • MRSA LabID surveillance • Antimicrobial resistance in select pathogens www.michigan.gov/hai

37. SHARP Surveillance Reports • SHARP releases state-wide HAI reports quarterly, semiannually, and annually which are posted at www.michigan.gov/hai • All hospital data is de-identified and aggregated • Individual hospital data is not made public • SHARP also compiles hospital specific HAI reports which are only shared with those individual hospitals www.michigan.gov/hai

38. SHARP Surveillance Currently there are 83 Michigan hospitals sharing HAI data with SHARP, 82 hospitals releasing their data to the Michigan Health and Hospital Association MHA Keystone Center, and 13 hospitals releasing their NICU data to the Vermont Oxford Network (9/26/13). www.michigan.gov/hai

39. SHARP HAI Data: MRSA Lab ID www.michigan.gov/hai

40. SHARP HAI Data: CDI LabID www.michigan.gov/hai

41. SHARP HAI Data: SIR www.michigan.gov/hai

42. SHARP HAI Data: CLABSI www.michigan.gov/hai

43. SHARP HAI Data: CAUTI www.michigan.gov/hai

44. SHARP HAI Data: CAUTI www.michigan.gov/hai

45. MDCH Prevention Initiatives MRSA/C. Diff CRE

46. MDRO Prevention Initiatives • SHARP also has started two prevention initiatives aimed to reduce the incidence and prevalence of MDROs in healthcare facilities in Michigan: • Methicillin-Resistant Staphylococcus aureus(MRSA) and Clostridium difficile(CDI) prevention initiative • Carbapenem-Resistant Enterobacteriaceae(CRE) surveillance and prevention initiative Staphylococcus aureus Citrobacterfreundii Enterobacter cloacae Escherichia coli Klebsiellapneumoniae

47. MDRO Prevention Initiatives SHARP recruited facilities into the two initiatives Both will measure the baseline prevalence and incidence of their respective organisms Then there will be a period of measurement during which facilities are encouraged to begin implementing infection prevention interventions to reduce the transmission of these organisms www.michigan.gov/hai Planning Stage Baseline Stage Intervention Stage

48. MDRO Prevention Initiatives MRSA/CDI Contact- Gail Denkins DenkinsG@michigan.gov CRE Contact- Brenda Brennan BrennanB@michigan.gov www.michigan.gov/hai

49. MRSA/CDI Prevention Collaborative Established September 28, 2011 and includes representation from: • MDCH • Michigan Society for Infection Prevention and Control (MSIPC) • Michigan Health and Hospital Association(MHA) Keystone Center for Patient Safety and Quality • MPRO (Michigan's Quality Improvement Organization) • Long Term Care • Michigan Association of Local Public Health (MALPH)

50. MRSA/CDI Prevention Collaborative The Collaborative works to integrate evidence based best practices along the continuum of care to reduce and eliminate the occurrence of MRSA and CDI among Michigan citizens