Lab ID Events MRSA Bloodstream Infection and C. difficile

Transcription

1 Lab ID Events MRSA Bloodstream Infection and C. difficile

2 MDRO and CDI Module Methicillin-resistant Staphylococcus (MRSA), Vancomycinresistant Enterococcus(VRE), certain gram negative bacilli, Clostridium difficile have increased in prevalence in U.S. hospitals over the last three decades Limited treatment options become concern Increased length of stay HICPAC has approved guidelines for the control of MDROs. The MDRO and CDI modules of the NHSN can provide a tool to assist facilities in meeting some of the criteria outlined in the guidelines. This presentation will focus on MRSA Bacteremia and C difficile reporting.

3 LabID Core Reporting Option 1: Laboratory-Identified (LabID) Event Reporting 1A: MDRO LabID Event Reporting (MRSA Bloodstream Infection) 1B: Clostridium difficile (C. difficile) LabID Event Reporting Option 2: Infection Surveillance Reporting 2A: MDRO Infection Surveillance Reporting 2B: C. difficile Infection Surveillance Reporting All reporting depends on your facility objectives and required reporting by state and regulatory agencies. NOTE: LabID Event reporting and Infection Surveillance reporting are two separate and independent reporting options. See Appendix 3: Differentiating Between LabID Event and Infection Surveillance for key differences between the two options.

4 LabID Reporting Uses lab data without clinical evaluation of patient Less labor-intensive Provide proxy measures for MDRO and C difficile Collecting and tracking positive lab results collected for clinical purposes Active Surveillance Cultures not included Two reporting options

5 Background MRSA Bacteremia 30% of the population has MRSA colonized in their nose or on their skin. Of the 609 infection related, Staphylococcus aureus isolates reported through TxHSN in 2012, 55% tested sensitive to oxacillin/methicillin. The incidence of S. aureus bacteremia and its complications has increased sharply in recent years. Urgent need for improved strategies and better antibiotics to prevent and treat S. aureus bacteremia. Increased hospital stay and the treatment costs associated with MRSA bacteremia.

6 Background Increased frequency of invasive procedures Increased numbers of immunocompromised patients Increased resistance of S. aureus strains to available antibiotics

7 Health.gov Reduce the incidence of invasive health care-associated MRSA infections. Baseline infections per 100,000 persons( ) 2012 Progress 31% overall reduction or 18.6 infections per 100,000 persons 2013 Target 50% reduction or 13.5 infections per 100,000 persons Proposed 2020 Target: 75% reduction from baseline.

8 MRSA NHSN Defintion Includes S. aureus cultured from any specimen that tests oxacillin-resistant, cefoxitin-resistant, or methicillinresistant by standard susceptibility testing methods, or by a laboratory test that is FDA-approved for MRSA detection from isolated colonies; these methods may also include a positive result by any FDA-approved test for MRSA detection from specific sources.

9 NHSN: MRSA Positive Blood Isolate Any blood specimen obtained for clinical decision making for MRSA Excludes tests related to active surveillance testing.

10 MRSA Bacteremia LabID Event MRSA positive blood specimen for a patient in a location with no prior MRSA positive blood specimen result collected within 14 days for the patient and location. Duplicate MRSA Bacteremia LabID Event Any MRSA blood isolate from the same patient and same location, following a previous positive MRSA blood laboratory result within the past 14 days.

11 Choose at least 1 reporting method Method Numerator Data Reporting Denominator Data Reporting lity-wide by location Specimens) cted locations (All cimens) rall Facility-wide tient (FacWideIN), All cimens Enter each MDRO LabID Event from all locations seperately Ener each MDRO LabID Event from all inpatient locations seperately Enter each MDRO LabID Event from all inpatient locations seperately rall Facility -wide Enter each MDRO LabID Event patient (FacWideOUT) from all outpatient locations seperately Report separate denominators for each location in the facility as specified in the NHSN Monthly Reporting Plan Report separate denominators for each location monitored as specified in the NHSN Monthly Reporting Plan Report only one denominator for the entire facility (admissions, patient days) Report only one denominator for all outpatient locations (total number of encounters) rall Facility-wide tient, Blood cimens Only rall Facility-wide patient, Blood cimens Only Enter each MDRO LabID Blood Specimen Event from all inpatient locations seperately Enter each MDRO LabID Blood Specimen Event from all outpatient locations seperately Report only one denominator for the entire facility (admissions, patient days) Report only one denominator for all outpatient locations (total number of encounters)

12 Clostridium difficile C. difficile infections continue to rise C. difficile infections linked to about 14,000 deaths each year. CDC Vital Signs Emerging Infections Program % CDI were health care associated 75% had onset not currently hospitalized 52% POA but largely health-care related. Antibiotic use and healthcare exposure greatest risk factors.

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15 C. difficile risk factors. Antimicrobial exposure Acquisition of C. difficile two main modifiable. Advanced age Underlying illness Immunosuppression Tube feeds Gastric acid suppression 1 st

16 Infection Control Strategies Hand hygiene Contact precautions Identify cases within hospital (appropriate hand hygiene and room disinfection) Environmental disinfection Appropriate use of antibiotics Laboratory-based alert system for immediate notification of positive test results Educate about CDI: HCP, housekeeping, administration, patients, families ttention to surface cleaning and use of contact precautions when treating those known to be infected can reduce spread by 20%

17 Supplemental Infection Control Strategies Extend use of Contact Precautions beyond duration of diarrhea (e.g., 48 hours)* Presumptive isolation for symptomatic patients pending confirmation of CDI Evaluate and optimize testing for CDI Implement soap and water for hand hygiene before exiting room of a patient with CDI Implement universal glove use on units with high CDI rates* Use sodium hypochlorite (bleach) containing agents for environmental cleaning Implement an antimicrobial stewardship program

18 Health.gov Reduce facility-onset Clostridium difficile infections in facility-wide health care Baseline: 1.0 SIR ( ) 2012 Progress: 2% reduction or 0.98 SIR 2013 Target: 30% reduction or 0.70 SIR Proposed 2020 Target: 30% reduction from 2015 baseline.

19 NHSN Definition Clostridium difficile A positive laboratory test result for C. difficile toxin A and/or B, (includes molecular assays (PCR) and/or toxin assays) OR A toxin producing C. difficile organism detected by culture or other laboratory means performed on a stool sample.

20 Choose one or more reporting choices Method ility-wide by ation ected locations erall Facility-wide atient (FacWideIN) erall Facility-wide tpatient cwideout) Numerator Data Reporting Enter each CDI LabID Event from all locations seperately Enter each CDI LabID Event from selected locations seperately. Enter each CDI LabID Event from all inpatient locations seperately Enter each CDI LabID Event from all outpatient locations seperately Denominator Data Reporting Report separate denominators for each location in the facility Report separate denominators for each location monitored as specified in the NHSN Monthly Reporting Plan Report only one denominator for the entire facility (e.g., total number admissions and total number of patient days) Report only one denominator for all outpatient locations (e.g., total number of encounters)

21 NICU C. difficile Surveillance NOT performed in Specialty Care Nurseries Babies in LDRP Well baby nurseries

22 C. Difficile Laboratory- Identified (LabID) Event All non-duplicate C. difficile toxin-positive laboratory results. Can include specimens collected in the Emergency Department of the admitting facility or other affiliated outpatient location, if collected same calendar day as patient admission.

23 Community Onset CDI Data Analysis Positve cultures obtained on day 1 (admission date), day 2, and day 3 of admission. Hospital Onset Positive cultures obtained on or after day 4 Community-Onset Healthcare Facility-Associated Positive culture collected from a patient discharged from the facility < 4 weeks prior to current date of stool specimen collection.

24 Duplicate C. difficile test Any C. difficile toxin-positive laboratory result from the same patient and location, following a previous C. difficile toxin-positive laboratory result within the past two weeks (14 days) (even across calendar months). There should be 14 days with no C. difficile toxinpositive laboratory result for the patient and location, before another C. difficile LabID Event is entered into NHSN for the patient and location. The date of specimen collection is considered Day 1.

25 CDI Standardized Infection Ratio (SIR) he SIR is calculated by dividing the number of bserved events by the number of predicted vents. he number of predicted events is calculated sing LabID probabilities estimated from NHSN ata during a baseline time period. O) HAIs AIs SIR=Observed Expected (E) alculated for FacWideIN surveillance nly.

26 C. difficile rates C. difficile rates are typically computed at a rate per 10,000 patient days using this formula: # of C. difficile infections x 10,000 = C. difficile rate per 10,000 patient days

27 MRSA Bloodstrea MRSA blood isolate / C. difficile specimen per patient and location m and C. difficile Test Result Algorithm for LabID Events LabID Event No Prior (+) MRSA from blood / C. difficile in <2 weeks from same patient and location (including across calendar months) Yes Duplicate MRSA Bloodstream isolate / C. difficile test Not a LabID Event

28 Case Study #1 Mr. Smith had been in the hospital with pneumonia for 10 days. He was discharged on antibiotics. Twenty-four hours after discharge, he was seen in the emergency department complaining of watery diarrhea every 1-2 hours. His stool specimen from the ED was C difficile toxin positive. He was treated with IV fluids and Flagyl and sent home to follow up with his primary physician. He returns to the hospital one week later. Admission C difficile tests are positive. What is reported?

29 Case Study #1 A: The re-admission CDI. CMS reporting requirements include only inpatient LabID reporting. Positive C. difficile tests must be reported from inpatients and from ED patients if admitted to the hospital the same calendar day. The CDI positive lab obtained in the ED 24- hours after the first hospital discharge is not reported because the patient was not admitted. The CDI-positive lab obtained on readmission must be reported.

30 Case Study #2 A 70 year-old man with no significant past medical history admitted via the ED goes to the OR for a fractured hip from a fall. On post-op day 3, the orthopedic surgeon discharged him to home with a 10-day antibiotic prescription since he developed pneumonia after surgery. He had no fever or dyspnea at discharge. The patient returned to the ED after being home for a week complaining of weakness and diarrhea for over 24 hours. A stool specimen was collected at 10 pm in the ED and and then admitted to the medical/surgical floor at 12:15 AM for diarrhea and dehydration. The stool is positive for Clostridium difficile. Q: Should this positive stool specimen be reported as a CDI LabID event?

31 Case Study #2 A: No. The specimen date was prior to the date of admission and would not be included in CDI inpatient LabID reporting. If the patient would have been admitted at 11:59 pm the same day, then it would have been reported as CDI LabID event.

32 Case Study #3 On January 1 st, Mr. Smith was readmitted to the Intensive Care Unit with redness, pain and purulent drainage at the peripheral IV catheter site. Blood cultures were drawn. Fluid cultures were obtained aseptically. January 2 nd, one of the blood cultures was reported to have grown Staph aureus resistant to oxicillan. Is this an MRSA bacteremia?

33 YES Case Study #3 It must be reported by your hospitals as a MRSA BSI LabId event. It would be attributed to the Intensive Care Unit. For the blood culture positive for MRSA, a LabID event must be reported whether it s a primary or secondary BSI are reported if the pathogen is MRSA.

34 LabID Event calculator

35 QUESTIONS?

36 References NHSN MDRO/CDI Module Protocol and supporting documents Health.gov CDC vital signs