Preventing HAIS
Preventing HAIS
Preventing
Healthcare-Associated Infections (HAIs)
Hospitals
Dialysis Ambulatory
Facilities Facilities
Long-term
Care
Surgical procedures are increasingly
performed in outpatient settings
60
All Outpatient
Settings
50
Procedures (millions)
40
30
20
10
Hospital
Inpatient
0
1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005*
Source: Avalere Health analysis of Verispan’s Diagnostic Imaging Center Profiling Solution, 2004, and American Hospital Association
Annual Survey data for community hospitals, 1981-2004.
* 2005 values are estimates.
Outbreaks due to errors in
outpatient settings
Endoscopy clinic (HCV): NYC 2001, NV 2008
Private medical practice (HBV): NYC 2001
Pain remediation clinic (HCV): Oklahoma 2002, NY
2007
Oncology clinic (HCV): Nebraska, 2002
• State authorities notified and tested thousands of patients
Common themes
• “Obvious” violations in standard procedures
• Preventable with basic infection control practices
• HCWs not aware that practices were in error
Examples of multidrug resistance in
HAI pathogens
Acinetobacter baumannii
• About 75% are multidrug resistant*
10% increase from 2000
Pseudomonas aeruginosa
• About 17% are multidrug resistant*
Staphylococcus aureus
• MRSA causes about 55% of HAIs (Antimicrobial-Resistant Pathogens Associated
with Healthcare Associated Infections, Annual Summary of Data Reported to the NHSN at CDC, 2006-
2007)
* Percent Acinetobacter baumannii and P. aeruginosa in ICUs that are multidrug-resistant, NNIS and NHSN, 2000-2008.
Includes ICUs only (MICU, SICU, MSICU) and device-related infections only (CLABSI, CAUTI, VAP).
Estimated Clostridium difficile cases
by setting
Clostridium difficile hospitalizations Hospital-acquired,
400,000
Any listed diagnoses hospital-onset cases
Primary diagnosis
350,000
• 165,000, $1.3 billion excess
300,000 costs, 9,000 deaths annually
Campbell, Infect Control Hosp Epidemiol. 2009 Dubberke, Emerg Infect Dis. 2008
Dubberke, Clin Infect Dis. 2008 Elixhauser et al. HCUP Statistical Brief #50. 2008
MRSA has moved beyond
hospital settings
~100,000 invasive MRSA
infections per year (normally
sterile site)
25% were “nosocomial”
60% identified before or in first
2 days of hospitalization
• But with contacts to healthcare
settings; healthcare-associated
community-onset
15% community-associated
Multidrug-resistant gram negative infections in
long-term care facilities
In one study of 1,661 clinical
cultures from one LTCF
(Nov. ’03-Sept. ’05)*
• 180 (11%) MDR GNR
• 104 (6%) MRSA
• 11 (1%) VRE
Number of reports of sporadic cases from as early as
2004 from LTAC and LTCF
Similar thing had been recognized with ESBLs (e.g.,
movement for acute care into LTCF)
* O’Fallon E, et al. J Gerontol 2009; 64:138-41.
CDC’s role in HAI prevention
Strengthen surveillance and epidemiology
Support to state and local health departments
Implement what works and identify gaps for
prevention
Provide leadership in health policies
CDC’s role in HAI prevention
Data for action
National Healthcare Safety Network (NHSN)
Internet based reporting system through CDC’s Secure
Data Network
4500+ US healthcare facilities currently participate from
all 50 states
Standard definitions, methods, and protocols used
nationally
Data entry transitioning to automated electronic data
capture
National system for tracking and comparing HAI rates
Minimize user burden
• Streamlines data reporting
• Uses existing electronic data (e.g., laboratory information systems,
operating room, pharmacy, clinical, administrative databases)
Open to all: hospitals, health departments, ambulatory
care, dialysis facilities, etc.
Hospitals using NHSN are preventing
bloodstream infections
Trends in bloodstream infections* by ICU type, NHSN hospitals, 1997-2007
Pooled Mean Annual CLABSI Rate per 1,000 Central Line Days
Medical
5 Medical/Surgical--Major Teaching
Medical/Surgical--Non-Major Teaching
4 Pediatric
Surgical
2
Burton DC, et al. Methicillin-
Resistant Staphylococcus aureus
1 Central Line-Associated Bloodstream
Infections in US Intensive Care Units,
1997-2007. JAMA. 2009;301(7):727-
0
736.
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
CDC’s role in HAI prevention
Data for action
Emerging Infections Program
Population based surveillance in 9 states
Especially important for understanding the dynamic
epidemiology of healthcare-associated infections due to
MRSA and C. difficile, and other emerging multidrug
resistant bacteria causing HAIs
HAI Prevalence Survey in 2011
Adherence to CDC guidelines reduces HAIs
Examples of Success: Pennsylvania, Michigan
10
ICUs at 103 Michigan
hospitals, 18 months
0
0 18
MMWR 2005;54:1013-16.
State of prevention knowledge and science
Guidelines developed for each type of infection and based
on systematic reviews of medical literature
• Prevention of central line-associated blood stream infections
• Prevention of catheter-associated urinary tract infections
• Prevention of surgical site infections
• Prevention of healthcare-associated pneumonia
• Management of multidrug-resistant organisms
Recommendations graded according to evidence
Guidelines contain many recommendations
Current efforts to help prioritize interventions that are
most effective
Adherence to infection control guidelines is
incomplete
Many HAIs are preventable with current
recommendations
Failure to use proven interventions is unacceptable
Only 30%-38% of U.S. hospitals are in full compliance
Just 40% of healthcare personnel adhere to hand hygiene
Insufficient infection control infrastructure in non-acute
care settings has allowed major lapses in safe care
Local success fuels national prevention
National
Regional
Unit Facility
Local
CDC knowledge and data fuels National
National
local to national CLABSI expansion of
Regional CLABSI
prevention prevention
Subsequent 60% Reduction in
projects based CLABSI between
upon CDC 1999-2009
prevention: • State-based public
reporting using
Facility • Michigan
Keystone NHSN
Unit Pittsburgh • Institute for
• State/regional
Outbreak Regional prevention
Healthcare collaboratives
Investigations Healthcare Improvement
NHSN Data (CUSP, Recovery Act
Initiative • Others projects)
Prevention First successful,
large-scale CLABSI
• CMS/IPPS –
Research (e.g. prevention hospitals report
chlorhexidine CDC Guidelines demonstration project CLABSIs for full
bathing) Medicare payment
Inputs Outputs
Increasing adherence to CDC guidelines
Recent successes
58% reduction in central line-associated bloodstream infections
(CLABSI) for ICU patients between 2001 and 2009
In 2009 alone: 3,000-6000 lives saved; $414 million in costs averted
Since 2001: 27,000 lives saved; $1.8 billion in costs averted
More needs to be done
• 41,000 CLABSI in non-ICU hospital patients
• 37,000 in dialysis centers
This is a model for other infections
• MRSA, Clostridium difficile, surgical-site infections, catheter-associated
urinary tract infections, ventilator-associated pneumonia
States with legislation for public
HAI reporting
2004
2011
DC*
NHSN – CDC’s National Healthcare Safety Network EIP – CDC’s Emerging Infections Program
NHDS – CDC’s National Hospital Discharge Survey SCIP – CMS’s Surgical Care Improvement Project
HCUP – AHRQ’s Healthcare Cost and Utilization Project
Tracking state-level progress
National impact of HAI prevention
18% reduction of standardized infection ratio (SIR) of central-line
associated bloodstream infections in 2009 (NHSN data)
5% reduction of surgical site infection SIR in 2009 (NHSN data)
10% reduction per year of hospital-onset invasive MRSA
incidence rate from 2005 through 2008 (EIP data)
March 2011 Vital Signs: CLABSI prevention between 2001 and
2009
• 58% reduction in ICU patients
• In 2009 alone: 3,000-6000 lives saved; $414 million in costs averted
• Since 2001: 27,000 lives saved; $1.8 billion in costs averted
The need for HAI prevention research
Prevented
Healthcare-associated
implementation of practices
Preventable known to prevent HAIs
Prevention
Approach Need for ongoing research
Unknown
to identify new strategies
to prevent the remaining
HAIs
Culture change
“Many infections are inevitable;
some might be preventable”
Patients Payors
Government
Healthcare
Facilities
For more information:
www.cdc.gov/winnablebattles
For more information please contact Centers for Disease Control and Prevention
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for
Disease Control and Prevention.