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Two critically important infection control issues — injection safety and antibiotic resistance — are vying to be the top priority in the next phase of the Department for Health and Human Services (HHS) Action Plan to Prevent Healthcare-Associated Infections (HAIs), said Don Wright, MD, MPH, Deputy Assistant Secretary for Healthcare Quality at the HHS.
"Over the next year we will be tackling the next phase — the candidates for that are still being discussed," Wright said recently in Anaheim at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC). "We are considering injection safety for a variety of reasons. There continue to be significant outbreaks related to injection safety and we also know with the demographics of increasing numbers of diabetics in the country there is an opportunity to [reduce HAIS] related to glucose monitoring and insulin injection. Another topic that is being considered is antimicrobial resistance and antibiotic stewardship. It is an issue that has great momentum in Washington, D.C., with the White House becoming interested as well as Congress."
This will be the fourth phase of the sweeping federal initiative, which has achieved some dramatic reductions in HAIs since it began in 2008 but is still struggling to affect Clostridium difficile and catheter-associated urinary tract infections (CAUTIs).
"It appears that we are on target to reach the 50% reduction in CLABSIs, the 25% reduction in SSIs, meet the SCIP process measures — [and for] invasive MRSA — significant decreases," Wright said. "I have to credit you and the thousands of providers that have actually translated what we know are good practices into bedside care that’s responsible for this. Clearly we are not making the headway with CAUTIs that we need to make, and there is a need for a great deal of improvement in the area of Clostridium difficile as well."
In that regard, the reduction targets for various infections are being finalized in the updated HHS plan, which will establish a new baseline in 2015 and set HAI percentage reduction goals for 2020. Though Wright said there may be some "tweaking" of the targets, they are expected to be finalized much as proposed, with the following goals set for 2020:
• Reduce central line-associated bloodstream infections in intensive care units and ward-located patients by 50% from 2015 baseline.
• Reduce CAUTIs in intensive care units and ward-located patients by 25% from 2015 baseline.
• Reduce the incidence of invasive health care-associated methicillinresistant Staphylococcus aureus infections by 75% from 2007-2008 baseline.
• Reduce facility-onset methicillin-resistant MRSA in facility-wide health care by 50% from 2015 baseline.
• Reduce facility-onset Clostridium difficile infections in facility-wide health care by 30% from 2015 baseline.
• Reduce the rate of C. diff hospitalizations by 30% from 2015 baseline.
• Reduce Surgical Site Infection admission and readmission by 30% from 2015 baseline.
"Concerning [resetting the baseline in] 2015, many of us have been looking to get a new benchmark to compare our information against," said the moderator of the APIC panel, Susan Dolan, RN, MS, CIC, an infection preventionist at Children’s Hospital Colorado in Aurora. "It’s really good to have those new targets, but I also think it makes it more challenging to then try to get your rates down even lower and meet them."
Dolan added a personal touch to the discussion, noting that her mother was recently hospitalized and "before we could get her home she developed C. difficile. She has now just finished a second round of antibiotics and we are hoping. We know we still have work to do. HAIs are still touching our lives every day — our patients’ lives, our family lives, our friends’ lives. These people need our help."
Indeed, Wright told APIC attendees they were "invaluable stakeholders" as the national HHS plan to reduce HAIs moves forward. All HHS forces are being brought to bear on HAIs, including "CMS financial incentives and the power of the purse — market driven incentives," he said.
The paradigm shift that has occurred with the national HAI plan can be largely traced to "two critical elements: accountability and transparency," said Denise Cardo, MD, MPH, director of the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention. "We had goals before, but now we have national goals that are embraced by CMS with the alignment of their incentive programs, their regulations. It is really working together — stopping the parallel work — and moving together toward real prevention."
While reducing the target HAIs is an ongoing process, the annual top priority item will likely receive additional funding as the HHS agencies collaborate on the identified problem and redouble their efforts. Previous top priority items have included acute care hospitals, ambulatory surgery centers and long-term care.
Given the increasing emphasis on antibiotic resistant infections, some of which are becoming virtually untreatable, one would think that would be the obvious choice over injection safety as the HHS priority. However, recall that it was the massive hepatitis C exposure incident in 2008 in a Las Vegas endoscopy clinic that drove national demands for action to prevent HAIs. Making matters worse, as originally reported in Hospital Infection Control & Prevention, CMS inspectors had actually visited the Las Vegas clinic but failed to recognize the reuse of single dose vials and other flagrant infection control breaches. Another sign that injection safety is becoming a top HHS priority is a recent memo by the Centers for Medicare & Medicaid Services (CMS) instructing it’s surveyors to contact public health departments if they see unsafe injection practices in health care settings. (See related story above) The Las Vegas HCV outbreak was followed shortly thereafter by a federal GAO report that essentially branded the HHS as a collection of agencies content to operate in their own silos.
"I think the title of that report tells it all: HAIs in Hospitals: Leadership needed by HHS,’" Wright said. "It indicated that there was not a coordinated strategy. The message I received as the department’s representative before [a Congressional committee] was You’re not doing enough.’ This was in the aftermath of the large outbreak in Nevada in ambulatory surgical centers where about 80,000 patients were [potentially] exposed to bloodborne pathogens through very poor infection control practices."
According to the CDC more than 50 outbreaks linked to reused and misused needles, syringes and medication vials have occurred since 2001, exposing tens of thousands of patients and leading to transmission of HCV, hepatitis and bacterial infections. In addition, patients have been infected with HCV and other pathogens by receiving contaminated solutions tainted by addicted health care workers diverting drugs for their own use. Outbreaks and patient notification events have occurred in hospitals, primary care clinics, pediatric offices, ambulatory surgical centers, pain remediation clinics, imaging facilities, oncology clinics, and health fairs.
If such highly publicized outbreaks continue, some patients may lose trust in the health care system, avoiding preventive and routine medical care that could leave them vulnerable to less treatable conditions later. Antibiotic stewardship is a more nebulous concept to many people, but the failure to reign in the massive overuse and misuse of the live-saving drugs could have devastating consequences.
"Antibiotic resistance is the topic of today and the topic of tomorrow," Cardo said. "It is a topic that you can talk to both Democrats and Republicans about and they both agree that it is important to address."
The CDC has been repeatedly warning that we are entering a post-antibiotic era, particularly as gram negative bacteria like carbapenem-resistant Enterobacteriaceae (CRE), exchange resistance plasmids and enzymes that can render most antibiotics useless.
The seriousness of this issue was driven home by another presentation at APIC, which revealed that a prolonged outbreak of CRE in a North Carolina hospital included three patients who acquired a CRE strain that was resistant to colistin — the absolute last line drug against many of these infections.1 If such strains gain a foothold and spread, a true era of untreatable CRE infections could result.
"One [patient] passed away and two survived," Catherine Passaretti, MD, medical director of infection prevention at Carolina Medical Center in Charlotte N.C., told HIC. "One [survivor] was a colonization — not a clinical infection so they didn’t require treatment. One with a surgical infection required amputation of the leg because we didn’t have [alternative antibiotics]. We treated them with a carbapenem and colistin regardless of the resistance pattern. That man is still alive."
In a recent CDC report on antibiotic pathogens,2 two of the three highest-rated "urgent threats" to public health are HAIs: CRE and C. diff, both of which may not be stopped without improved antibiotic stewardship programs and better collaboration and communication across the health care continuum.
"There is a need to collaborate," Cardo said. "Infection prevention is now beyond what you do within the walls of your institution. Infections will be a reflection of what is going on in your community."
While CRE is threatening to become untreatable, C. diff presents a different but similarly formidable problem. Overuse of broad spectrum antibiotics can wipe out commensal bacteria in the gut, setting the stage for a C. diff infection to emerge. The emergence of the North American pulsed-field gel electrophoresis type 1 (NAP1) strain around the turn of this century has driven a C. diff epidemic that now claims some 14,000 lives annually in the U.S. NAP1 has become the predominant outbreak strain of C. diff via several selective advantages that include enhanced spore formation, a 20-fold increase in toxins, a lower infectious dose, and the ability to survive indefinitely in the environment. Common sequelae to infection include diarrhea, colitis, toxic megacolon, and sepsis.3 As with any strain of C. diff, the spores are difficult to remove from the hands and switching from alcohol rubs to soap and water hand washing is frequently done during outbreaks. However, studies have shown the spores remain on the hands even after washing with soap,4 making antibiotic stewardship all the more critical to prevent C. diff infections in the first place.
"Early detection, infection control, environmental cleaning are extremely important, but the places that have had really major decreases in C. diff — like England — have improved antibiotic use. It’s a critical thing," Cardo said. "If you don’t do that you don’t prevent C. diff. That’s the reason we have published key elements of an antibiotic stewardship program that we now recommend for all hospitals in the United States."5 (See related story, p. 76.)
To improve surveillance for drug resistant pathogens, the CDC has developed an antibiotic use and resistance module and will soon be collecting data in its National Healthcare Safety Network (NHSN), she said. The CDC is shifting to more electronic data reporting, using indicators like lab-based "proxies" that will provide sufficient surveillance to develop prevention strategies without overburdening IPs with data collection. In this case, for example, the antibiotic data could come directly from the hospital’s medication-use system into the NHSN module. "It’s all electronic, you don’t need to do anything," Cardo told APIC attendees.
While no IP wants more data collection duties, Dolan said there is some concern that these time-saving reporting methods may lose some level of accuracy.
"As IPs we have spent so much time trying to perfect and make sure we are doing everything correctly and reading those definitions and the changing definitions," she said. "Now that we are moving to more lab-based surveillance, [there is some] uneasiness that we may feel. These new lab-based definitions are not as detailed as the others. We always want to make sure we are capturing everything and not capturing the things we don’t want. This movement to electronic surveillance — I understand the purpose and I get a lot of the reasons because that will hopefully free up our time so we can be out where we need to be and not sitting at the computer entering data."
Remember, the electronic surveillance data is for developing prevention strategies, not for making clinical decisions that require more detail, Cardo said.
"It’s great to have a lot of details, but most of the time we don’t use all of the details," she said. "We need to do this in a way in which we capture what is happening and use the data for prevention. Sometimes perfection is the enemy of action."
As outbreaks continue to be reported due to unsafe injection practices and improper use of medication vials, the Centers for Medicare & Medicaid Services (CMS) is telling its surveyors to contact public health departments immediately if they see such flagrant breaches of infection control.1
A recent memo from the CMS states that if State Survey Agencies (SAs) or Accrediting Organizations (AOs) witness the following practices it’s time to cite and sound the alarm by calling in public health authorities:
• Using the same needle for more than one individual
• Using the same (pre-filled/manufactured/insulin or any other) syringe, pen or injection device for more than one individual
• Re-using a needle or syringe which has already been used to administer medication to an individual to subsequently enter a medication container (e.g., vial, bag), and then using contents from that medication container for another individual;
• Using the same lancing/fingerstick device for more than one individual, even if the lancet is changed.
According to the CMS, SAs should consult with their state’s Healthcare Associated Infections (HAI) Prevention Coordinator or State Epidemiologist on the preferred referral process. Since AOs operate in multiple states, they do not have to confer with state public health officials to set up referral processes, but are expected to refer identified breaches to the appropriate state public health contact identified at: http://www.cdc.gov/HAI
Continuing to emphasize the importance of hospital adoption of antibiotic stewardship programs, the Centers for Disease Control and Prevention recommends seven key strategies to stem the tide of drug-resistant pathogens.1 To protect patients and preserve the power of antibiotics, hospital CEOs/medical officers should form an antibiotic stewardship program that includes, at a minimum, this checklist:
1. Leadership commitment: Dedicate necessary human, financial, and IT resources.
2. Accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
3. Drug expertise: Appoint a single pharmacist leader to support improved prescribing.
4. Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
5. Track: Monitor prescribing and antibiotic resistance patterns.
6. Report: Regularly report to staff prescribing and resistance patterns, and steps to improve.
7. Educate: Offer education about antibiotic resistance and improving prescribing practices.
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