Presentation from the 3rd Joint Meeting of the Antimicrobial Resistance and Healthcare-Associated Infections (ARHAI) Networks, organised by the European Centre of Disease Prevention and Control - Stockholm, 11-13 February 2015

1. U.S. Healthcare-Associated Infections and
Antimicrobial Use Prevalence Surveys:
Plans for 2015
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion
Shelley S. Magill, MD, PhD
Division of Healthcare Quality Promotion
U.S. Centers for Disease Control and Prevention
February 12, 2015

2. Overview
 Healthcare-associated infection (and antimicrobial use)
surveillance in the United States, then and now
 Key results from the first U.S. HAI and antimicrobial use
prevalence survey in 2011
 How the data have been used, and reasons for repeating the
survey in 2015
 Overview of objectives and methods for the 2015 HAI and
antimicrobial use prevalence survey—what’s new

3. U.S. HAI SURVEILLANCE SYSTEMS

4. www.cdc.gov/nhsn

5. National Healthcare Safety Network (NHSN)
 “Most widely used healthcare-associated infection (HAI)
tracking system” in the United States
 Facilities use standard NHSN surveillance protocols to track
infections and report data using the NHSN application
 NHSN data are used by healthcare facilities, state health
departments, federal agencies, and the public to:
 “Identify infection prevention problems by facility, state, or specific
quality improvement project
 Benchmark progress of infection prevention efforts
 Comply with state and federal public reporting mandates, and
ultimately,
 Drive national progress toward elimination of HAIs.”
www.cdc.gov/nhsn

6. http://www.cdc.gov/hai/eip/index.html

7. Emerging Infections Program (EIP)
 Network of 10 state health departments and academic
partners established in 1995
 Assess public health impact and evaluate approaches to prevention
and control of emerging infectious diseases
 HAI-related work established as formal EIP activity in 2009
 Core EIP work is active, population- and laboratory-based
infection surveillance with isolate collection
 Basis for epidemiological and laboratory analyses and special projects
performed at CDC and in EIP states
 Data are collected by trained EIP site staff working with a variety of
CDC programs across the agency
 Data are primarily used by CDC and other federal agencies to inform
national infection prevention and control strategies and policies

8. Then (2010-2011):
National Healthcare Safety Network
 Data reported from 2400 – 4500+ healthcare facilities
 Mostly acute care hospitals
 Most reporting from intensive care units (ICUs)
 Focus on reporting of device- and procedure-associated
infections
 HAI reporting driven by state reporting mandates and in
2011 by reporting programs of the federal Centers for
Medicare & Medicaid Services (CMS)
 CMS incorporated ICU CLABSI into its Hospital Inpatient Quality
Reporting (IQR) Program with data collection beginning Jan 1, 2011
 Little to no reporting of antimicrobial use
 NHSN Antimicrobial Use and Resistance (AUR) Module launched in
2011

9. Then (2010-2011):
Rationale for HAI and AU Prevalence Survey
 Redefine HAI burden (i.e., to update the oft-quoted “1.7
million HAIs per year” from analysis of 1990s-2002 data*)
 Describe the full spectrum of HAIs across acute care
inpatient populations to identify areas in need of prevention
attention
 Complements focused reporting of selected HAIs to NHSN
 Describe patient-level epidemiology of antimicrobial use in
acute care hospitals to identify high-impact targets for
stewardship
 Complements consumption data gathered electronically through
reporting to AUR Module
*Klevens M, et al. Public Health Reports 2007;122:160-6.

10. Now (2015):
National Healthcare Safety Network
 Approximately 13,000 healthcare facilities
 Expansion of HAI reporting beyond acute care hospitals:
 Long term acute care, nursing homes, dialysis centers, inpatient rehab,
ambulatory surgery centers
 Expansion of reporting within acute care hospitals:
 Outside the ICU
 Most reporting still focused on device and procedure-associated HAIs
 All HAI definitions have been revised as of January 2015
 Multiple infection types now part of CMS Hospital IQR:
 Central line-associated bloodstream infection (CLABSI)
 All ICU and medical and surgical wards (adult and pediatric)
 Catheter-associated urinary tract infections (CAUTI)
 Non-neonatal ICU and medical and surgical wards (adult and pediatric)
 Surgical site infections (SSI), colon and hysterectomy procedures
 Hospital-onset MRSA bacteremia (facility wide)
 Hospital-onset Clostridium difficile infection (CDI) (facility wide)

11. Now (2015):
Rationale for HAI and AU Prevalence Survey
 Is there still a role for a periodic, large-scale prevalence
survey in U.S. acute care hospitals?
 What is the role?

12. U.S. HAI and AU Prevalence Surveys
Pilot HAI survey
•1 city
•9 hospitals
•855 patients
Limited roll-out
HAI and AU
survey
•10 states
•22 hospitals
•2015 patients
Full-scale HAI
and AU survey
•10 states
•183 hospitals
•11,282 patients
Full-scale HAI
and AU survey
•10 states
•~180 hospitals
•~11,300 patients
2009 2010 2011 2015

13. Emerging Infections Program Survey Participation, 2011
GA: 22
hospitals,
1395 patientsTN: 25
hospitals,
1486 patients
MD: 21
hospitals,
1372 patients
MN: 24
hospitals,
1358 patients
NY: 23
hospitals,
1545 patients
CT: 13
hospitals, 945
patients
OR: 15
hospitals, 898
patients
CA: 8
hospitals, 514
patients
CO: 12
hospitals, 877
patients
NM: 20
hospitals, 892
patients

14. Key Prevalence Survey Results, 2011: HAIs
 1 in 25 hospital inpatients (4%) had at least one HAI
 Estimated national burden of 722,000 HAIs in 648,000
patients in 2011
 ~75,000 patients with HAIs died during their hospitalizations
Magill SS, et al. NEJM 2014;370:1198-208.

15. HAI Distribution, 2011
PNEU, 110
(22%)
VAP, 43
(39% of PNEU)
Other, 83 (16%)
UTI, 65 (13%)
CAUTI, 44
(68% of UTI)
GI, 86 (17%)
BSI, 50
(10%) CLABSI, 42
(84% of BSI)
SSI, 110 (22%)
PNEU
VAP
Other
UTI
CAUTI
GI
BSI
CLABSI
SSI
#1 (tie) #1 (tie)
#3
#4
#5

16. Proportion of HAIs Detected in the Survey that are
Commonly Reported to NHSN, 2015
0%
20%
40%
60%
80%
100%
69%
31%
CLABSI and CAUTI (all
locations), hospital-
onset CDI, MRSA
bacteremia, SSIs
associated with
common procedures

17. Based on prevalence survey data: what proportion of
HAIs are routinely reported to NHSN for the CMS
Hospital IQR Program?
0%
20%
40%
60%
80%
100%
2011 2015
97%
71%
3%
29%
HAIs not
included in CMS
reporting
HAIs included in
CMS reporting

18. Where are HAIs occurring?
Critical care
locations, 34%
Wards and
other non-ICU
locations,
66%

19. HAI Take-Home Messages, 2011 Survey
 Survey helped us describe the full spectrum of HAIs in
hospitals— beyond those systematically tracked by NHSN.
 Survey data show what new challenges are likely to require
increased attention and prevention efforts moving forward
(e.g., PNEU).
 Bottom line: Progress is being made, but there is much
more work to be done to prevent the wide spectrum of
infections still common in hospitals.

20. Key Prevalence Survey Results, 2011: Antimicrobial Use
 50% of patients were on antimicrobials at the time of the
survey
 Of patients getting antimicrobials, half were getting ≥2
drugs
 Few differences in treatment given to patients inside and
outside of ICUs, for community and healthcare infections
Magill SS, et al. JAMA 2014;312:1438-46.

21. Antimicrobial Drug Use Prevalence and Distribution
 5635 patients on antimicrobial drugs (50%, 95% CI 49 to 51%)
1388, 14.1%
1213, 12.3%
1081, 11.0%
1037, 10.5%
0 200 400 600 800 1000 1200 1400
Fluoroquinolones
Glycopeptides
Penicillin
combinations
Third generation
cephalosporins
Number of Drugs (N=9865)

22. Antimicrobial Treatment
Vancomycin IV,
ceftriaxone,
piperacillin-
tazobactam,
levofloxacin,
45%
Everything else
(79 other
drugs), 55%

23. Antimicrobial Use Take-Home Messages, 2011 Survey
 Lots of antimicrobials are being used in acute care
hospitals—and mostly broad spectrum drugs and drugs used
to treat resistant pathogens
 Even in patients who are not in the intensive care unit and patients
who do not have HAIs
 Survey data suggest high impact areas for national
stewardship efforts
 Treatment for lower respiratory, urinary tract, and skin and soft tissue
infections, and use of 4 specific drugs (vancomycin, pip/tazo,
ceftriaxone and levofloxacin)—covers about 50% of all antimicrobial
use in hospitals.

24. How Prevalence Survey Data
Have Been Used
 Used to generate national burden estimates for CDC’s report
on “Antimicrobial Resistance Threats in the United States”
 Puts the burden in context for the public and for policy makers
 Prompted initiation of efforts to describe clinical events detected by
pneumonia and lower respiratory infection definitions
 Highlighted the potential for improving prescribing in U.S.
hospitals (CDC “Vital Signs” report)
 Justified the need for policy changes outlined in the National Strategy
to expand antibiotic stewardship programs to all U.S. hospitals
 Prompted additional work on approaches to describing quality of
antimicrobial prescribing

25. Why repeat the survey in 2015?
 Maintain awareness of all HAIs affecting hospital patients
 Only system right now providing “comprehensive” view of acute care
HAIs; complements NHSN
 New targets, changes over time
 Update national burden estimates
 Estimates can be used to validate estimates generated using other
systems (e.g., National Healthcare Safety Network, NHSN)
 Might be able to provide inpatient AU burden estimate, too (in 2015)
 Describe antimicrobial prescribing in hospitals at the patient
level
 Only system right now that can provide patient-level use and
prescribing quality data from acute care setting

26. Emerging Infections Program Survey Anticipated
Participation, 2015
GA: 22
hospitals?
TN: 25
hospitals?
MD: 21
hospitals?
MN: 24
hospitals?
NY: 23
hospitals?
CT: 13
hospitals?
OR: 20
hospitals?
CA: 20
hospitals?
CO: 20
hospitals?
NM: 20
hospitals?

27. Hospital and Patient Selection
 Hospitals
 Sites will seek to engage same hospitals that participated in 2011
 Site with <20 hospitals in 2011 will try to recruit additional hospitals
through stratified random sampling scheme based on hospital bed size
 Patients
 Random sample of acute care inpatients on morning of survey
 Patients selected through use of random sort of acute care bed
numbers done prior to survey
 100 patients in large hospitals, 75 in small and medium hospitals (or
all acute care inpatients if <75)

28. Hospital-Level Data Collection
 NEW in 2015—Healthcare Facility Assessment
 Administered once to each participating hospital
 During month prior to survey date
 Hospital characteristics
 Infection control resources, policies, practices
 Stewardship resources, policies, practices
 EIP team will also collect certain hospital characteristics
using public data sources
 Urban vs. rural hospitals
 Teaching vs. non-teaching

29. 2015 Patient Data Collection: Antimicrobial Use
All patients
• Demographics, payer information
• Devices, body mass index
• On antimicrobials or not at time of survey
• Hospital admission and discharge dates and outcome
50% of
patients
• Drug name and route
• First and last dates, total days of treatment (dose optional)
• Rationale for use
• Sites of infection and infection onset location
26% of
patients
• Allergies and underlying conditions
• Infection syndromes, severity of illness
• Microbiology and laboratory data
NEW: Prescribing
quality assessment
If on antimicrobials, then
If treatment with IV vancomycin, FQs, or for CAP or UTI, then

30. Antimicrobial Quality Assessment (AQUA) Forms
 Case eligibility form (excludes infants, children for FQs, and
patients with risk factors for healthcare-associated
pneumonia)
 Patient assessment (underlying conditions, etc.)
 Event-specific forms (microbiology and other lab data,
clinical signs and symptoms of UTI, pneumonia, etc.)

31. 2015 Patient Data Collection: HAIs
All patients
• Demographics, payer information
• Devices, body mass index
• On antimicrobials or not at time of survey
• Hospital admission and discharge dates and outcome
50% of
patients
• Drug name and route
• First and last dates, total days of treatment (dose optional)
• Rationale for use
• Sites of infection and infection onset location
36% of
patients
• HAIs, 2011 and 2015 NHSN definitions
• Onset and treatment start dates
• Pathogens and susceptibility
NEW: Two sets of HAI
definitions
If on antimicrobials, then
If patient got antimicrobials for treatment or no reason

32. HAI Form

33. HAI Form

34. Timeline for Data Collection and Management
Primary Team in
each hospital
collects
demographic,
device, and limited
antimicrobial data
EIP Team reviews
medical records to
collect antimicrobial
drugs (ADs), rationale,
infection sites and
onset locations; HAI
determinations,
antimicrobial use
quality assessment;
enters into web-based
data management
system
1-day surveys
(May-Sept 2015)
5-18 mos after surveys
(Dec 2016)
1-12 mos after
surveys (June 2016)
EIP Teams work with
CDC to clean data,
begin analysis

35. Challenges
 Hospital recruitment
 Ebola activities have stretched hospital and state health department
resources; EIP sites are concerned this may impact hospitals’
willingness to engage in the survey
 Antimicrobial use data collection
 Quality assessment forms are complex and time-consuming to
complete; also these are the newest forms, and sites have the least
experience with them
 HAI data collection
 Taking into account use of both 2011 and 2015 definitions, sites will be
applying 68 different HAI definitions

36. … and Opportunities
 Largest U.S. experience assessing prescribing quality
 Opportunity to see what changes have occurred over time
and refine burden estimation process
 Experience will help inform decision making about whether
to conduct surveys in other healthcare settings
 E.g., nursing homes—pilot survey in 9 nursing homes completed in
2014, discussions underway for possible scale-up in 2016-2017

37. Acknowledgments
 Participating hospitals and personnel
 EIP site teams
 EIP Healthcare-Associated Infections/Community Interface Steering Group
 Phase 1 prevalence survey participants
 ECDC and EU prevalence survey colleagues
 U.S. CDC colleagues
 Many others …
The findings and conclusions in this presentation are those of the author and do not necessarily
represent the views of the Centers for Disease Control and Prevention.

38. For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: www.cdc.gov
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.
Thank you!
smagill@cdc.gov
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion