About the Webinar: Defeating Superbugs: Hospitals on the Front Lines http://www.modernhealthcare.com/article/20140917/INFO/309179926 Hospitals across the country are facing a grim reality in which some of the most deadly healthcare-associated infections they encounter are untreatable with first- or even second-line antibiotics. These “superbugs” affect at least 2 million Americans each year and lead to 23,000 deaths. And their threat is growing, public health officials warn. This editorial webinar and “Defeating Superbugs” white paper will explore the steps providers must take to ramp up surveillance efforts, promote appropriate antibiotic use and control outbreaks. Our panel of experts will share their organizations' experiences as well as proven strategies for success. Registration for this webinar includes Modern Healthcare's “Defeating Superbugs” white paper, with proven tips and strategies for promoting appropriate antibiotic use, improving infection surveillance, identifying drug-resistant infections and dealing with outbreaks. KEY TAKEAWAYS - Best practices for effective antimicrobial stewardship - Real-world examples of effective interventions, including universal rapid testing for drug-resistant MRSA - Tips for engaging senior leadership - Aggressive strategies for controlling outbreaks PANELISTS Lance Peterson Director of the Clinical Microbiology and Infectious Disease Research Division NorthShore University HealthSystem, Evanston, Ill. Anurag Malani Medical Director for the Infection Prevention and Antimicrobial Stewardship Programs St. Joseph Mercy Hospital, Ann Arbor, Mich. Robert Weinstein Chief Medical Officer for Population Health Chairman of the Department of Medicine, Cook County Health and Hospitals System; Professor, Rush University Medical Center, Chicago MODERATOR Maureen McKinney Editorial Programs Manager Modern Healthcare

1. Welcome...
During today’s discussion, feel free to submit questions at any time
by using the questions box. A follow-up e-mail will be sent to all
attendees with links to the presentation materials online.
Today’s topic
Defeating Superbugs: Hospitals on the Front Lines
Dr. Robert Weinstein
Chairman, Department of
Medicine, Cook County
Health and Hospitals
System; professor,
Rush University Medical
Center, Chicago
Dr. Lance Peterson
Director, Clinical
Microbiology and Infectious
Disease Research Division,
NorthShore University
HealthSystem,
Evanston, Ill.
Dr. Anurag Malani
Medical director,
Infection Prevention
and Antimicrobial
Stewardship Programs,
St. Joseph Mercy Hospital,
Ann Arbor, Mich.

2. Now speaking...
Please use the questions box on your webinar dashboard
to submit comments to our moderator
Maureen McKinney
Editorial programs manager,
Modern Healthcare

3. Housekeeping
1. Viewer Window 2. Control Panel

4. Now speaking...
Please use the questions box on your webinar dashboard
to submit comments to our moderator
Dr. Anurag Malani
Medical director, Infection Prevention and Antimicrobial
Stewardship Programs, St. Joseph Mercy Hospital,
Ann Arbor,Mich.

5. What is Antimicrobial Stewardship?
“The selection of the optimal antimicrobial
agent, route of administration, dose, and
duration to provide maximal clinical benefit,
while minimizing unintended consequences.”

6. Why Antimicrobial Stewardship?
• Up to 50% of abx use is inappropriate
• High quantity, poor quality
• Inappropriate and unnecessary abx use can
lead to selection of resistant pathogens
• Antimicrobial resistance continues to increase
• Emergence of antimicrobial resistance leads to
significant impact on pt morbidity & mortality,
health care costs
Dellit TH, et al. Clin Infect Dis 2007;44:159-77

7. How We Acquire Antibiotic Resistant Organisms in Hospitals
Paterson DL. Clin Infect Dis 2006;42:S90-5

8. Resistance: A Public Health Crisis
www.cdc.gov/drugresistance/healthcare

9. Antimicrobial Resistance Continues to Increase
Wenzel et al. Infect Cont Hosp Epi 2008;29:1012-8

10. Increase of Carbapenem-Resistant Enterobacteriaceae
(CRE) Infections

11. KPC-producing CRE in the U.S. - 2014
http://www.cdc.gov/hai/organisms/cre/TrackingCRE.html

12. Urine Culture Showing CRE

13. Antibacterials Approved by the FDA, 1983 - 2007
Spellberg B et al. Clin Infect Dis. 2008;46:155-164

14. Impending Crisis of New Antibiotics
• Last new class of drugs active against GNB, in
the 1970s, – “Trimethoprim”
• No new classes of antimicrobials in the
foreseeable future
• No new drugs to deal with multi-resistant GNB
until 2018
• WHO – “Antibiotic resistance” as one of major
threats to human health
1. Bartlett J. Clin Infect Dis 2011;53:S4.
2. http://www.ecdc.europa.eu/en/publications/Publications/Forms/ECDC_DispForm.aspx?ID=444.

15. Controlling Resistance?
• A combination of BOTH
– Effective antimicrobial stewardship program
AND
– Comprehensive infection control program
– Have been shown to limit the emergence and
transmission of antibiotic resistant bacteria
Dellit TH, et al. Clin Infect Dis 2007;44:159-77

16. Antimicrobial Stewardship Works
Impact of a Reduction in the Use of High-Risk Antibiotics on the Course of an Epidemic of
Clostridium difficile-Associated Disease Caused by the Hypervirulent NAP1/027 Strain
Valiquette L, et al. Clin Infect Dis 2007;45:112-121

17. Antimicrobial Stewardship Reduces Costs
Standiford H, et al. Infect Cont Hosp Epi 2012;33:338-46.

18. Antimicrobial Stewardship Program Goals
• Ensure appropriate antimicrobial use
- Optimal selection, dose, duration
• Reduce or attenuate advancing antimicrobial resistance
• Improve patient outcomes and reduce adverse events
related to antimicrobials
- Decrease Clostridium difficile infection
- Decrease morbidity and mortality
- Decrease length of stay
• Decrease healthcare expenditures and antimicrobial
costs
Dellit TH, et al. Clin Infect Dis 2007;44:159-77
Ohl CA. Seminar Infect Control 2001;1:210-21

19. Antimicrobial Stewardship Interventions
• Prospective audit with intervention and feedback
• Formulary restriction and preauthorization
• Education
• Streamlining and de-escalating
• Dose optimization
• Guidelines and clinical pathways
• Parenteral to oral conversion
Dellit TH, et al. Clin Infect Dis 2007;44:159-77

20. Antimicrobial Stewardship Partners
Information Technology
Clinical Pharmacists
Infection Control
Microbiology Lab
ID Physicians &
Fellows
Abx Subcommittee
Pharmacy and
Therapeutics
Committee
Clinicians & Residents
Administration
Antimicrobial
Stewardship Team

21. SJMAA Antimicrobial Stewardship Program
• Initiated in 2009
– 2 ID physicians, 3 ICU pharmDs
• Focus on restricted abx
- New starts, duration
• Interventions
- Approve
- Stop abx
- Change/Narrow abx
- Obtain ID Consult
- Against ASP advice

22. SJMAA Antimicrobial Stewardship Program

23. Outcomes from SJMAA ASP Year One

24. Demographic and clinical characteristics and outcomes
of patients pre-ASP compared to patients post-ASP

25. Multivariable analysis for association
of ASP and patient outcomes
Malani AN, et al. Am J Infect Control 2013;41:145-8.

26. Flow Diagram of Outcomes from ASP
Malani AN, et al. Am J Infect Control 2013;41:145-8.

27. FY 2009 FY 2010 FY 2011 FY 2012
Percent
Change
Antimicrobial
agents total costs
1,503,748 1,274,837 1,231,079 1,221,275
-18.8
(-784,053)
Total patient days 147,955 144,783 146,332 146,310
Antimicrobial
costs per patient
day (average)
10.16 8.81 8.41 8.35 -17.8
Targeted
antimicrobial
agents
462,404 297,851 278,998 342,997
-25.8
(-467,360)
Antimicrobial Costs by Fiscal Year

28. Improving Antibiotic Use Reduces Rates of C. difficile
14
12
10
8
6
4
2
0
2008 2009 2010 2011 2012 2013
Cases per 10,000 Pt Days
HO-CDI
Two-step testing
PCR testing
Initiation of ASP

29. Current State of Stewardship
• Track all restricted antimicrobials
• Track all antimicrobials in high risk pts
• Use software for surveillance, tracking, clinical
decision support
• Development of bundles for specific
infections/syndromes
• Use of antimicrobial timeouts and rapid
diagnostic testing
• Lead quality initiatives related to abx use (i.e.
SCIP)

30. Clostridium difficle Infection Powerplan

31. Antimicrobial Management Page

32. Summary
• Primary mission of ASPs is patient safety
• Goals of ASPs are to ensure that there are
systems and support to help providers use
antibiotics optimally
• ASPs can improve pt outcomes, reduce tx costs,
reduce CDI, & reduce or slow the development
of resistant organisms
• ASPs can and must be implemented across
continuum of care

34. Now speaking...
Please use the questions box on your webinar dashboard
to submit comments to our moderator
Dr. Robert Weinstein
Chairman, Department of Medicine, Cook County
Health and Hospitals System; professor,
Rush University Medical Center, Chicago

35. TOPICS
• Scope of Multidrug Resistant Organisms
(MDROs)
• MDRO Resistance Iceberg and Networks
• Impact of a Control Bundle on CRE
• Lessons Learned

36. http://www.cdc.gov/drugresistance/threat-report-2013/

37. Infections Control Measures
Are Based on Epidemiology
RESISTANCE “ICEBERG”
Adapted from Weinstein & Kabins, Am J Med 1981; 70:449-54.

38. Carbapenem Resistance: Hospital and
Legend
LTACH
Nursing Home
Acute Hospital
Patient
Long-term Care Interrelations
Social Network depiction
of LTACH, Nursing Home,
& Hospital spread of
Carbapenem-resistant
Klebsiella pneumoniae
LTACH, Long term acute care
hospital; MDRO, Multidrug
resistant organism
Won et al, Clin Infect Dis 2011; 53(6):532-40.

39. These Interrelations Are Not A New Problem
Wiener et al, JAMA 1999; 281:517-23.

40. Source Control of MDROs —Remove the Fecal Patina
MDRO, Multi-drug resistant organism
Vernon et al, Arch Intern Med 2006; 166:306-12.

41. Risk Ratios for Skin Contamination and Environmental or
Healthcare Worker Contamination by or
Patient Acquisition of VRE
VRE, Vancomycin-resistant enterococci
Vernon et al, Arch Intern Med 2006; 166:306-12.

42. Axillary Cultures for CREs Before and After
Chlorhexidine Bathing
Before After
CRE, Carbapenem-resistant Enterobacteriaceae
Kindly provided by Mary K. Hayden, MD

43. Long-term Care MDRO Control Bundle
MDRO, Multi-drug resistant organism
Munoz-Price et al, Infect Control Hosp Epidemiol 2010; 31(4):341-7.

44. Epidemiologic Curve of Patients Colonized with K.
pneumoniae Carbapenemase (KPC)–producing Gram-negative
Rods at a Long-term Acute Care Hospital
• Daily 2% chlorhexidine cleansing of all patients
• Admission surveillance cultures
• Serial point prevalence surveillance
• Contact precautions
• Personnel training
• Enhanced environmental cleaning
Monthly distribution of patients with KPC-positive clinical isolates or admission surveillance cultures is shown.
January's and April’s isolates were probable KPC producers (on the basis of phenotype); all other isolates were
confirmed to produce KPC by means of polymerase chain reaction. Stars indicate 1 patient (depicted by these 2
rectangles) who was found to be a KPC carrier at admission and then 6 days later was found to have KPC-positive
Klebsiella pneumoniae in clinical cultures of urine and sputum samples.
Munoz-Price et al, Infect Control Hosp Epidemiol 2010; 31(4):341-7.

45. LESSONS LEARNED
• Antibiotic Resistance — A BIG and CONTINUING problem
• Control needs regional approach and support from the top
• Bundles can control emerging resistance — for CRE & KPC
– Daily cleansing of all patients with chlorhexidine
– Surveillance culturing
– Cohorting and/or single room nursing with contact precautions
– Enforcing HAND HYGIENE
• We can control problems; is there potential to eliminate
resistance?
CRE, Carbapenem-Resistant Enterobacteriaceae;
KPC, Carbapenemase-producing Klebsiella pneumoniae

46. Dr. Lance Peterson
Director, Clinical Microbiology and Infectious Disease
Research Division, NorthShore University HealthSystem,
Evanston, Ill.
Now speaking...
Please use the questions box on your webinar dashboard
to submit comments to our moderator

47. Potential COI
• Research Grants
– AHRQ, BD GeneOhm, CDC, Cepheid, GeneWeave,
NorthShore, MicroPhage, Nanogen, Nanosphere, NIAID,
Pfizer, Rempex, Roche, 3M, Washington Square Health
Foundation
• Consultations (in conjunction with research
projects and new diagnostics)
– BD GeneOhm, Cepheid, Merck, Pfizer, Roche

48. Objectives
• Review the progress in MRSA control using
active surveillance testing (AST)
• Insights from analyzing scientific reports
– Granular understanding the biology of Infection Control
• Discuss Control of MRSA in Long Term Care

49. Why Care About MRSA?
US Infection Mortality 2005
FR DeLeo &
HF Chambers
JCI 119:2464, 2009

50. Clonal versus Panmictic Evolution
SS.. aauurreeuuss PP.. aaeerruuggiinnoossaa
M. tuberculosis H. pylori
Courtesy of H Grundmann (Bejing 2008)

51. Why Look for MRSA Carriers?
Colonized Patients Spread MRSA
• Compared 58 patients with MRSA disease to
57 with nasal colonization to determine risk for
skin and environmental contamination
– Skin and environment contaminated 50 vs 47%
– Various skin sites 38-66% vs 30-63%
– Various environment sites 27-60% vs 21-63%
• Glove acquisition from skin 14-45% vs 16-38%
• “Strategies to limit transmission must address
colonized patients”
S Chang et al. CID 48: 1423-8, 2009

52. 10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
Total MRSA Healthcare Infections
P = 0.15
P 0.001
2 BSI in 4 hospitals
8/03 - 7/04 9/04 - 7/05 9/05 - 7/06 8/06 - 7/07 8/07 - 7/08 8/08 - 7/09
Prevalence Density
Years
Total
ICU surveillance Universal surveillance
70% reduction in
total MRSA disease
during hospitalization
and 30 days post-discharge
(Cases/10,000 patient-days)
LR Peterson et al. Decennial Meeting on
Nosocomial Infections, Atlanta, 2010
A Robicsek et al. Ann Int Med 148:409-18, 2008

53. VA Healthcare Continued Program
p0.0001 from
start to end
• Between 2007 and 2010 there was a 38%
increase in the number of hospitals with no
MRSA infections SM Kravolic et al. AJIC 41:456-8, 2013

54. Can We Afford MRSA Control?

55. How Much Does MRSA HAI Cost?
Mean Total
Cost
95% CI Mean Profit/Loss 95% CI
No MRSA HAI
(n=5796)
LOS 8d
$50,013 $42,363,
$57,662
-$25,000 -$28,883,
-$21,116
MRSA HAI
(n=178)
$73,795 $63,743,
$83,847
-$35,479 -$42,034,
-$28,923
Excess $23,783 $16,771,
$30,794
-$10,479 -$16,110,
-$4,848
LR Peterson et al. Jt Com J Qual Pt Safety 33:732-8, 2007

56. Medical and Economic Outcome
• Excess expense of MRSA infection (compared
to no infection) = $24,000
• The first 8 years of NorthShore MRSA
containment program prevented 813 infections
– Net direct benefit from medical expense reduction is
over $16 million ($2M/Year)
– Number of deaths avoided = 144 (18/Year)
LR Peterson. JCM 48:683-9, 2010
LR Peterson et al. Jt Comm J Qual Patient Saf 33:732-8, 2007
RM Klevens et al. JAMA 298:1763-71, 2007

57. Prospective Validation, Sept-Nov 2011
For a preventable infectious disease,
testing cost declines with time

58. What About Conflicting Literature
– Practices that Impact Results?
Over 10,000 articles on antimicrobial
resistance published in the last half-century

59. Predictors of Program Success
L Peterson, JCM, 48:683-9, 2010
Author MRSA
Prevalence
Mean Length of
Hospital Stay
Test
Sensitivity
Time to
Result
Reporting
Length of
Intervention
Period
Estimated
MRSA Days
Captured
Program was
Successful
Harbarth et al 6.7% 3.7 to 4 days 84% 22.2 hours 5 to 17 months 63% No reduction in
disease
Harbarth et al 5.1% 6.4 days 84% 22 to23 hours 9 months 72% No reduction in
disease
Robicsek et al 6.3% 4.6 days 98% 15 hours 21 months 85% Reduction in
disease with
universal
surveillance
Jeyaratnam et al 6.7% 3.8 days 87.8% 22 hours 5 months 67% No reduction in
transmission or
disease
Hardy et al 6.3% 7.2 days 98% 22 hours 8 months 86% Reduction in
transmission
Hardy et al 5.2% 6.5 days 73% 42 hours
(direct culture)
8 months 53% No reduction in
transmission
Bowler et al 14.6% 1 year 80% 48 hours 2 years 80% Reduction in
disease
Disease
reduced with
pre-emptive
isolation

60. Daily Chlorhexidine Bathing
• Multicenter, non-blinded cluster randomized trial
to assess effect on MDRO acquisition and BSI
HAI in 9 ICUs and a BMT unit
– Chlorhexidine (2%) or plain cloth for 6 months and
then switch for 6 months on 7,727 patients
• MDRO acquisition was 23% lower (p=.03)
– No difference for MRSA acquisition (p=.29)
• All BSI was 28% lower with chlorhexidine (p.01)
– 6.6 vs 4.8 BSI/1,000 patient days ( due to CLABSI)
– Difference due to CNS (p.01), not MRSA, GNR or
fungi MW Climo et al. NEJM 368:533-42, 2013

61. What About Decolonizing Everyone?
NEJM Results NS Results Comments
Scope/Population 18 months/29 ICUs
101,600 patient days
38 months/4 ICUs
55,350 patient days
Similar hospital
types
Outcome No screening and
Decolonize all
Screen all and only
Isolate positives
Rate of MRSA
clinical isolates
2.1 per 1,000
patient days
0.3 per 1,000
patient days
NS data based on
342,000 patients
Rate of all cause
ICU bacteremia
3.6 per 1,000
patient days
1.0 per 1,000
patient days
In ICU NS is 3-fold
lower
Rate of MRSA
bacteremia
0.47 per 1,000
patient days
0.018 per 1,000
patient days
In ICU NS is 25-
fold lower
Cost $40 per patient* $27-$37 per patient
(includes all MDROs)
NS cost range
based on test price
*Range of prices for 5 days of Bactroban Nasal® from 11 on-line
pharmacies is $116.15-$120.45, making the $40 estimate
problematic (http://www.goodrx.com/bactroban-nasal);
last accessed June 7, 2013)
S Huang et al. NEJM May 29, 2013
KE Peterson et al. ICHE 33:790-5, 2012
A Robicsek et al. ICHE 32:9-19, 2011
A Robicsek et al. Ann Int Med 148:409-18, 2008
LR Peterson et al. Jt Comm J Qual Patient Saf 33:732-8, 2007

62. Illinois Summary (2012)
Public Reported MRSA Infection Rates
Trends in methicillin-resistant Staphylococcus aureus (MRSA) in Illinois based on
Hospital Discharge Data, 2009-2012. Illinois Department of Public Health.
http://www.healthcarereportcard.illinois.gov/files/pdf/mrsa_2012_Trends.pdf
L Peterson, unpublished data

63. Does My Hospital Have a MRSA
Problem?
• Calculate your own MRSA BSI MRSA rate
– A = number of persons 2 days after admission in
one year with MRSA BSI
– B = number of annual patient days
• A/B times 10,000 = Annual MRSA BSI HAI
rate per 10,000 patient days
• If over 0.1, then consider if improvement(s)
can be made

64. MRSA in Long Term Care
• Study of MRSA control in 3 LTCFs
• Performed surveillance testing and
decolonized positive persons (no isolation)
• 16,773 swabs over 2 years
Period MRSA
Infections
PD Rate/1000 PD p Value
Baseline 44 365,809 0.120 ref
Year 1 23 294,165 0.078 (35% ) =0.09
Year 2 12 287,847 0.042 (65% ) 0.001
LR Peterson et al. Funded by the AGENCY FOR HEALTHCARE
RESEARCH AND QUALITY (Grant R18 HS19968 award)

65. Summary of Evidence
View of LP
• Majority of the evidence supports
– MRSA clinical infection remain important
– Surveillance and isolation or decolonization if the
goal is to reduce MRSA disease
• Majority of the evidence refutes
– Hand hygiene alone can prevent MRSA
transmission and subsequent disease
– Universal chlorhexidine decolonization can reduce
MRSA clinical disease

66. The NorthShore Program

67. Defeating Superbugs: Hospitals on the Front Lines
Today’s panelists...
Dr. Robert Weinstein
Chairman, Department of
Medicine, Cook County
Health and Hospitals
System; professor,
Rush University
Medical Center, Chicago
TODAY’S MODERATOR
Maureen McKinney
Editorial programs
manager,
Modern Healthcare
Dr. Anurag Malani
Medical director,
Infection Prevention and
Antimicrobial
Stewardship Programs,
St. Joseph Mercy Hospital,
Ann Arbor, Mich.
Dr. Lance Peterson
Director of the Clinical
Microbiology and Infectious
Disease Research Division,
NorthShore University
HealthSystem,
Evanston, Ill.
During today’s discussion, feel free to submit questions at any time by using the questions box.

68. Thank you...
... for attending today’s editorial webinar on the role of hospitals in the battle against superbugs.
We also thank our panelists, Dr. Anurag Malani, medical director of the Infection Prevention and
Antimicrobial Stewardship Programs, St. Joseph Mercy Hospital, Ann Arbor,Mich.; Dr. Lance Peterson,
director of the Clinical Microbiology and Infectious Disease Research Division at NorthShore University
HealthSystem, Evanston, Ill.; and Dr. Robert Weinstein, chairman of the Department of Medicine,
Cook County Health and Hospitals System, and professor at Rush University Medical Center, Chicago.
Expect a follow-up e-mail within two weeks. For more information,
send an e-mail to webinars@modernhealthcare.com
Register now for Modern Healthcare’s next virtual conference, “Building Tomorrow’s Delivery Model,” set for
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