Should Antibacterial-Resistant Infection

52 Pages·2008·0.75 MB·English

Preventing and Treating Serious ID
Adverse Events in the Hospital:
MRSA and Clostridium difficile
B. Joseph Guglielmo, Pharm.D.
Professor and Chair
Department of Clinical Pharmacy
School of Pharmacy
University of California San Francisco
Should Antibacterial-Resistant
Infection (or Superinfection) Be
Considered an ADE?
FDA Definition of ADE
FDA categorizes a serious adverse event
(events relating to drugs or devices) as one
in which “the patient outcome is death, life-
threatening (real risk of dying),
hospitalization (initial or prolonged),
disability (significant, persistent, or
permanent), congenital anomaly, or
required intervention to prevent permanent
impairment or damage.”
Cost and LOS Associated with ADE
• Additional length of stay associated with an ADE was 2.2
days, and the increase in cost associated with an ADE was
$3244.
• For preventable ADEs, the increases were 4.6 days in
length of stay and $5857 in total cost.
• After adjustment, the estimated posteventcosts attributable
to an ADE were $2595 for all ADEs and $4685 for
preventable ADEs.
• Estimated annual costs attributable to all ADEs and
preventable ADEs for a 700-bed teaching hospital are $5.6
million and $2.8 million, respectively.
(JAMA 1997; 277:307-11)
Antibacterial-resistant Staphylococcus
aureus is Associated with Increased Cost
and LOS
• Surgical site infection: MRSA associated with increase in
LOS of 5 days after infection. Charges were $29,455 for
controls, $52,791 for MSSA, $92,363 for MRSA (Clin
Infect Dis 2003; 36: 592)
• Bacteremia: MRSA bacteremiaassociated with a median
attributable length of stay of 2 days and a median
attributable increase in hospital charge of $6,916 (Infect
Control Hosp Epidemiol2006; 26: 166)
• Ventilator-associated pneumonia: MRSA associated with
increase in 5.3 ICU days, 3.8 days LOS, 4.4 days receiving
mechanical ventilation, when compared to MSSA (Crit
Care 2006; 10: 157)
Superinfection Due to C. difficile is
Associated with Increased Cost and
LOS
• Clostridium difficile-associated diarrhea
(CDAD) in the critical care unit is
associated with increased LOS, i.e. 6.1 D vs
3.0 D, and increased ICU cost, i.e. $11,353
vs $6,028
(Infect Control Hosp Epidemiol 2007; 28: 123)
Medicare Payment
• As of October 2008, in the United States,
Medicare will refuse to pay for conditions
that result from preventable errors
• “The hospital cannot bill the beneficiary
for any charges associated with the
hospital-acquired complication.”
• Private insurers are also considering
adopting the new rules (NY Times)
Non-reimbursable Conditions
1. Catheter-associated urinary tract infection
2. Catheter-associated vascular infections
3. Pressure ulcers
4. Objects left during surgery
5. Air embolism
6. Blood incompatibility
7. Mediastinitis
8. Falls
Non-reimbursable Conditions
(yet to be confirmed)
1. Staphylococcus aureus bacteremia
2. Ventilator-associated pneumonia
3. Clostridium difficile-associated diarrhea
Community-Acquired Methicillin
Resistant Staphylococcus aureus
(CA-MRSA): Epidemiology,
Outcomes and Treatment
8
7
6
5
MRSA
Admissions/ 4
1000
Admissions 3
2
1
0
1999 2000 2001 2002 2003 2004 2005
(Emerging Infect Dis 2007; 13: 1840)
90000
80000
70000
s
n 60000
o
ati Cellulitis/Abscess
aliz 50000 Postoperative
t
spi 40000 Device-related
o Osteomyelitis
H
o 30000
N
20000
10000
0
1999 2000 2001 2002 2003 2004 2005
(EmergInfect Dis 2007; 13: 1840)
Definitions MRSA Infection
• Health care-associated
– Community-onset (one of the following)
• Presence of invasive device at time of admission
• History of MRSA colonization or infection
• History of surgery, hospitalization, dialysis, residence in a
long-term care facility in previous 12 months
– Hospital-onset: positive culture >48hrs after hospital
admission
• Community-associated: cases with no documented
community-onset risk factor
Invasive MRSA Infection in U.S. July 2004-December 2005
Healthcare-Associated
Community Onset
Healthcare-Associated
Hospital Onset
Community-
Associated
Unknown
(JAMA 2007; 298: 1763)
Background: CA-MRSA
• Until the current decade, MRSA occurred almost
exclusively in hospitalized patients or persons
with extensive contact with the health care system
• CA-MRSA has caused outbreaks among
– Children
– Prisoners
– Participants on sports teams
– Military personnel
– MSM
Cases of MRSA Infection among St. Louis Rams
Professional Football Players in 2003
(Kazakovaet al. N EnglJ Med 2005; 352: 468)
Epidemiology
• 80-90% of CA-MRSA infections manifest
as skin or skin structure infections
• Necrotizing pneumonitis, necrotizing
fascitis, sepsis also reported
• Recurs in patients and spreads within
households
True or False?Antecedent
antibacterial use is associated
with increased risk of CA-
MRSA?
1. True
2. False
(Moran et al. NEJM 2006; 355: 666)
Molecular Makeup of CA-MRSA
Clone USA300:
• Presence of Panton-Valentine leukocidin(PVL) is
associated with USA300 (and other CA-MRSA strains)
• PVL and/or other virulence factors account for the
virulence of USA300
• Generally, methicillinresistance associated with CA-
MRSA results in some reduction of biological fitness
• USA300 may contain other genomic adaptations that
overcome this reduction in fitness
• USA300 produces many virulence determinants, including
α-hemolysin, enterotoxins Q and K, staphylokinase,
proteases