Healthcare-Associated Infections Still Major Issue, CDC Says

Larry Hand

Disclosures

March 26, 2014

The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, released 2 reports March 26 on healthcare-associated infections (HAIs): one with good news on progress made against some infections, but another that demonstrates squarely the extent of the problem today and the need to combat the drug-resistant pathogens at the center of many infections.

"CDC is known for handling outbreaks, but it's even more important to be scanning the horizon for the next important threat that needs to be tackled," Michael Bell, MD, deputy director of the CDC's Division of Healthcare Quality Promotion, said at a news conference. "Despite the progress that we've seen, three quarters of a million patients every year end up with [HAIs]. We found that on any given day 1 out of 25 patients has a hospital infection, and of those people, as many as 1 out of 9 go on to die. This is not a minor issue."

In the first report, published in the March 27 issue of the New England Journal of Medicine, Shelley S. McGill, MD, PhD, from the CDC, and colleagues describe the results of a survey they conducted to determine prevalence of HAIs and update estimates of the national burden of the infections. The survey covered 183 acute care hospitals in 10 geographically diverse states.

Of 11,282 patients included in the survey, 452 had 1 or more HAIs (4.0%; 95% confidence interval [CI], 3.7% - 4.4%), for a total of 504 infections. Pneumonia and surgical site infections each accounted for 21.8% of infections. Gastrointestinal infections accounted for just more than 17.1%.

Respondents reported Clostridium difficile as the most common pathogen, responsible for 12.1% of all HAIs and 70.9% of gastrointestinal infections, followed by methicillin-resistant Staphylococcus aureus (MRSA, 10.7%), Klebsiella pneumoniae and K oxytoca (9.9%), and Escherichia coli (9.3%).

Of the 504 HAIs reported in the survey, 98 (19.4%) were present on admission, arising from previous admissions to the same hospitals. Most of those infections were surgical site (67.3%) and gastrointestinal (9.2%).

Of the 452 patients with HAIs in the survey, researchers had data on outcomes for 436 patients, of whom 50 (11.5%) died during their hospitalizations.

Using multivariable regression analysis, the researchers determined that older patients, those hospitalized for a longer time, those in a large hospital, patients who had a catheter in place, patients receiving mechanical ventilation support, or those in critical care had increased risk for HAI.

National Burden Estimates

On the basis of these findings plus data from the Nationwide Inpatient Sample database, the researchers calculate estimates for the national burden of HAIs. They estimate that 648,000 patients had at least 1 HAI in 2011 (95% CI, 246,400 - 987,300 patients), with pneumonia and surgical site infections accounting for about half of those HAIs.

They estimated the total number of HAIs for the 648,000 patients at 721,800 (95% CI, 214,700 - 1,411,000 infections).

Limitations of the study include possible lack of generalizability to other acute care hospitals and the inability to account for HAIs that occur in other settings, such as nursing homes. Despite that, the researchers write, their national estimates "are remarkably similar to estimates from other data sources."

"The report sounds the alarms about what we need to be addressing," Dr. Bell said at the news conference. "It also shines the light on several important pathogens. At the top of the list is...C diff[, which] causes antibiotic-related diarrhea. In the past, going back 12 years or so, it was more of a nuisance than anything else. But today, the type of bacteria spread in this country have such a strong toxin that it is a very severe infection requiring colon removal in some cases. And that deadly diarrhea is contributing to an unacceptable number of infections."

He continued, "Staph infections continue to be a problem, including the antibiotic-resistance type, MRSA, and we're seeing a lot of infections relating to the enterobacteriaceae. This is a family of bacteria that includes E coli and Klebsiella. Some of those bacteria, the nightmare bacteria, are now completely untreatable. That means that as a doctor, I have nothing left I can offer a patients who has an infection like this in the hospital."

These microbes, mentioned also in last year's CDC report on antibiotic resistance, are a major focus of President Obama's FY2015 budget initiative, "where he's trying to drive progress by cutting some of these infections by 50% or more in 5 years. This is a major important investment in making sure hospital care remains safe," said Dr. Bell.

State-Level Data a "Mixed Bag"

In the second report, the National and State Healthcare-associated Infection Progress Report, the CDC described progress that has been made against HAIs in the past few years. For a subset of infection types commonly required to be reported nationally, researchers report the following:

  • a 44% decrease in central line–associated bloodstream infections between 2008 and 2012,

  • a 20% decrease in infections related to the 10 surgical procedures tracked between 2008 and 2012,

  • a 4% decrease in hospital-onset MRSA between 2011 and 2012, and

  • a 2% decrease in hospital-onset C difficile infections between 2011 and 2012.

The progress report is based on data from the CDC's National Healthcare Safety Network, the HAI tracking system for more than 12,600 healthcare institutions across all 50 states, the District of Columbia, and Puerto Rico.

"As a nation, we're moving in the right direction, but there's a great deal of work still to be done," Dr. Bell said. He described progress at the state level as a "mixed bag," with some states doing well with some types of infections and others not so much. He did cite Florida and Georgia as making good progress in key areas: Florida experienced a reduction in catheter-associated infections and Georgia had a reduction in bloodstream infections in babies in intensive care units.

In response to a question, Dr. Bell later summed up the challenge of addressing drug resistance: "The challenge that we have is that it takes a long time to go from some rare chemical in a jungle to something that we know is safe and effective for human beings. During that span of time, what we have right now is pretty much it. A lot of the very intense work that we're doing with regard to antibiotic stewardship and prevention of resistance is about how we keep this handful of antibiotics that still work for us effective and available for the next, who can say, 7 to 8 years before we have a new, truly useful antibiotic that's come through the pipeline."

One coauthor has reported receiving lecture, consulting, and board membership fees and owning stock in the Infectious Disease Consulting Corporation; another coauthor has reported receiving travel support from Parexel; none of the other authors have reported any relevant financial relationships.

N Eng J Med. 2014;370:1198-1208.

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