Basic HAI Surveillance

1
SURVEILLANCE
OF HAIs
Name of Speaker
Date and venue
@gonnabedess @gonnabedess
Philippine Hospital Infection Control Society, Inc.
Case
From 29 December 1988 to 21 January 21
1989, B. cepacia was isolated from
1. PF of 4 patients on PD (peritonitis)
2. Blood of two patients at another
children's hospital
March 03, 1989 / 38(8);133-134

2
Case
OUTLINE
 Definition of Surveillance
 Goals of Surveillance
 Components of Surveillance
 Steps in Surveillance of Nosocomial
Infection

3
Disclaimer
 This lecture is intended to overwhelm
provide you with an overview about
surveillance NOT to teach you the
specific steps to conduct it
SURVEILLANCE
 “The ongoing systematic collection, analysis
and interpretation of healthcare data
essential to the planning, implementation,
and evaluation of public health practice,
closely integrated with the timely
dissemination of these data to those
contributing data or to other interested groups
who need to know.”
Lennox K. Archibald and Walter J. Hierholzer, Jr.
C. Gen Mayhall’s Hospital Epidemiology and Infection Control.
4th Edition. 2011

4
SURVEILLANCE
 “…is used to identify nosocomial
infections and other adverse events that
may be prevented…”
SURVEILLANCE
 “…is used to establish endemic rates
of health-related events or
diseases…”

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Goals of Surveillance
 to define endemic rates
 to identify increases in infection rates
 to identify specific risks
 to inform hospital personnel of the risks
of the cares or procedures they provide
■ to apply targeted interventions and to
evaluate their effect in an ongoing system
(Mintjes-de Groot AJ 2000)
OUTLINE
 Steps in Surveillance of Nosocomial
Infection

6
COMPONENTS
OF
SURVEILLANCE
Kenrad E. Nelson and Carolyn Masters Williams.
Infectious Disease Epidemiology: Theory and Practice, 3rd
edition. 2013.
“The building blocks of surveillance
comprise:
1. collecting relevant data systemically for a
specified purpose and during a defined period
of time,
2. managing and organizing the data,
3. analyzing and interpreting the data and
4. communicating the results to those empowered
to make beneficial changes…”

7
The The building blocks of surveillance comprise collecting relevant data systemically for a specified purpose and during a defined period of time, managing and
organizing the data, analyzing and interpreting the data and communicating the results to those empowered to make beneficial changes…
Xy = a+b+c ; y= mc – rta’
Xy = a+b+c ; y= mc – rta’ The The building blocks of surveillance comprise collecting relevant data systemically for a specified purpose and during a defined
period of time, managing and organizing the data, analyzing and interpreting the data and communicating the results to those empowered to make beneficial
changes…
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changes…
5
Definition
 Use standardized written case definitions to
ensure precise surveillance. Where available
and applicable, use previously published,
validated definitions.
 For accurate and valid comparisons of data,
use the same definitions over time.

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Collection
 Know your population to determine which
subset requires targeting
 Assess your capability to identify your method
of data collection
Data Management
 Combine only homogenous data
– Always qualify and describe your data source
– May apply risk stratification to ensure homogeneity
 Comparisons are valid only if all contributors
to the data have:
– used the same surveillance intensity
– used similar data collection methods
– applied the same surveillance definitions
– addressed differences in populations/case mix
– stratified data as appropriate

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Data Management
 Note that rates can be accurate and
consistent but still not useful or
interpretable if the numerator is too
small (infrequent event) or the
denominator is of inappropriate size
(usually too small).
Communication
 Timely
 Simple and understandable
 Relayed to the relevant persons

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OUTLINE
 Steps in Surveillance of
Nosocomial Infection
STEPS IN SURVEILLANCE
FOR NOSOCOMIAL
INFECTIONS

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FOR HAIs
1. Identify Surveillance Strategy
2. Data collection
3. Case-Finding Method
4. Consolidation and Tabulation
5. Calculating Rates
6. Analysis and Interpretation
7. Validation
FOR HAIs
Identify Surveillance Strategy

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Surveillance Strategies for
Case Findings
 Scope of
infection control
program
 Patient or
Laboratory -
based
 Active
vs
Passive
 Retrospective
vs
Prospective
or concurrent
 Methods
of
Surveillance
Methods of Surveillance
1. Hospital-wide Surveillance
(Traditional)
2. Limited Periodic Surveillance
3. Prevalence Surveillance
4. Targeted Surveillance : unit / site
specific / rotational
5. Objective/Priority Based Surveillance

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1. Hospital-Wide Surveillance
(TRADITIONAL)
Advantage
 MOST comprehensive
method
 collects data on all
infection, sites, units
 establishes baseline
infection rates
 recognizes outbreaks
early
 identifies clusters
 increase visibility of
infection control
professional (ICP)
Disadvantage
 expensive, labor intensive
labor , time-consuming,
yields excessive data
 leaves little time to
analyze data and initiate
changes (no definite
management objective)
 detects infections that can
not be prevented
 Overall infection rate not
valid for interhospital
comparison
2. Limited Periodic Surveillance
Advantage
 increases efficiency of
surveillance
 liberates ICP to perform
other activities
 utilized resources more
effectively
 reduces time spent
doing surveillance by
45%
Disadvantage
 provides data only
during periods in which
surveillance is
conducted
 may miss cluster or
outbreaks during
nonsurveyed periods

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3. PREVALENCE
SURVEILLANCE
ADVANTAGE
 documents nosocomial
infection trends identifies
risk factors
 relatively quick and
inexpensive
 identifies areas that need
additional surveillance
DISADVANTAGE
 data collection may be
tedious
 must collect data in short
time period
 data are restricted to a
specified time period
 cannot compare
prevalence rate with
incidence rates
 few studies on prevalence
rates published
 may miss clusters or
outbreaks
4. Targeted Surveillance
Advantage
 focus on patient at risks; on infections
with known control measures to reduce
infection risk
 concentrates limited resources on high-
risk areas
 can determine valid denominator

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Advantage
 requires less personnel and
liberates ICP to perform other
activities
 increases efficiency of surveillance
 flexible - can be mixed with other
methods
Disadvantage
 no baseline rates in other units
 collects data only for targeted
patients at risk
 can miss clusters or outbreaks in
nonsurveyed areas or populations

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4. Targeted Surveillance :
ROTATING
Advantage
 less expensive
 less time-consuming
 less personnel
 all areas of hospital
surveyed
Disadvantage
 can miss clusters of
infection
Objective / Priority Based
Surveillance
Advantage
 adaptable to
hospital with special
interest and
resources
 focuses on specific
problems of the
individual institution
Disadvantage
 no baseline rates of
infection
 may miss clusters /
outbreaks

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FOR HAIs
Data collection
Sources of Data for
Surveillance
 Laboratory-based
Information
 Patient-based
Information
 Other departments ,
services or agencies

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Sources of Data for
Surveillance
 Patient-based Information
 Patient examination
 Clinical ward rounds
Sources of Data for
Surveillance
 Patient-based
Information
Culture
organism
antimicrobial
susceptibility
pattern
Clinical Data
fever
p.e. findings
x-ray results
Predisposing
factors
surgery
chemotherapy
antibiotics
steroids
underlying disease
Exposure factor
Patient’s name
Age
Sex
Hospital number
Ward service
Admission data
Infection onset
data

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Sources of Data for
Surveillance
 Patient-based
Information
 Communication with staff
 Patient medical record
– Medication records
– Temperature records
– Radiology reports
– Laboratory reports
 Kardex review
Sources of Data for
Surveillance
 Patient-based
Information
 Communication with staff
 Patient medical record
 Kardex review
 Treatments, Wound dressing
changes
 Intravenous fluids, Antibiotics
 Urinary catheter, Surgery
 Isolation precautions

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Sources of Data for
Surveillance
Information
 Patient-based
Information
 Bacteriology, Mycology,
Parasitology, Serology , Virology
and Pathology reports
 Antimicrobial susceptibility
patterns
Sources of Data for
Surveillance
Information
 Patient-based
Information
 Other departments , services or agencies
 Admission department
 Operating suite
 Emergency Department
 Outpatient clinics
 Risk Control (for
incident reports and
other data)
 Employee health

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Sources of Data for
Surveillance
Information
 Patient-based
Information
 Other departments , services or agencies
 Home-care agencies
 Multicenter surveillance systems (e.g. NNIS)
 Local and state health departments (e.g.
MMWR)
FOR HAIs
Data collection
Case-Finding Method

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CASE-FINDING
METHODS
 TOTAL CHART REVIEW
 SELECTIVE MEDICAL RECORD
REVIEW BASED ON :
– Laboratory Reports, Kardex screening,
Fever, Antibiotic use, Fever and
Antibiotic use, Readmission, Autopsy
reports, Ward Liason surveillance,
Laboratory-based and ward-liason
surveillance, risk-factor-based
surveillance
METHOD DEFINITION Sensitivity Estimated
Time(Hrs)
/500 beds
Total Chart Review Review all patient 0.74-0.94 35.7-53.6
medical records
Selective Medical Record
Review based on:
Laboratory reports microbiology reports to 0.77-0.91 23.2
identify pts with (+)
cultures
CASE FINDING
METHODS

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CASE FINDING
METHODS
Time(Hrs)
/500 beds
Review based on:
Kardex screening Patient Kardex to det. 0.75-0.94 14.3-22.3
patients at risk for infxn
Fever Temperature record to 0.09-0.56 8
ident. pts with T>37.8C
Antibiotic use Medication record to 0.57 14.3
ident. pts receiving abs
CASE FINDING
METHODS
Time(Hrs)
/500 beds
Review based on:
Fever and Ab use Temp record to ident. 0.70 13.4
pts with T>37.8 and med
rec. to ident. Pts on Abs
Readmission admission record for pts 0.08 -------
readmitted with infection
Autopsy report (AR) AR to ident. pts w/ infxn 0.08 0.53

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CASE FINDING
METHODS
Time(Hrs)
/500 beds
Review based on:
Ward Liason Surv. Pts reported by nursing 0.62 17.6
(WLS) staff to have an infection
Laboratory-based and Microbiology reports to 0.76-0.89 31.8
Ward Liason Surv. Ident. Pts with (+) culture
and pts reported by nurses
Risk-Factor-based S. Nursing rep and Med rec. 0.50-0.89 32.4
FOR HAIs
Data collection
Case-Finding Method
Consolidation and Tabulation

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FOR HAIs
Data collection
Case-Finding Method
Calculating Rates
SURVEY
 Incidence Rate (I)
No. of infections acquired in a month
No. of patients discharged in a month
=

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SURVEY
 Prevalence Rate (P)
No of infections (ACTIVE) in
hospitalized patients at the time of the
survey
No. of patients present at the time of the
survey
=
Device-related infections
No. of infections
(CAUTI, MV, CLABSI)
No. of device days
X 1000

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FOR HAIs
Data collection
Case-Finding Method
Calculating Rates
Analysis and Interpretation
Data Analysis and
Interpretation
 Significant change in current rates
 Monitor both rate and pattern of
endemic disease (significant fluctuation)
 Tabulated data and analysis should be
distributed
 Examine how component parts relates
 Chi-square, Fisher’s test, Student T-test

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FOR HAIs
Data collection
Case-Finding Method
Calculating Rates
Analysis and Interpretation
Validation
VALIDATION
 Key aspect of surveillance to assure
accuracy of data collection while being
efficient and cost-effective

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VALIDATION
 Concurrent surveillance
 MD / Nurse Epidemiologist (Gold
Standard)
 Prospective / Retrospective Review of
Charts
 Examine the chart, microbiologic data
 Various unit / staggered interval
OUTLINE
 Steps in Surveillance of HAIs

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Thank you!
ANTIBIOTIC
POLICIES

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OUTLINE
Goals of antibiotic policy
Difficulties in formulating
antibiotic policies
Selected policies on
antibiotic usage
GOALS
 To promote rational antibiotic use
 To prevent or delay emergence of
resistant bacterial strains

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Difficulties in Formulating
Antibiotic Policies...
 bacterial population differ
 antibiotic resistance pattern differ
 clinical choice varies
 availability of antibiotics
 cost of antibiotic varies
 route of antibiotic varies
Antimicrobial Agent Team
Functions :
Selection of Antimicrobial
agent -> Formulary
Educational Programs

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1. Restriction of
antibiotic use
ANTIBIOTIC POLICIES
Classification of Antibiotics
Non-Restricted
 issuance of these antibiotics does not
require approval of Infectious Disease
Consultants or ID Fellows, but their use
should be based on sound clinical
judgement
 Examples: erythromycin, penicillin V,
co-trimoxazole, amoxicillin, tetracycline,
chloramphenicol
Adapted from:
UP-PGH HICCU Antibiotic Policy

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Restricted
 issuance of these antibiotics require
approval of an Infectious Disease
Consultants or ID Fellows
 Examples: amoxicillin-clavulanic acid,
gentamicin, clindamycin , cefoxitin etc.
Adapted from:
Very Restricted
 issuance of these antibiotics require
approval of Infectious Disease
Consultants .
 Only very limited stocks should be
made available in the pharmacy
Adapted from:

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Very Restricted
 indicated for treatment of life-
threatening infections documented by
culture and sensitivity test, indicating
resistance to other effective and less
expensive antibiotics
 Example: vancomycin, imipenem-
cilastatin, amphotericin B, amikacin etc.
Adapted from:
1. Restriction of
antibiotic use
2. Limited
susceptibility
reporting
ANTIBIOTIC POLICIES

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OSPITAL NG STA. CRUZ
Name: Juan de la Cruz Age: 35 yrs old Sex: Male Room Number: Room 322 Bed A
Hospital Number: 2004-000456 Attending Physician: Dr. Jose De La Rosa
Specimen: Blood A and B Date Submitted: July 1, 2004 Date Reported: July 5, 2004
Organism: Positive growth of Salmonella typhi
S I R S I R
Amoxicillin Ertapenem
Amoxicillin-Clavulanic acid Imipenem-Cilastatin
Ampicillin X Meropenem
Ampicillin-Sulbactam Aztreonam
Cefoperazone-Sulbactam Ciprofloxacin X
Ticarcillin-Clavulanid acid Gentamicin
Piperacillin-Tazobactam Tobramycin
Cephalothin Netilmycin
Cefuroxime Amikacin
Cefoxitin Erythromycin
Ceftriaxone X Trimethoprim-Sulfamethoxazole X
Ceftazidime Tetracycline
Cefepime Clindamycin
Cefpirome Chloramphenicol X
Vancomycin
Legend: S= sensitive, I= intermediate, R= resistant
OSPITAL NG STA. CRUZ
Name: Juan de la Cruz Age: 35 yrs old Sex: Male Room Number: Room 322 Bed A
Hospital Number: 2004-000456 Attending Physician: Dr. Jose De La Rosa
Specimen: Blood A and B Date Submitted: July 1, 2004 Date Reported: July 5, 2004
Organism: Positive growth of Salmonella typhi
S I R S I R
Amoxicillin Ertapenem
Amoxicillin-Clavulanic acid Imipenem-Cilastatin
Ampicillin X Meropenem
Ampicillin-Sulbactam Aztreonam
Cefoperazone-Sulbactam Ciprofloxacin
Ticarcillin-Clavulanid acid Gentamicin
Piperacillin-Tazobactam Tobramycin
Cephalothin Netilmycin
Cefuroxime Amikacin
Cefoxitin Erythromycin
Ceftriaxone Trimethoprim-Sulfamethoxazole X
Ceftazidime Tetracycline
Cefepime Clindamycin
Cefpirome Chloramphenicol X
Vancomycin
Legend: S= sensitive, I= intermediate, R= resistant

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1. Restriction of
antibiotic use
2. Limited
susceptibility
reporting
3. Concurrent
monitoring of
antibiotic usage
ANTIBIOTIC POLICIES
Methods to Evaluate
Antimicrobial Use in Hospital
A. PATTERN OF USE OF ANTIBIOTICS
BY MEDICAL STAFF
 Review current practices for selected
indications
– prophylactic antibiotics in surgery
– antibiotics for specific infections
 Gross utilization data based on pharmacy
record

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Methods to Evaluate
A. PATTERN OF USE OF ANTIBIOTICS
BY MEDICAL STAFF
 Survey of usage on individual services
 Survey of routine orders for prophylaxis in
surgery
 Survey of orders for specific infectious dse
 Case review by independent cases
 Guidelines for audit
Methods to Evaluate
B. TRENDS
 identify yearly purchase
 identify consumption of
– each agent
– each group drugs (cephalosporins, etc.)
– each class (antibacterial, etc.)

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Methods to Evaluate
C. DATA
 number of units (grams), cost for each agent
 number of patients treated with each drug
1. Restriction of
antibiotic use
2. Limited
susceptibility
reporting
3. Concurrent
monitoring of
antibiotic usage
4. “Audit of Use”
ANTIBIOTIC POLICIES

40
ANTIBIOTIC AUDIT
Some Practices that warrant auditing…
 orders for antibiotics in the absence
of minimal diagnostic procedures
 concurrent use of more than 2
antibiotics
 use of more than 5 antibiotics during
a single hospitalization
 continuous treatment with
antimicrobial agents for more than 21
days
ANTIBIOTIC AUDIT
 use of parenteral drugs when
identical oral preparation can be
used
 prophylactic use in surgery for >48
hours
 procedure for which prophylaxis is
NOT an accepted practice

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ANTIBIOTIC AUDIT
 use of aminoglycosides without
obtaining a measure of renal function
 use of antibiotics in afebrile patients
with indwelling catheter
1. Restriction of
antibiotic use
2. Limited
susceptibility
reporting
3. Concurrent
monitoring of
antibiotic usage
5. “Automatic” Stop
Order
ANTIBIOTIC POLICIES

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EMPIRIC THERAPY
 treatment of suspected serious or
life-threatening infection pending
results of culture and sensitivity
tests
 Initial dose may be issued for 24
hrs BUT subsequent doses will
need approval of the Antimicrobial
Agent Team
Antimicrobial Agent Team
Composition :
 Infectious disease physician
 Infection control practitioner
 Clinical Microbiologist
 Clinical Pharmacists
Example: Philippine General Hospital (PGH)
Antibiotic Surveillance and Control Team
(Infectious Disease Consultants and Fellows)

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DEFINITIVE THERAPY
 Treatment of serious or life-threatening
infection documented by culture and
sensitivity tests
 a 7-day automatic stop order shall be
implemented
PROPHYLAXIS USE
 use to prevent infectious complications
in high risk setting
– Aminoglycosides : Netilmycin
– Cephalosporins : Cephalothin , Ceftriaxone
– Pen with BLI : Amoxiclav or Ampicillin-
sulbactam
– Quinolones : Ciprofloxacin
– Anaerobic Infection : Metronidazole,
Clindamycin

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1. Restriction of
antibiotic use
2. Limited
susceptibility
reporting
3. Concurrent
monitoring of
antibiotic usage
5. “Automatic” Stop
Order
6. Hospital Formulary
ANTIBIOTIC POLICIES
HOSPITAL FORMULARY
 Lists the indication
for which the
antibiotics are
required
 List the categories
of antibiotics
 List the antibiotics
that are similar in
spectrum, safety,
kinetics

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HOSPITAL FORMULARY
 Draft an antibiotic policy
 Discuss the draft policy
with the clinicians
 When policy has been
agreed, inform
Microbiology section
and Pharmacy
 Enter the policy in the
hospital formulary
 Review the policy
periodically
ありがとう (JP) Thank you (En)
Arigatou

Basic HAI Surveillance

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