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	The Growing Risk of Hospital Acquired Infections Hospital acquired infections (HAIs), also known as nosocomial infections, are among the most costly yet preventable risk factors facing today’s hospital systems.		Bugs of the Month: Hospital Acquired Infections Five key HAI-related bugs are featured: MRSA, VRE, Streptococcus pneumoniae, Pseudomonas aeruginosa and Klebsiella pneumoniae.
	Empiric Treatment and Increased Drug Resistance The initiation of anti-infective therapy prior to a confirmed diagnosis, known as empiric treatment, is commonly practiced in many settings, including hospitals, outpatient settings, doctors’ offices and long-term care facilities.		Do You Know? What is the approximate treatment cost for a patient who has acquired a nosocomial infection?   a) $15,000   b) $35,000   c) $50,000
	Common ICD-9 Codes & V-Codes for Hospital Acquired Infections A list of the most widely used ICD-9 codes and V-codes for diagnosing HAIs.		Resource Center Links to more information regarding the prevalence and treatment of HAIs.
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The Growing Risk of Hospital Acquired Infections

Hospital acquired infections (HAIs), also known as nosocomial infections, are among the most costly yet preventable risk factors facing today’s hospital systems. This is a deadly serious trend — nosocomial infections are estimated to more than double the mortality and morbidity risks of any admitted patient. Over two million patients are being diagnosed yearly with HAIs, at an astounding cost of nearly $65 billion dollars, and mortality rates have climbed to 5 percent, or 90,000 patients per year. Avoiding exposure to these pathogens has increased awareness of treatment modalities outside of the acute care setting. Home management of these patients allows for timely treatment schedules with home IV anti-infectives, controlling increased spread of infection and decreasing overall morbidity and mortality.

This special edition of the CoramClick focuses on five key HAI-related infections, the growing concern that increased drug resistance poses in combating this deadly trend, and available therapy management practices that minimize this risk.

Empiric Treatment and Increased Drug Resistance

The initiation of anti-infective therapy prior to a confirmed diagnosis, known as empiric treatment, is commonly practiced in many settings, including hospitals, outpatient settings, doctors’ offices and long-term care facilities. While this management practice is needed to quickly combat impending serious complications, it is important to justify and treat these patients with clinically supported guidelines of therapy in order to help limit overall growth of antimicrobial resistance.

The following algorithms depict both empiric therapy guidelines as well as de-escalation strategies. The goal of these particular guidelines is to properly initiate therapy in those patients suspected of a bacterial infection, and to discontinue therapy when criteria and lab values point to negative results.

Common ICD-9 Codes and V-Codes for Hospital
Acquired Infections

Below is a list of the most widely used ICD-9 codes and V-codes for diagnosing hospital acquired infections. Please note that this list is not all inclusive.

Bugs of the Month:
Hospital Acquired Infections

Image courtesty of the CDC

Staphylococcus Aureus (MRSA)
Overview: In 2000, it was estimated that 120,000 people were hospitalized per year, which resulted in costs of $3.2 billion to $4.2 billion. In 2005, 94,360 patients developed a serious, invasive MRSA infection. Of those, 18,650 died during hospitalization, resulting in a 1:5 mortality ratio. MRSA accounts for 52.3 percent of Staphylococcus aureus nosocomial infections and is now endemic in many hospitals. It is one of the leading causes of nosocomial pneumonia and surgical site infections, and the second leading cause of nosocomial blood stream infections.

The anterior nares (nose) is the most common site of colonization. MRSA also lives harmlessly on skin surfaces of the mouth, genitals and rectum and only causes illness when the skin is broken and bacteria is introduced. Other sites include the axillae, perineum, bone, wounds and tracheostomy, as well as venouscatheter exit sites. MRSA is commonly isolated from urinary catheter and G-tube exit sites in nursing home residents.

Treatment: The preferred treatment for MRSA nasal colonization is mupirocin ointment applied to the nares. Vancomycin is the drug of choice for serious MRSA-related infections. One emerging trend in MRSA resistance is the development of vancomycin-resistant Staphylococcus aureus (VRSA).

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is also involved in two-thirds of all MRSA cases. More recently, new strains of MRSA have become more common among current or previously hospitalized patients. It infects seemingly healthy people, often children, and primarily causes skin and soft tissue lesions such as boils, abscesses and cellulitis. The occurrence of true community-acquired MRSA infections in low-risk, healthy individuals, while relatively infrequent, is increasing in incidence, particularly in pediatric populations.

Image courtesty of the CDC

Vancomycin Resistant Enterococci (VRE)
Overview: Two types of organisms have shown resistance to vancomycin: Enterococcus faecalis (approximately 90 percent of enterococcal infections) and Enterococcus faecium (approximately seven percent of enterococcal infections). Since 1989, VRE has emerged as an important nosocomial pathogen — with a hospital prevalance of 0.3 percent in 1989, rising to 27.5 percent in 2002. It is now the third most common organism associated with nosocomial infections. More than half of all clinical isolates of Enterococcus faecium in the United States are not treatable with vancomycin. VRE is predominantly found in the intensive care unit (ICU). In fact, in one out of four ICUs, at least 25 percent of the enterococcal isolates were resistant to vancomycin. However, rates in all hospital units are approaching those of the ICU. VRE is most frequently isolated from the urinary tract; surgical sites, primarily abdominal and pelvic wounds; indwelling endovascular catheters and in endocarditis. Cultures from the nose, throat and mouth have also isolated VRE. During outbreaks, VRE has been cultured from patient gowns, bedside rails, hospital floors, door handles, blood pressure cuffs, wash basins, glucose meters and hemodynamic monitoring devices. VRE has been shown to survive five to seven days on countertops. It has been isolated from the hands of healthcare workers (ranging from 26–47 percent in various studies) as well as from the hands of caregivers of infected patients at home.

Treatment: Treatment of VRE infections can be challenging, in large part because antibiotic susceptibility varies within strains. Bactericidal agents that exhibit synergy are generally used to treat VRE infections. Additionally, penicillin and ampicillin may be effective against certain strains of VRE that remain susceptible to these antibiotics, but usually require higher doses than those used for treatment of other pathogens.

Image courtesty of the CDC

Streptococcus Pneumoniae (S. pneumoniae)
Overview: Streptococcus pneumoniae (S. pneumoniae), a gram-positive bacteria, is among the leading causes of invasive bacterial illness and death worldwide, and is a particular risk to young children, persons with underlying debilitating medical conditions and the elderly. S. pneumoniae is a leading cause of morbidity and mortality in the United States, responsible for an estimated 700–6,000 cases of meningitis, 17,000 cases of bacteremia or other invasive diseases, 500,000 cases of pneumonia, millions of cases of otitis media in children under five, and 40,000 deaths. The mortality rate for those hospitalized with the invasive disease is 14 percent. S. pneumoniae accounts for at least one-third of acute otitis media and acute sinusitis cases, making it the most prevalent pathogen of the upper respiratory tract. It is also the pathogen most likely to cause invasive complications of those infections, such as mastoiditis, bacteremia, and meningitis. S. pneumoniae is the most common causative organism in community-acquired pneumonia (CAP), accounting for a reported 30–75 percent of cases, with a mortality rate of 12.3 percent. It is associated with increased risk in patients with such host factors as COPD, alcoholism, diabetes, sickle cell anemia, asplenism, s/p influenza, neutropenia and HIV infection. In the outpatient setting, the carrier rate for S. pneumoniae is high with pharyngeal colonization of 5–10 percent in healthy adults and 20–40 percent of healthy children, with the rate highest in mid-winter. Preventing S. pneumoniae is possible and important, but also challenging given that the supplies of pediatric vaccine are inadequate and adult vaccines are underused. Despite recommendations, vaccine rates are less than 30 percent in the elderly, and up to two-thirds of patients hospitalized in the last four years with serious pneumococcal disease have not been vaccinated as recommended.

Treatment: The current vaccine for S.pneumoniae (a 23-valent preparation), used for persons greater than two years of age, provides coverage against approximately 90 percent of the most frequently reported causative strains. Multiple antibiotic resistant strains of S. pneumoniae first emerged in the early 1970s and have rapidly increased since 1995. Surveillance data continue to reveal increasing resistance of S. pneumoniae to a variety of antimicrobial agents including penicillins, cephalosporins, macrolides and quinolones.

Image courtesty of the CDC

Pseudomonas Aeruginosa
Overview: Pseudomonas aeruginosa epitomizes an opportunistic pathogen in humans. The bacterium almost never infects intact tissues, yet there is hardly any tissue that it cannot infect if the tissue defenses are compromised in some manner. Pseudomonas aeruginosa is an aerobic bacterial pathogen, the most significant of the Pseudomonas strains in terms of human infection, morbidity and mortality. It rarely causes disease in healthy persons, but it poses a significant threat to patients with underlying medical problems. It is particularly virulent in patients who are neutropenic or otherwise immunosuppressed — oncology, transplant and AIDS populations. Pseudomonas aeruginosa is primarily a nosocomial pathogen. According to the CDC, the overall incidence of Pseudomonas aeruginosa infections in American hospitals averages approximately 4 per 1,000 discharges. It is the fourth most commonly isolated nosocomial pathogen, accounting for 10.1 percent of all hospital-acquired infections and the leading cause of both nosocomial pneumonia and infections in burn patients. Pseudomonas aeruginosa infections have a high mortality rate, particularly in cases of burns, bacteremia or lower respiratory infections. Mortality rates range from 15–20 percent of patients with severe ear infections to 40–77 percent in burn patients with Pseudomonas aeruginosa bacteremia and 89 percent in patients with left-sided endocarditis.

Diagnosis of Pseudomonas aeruginosa is typically obtained via culture. Pseudomonas aeruginosa is often suspected in culture and on external body sites, such as surgical wounds, due to its characteristic blue-green pus and fruity odor, which has been described as a musty grape-like or corn tortilla odor.

Treatment: Since the most important defense against Pseudomonas aeruginosa is the neutrophil, supporting a neutropenic patient’s neutrophil recovery is a key treatment strategy. Early diagnosis and prompt treatment are key to a positive outcome. Like so many pathogens, Pseudomonas aeruginosa is increasingly resistant to numerous antibiotics, particularly in nosocomial infections. The development of resistance during treatment is also well documented, even with combination drug strategies, and therapy switches may be required.

Image courtesty of the CDC

Klebsiella Pneumoniae
Overview: Klebsiella pneumoniae, one of five strains of Klebsiella, is a gram-negative, aerobic, enteric pathogen. It is among the most common gram-negative bacteria encountered by physicians and is problematic as a nosocomial pathogen and, increasingly, as a community-acquired pathogen. Klebseillae are ubiquitous in nature. In humans, they present as normal flora in the gastrointestinal and biliary tracts. The bacteria may also colonize in the skin pharynx, sterile wounds and urine. Klebsiella bacteria account for approximately 8 percent of all HAI infections in the United States, including as many as 14 percent of cases of bacterial sepsis. This is increasingly challenging and costly due to the growing resistance profile of the bacteria. Common sites of infection include the urinary, respiratory and biliary tracts, and surgical wounds. Potential results of these infections are bacteremia, thrombophlebitis, UTIs, choleycystitis, diarrhea, URIs, wound infection, osteomyelitis, endocarditis and/or meningitis. The emergence of Klebsiella pneumoniae as an extended-spectrum ß-lactamase (ESBL), resistance-producing bacteria is creating significant resistance problems with this pathogen and dangerously limits treatment options in many cases.

Treatment: ß lactam antibiotics are among the safest and most commonly prescribed antibiotics in the United States; however, emergence of ß lactam resistance in Klebsiella pneumoniae is increasingly limiting their utility. Extensive use of broad-spectrum antibiotics in hospitalized patients has led to both increased carriage of Klebsiella and, subsequently, the development of highly virulent and easily spread, multidrug-resistant strains that produce extended-spectrum beta-lactamase (ESBL).

What is the approximate treatment cost for a patient who has acquired a nosocomial infection?
   a) $15,000   b) $35,000   c) $50,000

Answer - b) $35,000
Nosocomial infections affect over two million patients per year at a 5 percent mortality rate, or 90,000 deaths per year. The total cost to treat these infections is approaching $65 billion annually.

Centers for Disease Control and Prevention (CDC)
For more information regarding the prevalence and treatment of HAIs, please visit the Centers for Disease Control and Prevention (CDC) website at www.cdc.gov. General information about disease states and conditions are listed as well as data, statistics, links to other publications and many other useful tools and resources.

Bibliography

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