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Hospital Harm: Infections due to Clostridium difficile, MRSA or VRE

Healthcare-associated infections result in a substantial burden of disease in Canadians, and are an important public health problem. They are also a burden on Canada's healthcare system and a barrier to timely access to care for all Canadians (Public Health Agency of Canada 2017, "Routine").

While it is important to prevent, and control the spread of all infections, there are certain, antimicrobial resistant organisms that are more prevalent and pose a great risk in healthcare settings.

Topics
  • Patient safety
  • Hospital harm
Audience

  • Point of care provider

  • Quality or safety improvement lead

  • Policy advisor or analyst

Goal

Reduce the incidence of infections due to C. difficile, MRSA or VRE.

Overview and Implications

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

Antimicrobial Resistance (AMR) occurs when microbes (e.g. bacteria, viruses, fungi and parasites) evolve in ways that reduces or eliminates the effectiveness of antimicrobial medicines (e.g. antibiotics, antivirals, antifungals and antiparasitics) to treat infections. When microbes are exposed to antimicrobials, they adapt and become more resistant (Public Health Agency of Canada 2017, "Tackling"). (These organisms include (but are not limited to) methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE) and Clostridium difficile (C. difficile).

The Public Health Agency of Canada (PHAC) estimates that approximately two per cent of patients admitted to large, academic Canadian hospitals will have acquired an infection with an Antibiotic Resistant Organism (ARO) during the course of their hospital stay (Mitchell et al. 2019) and that at any given time, three to 10 per cent of patients who are hospitalized in Canada will either be infected or be a carrier of an ARO (Martin et al. 2019). According to Dr. Tedros Adhanom Ghebreyesus, Director General, World Health Organisation "AMR is one of the most urgent health risks of our time and threatens to undo a century of medical progress" (World Health Organization 2019). Globally, today, 700,000 people die of resistant infections every year; and, if no action is taken, it's estimated that by 2050, 10 million lives are at risk worldwide due to the rise of drug resistant infections (Review on Antimicrobial Resistance, 2016).

The Government of Canada is com mitted to taking action to prevent, limit, and control the emergence and spread of AMR. The Federal Action Plan on Antimicrobial Resistance and Use in Canada (Public Health Agency of Canada, 2015) outlines 3 pillars of action:

  1. Surveillance: Detecting and monitoring trends and threats in order to inform strategies to reduce the risks and impacts of antimicrobial resistance.

  2. Stewardship: Conserving the effectiveness of existing treatments through infection prevention and control guidelines, education and awareness, regulations, and oversight.

  3. Innovation: Creating new solutions to counteract loss in antimicrobial effectiveness through research and development (Public Health Agency of Canada, 2015).

In addition to the Federal Action Plan, a Pan-Canadian Framework for Action (Public Health Agency of Canada 2017, "Tackling") outlines a One Health approach from both the human and agriculture perspectives. The framework encompasses the three pillars listed above, as well as a fourth pillar for Infection Prevention and Control (IPC).

Clostridium difficile Infection (CDI)

Clostridium difficile (C. difficile) is a bacterium that causes mild to severe diarrhea and intestinal conditions like pseudomembranous colitis (inflammation of the colon).

C. difficile bacteria and their spores are found in feces. People can get infected if they touch surfaces contaminated with feces, and then touch their mouth. This may occur as a result of contamination of the patient environment, of shared equipment, or via the hands of healthcare workers. The elderly, those with other co-morbid illnesses, those who are hospitalized, or who are taking antibiotics, are at a greater risk of infection. Certain antibiotics used over a prolonged period of time increase the chance of developing a C. difficile infection (CDI). Nearly all antibiotics have been implicated in CDI, but broad-spectrum antibiotics and certain antibiotic classes, such as cephalosporins, clindamycin, and fluoroquinolones, seem to have a higher risk for placing patients at risk of CDI.

C. difficile spores can exist for five (5) months on hospital surfaces. C. difficile is the most frequent cause of infectious diarrhea in hospitals and long-term care facilities in Canada, as well as in other industrialized countries and it is associated with increased hospital costs, including increased length of stay (Association for Professionals in Infection Control and Epidemiology 2013; Public Health Agency of Canada 2014; McDonald et al. 2018; NICE 2015; Centers for Disease Control and Prevention 2016, "Clostridium difficile").

Methicillin-resistant Staphylococcus aureus (MRSA)

Staphylococcus aureus (Staph) is a type of bacteria that is commonly found on the skin and in the noses of healthy people. Some Staph bacteria are easily treatable while others are not. Staph bacteria that are resistant to the antibiotic methicillin are known as Methicillin-resistant Staphylococcus aureus or MRSA. If left untreated, MRSA infections may develop into serious, life-threatening complications such as infections of the bloodstream, bones and/or lungs (e.g., sepsis, pneumonia, etc.).

Methicillin-resistant Staphylococcus aureus (MRSA) is commonly found in Canadian hospitals and in the community. On one end of the spectrum, individuals can be colonized (carriers) and asymptomatic. On the other end of the spectrum, MRSA can lead to life-threating infection including septic shock and death. MRSA is spread by skin to skin contact or through contact with items contaminated by the bacteria. Those with weakened immune systems, chronic illnesses, hospitalized or having medical procedures are more at risk of acquiring infection. MRSA has been shown to spread easily in healthcare settings. MRSA can cause infections in a number of places, such as skin and soft tissue, blood, bones, joints, heart valves, lungs, and surgical wounds. (Public Health Agency of Canada 2008; Calfee 2012, Centers for Disease Control and Prevention 2016, "MRSA").

Vancomycin-resistant Enterococci (VRE)

Enterococci are bacteria that live in the human intestine and are often found in the environment. Generally, these bacteria do not cause illness; however, when illness does occur, it can usually be treated with antibiotics. Vancomycin-resistant Enterococci (VRE) are strains of enterococci bacteria that are resistant to the antibiotic vancomycin. A person who is colonized with VRE does NOT have symptoms. A person is considered to be infected with VRE when symptoms ARE present.

VRE infections occur primarily in healthcare settings among patients with weakened immune systems, chronic illnesses and medical procedures/instrumentation. Those who have been previously treated with vancomycin or other antibiotics for long periods of time; those who have undergone surgical procedures and those with medical devices such as urinary catheters are at a higher risk of becoming infected with VRE. VRE tends to focus on places like the gastrointestinal tract, urinary tract, heart valves, blood, and any prosthetic devices, such as artificial joints, prosthetic heart valves, and intravenous catheters.

Vancomycin-resistant Enterococci (VRE) is considered a healthcare-associated drug-resistant organism. It can spread from patient to patient when bacteria are carried on the hands of healthcare workers and occasionally through contact with contaminated equipment or other surfaces (e.g. toilet seats, bedrails, door handles, soiled linens, stethoscopes, etc.) (Public Health Agency of Canada 2010; Calfee 2012; Centers for Disease Control and Prevention 2011).

Importance to Patients and Families

When patients get an infection while in hospital, it delays healing, extends the patient's length of stay and increases their risk for harm and readmission. By implementing infection prevention and control practices, patients are safer. Organisms can be spread from person to person in the hospital in different ways. Bacteria can be spread between patients on pieces of equipment and on unwashed hands. Since germs can live on many surfaces, staff, family and visitors can spread infections without knowing. Healthcare workers, patients, family, friends and visitors all have a role to play in preventing healthcare-associated infections. Hand hygiene is one of the most important ways to stop the spread of infections (Canadian Patient Safety Institute 2012).

Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of Infections due to Clostridium difficile, MRSA or VRE, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

Measures

Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:

You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.

Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.

Whenever possible, use measures you are already collecting for other programs.

Try to include both process and outcome measures in your measurement scheme.

Discharge Abstract Database

Discharge Abstract Database (DAD) Codes included in this clinical category: B18: Infections due to Clostridium difficile, MRSA or VRE

Concept: Bacterial infections identified during a hospital stay due to Clostridium difficile (C. difficile), methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE).

Surveillance, Outbreak Management

HAI surveillance should be performed to guide infection prevention and control interventions and detect outbreaks, with timely feedback of results to healthcare workers and stakeholders and through national networks (World Health Organization 2016).

Outbreak Management Outbreaks of both infectious and noninfectious adverse events can occur in any healthcare setting and pose a threat to patient safety. Regardless of scope, investigation of a potential outbreak involves certain epidemiological components. Cooperation between healthcare epidemiologists, infection preventionists, and public health experts is important in effectively managing outbreak responses in healthcare settings. The ultimate goal of any outbreak investigation is to identify probable contributing factors and to stop or reduce the risk for future occurrences (Campbell, 2014).

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