In the United States, it is estimated that approximately 1 out of every 25 hospitalized patients will contract a healthcare-associated infection (HAI). There were an estimated 722,000 infections in U.S. acute care hospitals in 2011. Additionally, about 75,000 hospital patients with HAIs died during their hospitalizations according to a recent prevalence study. More than half of all HAIs occurred outside of the intensive care unit. (citation)
The most common types of infections in U.S. acute care hospitals include: (citation)
- Pneumonia (22%, 157,500 estimated infections in 2011)
- Surgical site infections (22%, 157,500 estimated infections in 2011)
- Gastrointestinal infections (17%, 123,100 estimated infections in 2011)
- Urinary tract infections (14%, 93,300 estimated infections in 2011)
- Primary bloodstream infections (11%, 71,900 estimated infections in 2011)
Device-associated infections (i.e., central line-associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia) accounted for about one-quarter (26%) of all HAIs in 2011.
It is important to understand the different types of HAIs and how they are spread to be able to effectively prevent them.
Urinary tract infections (UTIs) occur when germs enter the urinary system and affect the bladder (which stores the urine) and/or the kidneys (which filter the blood to make urine). These infections are often associated with the use of a catheter, which is a tube placed into the bladder to drain urine.
Surgical site infections (SSIs) occur after surgery in the part of the body where the surgery took place. These infections may involve only the skin, or may be more serious and involve tissue under the skin, organs, or implanted material. SSIs sometimes take days or months after surgery to develop.
Respiratory or lung infections (such as pneumonia) can also be healthcare-associated. Ventilator-associated pneumonia (VAP) is a type of lung infection that occurs in a person who has been on a ventilator. A ventilator is a machine that helps a person breathe by giving oxygen through a tube placed in the mouth, nose, or through a hole in the front of the neck. Germs can enter the ventilator and get into the patient’s lungs, causing illness.
Central line-associated bloodstream infections (CLABSIs) occur when germs enter the bloodstream through a central line. A central line is a tube that is placed in a large vein to give fluids, blood, or medications, or to do certain medical tests quickly.
Multidrug-resistant organisms (MDROs) can cause infections of the blood, skin, or organ systems. These infections have arisen due to the overuse or misuse of antibiotics, which has resulted in the germs becoming more resistant to antibiotic therapy. Methicillin-resistant Staphyloccocus aureus (MRSA) is an example of a MDRO. Approximately 16% of HAIs are associated with MDROs.
Clostridioides difficile (or C. difficile) is a bacterium that can cause diarrhea and other intestinal problems. These infections are often associated with prolonged antibiotic use because antibiotics can wipe out “good” bacteria in the gut, allowing the C. difficile bacteria to grow and cause illness.
Bloodborne pathogens (BBPs) such as hepatitis B, hepatitis C, or HIV, can be spread in healthcare settings through contact with an infected individual’s blood or body fluids.
Other illnesses or infections such as influenza, norovirus, tuberculosis, and scabies can also be transmitted in healthcare settings.
For basic information on the difference between bacteria, viruses, fungi, and parasites, please see the Microbiology 101 PDF.
What are carbapenems? Which organisms can become carbapenem-resistant? Why should I be concerned about carbapenem-resistant organisms (CROs)? What are the risk factors for getting an infection caused by a CRO? How are CRO infections transmitted? Carbapenemase-Producing Organisms (CPOs) Carbapenemase Genes Infections caused by CPOs have been identified in all Virginia regions. Carbapenemase genes that have been identified in the United States are presented in Table 1. Determining the carbapenemase gene responsible for carbapenem resistance is critical to the public health response and for clinical decision-making. Table 1. Carbapenemase Genes Containment Strategy Approach In Virginia, a systematic public health response and investigation occurs upon identification of every CPO case. The response activities have a tiered approach based on local epidemiology. Table 2. Virginia Containment Strategy Tiers for CPO Containment Strategy Response A coordinated approach between healthcare facilities and local health departments is necessary to slow the spread of CPOs. The public health response involves: Containment Strategy Recommendations For more information, see the VDH CPO Containment Strategy Information in the Resources section. Please refer to the interpretive guidance for more information. VDH reports on CPOs coming soon!
Carbapenems are a class of broad-spectrum antibiotics reserved to treat serious multidrug-resistant infections. Carbapenems are often considered antibiotics of last resort to treat an infection. This antibiotic class includes the following generic names: doripenem, ertapenem, imipenem, and meropenem.
All organisms have the potential to become resistant to carbapenems. Organisms of greatest concern include the Enterobacteriaceae family. Common organisms in this family include E. coli and Klebsiella species. Other organisms that can become resistant to carbapenems that are highly concerning include Acinetobacter and Pseudomonas species.
Infections that are resistant to these antibiotics are very difficult to treat. CDC considers these types of antibiotic-resistant infections an urgent threat in the United States. CROs may cause a variety of infections ranging from gastrointestinal illness and pneumonia, to invasive infections of the bloodstream or organs.
Healthy people usually do not get CRO infections. Patients who require devices like ventilators (breathing machines), urinary (bladder) catheters, or intravenous (vein) catheters; patients who are taking long courses of certain antibiotics, patients who are immunocompromised; and patients who have received international healthcare are most at risk for CRO infections.
CRO is spread through contact with infected or colonized people, particularly contact with wounds, stool or contaminated hands or devices.
Virginia Containment Strategy for Carbapenemase-Producing Organisms (CPO)
Imipenemase metallo-β-lactamase (IMP)
Endemic to areas outside of the United States
Klebsiella pneumoniae carbapenemase (KPC)
Most widespread in the United States; more commonly seen in Enterobacteriaceae compared to other gram-negative organisms
New Delhi metallo-β-lactamase (NDM)
Endemic to areas outside of the United States; increasing reports of United States residents without international healthcare exposure
Oxacillinase-type carbapenemases (OXA)
Different subtypes such as OXA-48 or OXA-23
Verona Integron-encoded metallo-β-lactamase (VIM)
Endemic to areas outside of the United States; more commonly seen in Pseudomonas spp. that produce a carbapenemase
CP-CRPA: Carbapenemase-producing carbapenem-resistant Pseudomonas aeruginosa; IMP: imipenemase; KPC: Klebsiella pneumoniae carbapenemase; NDM: New Delhi metallo-β-lactamase; VIM: Verona integron-encoded metallo-β-lactamase: CP-CRE: Carbapenemase-producing carbapenem-resistant Enterobacteriaceae
Virginia Reportable Disease List
Virginia Isolate Submission List
Impact in Virginia
What are carbapenems?
Which organisms can become carbapenem-resistant?
Why should I be concerned about carbapenem-resistant organisms (CROs)?
What are the risk factors for getting an infection caused by a CRO?
How are CRO infections transmitted?
Carbapenemase-Producing Organisms (CPOs)
Infections caused by CPOs have been identified in all Virginia regions. Carbapenemase genes that have been identified in the United States are presented in Table 1. Determining the carbapenemase gene responsible for carbapenem resistance is critical to the public health response and for clinical decision-making.
Table 1. Carbapenemase Genes
Containment Strategy Approach
In Virginia, a systematic public health response and investigation occurs upon identification of every CPO case. The response activities have a tiered approach based on local epidemiology.
Table 2. Virginia Containment Strategy Tiers for CPO
Containment Strategy Response
A coordinated approach between healthcare facilities and local health departments is necessary to slow the spread of CPOs. The public health response involves:
Containment Strategy Recommendations
For more information, see the VDH CPO Containment Strategy Information in the Resources section.
Please refer to the interpretive guidance for more information.
VDH reports on CPOs coming soon!
Resources for Providers
Resources for Patients
Clostridioides difficile (“C. difficile” or “C. diff”) is a type of spore-forming bacteria that produces two types of toxins. The main clinical symptoms of C. difficile infection (CDI) are watery diarrhea, fever, nausea, abdominal pain/tenderness, and loss of appetite. More serious conditions can also result such as pseudomembranous colitis (inflammation of the colon), perforations of the colon, and sepsis. It is possible to carry C. diff bacteria in your body but not show any symptoms; this is called colonization. After treatment, repeat testing is not recommended if the patient’s symptoms have resolved, since many patients remain colonized with the bacteria.
Some patients/residents may be at higher risk for developing CDI due to prolonged use of antibiotics, underlying gastrointestinal issues or prior gastrointestinal surgery, history of frequent hospitalizations, immunocompromised status, advanced age, or other underlying chronic health conditions. It is important that both the patient and the healthcare providers take the appropriate steps to help prevent an infection.
Estimated burden of CDI in healthcare facilities in the United States:
- In a recent national prevalence survey, Clostridioides difficile was the most commonly reported pathogen, causing 12% of HAIs, and an estimated 80,400 hospital-onset infections (citation).
- According to the latest CDC National and State HAI Progress Report, in 2014, acute care hospitals experienced an 8% reduction in hospital-onset C. difficile infections compared to 2011.
- Virginia hospitals experienced a 2% reduction in hospital-onset C. difficile infections between 2011 and 2013.
- C. difficile accounts for 15-25% of all episodes of antibiotic-associated diarrhea.
- In Virginia, hospitalizations for C. difficile increased from 9 per 100,000 people in 2000 to 29 per 100,000 people in 2010. (citation) In 2010 in Virginia:
- The rate of hospitalization with C. difficile was more than twice as high for people 85 years or older than for people 65 to 84 years of age.
- Compared to men, C. difficile hospitalization rates were 30% higher for women.
- In 2009, patients diagnosed with C. difficile in Virginia hospitals stayed an average of 13.2 days, almost three times as long as the average stay of all other patients (4.6 days). (citation)
- CDI has been associated with an attributable mortality rate of 6.9% at 30 days after diagnosis and 16.7% at 1 year. (citation)
- Nationally, the estimated cost per infection ranges from $6,000 - $9,000 and the estimated total cost per year ranges from $1 billion - $1.6 billion. (citation)
- In 2009 in Virginia, the total hospital cost for patients with C. difficile was over $157 million. The average hospital cost for patients with C. difficile was nearly three times higher than patients without C. difficile ($23,190 vs. $8,860). (citation)
Reporting and Surveillance
- In January 2013, the Centers for Medicare and Medicaid Services (CMS) began requiring acute care hospitals participating in their Hospital Inpatient Quality Reporting Program to report C. difficile LabID events (positive laboratory test results for C. difficile) at the facility-wide inpatient level (for all inpatients) through the National Healthcare Safety Network (NHSN). These data are publicly available on Hospital Compare. In September 2015, the VDH reporting regulations were updated to align state reporting requirements with the CMS Hospital Inpatient Quality Reporting Program. Under the new regulations, hospitals are reporting C. difficile Lab ID event data to VDH through NHSN. For more information on these data and the state regulations mandating their reporting, please see the VDH Reporting Regulations page.
- Other CMS quality reporting programs require C. difficile LabID event reporting from long-term acute care hospitals (January 2015 to present) and inpatient rehabilitation facilities (January 2015 to present).
- From 2012-2013, VDH and VHQC implemented a C. difficile infection prevention collaborative with enrolled acute care and long-term care facilities to conduct surveillance for C. difficile labID events, implement prevention strategies, and share best practices. Collaborative resources available by contacting the VDH HAI Program.
Prevention Strategies for Healthcare Providers
To prevent CDI, doctors, nurses, and other healthcare providers should follow CDC infection prevention guidelines including:
- Use antibiotics judiciously.
- Implement contact precautions for patients/residents with known or suspected CDI:
- Place patients/residents with CDI in private rooms. If private rooms are not available, patients/residents can be placed in rooms (cohorted) with other persons with CDI.
- Use gloves when entering the room of a patient/resident with CDI and during patient/resident care.
- Perform hand hygiene after removing gloves.
- Because alcohol does not kill C. difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. However, early experimental data suggest that, even using soap and water, the removal of C. difficile spores is more challenging than the removal or inactivation of other common pathogens.
- Preventing contamination of the hands via glove use remains the cornerstone for preventing C. difficile transmission via the hands of healthcare workers.
- If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients/residents with CDI.
- Use gowns when entering the room of a patient/resident with CDI and during patient/resident care.
- Use dedicated medical equipment or perform cleaning and disinfection of any shared medical equipment.
- Continue these precautions until diarrhea ceases.
- Because patients/residents with CDI continue to shed the bacteria for a number of days after diarrhea stops, some facilities routinely continue isolation for either several days beyond symptom resolution or until discharge, depending upon the type of setting and average length of stay.
- Implement an environmental cleaning and disinfection strategy:
- Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently.
- Consider using an Environmental Protection Agency (EPA)-registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions. Generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used.
- Note: Standard EPA-registered hospital disinfectants are not effective against Clostridioides difficile spores.
- Hypochlorite-based disinfectants may be most effective in preventing C. difficile transmission in units with high endemic rates of C. difficile infection.
Clinical Practice Guidelines for Clostridioides difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)
Clostridioides difficile Infection in Adults and Children (2013) – a policy statement from the American Academy of Pediatrics
SHEA/IDSA Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals - C. difficile
CDC CDI Prevention Collaborative Toolkit – contains background on epidemiology of CDI as well as core and supplemental prevention strategies
Tools and Resources
Advancing Excellence in America’s Nursing Homes - checklists for nursing homes to help improve C. diff prevention policies, procedures, knowledge and practices. Includes assessment checklists for early identification/containment, hand hygiene, cleaning/disinfection, and antibiotic stewardship.
AHA/HRET Hospital Engagement Network 2.0 – change package, improvement strategies, checklist, and other resources
Antimicrobial stewardship webpage
APIC Guide to Preventing Clostridioides difficile Infections, 2013
CDC Commentary: Testing for Clostridioides difficile Infection (Medscape login required; registration free)
CDC Vital Signs Report: Making Health Care Safer – Reducing Clostridioides difficile Infection (March 2012) - latest findings of progress on C. difficile prevention in different healthcare settings
Morbidity and Mortality Weekly Report (MMWR) – March 6, 2012 - more detailed information on methodology of Vital Signs report
C. difficile fact sheet for assisted living facilities and nursing homes
Clostridioides difficile in Long-Term–Care Facilities for the Elderly, 2002 (SHEA Position Paper)
Clostridioides difficile Prevention - educational flyer for consumers that contains C. difficile facts and prevention strategies. Developed by VDH and VHI.
Deadly Diarrhea (CDC infographic)
Drug Resistance and Antibiotic Stewardship fact sheet
General C. difficile fact sheet
NHSN Multidrug-resistant Organism and Clostridioides difficile Infection (MDRO/CDI) Module – click on the appropriate healthcare setting and select the MDRO/CDI link to access the training, protocols, forms, analysis resources, and other support materials
SHEA Patient Education Guide (C. diff) – fact sheet that educates patients and their families about 7 types of HAIs (including C. diff) and how to work with healthcare professionals to prevent them.
Vermont Department of Health C. diff Patient Education Guide
VHQC/VDH Clostridioides difficile infection prevention collaborative
- Conducted in partnership with VHQC
- Statewide project with enrolled acute care and long-term care facilities to conduct surveillance for C. difficile lab ID events, implement prevention strategies, and share best practices
- Collaborative resources available by contacting the VDH HAI Program
Methicillin-Resistant Staphylococcus Aureus (MRSA)
Methicillin-resistant Staphylococcus aureus (MRSA) is a type of Staphylococcus (staph) bacteria that is resistant to certain antibiotics called beta-lactams. These antibiotics include methicillin and other more common antibiotics such as oxacillin, penicillin, and amoxicillin. In the community, most MRSA infections are skin infections and may appear as red boils or pimples. More severe or potentially life-threatening MRSA infections occur most frequently among patients in healthcare settings and may initially present as symptoms such as fever and pain at the site of infection. While 25% to 30% of people are colonized in the nose with staph, less than 2% are colonized with MRSA. (citation)
Like MRSA, Vancomycin-intermediate Staphylococcus aureus (VISA) and Vancomycin-resistant Staphylococcus aureus (VRSA) are types of staph bacteria that are resistant (or have intermediate resistance) to certain antibiotics. Because of their resistance to antibiotics, VISA/VRSA infections can be more difficult to treat. VISA/VRSA infections may affect the skin or may get into the bloodstream, causing a more serious type of infection.
Enterococci are a type of bacteria found naturally in the environment, as well as in the human intestines and the female genital tract. When these bacteria develop resistance to vancomycin, they become Vancomycin-resistantEnterococci (VRE). Most VRE infections occur in people who are hospitalized.
Factors that increase a patient’s risk of developing an infection caused by a MDRO may vary depending on the type of organism. In general, risk factors include underlying health conditions, a weakened immune system, prolonged hospitalization, exposure to an invasive device such as a ventilator or catheter, recent surgery, and frequent antibiotic use.
MDROs are transmitted via direct contact with an infected person or indirect contact with contaminated objects/surfaces in the environment of an infected person. It is important that both the patient and the healthcare providers take the appropriate steps to help prevent an infection caused by a MDRO.
- An estimated 9,700 hospital-onset MRSA bloodstream infections occur annually in United States hospitals. (citation)
- More than 80,000 invasive MRSA infections occurred in the United States in 2011. (citation)
- According to the latest CDC National and State HAI Progress Report, in 2014, acute care hospitals experienced a 13% reduction in hospital-onset MRSA infections compared to 2011.
- Virginia hospitals have experienced a 9% decline in hospital-onset MRSA infections between 2011 and 2013.
- Of the HAIs reported to the National Healthcare Safety Network from 2009-2010: (citation)
- Nearly 20% of pathogens reported from all HAIs were the following multidrug-resistant organisms: MRSA (8.5%); vancomycin-resistant Enterococcus (3%); extended-spectrum cephalosporin–resistant K. pneumoniae and K. oxytoca(2%), E. coli (2%), and Enterobacter spp. (2%); and carbapenem-resistant P. aeruginosa (2%), K. pneumoniae/oxytoca (<1%), E. coli (<1%), andEnterobacter spp. (<1%).
- 44-59% of healthcare-associated S. aureus infections were caused by MRSA.
- 62-83% of healthcare-associated Enterobacter faecium infections were resistant to vancomycin.
- There are nearly 19,000 deaths each year due to invasive MRSA infections. (citation)
- Patients with bloodstream infections or surgical site infections caused by MRSA have a higher risk of death compared with patients with infections caused by a strain of Staphylococcus aureus (staph) that does not have resistance to antibiotics. (citation)
In January 2013, the Centers for Medicare and Medicaid Services (CMS) began requiring acute care hospitals participating in their Hospital Inpatient Quality Reporting Program to report MRSA bacteremia facility-wide using the National Healthcare Safety Network (NHSN). These data are publicly available on Hospital Compare.
In September 2015, the VDH reporting regulations were updated to align state reporting requirements with the CMS Hospital Inpatient Quality Reporting Program. Under the new regulations, hospitals are reporting MRSA bacteremia LabID event data to VDH through the NHSN. For more information on these data and the state regulation mandating their reporting, please see the VDH Reporting Regulations page.
Other CMS quality reporting programs require MRSA bacteremia LabID event reporting from long-term acute care hospitals (January 2015 to present) and inpatient rehabilitation facilities (January 2015 to present).
Prevention Strategies for Healthcare Providers
Because colonization (presence of an organism in/on the body without showing any symptoms) with a MDRO generally precedes infection (presence of an organism in/on the body causing tissue invasion or damage and actively causing symptoms), interventions primarily target two broad areas:
- Preventing transmission from colonized persons to uncolonized persons
- Preventing infection in colonized persons, which includes:
- Strategies aimed at preventing device-associated and procedure-associated infections (e.g., central line-associated bloodstream infections, surgical site infections). These strategies are general, so they apply to patients with or without a MDRO.
- Decolonization strategies
To prevent the transmission of MRSA, doctors, nurses, and other healthcare providers can do the following things:
- Clean their hands with soap and water or an alcohol-based hand rub before and after touching the patient or the patient’s environment.
- Implement contact precautions, including the use of gown and gloves for patient care and use of dedicated non-essential items such as blood pressure cuffs and stethoscopes.
- Identify previously colonized or infected patients.
- Ensure that the facility has a mechanism for rapidly communicating positive laboratory results from the laboratory to clinical areas.
- Provide ongoing education to improve adherence to hand hygiene, improve adherence to contact precautions, and to better understand the problem.
- Facilities may also implement additional strategies including active surveillance testing, decolonization programs, or chlorhexidine bathing.
CDC MRSA Prevention Collaborative Toolkit - contains background on epidemiology of MRSA as well as core and supplemental prevention strategies
Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA) for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children (2011)
SHEA/IDSA Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals - MRSA
Tools and Resources
APIC Guide to the Elimination of Methicillin-Resistant Staphylococcus Aureus Transmission in Hospital Settings, Second Edition, 2010
APIC Guide to the Elimination of Methicillin-Resistant Staphylococcus Aureus (MRSA) in the Long-Term Care Facility, 2009
CDC website - MRSA
General MRSA fact sheet
MRSA fact sheet for assisted living facilities and nursing homes
OSHA Hospital e-Tool: MDRO/MRSA module - information to help stop the spread of MRSA among employees and others working in healthcare and other industries.
Personal prevention of MRSA skin infections – for patients
SHEA Patient Education Guide (MRSA)– fact sheet that educates patients and their families about 7 types of HAIs (including MRSA) and how to work with healthcare professionals to prevent them.
(Gorwitz RJ et al. Journal of Infectious Diseases. 2008:197:1226-34.)