Methicillin Resistant Staphylococcus aureus MRSA Proposed Revision of

Methicillin Resistant Staphylococcus aureus (MRSA): Proposed Revision of ICD-9 Codes Rachel Gorwitz, MD, MPH Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

Staphylococcus aureus n n Common human colonizer Common cause of skin infections Potential to cause severe / invasive infections Transmission: Direct contact

Methicillin-Resistant Staphylococcus aureus (MRSA) n n Resistant to all currently available β-lactam antibiotics (penicillins, cephalosporins) Accounts for majority of S. aureus infections in healthcare settings – n Associated with increased morbidity, mortality, and healthcare costs as compared to methicillin-susceptible S. aureus (MSSA) 1990 s: Emerged as a community pathogen – – Mainly skin infections Occasionally severe / life-threatening

Increasing awareness of HAI preventability Mandatory reporting of HAI Emergence of communityassociated MRSA Increasing MRSA rates Controversy over control measures Public Interest in MRSA Changes in virulence Congressional interest in MRSA Reports of successful control in some facilities HAI = healthcare-associated infection MRSA-specific legislation Media interest

Sources of MRSA Surveillance Data n n Active Bacterial Core Surveillance Project National Healthcare Safety Network (NHSN) National surveys using ICD-9 codes Specialized Projects – – EMERGEncy ID Net National Health and Nutrition Examination Survey

Active Bacterial Core Surveillance Areas (Invasive MRSA) Minnesota Oregon New York Connecticut California Maryland Colorado Tennessee Georgia Total Population: ~ 16. 3 million

ABCs MRSA Case Categorization n Healthcare-associated: – – Hospital-onset: Cases with positive culture obtained >48 hrs after hospital admission (may also have risk factors) Community-onset: Cases with at least 1 of the following risk factors: • n Invasive device at time of admission; h/o MRSA infection or colonization; h/o surgery, hospitalization, dialysis, or residence in a LTC facility in 12 mos preceding culture Community-associated: Cases with community -onset and none of above risk factors documented

Methods of Invasive MRSA Surveillance MRSA + Isolates from invasive site Unique MRSA Patients Medical Record Review Healthcare Risk Factors Healthcare-Associated Community-Associated

ABCs Invasive MRSA Surveillance 2005 National estimates: 94, 360 infections; 18, 650 deaths 28% 14% 59% Community-Associated Healthcare-Associated (community-onset) Healthcare-Associated (hospital-onset) Klevens et al JAMA 2007; 298: 1763 -71

National Healthcare Safety Network (NHSN) n n Voluntary, confidential, internet-based system for monitoring healthcare-associated events and processes (including HAIs) Purposes: – – – n Provide national estimates of magnitude of adverse events, trends Provide risk-adjusted data for interfacility comparisons Assist facilities in developing surveillance and analysis methods Facility-associated infection: – No evidence infection was present or incubating at time of admission (as assessed by trained infection control professional)

Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections n n Nationally representative surveys of hospitalizations and ambulatory care visits Utilize: – – – n Specific S. aureus infection codes (038. 11 septicemia, 482. 41 pneumonia) S. aureus organism code (041. 11) Codes for syndromes typical of S. aureus (e. g. , 682 cellulitis and abscess) Methicillin resistance data from V codes (V 09. 0) or external data sources

Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections n Kuehnert et al, Emerg Infect Dis 2005 – – n Klein et al, Emerg Infect Dis 2007 – n 291, 542 annual hospital discharges with S. aureus infection-related diagnoses 1999 -00 125, 969 MRSA 62% in S. aureus-related hospitalizations 1999 -2005; >2 -fold in MRSA-related hospitalizations Mc. Caig et al, Emerg Infect Dis 2006 – 11. 6 million annual ambulatory care visits for skin infections typical of S. aureus 2001 -03

Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections: Challenges n n n With exception of septicemia and pneumonia, S. aureus organism code not linked to clinical syndrome Resistance code (V 09. 0) not linked to clinical syndrome or S. aureus organism code (041. 11) National surveys contain a limited number of ICD-9 fields → organism codes and resistance codes may be deleted Current resistance code (V 09. 0) not specific for S. aureus or for methicillin-resistance Currently no colonization code specific for S. aureus or MRSA (falls under V 02. 59 – Other specified bacterial diseases)

Proposal: Modification of ICD-9 Codes for MRSA n Pages 17 -18 of agenda

Acknowledgements n n n Kate Ellingson Scott Fridkin Jeffery Hageman Michael Jhung John Jernigan Monina Klevens Cliff Mc. Donald Cathy Rebmann Chesley Richards Melissa Schaefer Arjun Srinivasan

Legislative Activity for Public Reporting of Healthcare. Associated Infections WA Jul-2008 MT VT Feb-2007 ND ME MN OR NH ID SD NY Jan-2007 WI WY MI IA NE NV PA Feb-2008 OH UT CO Jan-2008 CA Jan-2008 IL IN DC WV KS MO KY AZ OK Jul-2008 NM * MS TX AL RI CT Jan-2008 NJ Jan-2009? DE Feb-2008 MD Jul-2008 NC TN Jan-2008 AR 2008 VA Jul-2008 MA Jul-2008 SC Jul-2007 GA Mandates Public Reporting, Using NHSN Mandates Public Reporting LA Pending Legislation FL AK HI * Voluntary reporting using NHSN 2/13/2008