A combination of antibiotic stewardship, infection prevention, and environmental cleaning contributed to a 20% reduction in Clostridioides difficile from 2016 to 2017, the Centers for Disease Control and Prevention (CDC) reports.1
“This is the first time we have seen a decline of this magnitude for C. difficile,” says Athena Kourtis, MD, PhD, MPH, a medical epidemiologist at the CDC. “We are very encouraged by that, and it actually puts us on target to meet the goal for the national action plan.”
From a baseline of 2015, the national healthcare-associated infection (HAI) action plan calls for a 30% reduction in overall C. diff infections by 2020.2 The surveillance data reported were drawn from hospitals reporting to the CDC’s National Healthcare Safety Network (NHSN).
“We have some data suggesting these trends are continuing, and we are really encouraged by that,” Kourtis says.
C. difficile, which kills some 15,000 patients annually, frequently emerges after the administration of antibiotics used for other infections disrupts the commensal bacteria in the gut. As a result, antibiotic stewardship programs tempering the use of the drugs have been heavily emphasized in recent years.
“Antibiotic stewardship has played a big role,” she says. “C. diff can cause diarrhea [and] colitis, and can even be life-threatening. [The reduction] may also have to do with enhanced environmental cleaning because C. diff sheds spores that can survive as a dormant form of the bacteria in the environment.”
One caveat on the findings is that the NHSN data reflect hospital-onset C. diff, not community-onset cases. The latter include patients who have no recent history of hospitalization but likely received antibiotics after visiting a doctor, dental office, or clinic. This proportion of C. diff patients appears to be increasing, so further reducing the pathogen will remain a challenge.
Off Target on MRSA
In contrast to C. diff, the CDC is not on track to achieve the 2020 goal for reduction of methicillin-resistant Staphylococcus aureus (MRSA) infections, despite a 14% decline reported for 2017 in the NHSN data. The national plan calls for a 50% reduction in MRSA bacteremia from 2015 to 2020.
“There has been a stall in our progress against staph infections,” Kourtis says. “If you look at the data so far, we are really not on track to meet that [national] goal. We are on track for a 25% decline or so, not 50%.”
In terms of hospital prevention, the CDC is concerned that there is some fatigue setting in with the rigorous demands of putting patients in contact isolation.
“That may be a factor in the less-than-optimal decline we are seeing in hospital onset infections,” she says. “The CDC continues to support the use of contact precautions, and we renewed the recommendation for them last summer on our website.”
There are some data that suggest outliers, as 6% of the NHSN hospitals reporting on MRSA had significantly worse infection rates than the national average. However, no data were reported by the CDC suggesting these hospitals had lax compliance with contact precautions.
“I think it varies by facility in how much time you put into building and maintaining compliance,” says Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology. “You are always fighting complacency with healthcare staff being compliant with precautions. It is an ongoing issue.”
Some hospitals have moved away from contact precautions as a willful strategy, dropping gloves and gowns on room entry and emphasizing standard precautions with all patients. Some of these hospitals have reported success, but Kourtis says the CDC is looking at the bigger picture in reiterating its recommendation for contact precautions.
“It is time-intensive with gloves and gowns, and people washing their hands before and after,” she concedes. “But it is important. The benefits are not just in preventing infections while the patient is in the hospital. Infections can happen after patients are discharged. Post discharge is a high-risk time for developing an infection that was really acquired in the hospital.”
Thus, patients colonized with MRSA due to lack of contact precautions or lax use of them may develop infection after discharge.
“You need to look not only at the short intervals while a patient is hospitalized, but look at the time after, look at readmissions to the same hospital or to other hospitals,” Kourtis says. “The CDC can see [trends] in local, state, and regional data. We are in a better position to assess interventions like contact precautions and the effect of stopping them.”
Although infection reductions are difficult, the fact that the numbers are going down at all is a testament to infection preventionists and their clinical and public health partners. IPs are a long way from the era when a few hundred hospitals in the NHSN were reporting infection rates primarily for benchmarking rather than aggressive prevention.
IV Drugs Spike Infections
There is an enduring analogy in healthcare epidemiology that preventing infections is like squeezing a balloon; attacking one area triggers a proportional expansion in another. Similar to the situation with C. diff, hospital-onset MRSA is being reduced, but infection is expanding in community-onset cases.
Some of the increase in the community is being driven by drug use, as the CDC reports that “people who inject drugs are 16 times more likely to develop an invasive MRSA infection.”3
“We are seeing an increase in community-onset MRSA infections, and we think that may be linked to the opioid crisis,” Kourtis says. “We are seeing some trends both geographically and in the age groups involved that this may be linked to unsafe injection practices. Many of the opioid abuse problems have had healthcare contact before, have visited emergency departments, or have been hospitalized.”
Thus, some of the cases may have resulted in MRSA exposure in healthcare that is amplified by the many risk factors associated with injection drug use. Many of these may present as skin infections but can become systemic and pose a serious threat in these patients.
“This is a little bit under the radar,” she says. “Most of the [injection drug] prevention efforts so far have been focusing on transmission of bloodborne pathogens like HIV and hepatitis. Not as much thought has been given to skin or fungal infections. We see these happening more and more, and these are not always localized to the spot of the infection.”
In North Carolina, from 2007 to 2017, there was a twelvefold increase in endocarditis rates associated with injection drug use, according to the CDC.4
“We have seen cases of bloodstream infections that cause endocarditis, a potentially life-threating infection in the heart valves,” Kourtis says. “So this is something we really want the clinicians to keep in mind and for the patients to be aware.”
MRSA is not the only infection problem being exacerbated by injection drug use, as other bacterial and fungal infections like Streptococcus and Candida are increasing in this population. For example, in New Mexico in 2017, one in five Group A strep infections were in injection drug users.5
In addition, 10% of patients with Candidemia infection in 2017 nationally reported a history of injecting drugs, the CDC reported.6 The cost is considerable, as infections related to injecting drugs cost $11.4 million at a single hospital in Miami, the CDC reports.7
The CDC is distributing information8 to clinicians and patients, underscoring that risk factors for infection include sharing contaminated syringes and needles, skin wounds, and poor personal hygiene linked to homelessness. In addition to bacteremia and fungemia, infections related to drug addiction and injection can present as botulism, cellulitis, and endocarditis.
The CDC recommends, among other things, that IPs and clinician colleagues “be on alert for infections among patients who inject drugs”:
- “[Consider] bacterial or fungal infection as a cause of symptoms. Infections can present with symptoms similar to withdrawal (e.g., fever, myalgias).”
- “Assess for the presence of infections, especially in the case of a drug overdose.”
- “[If symptoms include] cranial nerve weakness, descending paralysis, or [failure] to respond to naloxone, consider wound botulism.”
- “Be aware of the risk of bloodstream infections from central lines in both inpatients and outpatients.”
- “In patients presenting with fungal and bacterial infections, consider whether injection drug use could be the cause.”
- CDC. HAI Data: National Data for Acute Care Hospitals, Year 2017. Available at: https://bit.ly/2UX3SD7.
- Department of Health and Human Services. Prevent Health Care-Associated Infections: National Targets and Metrics. Available at: https://bit.ly/2I7t4V0.
- Jackson KA, Bohm MK, Brooks JT, et al. Invasive Methicillin-Resistant Staphylococcus aureus Infections Among Persons Who Inject Drugs — Six Sites, 2005–2016. MMWR 2018;67:625–628.
- Schranz AJ, Fleischauer A, Chu VH, et al. Trends in Drug Use–Associated Infective Endocarditis and Heart Valve Surgery, 2007 to 2017: A Study of Statewide Discharge Data. Ann Intern Med 170:31–40.
- Valenciano SJ, McMullen C, Torres S, et al. Notes from the Field: Identifying Risk Behaviors for Invasive Group A Streptococcus Infections Among Persons Who Inject Drugs and Persons Experiencing Homelessness — New Mexico, May 2018. MMWR 2019;68:205–206.
- Toda M, Williams S, Berkow E, et al. Active, Population-based Laboratory Surveillance for Candidemia — four U.S. Sites, 2012–2016. MMWR Surveillance Summary; in press.
- Tookes H, Diaz C, Li H, et al. A Cost Analysis of Hospitalizations for Infections Related to Injection Drug Use at a County Safety-Net Hospital in Miami, Florida. PLoS One 2015;10(6):e0129360.
- CDC. Prevent Bacterial & Fungal Infections in Patients Who Inject Drugs. Available at: https://bit.ly/2VqulJG.
