Summary Report on Antimicrobial Resistant Organisms Surveillance Data from January 1, 2011 to December 31, 2015

Graph 1.1 HA-CDI from CNISP reporting hospitals only^ǂ, national and regional incidence rates per 10,000 patient days

 

ǂ HA-CDI from CNISP reporting hospitals only: includes all cases identified within a CNISP hospital only. HA-CDI as per the case definition in Appendix B.

Graph 2.1 MRSA national and regional incidence rates per 10,000 patient days

Graph 2.2 MRSA-BSI National and regional incidence rates per 10,000 patient days

Graph 3.1 VRE infections national and regional incidence rates per 10,000 patient days

Graph 3.2 VRE-BSI national and regional incidence rates per 10,000 patient days

Graph 4.1 CPO infections national and regional incidence rates per 10,000 patient days 

Appendix A

Hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP), as of December 2015

Participating hospitals from the Western region

Vancouver General Hospital, Vancouver, BC
Richmond General Hospital, Richmond, BC
UBC Hospital, Vancouver, BC
Lions Gate Hospital, Vancouver, BC
Powell River Hospital, Powell River, BC
Sechelt Hospital, Sechelt, BC
Squamish Hospital, Squamish, BC
Children’s and Women’s Health Centre, Vancouver, BC
Royal Jubilee, Victoria, BC
Nanaimo Regional General Hospital, Nanaimo, BC
Victoria General Hospital, Victoria, BC
Kelowna Hospital, Kelowna, BC
University of Northern BC, Prince George, BC
Peter Lougheed Hospital, Calgary, AB
Rockyview General Hospital, Calgary, AB
Foothills Hospital, Calgary, AB
South Health Campus, Calgary, AB
Alberta Children’s Hospital, Calgary, AB
University of Alberta Hospital, Edmonton, AB
Stollery Children’s Hospital, Edmonton, AB
Royal University Hospital, Saskatoon, SK
St. Paul’s Hospital, Saskatoon, SK
Regina General Hospital, Regina, SK
Pasqua Hospital, Regina, SK
Children’s Hospital, Winnipeg, MB

Participating hospitals from the Central region

Children’s Hospital of Western Ontario, London, ON
Victoria Hospital, London, ON
University Hospital, London, ON
Toronto Western Hospital, Toronto, ON
Toronto General Hospital, Toronto, ON
Princess Margaret Hospital, Toronto, ON
North York General Hospital, Toronto, ON
The Hospital for Sick Children, Toronto, ON
Mount Sinai Hospital, Toronto, ON
Sunnybrook Health Sciences Centre, Toronto, ON
Kingston General Hospital, Kingston, ON
Hamilton Health Sciences Centre, McMaster, Hamilton, ON
Hamilton Health Sciences Centre, Juravinski Site, Hamilton, ON
Hamilton Health Sciences Centre, General Site, Hamilton, ON
St Joseph’s Healthcare, Hamilton, ON
The Ottawa Hospital, Civic Campus, Ottawa, ON
The Ottawa Hospital, General Site, Ottawa, ON
The Ottawa Hospital, Heart Institute, Ottawa, ON
Children’s Hospital of Eastern Ontario, Ottawa, ON
Sudbury Regional Hospital, Sudbury, ON
Jewish General Hospital, Montréal, QC
Montréal Children’s Hospital, Montréal, QC
Maisonneuve-Rosemont Hospital, Montréal, QC
Montréal General Hospital, Montréal, QC
Royal Victoria Hospital, Montréal, QC
Montréal Neurological Hospital, Montréal, QC
Hôtel-Dieu de Québec de CHUQ, Québec, QC

Participating hospitals from the Eastern region

The Moncton Hospital, Moncton, NB
Queen Elizabeth Hospital, Charlottetown, PEI
Prince County Hospital, Summerside, PEI
QE II Health Sciences Centre, Halifax, NS
IWK Health Centre, Halifax, NS
Health Sciences Centre General Hospital, St. John’s, NL
Janeway Children's Health and Rehabilitation Centre, St. John’s, NL
St. Clare's Mercy Hospital, St. John’s, NL
Burin Peninsula Health Centre, Burin, NL
Carbonear General Hospital, Carbonear, NL
Dr. G.B. Cross Memorial Hospital, Clarenville, NL
Western Memorial Regional Hospital, NL

We gratefully acknowledge the contribution of the physicians, epidemiologists, infection control practitioners and laboratory staff at each participating hospital and the Public Health Agency staff within the Centre for Communicable Diseases and Infection Control and the National Microbiology Laboratory, Winnipeg.  

Appendix B: 2015 Surveillance Case Definitions and Eligibility Criteria

1. Clostridium difficile Infection (CDI)

To be included in the surveillance, a CDI patient must be:

• ONE year of age and older

Surveillance case definition for info episodes of CDI

• A “primary” episode of CDI is defined as either the first episode of CDI ever experienced by the patient or a new episode of CDI which occurs greater than eight (8) weeks after the previous confirmed case of CDI in the same patient, i.e. after the first C. difficile toxin-positive assay or PCR test. 

A patient is identified as having CDI if:

• they have diarrhea^* or fever, abdominal pain and/or ileus  AND a laboratory confirmation of a positive toxin assay or positive polymerase chain reaction (PCR) for C. difficile (without reasonable evidence of another cause of diarrhea).

OR

• they have a diagnosis of pseudomembranes on sigmoidoscopy or colonoscopy (or after colectomy) or histological/pathological diagnosis of CDI.

OR

• the patient is diagnosed with toxic megacolon (in adult patients only)

^* Diarrhea is defined as one of the following:

• 6 or more watery stools in a 36-hour period
• 3 or more unformed stools in a 24-hour period and this is new or unusual for the patient (in adult patients only)

NOTE: If the information about the frequency and consistency of diarrhea is not available, a toxin-positive stool or positive PCR will be considered as a case.

Once the patient has been identified with CDI, they will be classified as HA or CA based on the following criteria^{Footnote l}  and the best clinical judgment of the healthcare and/or infection prevention and control practitioner.

CDI is considered “healthcare-associated from your facility”^{Footnote m} if it meets the following criteria:

• The patient’s CDI symptoms occur in your healthcare facility 3 or more days after admission, with day of admission being day 1.

OR

• The patient’s CDI symptoms occur less than three (3) days after admission and are seen in a patient who had been hospitalized at your healthcare facility and discharged within the previous 4 weeks.

CDI is considered “healthcare-associated, another facility”  if it meets the following criteria:

• The patient’s CDI symptoms occur less than three (3) days after admission and are seen in a patient who is known to have been hospitalized at another healthcare facility and discharged within the previous four (4) weeks.

CDI is considered “community-associated” if it meets the following criteria:

• Patients seen in the Emergency Department, clinic, or other outpatient areas with positive test results for CDI are included  (if possible at your facility)^{Footnote n} 

OR

• Patient’s CDI symptoms occur three (3) days or less after admission to a healthcare facility (your facility or another), with the date of admission being day 1;

AND

• The symptom onset was more than twelve (12) weeks after the patient was discharged from any healthcare facility

CDI is considered “indeterminate” if it meets the following criteria:

• The patient with CDI does not meet any of the definitions listed above for HA- or CA-CDI. The symptom onset was more than four weeks but less than 12 weeks after the patient was discharged from any healthcare facility.

2. Methicillin-Resistant Staphylococcus aureus (MRSA)

MRSA surveillance inclusion criteria

MRSA case definition:

• isolation of Staphylococcus aureus from any body site

AND

• resistance of isolate to oxacillin

AND

• patient must be admitted to the hospital

AND

• is a "newly identified MRSA case" at a CHEC facility at the time of hospital admission or identified during hospitalization.

This includes:

• MRSA cases identified for the first time during this hospital admission
• Cases that have been previously identified at other non-CHEC sites (since we want newly identified MRSA cases at CHEC sites)
• Cases that have already been identified at your site but are new cases.  This can only be identified if the previously identified case has another strain.  This means the person was exposed again to MRSA and acquired another strain of it from another source (a new patient identifier should be assigned only if it is an MRSA infection, identified as a clinical isolate or bacteremia).

MRSA surveillance exclusion criteria:

• MRSA cases previously identified at other CHEC sites
• Emergency, clinic, or other outpatient cases
• Cases re-admitted with MRSA (unless it is a different strain) 

Healthcare-associated (HA) case definition:

Once the patient has been identified with MRSA, they will be classified as HA based on the following criteria and the best clinical judgement of the healthcare and/or infection prevention and control practitioner (IPC):

• Exposure to any healthcare setting (including long-term care facilities or clinics) in the previous 12 months^{Footnote o} 

OR

• Patient is on calendar day 3^{Footnote p}  of their hospitalization

Newborn healthcare-associated (HA) case definition:

A MRSA case in a newborn may be considered as HA if:

• The newborn is on calendar day 3 of their hospitalization
• The mother was not known to be a case on admission and there is no epidemiological reason to suspect that the mother was colonized prior to admission, even if the newborn is < 48 hours of age.

In the case of a newborn transferred from another institution, MRSA may be classified as HA if the organism was not known to be present and there is no epidemiological reason to suspect that acquisition occurred prior to transfer.

Community-associated case definition:

• MRSA identified on admission to hospital (Calendar Day 1 = day of hospital admission) and/or the day after admission (day 2)

AND

• Has no previous history of the organism

AND

• Has no prior hospital or long-term care admission in the past 12 months^{Footnote q} 

AND

• Has no reported use of medical devices

MRSA clinical infection

MRSA infection is determined using the 2014 CDC/NHSN surveillance definitions www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf for specific infections, and in accordance with the best judgment of the healthcare and/or IPC practitioner.

The MRSA infection would be considered HA if all elements of a CDC/NHSN site-specific infection criterion were present on or after the 3rd calendar day of admission to the facility (the day of hospital admission is calendar day 1). The MRSA infection would be considered CA if all elements of a CDC/NHSN site-specific infection criterion were present during the two calendar days before the day of admission, the first day of admission (day 1) and/or the day after admission (day 2) and are documented in the medical record.

MRSA Bloodstream infection (bacteremia)

To be considered a MRSA bloodstream infection the patient must have MRSA cultured (lab-confirmed) from at least one blood culture    

To classify the MRSA bloodstream infection as HA or CA, the following criteria taken from Friedman et al, Ann Intern Med 2002 will be used. The MRSA infection would be considered:

HA – your facility MRSA BSI: if the first positive blood culture for MRSA was obtained ≥ 48 hours after admission to your hospital

HA – MRSA BSI: if the first positive blood culture for MRSA was obtained ≥ 48 hours after hospital admission

OR

if the first positive blood culture for MRSA was obtained within 48 hours of admission, the patient meets one of the following criteria:

• (i) healthcare exposure in the previous 90 days (such as receipt of IV medications, IV chemotherapy, hemodialysis, etc);
• (ii) was hospitalized in the previous 90 days; or
• (iii) resides in a long-term care facility or nursing home.

CA – MRSA BSI: if the first positive blood culture for MRSA was obtained prior to hospital admission, or within 48 hours of admission, AND did not meet criteria for HA-BSI. 

3. Vancomycin-Resistant Enterococci (VRE)

VRE infection case definition:

• Isolation of Enterococcus faecalis or faecium 

AND

• Vancomycin MIC ≥ 8 ug/ml

AND

• Patient is admitted to the hospital

AND

• Is a "newly” identified VRE-infection at a CHEC facility at the time of hospital admission or identified during hospitalization

VRE infection is determined using the January 2015 Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) definitions/criteria for infections, and in accordance with the best judgment of the ICP.  These criteria should be met at the time of the culture that yielded VRE, or within 72 hours of the culture.

www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf

Exclusion criteria:

• Previously identified at other CHEC sites (to avoid duplicate reporting to CNISP)
• Identified through emergency, clinic, or other outpatient areas
• Re-admitted with VRE (UNLESS it is a different strain)

4. Carbapenemase-Producing Organisms (CPO), Carbapenemase-Producing Enterobacteriaceae (CPE) and Carbapenem-Producing Acinetobacter (CPA)

Any patient admitted to participating CNISP hospitals with a hospital laboratory confirmation (and subsequent confirmation by the NML) that tested/screened positive for a least one potential carbapenem-reduced susceptible Enterobacteriaceae and Acinetobacter spp., from any body site that meets the following CLSI criteria^{Footnote r} .

At least ONE of the following:	Enterobacteriaceae:
	MIC (μg/ml)	Disk diffusionTable - Footnote * (mm)
Imipenem	≥ 2	≤ 22
Meropenem	≥ 2	≤ 22
Doripenem	≥ 2	≤ 22
Ertapenem	≥ 1	≤ 21

At least ONE of the following:	Acinetobacter:
	MIC (μg/ml)	Disk diffusion (mm)
Imipenem	≥ 4	≤ 21
Meropenem	≥ 4	≤ 17
Doripenem	≥ 4	≤ 17

Carbapenems are a class of broad-spectrum antibiotics recommended as first-line therapy for severe infections caused by certain gram negative organisms and as directed therapy for organisms that are resistant to narrower spectrum antibiotics.

Carbapenem resistance can be due to changes in the permeability of the organism to the antibiotic, the up-regulation of efflux systems that “pump” the antibiotic out of the cell, and more recently due to the hyperproduction of enzymes that break down the carbapenems. This latter subset of carbapenem resistant organisms are called carbapenemase-producing organisms or CPOs and are of particular concern because of their ability to transfer resistance easily across different genus and species of bacteria. They are quickly becoming a public health problem not only because of the ability to cause healthcare-associated infections but because of the potential ease of colonizing both inpatient and outpatient populations creating a reservoir of bacterial resistance. 

CPE represents a subset of CRGN bacilli comprised of Enterobacteriaceae and CPA represents a subset of CRGN bacilli comprised of Acinetobacter identified as carbapenemase producing.  Mechanism may be either by acquisition of a carbapenemase gene e.g. NDM-1, OXA-48, KPC, VIM, IMP or by other cellular mechanisms such as permeability changes (efflux overpression, porin mutations), chromosomal B-lactamase up regulation e.g. E. coli, K. pneumonia, Citrobacter, Enterobacter, Serratia, Morganell, Proteus, Providencia.