Summary Report on Antimicrobial Resistant Organism (ARO) Surveillance Data from January 1, 2012 to December 31, 2016

Table of Contents

• Introduction
  1. Clostridium difficile infection (CDI)
  2. Methicillin-Resistant Staphylococcus aureus (MRSA)
  3. Vancomycin-Resistant Enterococci (VRE)
  4. Carbapenemase-Producing Enterobacteriaceae (CPE) and Carbapenemase-Producing Acinetobacter (CPA)
• Appendix A: Hospitals participating in the Canadian Nosocomial Infection Surveillance Program, as of December 2016
• Appendix B: 2016 Surveillance Case Definitions and Eligibility Criteria

Introduction

This report entitled Canadian Nosocomial Infection Surveillance Program (CNISP): Summary Report on ARO Surveillance Data from January 1, 2012 to December 31, 2016, was produced by the Centre for Communicable Diseases and Infection Control of the Public Health Agency of Canada (PHAC). The report provides a review of available ARO data in the healthcare setting in Canada.

The Centre for Communicable Diseases and Infection Control (CCDIC) coordinates the data collection and is responsible for the data management, analysis and report production related to this summary report.  CCDIC supports the use of these data to inform public health and policy action.  In addition, PHAC is committed to improving data quality, as well as defining and setting surveillance standards.

PHAC collects national data on various healthcare-associated infections, including AROs through the Canadian Nosocomial Infection Surveillance Program (CNISP), a collaborative effort of CCDIC, the National Microbiology Laboratory (NML) and sentinel hospitals across Canada who participate as members of the Canadian Hospital Epidemiology Committee (CHEC), a subcommittee of the Association of Medical Microbiology and Infectious Disease (AMMI) Canada.  Their ongoing contributions to national ARO surveillance are gratefully acknowledged.

As of December 2016, CNISP conducted surveillance in 65 acute-care hospitals in Canada (Appendix A). Of these, 12 are large acute, tertiary care hospitals with more than 500 beds available within the facility; 34 hospitals are of intermediate size (201 to 500 beds), while the remaining 19 hospitals are smaller facilities with less than 200 beds.  Acute tertiary care hospitals are major hospitals that offer a range of specialist services such as burn units, transplant units, trauma centres, specialized cardiac surgery etc. to which patients are referred from smaller hospitals. General urban acute-care hospitals provide overall medical and surgical services but do not always have specialised sub-specialities. There are 34 adult-only hospitals, 23 hospitals which treat both adult and children, and the remaining 8 hospitals are stand-alone pediatric facilities (Appendix A). Surveillance of AROs at participating hospitals is considered to be within the mandate of hospital infection prevention and control programs and does not constitute human research. The ability for a hospital to participate in CNISP ARO surveillance is based on the site capacity for data collection, access to hospital laboratory services and their operational capacity to participate in a given year.  Therefore, the variation in the number of reporting hospitals each year reflects the changes in the number of participating hospitals, which has generally increased over time.

CNISP surveillance provides key information that informs the development of federal, provincial, territorial and local infection prevention and control programs and policies. When carried out in a uniform manner, surveillance provides a measure of the burden of illness, establishes benchmark rates for internal and external comparison, identifies potential risk factors, and allows assessment of specific interventions. Surveillance for AROs is considered an important component of the quality of patient care.

This report provides case counts and rates based on data from January 1, 2012 to December 31, 2016.  All rates presented in this report represent infections and/or colonizations identified in patients admitted (inpatients) to CNISP hospitals. The report includes rates for Clostridium difficile infection (CDI) including healthcare- and community associated CDI, methicillin-resistant Staphylococcus aureus (MRSA) including healthcare- and community-associated MRSA and MRSA bacteremias, vancomycin-resistant Enterococci (VRE), carbapenemase-producing Enterobacteriaceae(CPE) and carbapenemase-producing Acinetobacter (CPA).

Where possible, rates are provided by region and include Western (British Columbia, Alberta, Saskatchewan and Manitoba), Central (Ontario and Quebec), and Eastern Regions (Nova Scotia, New Brunswick, Prince Edward Island and Newfoundland and Labrador). The territories do not currently submit data to PHAC.

National and regional infection rates are based on the total number of cases reported divided by the total number of patient admissions (multiplied by 1,000) or patient days (multiplied by 10,000). This report also provides strain type and antimicrobial resistance data for CDI, MRSA, VRE, CPE and CPA. 

The 2016 case definitions and eligibility criteria for these surveillance programs are provided in Appendix B.  Case definitions and eligibility criteria are reviewed each year prior to the start of the surveillance year by the CNISP working group responsible for overseeing each ARO surveillance activity.  CNISP working groups are comprised of members of CHEC and PHAC technical experts from CCDIC and NML. Case definitions and eligibility criteria may vary from one surveillance year to another as the surveillance protocols are reviewed and updated by the applicable CNISP working group.

This report supersedes the data in previous ARO reports. The most current report should be considered the most accurate. Data from 2016 are considered preliminary. Surveillance data are dynamic and results are subject to change as more updated data are made available by the participating hospitals. Data from previous ARO and Canadian Antimicrobial Resistance Surveillance System (CARSS) reports may vary slightly based on criteria used to analyze and report the data, but the overall reported trends remain similar. Note that for all years, only hospitals that submitted both numerator and denominator data are included in the rate calculations.

For questions or more information on these rates or for a copy of the most recent PHAC surveillance report, please contact the Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada by sending an email to phac.ccdic-clmti.aspc@canada.ca.

Results

1. Clostridium difficile Infection (CDI)

1a. Healthcare-associated Clostridium difficile Infection (HA-CDI)

Table 1.1 Number of HA-CDI from CNISP reporting hospitals only^{Table 1.1 - Footnote ǂ}, cases and incidence rates per 1,000 patient admissions and 10,000 patient days

Years	2012	2013	2014	2015	2016
National
No. of HA-CDI cases	3,482	3,160	2,870	2,930	2,814
Rate per 1,000 pt admissions	4.80	3.99	3.43	3.34	3.13
Rate per 10,000 pt days	6.03	5.19	4.39	4.33	4.05
No. of reporting hospitals	54	54	60	62	63
West
No. of HA-CDI cases	1,282	1,198	1,121	1,318	1,254
Rate per 1,000 pt admissions	4.76	3.61	3.10	3.35	3.10
Rate per 10,000 pt days	5.70	4.82	4.10	4.41	4.05
Central
No. of HA-CDI cases	1,997	1,732	1,510	1,356	1,290
Rate per 1,000 pt admissions	5.31	4.56	3.90	3.43	3.22
Rate per 10,000 pt days	7.14	6.08	5.13	4.62	4.35
East
No. of HA-CDI cases	203	230	243	256	270
Rate per 1,000 pt admissions	2.55	2.86	2.75	2.91	2.90
Rate per 10,000 pt days	2.80	3.07	2.81	3.06	3.07
Table 1.1 footnote ǂ HA-CDI from CNISP reporting hospitals only: includes all cases identified and have potentially been acquired only within a CNISP hospital. HA-CDI as per the case definition in Appendix B. Return to table 1.1 footnote ǂ

Graph 1.1 - Text Equivalent

Year	Region	Rate
2012	West	5.70
	Central	7.14
	East	2.80
	National	6.03
2013	West	4.82
	Central	6.08
	East	3.07
	National	5.19
2014	West	4.10
	Central	5.13
	East	2.81
	National	4.39
2015	West	4.41
	Central	4.62
	East	3.06
	National	4.33
2016	West	4.05
	Central	4.35
	East	3.07
	National	4.05

1 b. Community-associated Clostridium difficile Infection (CA-CDI)

Table 1.2 Number of CA-CDI from CNISP reporting hospitals only^{Table 1.2 - Footnote ǂ}, cases and incidence rates per 1,000 patient admissions and 10,000 patient days

Years	2012	2013	2014	2015	2016
National
No. of HA-CDI cases	*	*	*	1,036	937
Rate per 1,000 pt admissions	*	*	*	1.56	1.35
Rate per 10,000 pt days	*	*	*	2.03	1.76
No. of reporting hospitals	*	*	*	49	50
West
No. of HA-CDI cases	*	*	*	254	238
Rate per 1,000 pt admissions	*	*	*	1.15	1.05
Rate per 10,000 pt days	*	*	*	1.55	1.41
Central
No. of HA-CDI cases	*	*	*	676	598
Rate per 1,000 pt admissions	*	*	*	1.91	1.60
Rate per 10,000 pt days	*	*	*	2.57	2.17
East
No. of HA-CDI cases	*	*	*	106	101
Rate per 1,000 pt admissions	*	*	*	1.20	1.10
Rate per 10,000 pt days	*	*	*	1.27	1.15
Table 1.2 footnote ǂ CA-CDI includes all cases identified among admitted within a CNISP hospital. CA-CDI as per the case definition in Appendix B. Data collection began in 2015. Return to table 1.2 footnote ǂ

Table 1.3 Attributable mortality rate 30 days after date of first positive CDI test in adults with HA-CDI

Year	Number of deathsTable 1.3 Footnote *	Mortality rate (%)
2012	24	4.6
2013	21	3.9
2014	22	4.3
2015	16	3.8
2016	12	3.0
Table 1.3 footnote * Deaths directly and indirectly related to HA-CDI 30 days after the date of the first positive lab specimen or positive histopathology specimen. Mortality data are collected during the two-month period (March and April of each year) for adults (age 18 years and older) and year-round for children (age 1 year to less than 18 years old). Among pediatric patients, there was no death attributable to HA-CDI. Return to table 1.3 footnote *

Table 1.4 Number and proportion of select healthcare-associated C. difficile NAP strain types^{Table 1.4 Footnote ⱡ}

Strain Type	2012 No. (%)	2013 No. (%)	2014 No. (%)	2015 No. (%)	2016 No. (%)
NAP1	164 (33.3)	152 (29.6)	114 (23.6)	115 (22.9)	53 (11.8)
NAP4	77 (15.7)	90 (17.5)	92 (19.1)	106 (21.1)	91 (20.1)
NAP11	40 (8.1)	33 (6.4)	62 (12.9)	50 (9.9)	73 (16.2)
Other NAP typesFootnote *	91 (18.5)	91 (17.8)	84 (17.4)	94 (18.7)	72 (16.0)
Other-not assigned	120 (24.4)	147 (28.7)	130 (27.0)	138 (27.4)	162 (35.9)
Table 1.4 footnote ⱡ CDI isolates are collected for NAP typing during the two-month period (March and April of each year) for adults (age 18 years and older) and year-round for children (age 1 year to less than 18 years old from admitted patients only). Return to table 1.4 footnote ǂ Table 1.4 footnote * Other NAP strain types include NAP2, NAP3, NAP5, NAP6, NAP7, NAP8, NAP9, NAP10 and NAP12. Return to table 1.4 footnote *

Table 1.5 Antimicrobial resistance identified for healthcare-associated C. difficile isolates ^{Table 1.5 Footnote ⱡ}

Antibiotics	2012 No. (%)	2013 No. (%)	2014 No. (%)	2015 No. (%)	2016 No. (%)
Clindamycin	80 (16.3)	156 (30.5)	209 (43.4)	125 (24.9)	99 (22.0)
Moxifloxacin	192 (39.0)	166 (32.4)	137 (28.4)	138 (27.4)	72 (16.0)
Rifampin	4 (0.8)	13 (2.5)	5 (1.0)	10 (2.0)	7 (1.6)
Total isolates tested	492	512	482	503	451
Table 1.5 footnote ⱡ CDI isolates are collected for resistance testing during the two-month period (March and April of each year) for adults (age 18 years and older) and year-round for children (age 1 year to less than 18 years old) from admitted patients only. Return to table 1.5 footnote ⱡ Note: All C. difficile strains from 2012 to 2016 submitted to NML were susceptible to metronidazole and tigecycline. Only one isolate had a reduced susceptibility to vancomycin (24 µg/ml) in 2012.

2. Methicillin-Resistant Staphylococcus aureus (MRSA)

Table 2.1 Number of total^{Footnote *} MRSA infections and incidence rates per 1,000 patient admissions and 10,000 patient days

Years	2012	2013	2014	2015	2016
National
No. of MRSA cases	1,787	1,847	1,969	2,049	2,241
Rate per 1,000 pt admissions	2.17	2.11	2.12	2.16	2.3
Rate per 10,000 pt days	2.80	2.83	2.89	2.93	3.11
No. of reporting hospitalsFootnote a	51	53	58	59	61
West
No. of MRSA cases	844	898	949	1,117	1,272
Rate per 1,000 pt admissions	2.42	2.48	2.33	2.59	2.9
Rate per 10,000 pt days	3.30	3.40	3.29	3.55	3.91
Central
No. of MRSA cases	703	737	801	732	784
Rate per 1,000 pt admissions	1.83	1.78	1.91	1.75	1.82
Rate per 10,000 pt days	2.35	2.47	2.68	2.47	2.60
East
No. of MRSA cases	240	212	219	200	185
Rate per 1,000 pt admissions	2.63	2.15	2.19	2.03	1.77
Rate per 10,000 pt days	2.87	2.34	2.33	2.24	1.98
Table 2.1 footnote a Includes infections identified from blood AND clinical isolates as well as healthcare and community associated cases identified in admitted patients. Return to table 2.1 footnote a Table 2.1 footnote * Includes infections identified from blood AND clinical isolates as well as healthcare and community associated cases identified in admitted patients. Return to table 2.1 footnote *

Graph 2.1 - Text description

Year	Region	Rate
2012	West	3.30
	Central	2.35
	East	2.87
	National	2.80
2013	West	3.40
	Central	2.47
	East	2.34
	National	2.83
2014	West	3.29
	Central	2.68
	East	2.32
	National	2.89
2015	West	3.55
	Central	2.47
	East	2.24
	National	2.93
2016	West	3.91
	Central	2.60
	East	1.98
	National	3.11

Graph 2.1 footnote *

Includes infections identified from blood AND clinical isolates as well as healthcare and community associated cases identified in admitted patients.

Return to Graph 2.1 footnote *

Table 2.2 Number of Healthcare-associated (HA) MRSA^{Footnote *} infections and incidence rates per 1,000 patient admissions and 10,000 patient days

Years	2012	2013	2014	2015	2016
National
No. of HA-MRSA cases	1,112	1,137	1,172	1,192	1,206
Rate per 1,000 pt admissions	1.35	1.30	1.26	1.26	1.24
Rate per 10,000 pt days	1.74	1.74	1.72	1.70	1.67
No. of reporting hospitals	51	53	58	59	61
West
No. of HA-MRSA cases	517	554	535	630	676
Rate per 1,000 pt admissions	1.49	1.53	1.31	1.46	1.54
Rate per 10,000 pt days	2.02	2.10	1.86	2.00	2.08
Central
No. of HA-MRSA cases	382	400	460	405	381
Rate per 1,000 pt admissions	0.99	0.97	1.09	0.97	0.89
Rate per 10,000 pt days	1.28	1.34	1.54	1.37	1.26
East
No. of HA-MRSA cases	213	183	177	157	149
Rate per 1,000 pt admissions	2.33	1.85	1.77	1.59	1.43
Rate per 10,000 pt days	2.55	2.02	1.89	1.76	1.59
Table 2.2 footnote * HA-MRSA: includes all cases identified and have potentially been acquired within CNISP hospitals and/or from any other healthcare exposure (non-CNISP hospitals, clinics, long-term care facility, etc.) as per the case definition in Appendix B. Return to table 2.2 footnote *

Table 2.3 Number of HA-MRSA infections identified only at CNISP hospitals^{Footnote ǂ} and incidence rates per 1,000 patient admissions and 10,000 patient days

Years	2012	2013	2014	2015	2016
National
No. of HA-MRSA cases	817	870	869	850	873
Rate per 1,000 pt admissions	0.99	1.00	0.94	0.90	0.90
Rate per 10,000 pt days	1.28	1.33	1.28	1.21	1.21
No. of reporting hospitals	51	53	58	59	61
West
No. of HA-MRSA cases	377	423	387	455	486
Rate per 1,000 pt admissions	1.08	1.17	0.95	1.05	1.11
Rate per 10,000 pt days	1.47	1.60	1.34	1.44	1.49
Central
No. of HA-MRSA cases	261	289	331	276	269
Rate per 1,000 pt admissions	0.68	0.70	0.79	0.66	0.63
Rate per 10,000 pt days	0.87	0.97	1.11	0.93	0.89
East
No. of HA-MRSA cases	179	158	151	119	118
Rate per 1,000 pt admissions	1.96	1.60	1.51	1.21	1.13
Rate per 10,000 pt days	2.14	1.75	1.61	1.33	1.26
Table 2.3 footnote ǂ HA-MRSA from CNISP reporting hospitals only: includes all cases identified and have potentially been acquired only within a CNISP hospital. HA-MRSA as per the case definition in Appendix B. Return to table 2.3 footnote ǂ

Table 2.4 Number of community-associated (CA) MRSA infections and incidence rates per 1,000 patient admissions and 10,000 patient days

Years	2012	2013	2014	2015	2016
National
No. of CA-MRSA cases	539	549	654	729	921
Rate per 1,000 pt admissions	0.65	0.63	0.70	0.77	0.95
Rate per 10,000 pt days	0.84	0.84	0.96	1.04	1.28
No. of reporting hospitals	51	53	58	59	61
West
No. of CA-MRSA cases	309	321	380	449	569
Rate per 1,000 pt admissions	0.89	0.89	0.93	1.04	1.30
Rate per 10,000 pt days	1.21	1.21	1.32	1.43	1.75
Central
No. of CA-MRSA cases	216	207	243	245	322
Rate per 1,000 pt admissions	0.56	0.50	0.58	0.59	0.75
Rate per 10,000 pt days	0.72	0.69	0.81	0.83	1.07
East
No. of CA-MRSA cases	14	21	31	35	30
Rate per 1,000 pt admissions	0.15	0.21	0.31	0.35	0.29
Rate per 10,000 pt days	0.17	0.23	0.33	0.39	0.32

Table 2.5 Number of MRSA bloodstream infections (MRSA-BSI) and incidence rates per 1,000 patient admissions and 10,000 patient days

Years	2012	2013	2014	2015	2016
National
No. of MRSA BSI cases	324	349	439	491	606
Rate per 1,000 pt admissions	0.39	0.40	0.47	0.52	0.62
Rate per 10,000 pt days	0.51	0.53	0.64	0.70	0.84
No. of reporting hospitals	51	53	58	59	61
West
No. of MRSA BSI cases	115	128	161	215	279
Rate per 1,000 pt admissions	0.33	0.35	0.39	0.50	0.64
Rate per 10,000 pt days	0.45	0.48	0.56	0.68	0.86
Central
No. of MRSA BSI cases	164	179	236	225	281
Rate per 1,000 pt admissions	0.43	0.43	0.56	0.54	0.65
Rate per 10,000 pt days	0.55	0.60	0.79	0.76	0.93
East
No. of MRSA BSI cases	45	42	42	51	46
Rate per 1,000 pt admissions	0.49	0.43	0.42	0.52	0.44
Rate per 10,000 pt days	0.54	0.46	0.45	0.57	0.49

Graph 2.2 - Text description

Year	Region	Rate
2012	West	0.45
	Central	0.55
	East	0.54
	National	0.51
2013	West	0.48
	Central	0.60
	East	0.46
	National	0.53
2014	West	0.56
	Central	0.79
	East	0.45
	National	0.64
2015	West	0.68
	Central	0.76
	East	0.57
	National	0.70
2016	West	0.86
	Central	0.93
	East	0.49
	National	0.84

Table 2.6 All-cause mortality rate 30 days after the date of first positive culture per 100 MRSA-BSI cases

Year	Number of deathsFootnote *	Mortality rate (%)
2012	71	22.0
2013	92	25.3
2014	103	24.4
2015	96	20.5
2016	111	19.0
Table 2.6 footnote * All-cause mortality rate based on the number of cases with associated 30-day outcome data. Return to table 2.6 footnote *

Table 2.7 Number and proportion of select MRSA strain types identified

Strain Type	2012 No. (%)	2013 No. (%)	2014 No. (%)	2015 No. (%)	2016 No. (%)
CMRSA 2	271 (50.7)	278 (47.4)	302 (43.9)	266 (37.2)	279 (31.6)
CMRSA 7	28 (5.2)	24 (4.1)	41 (6.0)	48 (6.7)	72 (8.1)
CMRSA 10	179 (33.5)	214 (36.5)	266 (38.7)	303 (42.3)	408 (46.2)
Other strain typesFootnote *	52 (9.9)	63 (11.1)	70 (10.2)	76 (10.6)	92 (10.4)
Unassigned	4 (0.7)	6 (1.0)	9 (1.3)	23 (3.2)	33 (3.7)
Total	534	587	688	716	884
Table 2.7 footnote * Other strain types from 2012 to 2016 include CMRSA 1, CMRSA 3/6, CMRSA 4, CMRSA 5, CMRSA 8, ST88, ST97, ST398, ST772, USA 700, USA 1000, USA 1100 and European. MRSA non-blood isolates (urine, respiratory, wound, surgical site) are collected from January to March of every year and blood isolates are collected year round. Return to table 2.7 footnote *

Table 2.8 Antimicrobial resistance identified for MRSA isolates

Antibiotics	2012 No. (%)	2013 No. (%)	2014 No. (%)	2015 No. (%)	2016 No. (%)
Clindamycin	295 (78.9)	349 (83.5)	374 (65.4)	385 (54.1)	296 (42.7)
Ciprofloxacin	429 (83.0)	479 (85.8)	228 (84.1)	85 (81.7)	520 (74.9)
Daptomycin	0 (0.0)	2 (0.4)	2 (0.3)	5 (0.7)	0 (0.0)
Erythromycin	432 (83.6)	495 (88.7)	535 (84.4)	576 (80.9)	538 (77.5)
Fusidic acid	32 (6.2)	57 (10.2)	91 (14.4)	126 (17.7)	121 (17.4)
Mupirocin HLR	25 (4.8)	15 (2.7)	30 (4.7)	40 (6.6)	Not tested
Rifampin	0 (0.0)	3 (0.5)	3 (0.5)	3 (0.4)	9 (1.3)
Tetracycline	19 (3.7)	25 (4.5)	34 (5.4)	37 (5.2)	48 (6.9)
Tigecycline	2 (0.4)	25 (4.5)	17 (2.7)	6 (0.8)	0 (0.0)
TMP/SMX	12 (2.3)	25 (4.5)	14 (2.2)	14 (2.0)	18 (2.6)
Total isolates tested	517	558	634	712	694
Total # isolates tested for clindamycin =374 (2012), 418 (2013), 572 (2014) Total # isolates tested for Ciprofloxacin= 271 (2014) 104 (2015) Total # isolates tested for Mupirocin HLR = 608 (2015) MRSA non-blood isolates (urine, respiratory, wound, surgical site) are collected from January to March of every year and blood isolates are collected year round

All MRSA isolates from 2012 to 2016 submitted to NML were susceptible to linezolid and vancomycin.

3. Vancomycin-Resistant Enterococci (VRE)

Table 3.1 Number of total^{Footnote *} VRE infections and incidence rates per 1,000 patient admissions and 10,000 patient days

Years	2012	2013	2014	2015	2016
National
No. of VRE cases	394	322	293	271	299
Rate per 1,000 pt admissions	0.47	0.39	0.33	0.30	0.32
Rate per 10,000 pt days	0.61	0.52	0.45	0.41	0.43
No. of reporting hospitals	53	48	54	53	56
West
No. of VRE cases	223	154	149	142	146
Rate per 1,000 pt admissions	0.64	0.52	0.45	0.40	0.40
Rate per 10,000 pt days	0.87	0.72	0.65	0.56	0.54
Central
No. of VRE cases	168	161	143	127	145
Rate per 1,000 pt admissions	0.43	0.37	0.32	0.29	0.32
Rate per 10,000 pt days	0.55	0.51	0.44	0.41	0.45
East
No. of VRE cases	3	7	1	2	8
Rate per 1,000 pt admissions	0.03	0.08	0.01	0.02	0.08
Rate per 10,000 pt days	0.04	0.08	0.01	0.02	0.09
Table 3.1 footnote * Includes infections identified from blood AND clinical isolates. Return to table 3.1 footnote *

Graph 3.1 - Text description

Year	Region	Rate
2012	West	0.87
	Central	0.55
	East	0.04
	National	0.61
2013	West	0.72
	Central	0.51
	East	0.08
	National	0.52
2014	West	0.65
	Central	0.44
	East	0.01
	National	0.45
2015	West	0.56
	Central	0.41
	East	0.02
	National	0.41
2016	West	0.54
	Central	0.45
	East	0.09
	National	0.43

Graph 3.1 footnote *

Includes infections identified from blood AND clinical isolates.

Return to Graph 3.1 footnote *

Table 3.2 Number of VRE infections identified only at CNISP hospitals^{Footnote ǂ}, and incidence rates per 1,000 patient admissions and 10,000 patient days

Years	2012	2013	2014	2015	2016
National
No. of VRE cases	Footnote *	*	251	231	257
Rate per 1,000 pt admissions	*	*	0.28	0.26	0.28
Rate per 10,000 pt days	*	*	0.39	0.35	0.37
No. of reporting hospitals	*	*	54	53	56
West
No. of VRE cases	*	*	126	118	121
Rate per 1,000 pt admissions	*	*	0.38	0.33	0.33
Rate per 10,000 pt days	*	*	0.55	0.46	0.45
Central
No. of VRE cases	*	*	124	111	129
Rate per 1,000 pt admissions	*	*	0.27	0.25	0.28
Rate per 10,000 pt days	*	*	0.38	0.36	0.40
East
No. of VRE cases	*	*	1	2	7
Rate per 1,000 pt admissions	*	*	0.01	0.02	0.07
Rate per 10,000 pt days	*	*	0.01	0.02	0.07
Table 3.2 footnote * Data of where the VRE infection was acquired was not collected during 2012-2013. Return to table 3.2 footnote * Table 3.2 footnote ǂ VRE from CNISP reporting hospitals only: includes all cases identified and have potentially been acquired only within a CNISP hospital. VRE as per the case definition in Appendix B. Return to table 3.2 footnote ǂ

Table 3.3 Number of VRE bloodstream infections (VRE-BSI) and incidence rates per 1,000 patient admissions and 10,000 patient days

Years	2012	2013	2014	2015	2016
National
No. of VRE-BSI cases	92	98	93	89	121
Rate per 1,000 pt admissions	0.11	0.12	0.11	0.10	0.13
Rate per 10,000 pt days	0.14	0.16	0.14	0.14	0.18
No. of reporting hospitals	53	48	54	53	56
West
No. of VRE-BSI cases	38	31	35	35	45
Rate per 1,000 pt admissions	0.11	0.11	0.11	0.10	0.12
Rate per 10,000 pt days	0.15	0.15	0.15	0.14	0.17
Central
No. of VRE-BSI cases	53	67	58	53	75
Rate per 1,000 pt admissions	0.13	0.15	0.13	0.12	0.16
Rate per 10,000 pt days	0.17	0.21	0.18	0.17	0.23
East
No. of VRE-BSI cases	1	0	0	1	1
Rate per 1,000 pt admissions	0.01	0.00	0.00	0.01	0.01
Rate per 10,000 pt days	0.01	0.00	0.00	0.01	0.01

Graph 3.2 - Text description

Year	Region	Rate
2012	West	0.15
	Central	0.17
	East	0.01
	National	0.14
2013	West	0.15
	Central	0.21
	East	0.00
	National	0.16
2014	West	0.15
	Central	0.18
	East	0.00
	National	0.14
2015	West	0.14
	Central	0.17
	East	0.01
	National	0.14
2016	West	0.17
	Central	0.23
	East	0.01
	National	0.18

Table 3.4 Number and proportion of main VRE-BSI isolate types identified

	2012 No. (%)	2013 No. (%)	2014 No. (%)	2015 No. (%)	2016 No. (%)
vanA, Enterococcus faecium	65 (90.3)	72 (96.0)	70 (100.0)	75 (100.0)	88 (96.7)
vanB, Enterococcus faecium	7 (9.7)	3 (4.0)	0 (0.0)	0 (0.0)	3 (3.3)
Total	72	75	70	75	91

Table 3.5 Number and proportion of main VRE-BSI multi-locus sequence types (MLST) identified

	2012 No. (%)	2013 No. (%)	2014 No. (%)	2015 No. (%)	2016 No. (%)
ST117	24 (33.3)	26 (34.7)	16 (22.9)	13 (17.3)	21 (23.1)
ST18	14 (19.4)	14 (18.7)	20 (28.6)	11 (14.7)	14 (15.4)
ST412	10 (13.9)	14 (18.7)	7 (10.0)	12 (16.0)	13 (14.3)
OthersFootnote *	24 (33.3)	19 (25.3)	27 (38.6)	35 (46.7)	33 (36.3)
Total	72	75Footnote a	70	75Footnote b	91Footnote c
Table 3.5 footnote * Others include ST17, ST78, ST80, ST203, ST252, ST262, ST265, ST282, ST414, ST494, ST584, ST612, ST664, ST665, ST721, ST734, ST736, ST772, ST787, ST802, ST835, ST836, ST912, ST982, ST983, ST984, ST992, ST1032, ST1112, ST1113. Return to table 3.5 footnote * Table 3.5 footnote a 2 samples were untypeable. Return to table 3.5 footnote a Table 3.5 footnote b 4 samples were untypeable. Return to table 3.5 footnote b Table 3.5 footnote c 10 samples were untypeable. Return to table 3.5 footnote c

Tables 3.6 Antimicrobial resistance identified for VRE-BSI isolates

Antibiotics	2012	2013	2014	2015	2016
	No. (%)	No. (%)	No. (%)	No. (%)	No. (%)
Ampicillin	71 (98.6)	75 (100)	70 (100)	75 (100)	91 (100)
Chloramphenicol	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	2 (2.2)
DaptomycinFootnote a	2 (2.8)	5 (6.7)	0 (0.0)	0 (0.0)	7 (7.7)
HL-Gentamicin	16 (22.2)	13 (17.3)	7 (10.0)	6 (8.0)	13 (14.3)
HL- Streptomycin	29 (40.3)	28 (37.3)	29 (41.4)	27 (36.0)	32 (35.2)
Levofloxacin	72 (100)	75 (100)	70 (100)	75 (100)	91 (100)
Linezolid	0 (0.0)	1 (1.3)	0 (0.0)	0 (0.0)	1 (1.1)
Nitrofurantoin	11 (15.3)	14 (18.7)	15 (21.4)	25 (33.3)	35 (38.5)
Penicillin	71 (98.6)	75 (100)	70 (100)	75 (100)	91 (100)
Tigecycline	1 (1.4)	0 (0.0)	2 (2.9)	0 (0.0)	0 (0.0)
VancomycinFootnote b	71 (98.6)	75 (100)	70 (100)	74 (98.7)	88 (96.7)
Total isolates tested	72	75	70	75	91
Table 3.6 footnote a Daptomycin does not have breakpoints for intermediate or resistant. Therefore, these are non-susceptible. Return to table 3.6 footnote a Table 3.6 footnote b Some isolates were susceptible or intermediate to vancomycin but all harboured VanA or VanB. Return to table 3.6 footnote b

4. Carbapenemase-Producing Enterobacteriaceae (CPE) and Carbapenemase-Producing Acinetobacter (CPA)

This report presents data on Carbapenemase-Producing Enterobacteriaceae (CPE) and Acinetobacter (CPA). CPE and CPA rates are based on inpatients only and include both colonized and infected cases, with the exception of mortality data which includes only infected cases. Rates are based on individual patient data. This means that a patient identified with multiple organisms during the same admission is only included once in the rates. If they are re-admitted and identified as CPE or CPA, they are included in the rates again as their subsequent admission contributes to the denominator.  This explains the higher incidence rates presented in this report compared to previous reports. Consequently, data from previous years included in this report have been adjusted to reflect this change in reporting.

Table 4.1 Number of CPE cases^{Footnote *} and incidence rates per 1,000 patient admissions and 10,000 patient days

Years	2012	2013	2014	2015	2016
National
No. of CPE cases	39	45	44	54	93
Rate per 1,000 pt admissions	0.07	0.06	0.05	0.06	0.10
Rate per 10,000 pt days	0.08	0.08	0.07	0.08	0.14
No. of reporting hospitals	38	45	58	58	58
West
No. of CPE cases	6	22	12	21	22
Rate per 1,000 pt admissions	0.04	0.08	0.03	0.05	0.06
Rate per 10,000 pt days	0.05	0.11	0.04	0.07	0.07
CentralFootnote ǂ
No. of CPE cases	32	22	32	31	71
Rate per 1,000 pt admissions	0.09	0.05	0.07	0.07	0.16
Rate per 10,000 pt days	0.12	0.07	0.11	0.10	0.23
East
No. of CPE cases	1	1	0	2	0
Rate per 1,000 pt admissions	0.01	0.01	0.00	0.02	0.00
Rate per 10,000 pt days	0.01	0.01	0.00	0.02	0.00
Table 4.1 footnote * Includes both CPE infections and colonizations Return to table 4.1 footnote * Table 4.1 footnote ǂ The greater number of cases reported in the Central region is largely attributed to one hospital Return to table 4.1 footnote ǂ

Central ǂ - The greater number of cases reported in the Central region is largely attributed to one hospital.

Graph 4.1 - Text description

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

Year	Region	Rate
2012	West	0.050
	Central	0.120
	East	0.010
	National	0.080
2013	West	0.110
	Central	0.070
	East	0.010
	National	0.080
2014	West	0.040
	Central	0.110
	East	0.000
	National	0.070
2015	West	0.070
	Central	0.100
	East	0.020
	National	0.080
2016	West	0.070
	Central	0.230
	East	0.000
	National	0.140

Table 4.2 Number of CPA cases^{Footnote *} and incidence rates per 1,000 patient admissions and 10,000 patient days

Years	2012	2013	2014	2015	2016
National
No. of CPA cases	9	32	4	5	13
Rate per 1,000 pt admissions	0.02	0.04	0.004	0.01	0.01
Rate per 10,000 pt days	0.02	0.06	0.01	0.01	0.02
No. of reporting hospitals	38	45	58	58	58
West
No. of CPA cases	4	1	1	4	2
Rate per 1,000 pt admissions	0.03	0.004	0.003	0.01	0.01
Rate per 10,000 pt days	0.03	0.01	0.004	0.01	0.01
Central
No. of CPA cases	5	31	3	1	11
Rate per 1,000 pt admissions	0.01	0.07	0.01	0.002	0.02
Rate per 10,000 pt days	0.02	0.10	0.01	0.003	0.04
East
No. of CPA cases	0	0	0	0	0
Rate per 1,000 pt admissions	0.00	0.00	0.00	0.00	0.00
Rate per 10,000 pt days	0.00	0.00	0.00	0.00	0.00
Table 4.2 footnote * Includes both CPE infections and colonizations Return to table 4.2 footnote *

Table 4.3 All-cause mortality rate 30 days after the date of positive culture per 100 CPE and CPA inpatient infected cases^{Footnote *}

Year	Number of deaths/No. of CPE and CPA inpatients with outcome data	All-cause mortality rate per 100 infected cases
2012	2/18	11.1
2013	4/25	16.0
2014	5/24	20.8
2015	3/17	17.6
2016	3/28	10.7
Table 4.3 footnote * Includes only CPE and CPA infections Mortality rates are based on infected cases where outcome and classification data are available. Return to table 4.2 footnote *

Table 4.4 Number and proportion of main CPE and CPA pathogens identified^{Footnote a}

Pathogen	2012 No. (%)	2013 No. (%)	2014 No. (%)	2015 No. (%)	2016 No. (%)
Klebsiella pneumoniae	19 (31.2)	27 (28.4)	27 (38.0)	30 (35.7)	49 (35.8)
Escherichia coli	10 (16.4)	5 (5.3)	11( 15.5)	22 (26.2)	24 (17.5)
Serratia marcescens	5 (8.2)	11 (11.6)	6 (8.5)	3 (3.6)	3 (2.2)
Enterobacter cloacae complexFootnote b	11 (18.0)	4 (4.2)	12 (17.0)	10 (11.9)	23 (16.8)
Acinetobacter baumannii	8 (13.1)	37 (39.0)	8 (11.3)	9 (10.7)	17 (12.4)
OthersFootnote c	8 (13.1)	11 (11.6)	7 (9.9)	10 (11.9)	21 (15.3)
Total	61	95	71	84	137
Table 4.4 footnote a Includes both infections and colonizations Return to table 4.4 footnote a Table 4.4 footnote b Enterobacter cloacae complex includes Enterobacter cloacae and other Enterobacter spp., excluding E. aerogenes Return to table 4.4 footnote b Table 4.4 footnote c Others includes: Acinetobacter spp., Citrobacter spp., Klebsiella oxytoca, Kluyvera cryocrescens, Morganella morganii, Providencia rettgeri, Raoutella spp. Return to table 4.4 footnote c

Table 4.5.1 Number and proportion of resistance to specific antimicrobials identified for CPE

Antibiotics	2012 No. (%)	2013 No. (%)	2014 No. (%)	2015 No. (%)	2016 No. (%)
Piperacillin-Tazobactam	49 (96.1)	52 (91.2)	56 (88.9)	69 (92.0)	91 (76.5)
Cefotaxime	47 (92.2)	46 (80.1)	56 (88.9)	68 (90.1)	113 (95.0)
Ceftazidime	44 (86.3)	46 (80.1)	56 (88.9)	66 (88.0)	109 (91.6)
Meropenem	46 (90.2)	53 (93.0)	59 (93.7)	66 (88.0)	106 (89.1)
Ciprofloxacin	28 (54.9)	29 (50.1)	35 (55.6)	49 (65.3)	75 (63.0)
Amikacin	14 (27.5)	18 (31.6)	17 (27.0)	23 (30.7)	44 (37.0)
Gentamicin	23 (45.1)	26 (45.6)	32 (50.8)	39 (53.4)	51 (42.9)
Tobramycin	27 (53.0)	29 (50.9)	40 (63.5)	41 (54.7)	62 (52.1)
Trimethoprim-sulfamethoxazole	29 (56.9)	39 (68.4)	42 (66.7)	57 (76.0)	79 (66.4)
Tigecycline	11 (21.6)	10 (17.5)	11 (17.5)	13 (17.3)	28 (23.5)
Total no. of Isolates	51	57	63	75	119
All isolates were resistant to Ampicillin, and all but one to Cefazolin

Table 4.5.2 Number and proportion of resistance to specific antimicrobials identified for CPA

Antibiotics	2012 No. (%)	2013 No. (%)	2014 No. (%)	2015 No. (%)	2016 No. (%)
Piperacillin-Tazobactam	10 (100)	37 (97.4)	8 (100)	9 (100)	18 (100)
Cefotaxime	7 (70.0)	35 (92.1)	8 (100)	9 (100)	16 (88.9)
Ceftazidime	10 (100)	36 (94.7)	8 (100)	9 (100)	16 (88.9)
Meropenem	9 (90.0)	36 (94.7)	8 (100)	9 (100)	18 (100)
Ciprofloxacin	10 (100)	36 (94.7)	8 (100)	9 (100)	16 (88.9)
Amikacin	5 (50.0)	5 (13.1)	0 (0.0)	3 (33.3)	12 (66.7)
Gentamicin	5 (50.0)	34 (89.5)	8 (100)	7 (77.8)	14 (77.8)
Tobramycin	7 (70.0)	32 (84.2)	5 (62.5)	7 (77.8)	12 (66.7)
Trimethoprim-sulfamethoxazole	9 (90.0)	35 (92.1)	8 (100)	7 (77.8)	15 (83.3)
Tigecycline	3 (30.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Total no. of Isolates	10	38	8	9	18
All isolates were resistant to Ampicillin, Amoxicillin/Clavulanic Acid, Cefazolin, Cefoxitin

Table 4.6.1 Number and proportion of carbapenemase types identified for CPE

	2012 No. (%)	2013 No. (%)	2014 No. (%)	2015 No. (%)	2016 No. (%)
KPC	33 (64.7)	30 (52.6)	31 (49.2)	26 (34.7)	62 (52.1)
NDM	5 (9.8)	14 (24.6)	17 (27.0)	29 (38.7)	38 (31.9)
OXA-48	8 (15.7)	6 (10.5)	7 (11.1)	14 (18.7)	17 (14.3)
VIM	1 (2.0)	0 (0.0)	1 (1.6)	1 (1.3)	1 (0.8)
SMEFootnote *	3 (5.8)	6 (10.5)	5 (7.9)	3 (4.0)	1 (0.8)
GES-5	1 (2.0)	1 (1.8)	1 (1.6)	3 (4.0)	0 (0.0)
NMC/IMI	0 (0.0)	1 (1.8)	2 (3.2)	0 (0.0)	2 (1.6)
IMP	0 (0.0)	0 (0.0)	1 (1.6)	0 (0.0)	0 (0.0)
Total isolates tested	51	57Footnote **	63Footnote **	75Footnote **	119Footnote **
Table 4.6.1 footnote * Only found in Serratia marcescens Return to table 4.6.1 footnote * Table 4.6.1 footnote ** 1 isolate in 2013, 2 isolates in 2014, 1 isolate in 2015, and 2 isolates in 2016 harboured both NDM and OXA-48 Return to table 4.6.1 footnote **

Table 4.6.2 Number and proportion of carbapenemase types identified for CPA

	2012 No. (%)	2013 No. (%)	2014 No. (%)	2015 No. (%)	2016 No. (%)
OXA-23	5 (50.0)	5 (13.2)	5 (62.5)	8 (88.9)	6 (33.3)
OXA-24	1 (10.0)	4 (10.5)	0 (0.0)	0 (0.0)	3 (16.7)
OXA-58	1 (10.0)	0 (0.0)	0 (0.0)	111.1)	0 (0.0)
OXA-237	4 (40.0)	29 (76.3)	3 (37.5)	0 (0.0)	0 (0.0)
OXA-235	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	9 (50.0)
IMP	1 (10.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
NDM	0 (0.0)	0 (0.0)	0 (0.0)	1 (11.1)	0 (0.0)
Total isolates tested	10Footnote *	38	8	9Footnote **	18
Table 4.6.2 footnote * 1 isolate in 2012 harboured OXA-23, OXA-58, and IMP Return to table 4.6.2 footnote * Table 4.6.2 footnote ** 1 isolate in 2015 harboured OXA-58 and NDM Return to table 4.6.2 footnote **

Appendix A

Hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP), as of December 2016 

Participating hospitals from the Eastern region

• The Moncton Hospital, Moncton, NB
• Queen Elizabeth Hospital, Charlottetown, PEI
• Prince County Hospital, 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: 2016 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 primary 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 a} and the best clinical judgment of the healthcare and/or infection prevention and control practitioner.

CDI is considered “healthcare-associated from your facility”^{Footnote b} 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 c}
  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 CNISP hospital at the time of hospital admission or identified during hospitalization.

This includes:

• MRSA infections identified for the first time during this hospital admission
• Infections that have been previously identified at other non-CNISP hospitals (since we want newly identified MRSA cases at CNISP hospitals)
• Infections 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 is assigned only if confirmed with a different strain type)
  AND
• meets the criteria for MRSA infection as determined using the April 2015 CDC/NHSN surveillance definitions  for specific infections, and in accordance with the best judgment of the healthcare and/or IPC practitioner.

MRSA surveillance exclusion criteria:

• MRSA infections previously identified at other CNISP sites
• Emergency, clinic, or other outpatient cases who are not admitted to the hospital.
• Infections 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 d}
  OR
• Patient is on calendar day 3^{Footnote e} 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 have MRSA 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, long-term care admission or other exposure to a healthcare setting (rehab, clinics)^{Footnote 4} in the past 12 months^{Footnote 1}.        
  AND
• Has no reported use of medical devices.

MRSA clinical infection

MRSA infection is determined using the 2016 CDC/NHSN surveillance definitions 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: 

• healthcare exposure in the previous 90 days (such as receipt of IV medications, IV chemotherapy, hemodialysis, etc);
• was hospitalized in the previous 90 days; or
• 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 CNISP facility at the time of hospital admission or identified during hospitalization

       
VRE infection is determined using the January 2016 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.

Exclusion criteria:

• Previously identified at other CNISP 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)

Healthcare-associated, from your facility (e.g. infection from CNISP reporting hospital) is defined as an inpatient who meets the following criteria:

• Exposure to any healthcare setting (including long-term care facilities or clinics) in the previous 12 months
  OR
• Has been hospitalized for greater than 48 hours

4. 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 f}.

Carbapenems are a class of beta-lactam antibiotics with broad-spectrum activity 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 and/or the up-regulation of efflux systems that "pump" the antibiotic out of the cell, usually concomitant with the presence of an acquired extended-spectrum beta-lactamase (ESBL) or AmpC enzyme or the hyperproduction of intrinsic chromosomally –located beta-lactamase(s). More recently, resistance is increasingly due to the acquisition of enzymes that break down the carbapenems: carbapenemases (e.g. NDM-1, OXA-48, KPC, VIM, IMP etc). These latter subsets of carbapenem-resistant organisms are called carbapenemase-producing organisms (CPOs) and are of particular concern because of their ability to transfer resistance easily across different genera and species of bacteria. They are quickly becoming a public health problem not only because of the ability to cause healthcare acquired infections which have limited treatment options, but because of the potential for colonizing both inpatient and outpatient populations due to their ease of transmissibility, thus, creating a reservoir of bacterial resistance.