Canadian Nosocomial Infection Surveillance Program (CNISP):  Summary Report of Healthcare Associated Infection (HAI), Antimicrobial Resistance (AMR) and Antimicrobial Use (AMU) Surveillance Data from January 1, 2013 to December 31, 2017

Table of contents

• Introduction
• Methods
• Data Highlights
• Results
  1. Clostridioides difficile infection (CDI)
  2. Methicillin-Resistant Staphylococcus aureus (MRSA)
  3. Vancomycin-Resistant Enterococci (VRE)
  4. Carbapenemase-Producing Enterobacteriaceae (CPE) and Carbapenemase-Producing Acinetobacter (CPA)
  5. Escherichia coli (E. coli) Antibiogram
  6. Antimicrobial Use (AMU)
• Appendix A: Hospitals participating in the Canadian Nosocomial Infection Surveillance Program, as of December 2017
• Appendix B:Summary of hospitals participating in CNISP, 2017
• Appendix C: 2017 Surveillance Case Definitions and Eligibility Criteria
• Appendix D: Antibiotics included in antibiotic class categories

Introduction

This report entitled Canadian Nosocomial Infection Surveillance Program (CNISP): Summary Report of Healthcare Associated Infection (HAI), Antimicrobial Resistance (AMR) and Antimicrobial Use (AMU)  Surveillance Data from January 1, 2013 to December 31, 2017, was produced by the Centre for Communicable Diseases and Infection Control (CCDIC) of the Public Health Agency of Canada (PHAC). The report provides a review of available HAI, AMR and AMU surveillance data from sentinel hospitals across Canada.

PHAC collects national data on various healthcare associated infections and AMU 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 HAI surveillance are gratefully acknowledged.

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. 

CNISP surveillance provides key information that informs the development of federal, provincial, territorial and local infection prevention and control and antimicrobial stewardship 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 for the assessment of specific interventions. Surveillance for HAIs is considered an important component of the quality of patient care.

Methods

This report provides case counts and rates based on data from January 1, 2013 to December 31, 2017.  All rates presented in this report represent infections and/or colonizations identified in patients admitted (inpatients) to CNISP hospitals. 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 total number of cases divided by the total number of patient admissions (multiplied by 1,000) or patient days (multiplied by 10,000). Molecular characterization and antimicrobial resistance testing is conducted by the National Microbiology Laboratory (NML) on all patient-linked isolates received for CDI, MRSA, VRE, CPE and CPA with select results presented.  The 2017 case definitions and eligibility criteria for these surveillance programs are provided in Appendix C.

This report supersedes the data in previous CNISP reports. The most current report should be considered the most accurate. Surveillance data are dynamic and results are subject to change as more updated data are made available by the participating hospitals. Note that for all years, only hospitals that submitted both numerator and denominator data are included in the rate calculations.

For questions or more detailed information on these methods, rates or for a copy of the most recent surveillance report, please contact CNISP by sending an email to phac.cnisp-pcsin.aspc@canada.ca.

Data highlights

Clostridioides difficile Infection (CDI)

• From 2013 to 2017, healthcare associated CDI (HA-CDI)^{Footnote 1} rates have significantly decreased by 25%.
• Approximately one-third of all CDI cases^{Footnote 2} were community-associated CDI from 2015 to 2017.
• The number of deaths attributable to CDI during the two-month study period each year ranged from 12 (3.0% in 2016) to 22 (4.3% in 2014)^{Footnote 3}.
• Among HA-CDI strains from 2013 to 2017, NAP1 has significantly decreased by 44%, while NAP4 and NAP11 continue to increase from 17.4% to 21.6% and 6.4% to 13.7%, respectively.  A similar trend is observed from 2015 to 2017 among community associated C. difficile strains.
• A significantly larger proportion of NAP1 strains are identified among HA-CDI isolates (50.6%) compared to CA-CDI isolates (9.9%).

Methicillin-Resistant Staphylococcus aureus (MRSA)

• There has been a gradual but significant increase in overall MRSA infection rates (includes both bloodstream and non-bloodstream infections) since 2013. This increase in the overall rates is primarily driven by the increase in community-associated MRSA (CA-MRSA) infection rates.  Healthcare-associated (HA-MRSA) infection rates have continued to steadily decrease since 2013.
• Since 2015, CMRSA10 strain type (the strain associated with community-acquired MRSA) has been the predominant strain type identified. Prior to 2015, CMRSA2 (the strain associated with CA-MRSA) represented the largest proportion of strain types identified.
• There has been a significant decrease in all-cause mortality among patients identified with MRSA-BSI from 26% in 2013 to 16% in 2017.
• From 2013 to 2017, there has been a significant decrease in Clindamycin resistance (84% to 42%) among all MRSA isolates tested (blood and non-blood). 

Vancomycin-Resistant Enterococci (VRE)

• From 2015 to 2017 there has been a steady yet significant increase in VRE bloodstream infection (BSI) rates (approximately 28% each year), with the largest increase reported in Central Canada.
• From 2016 to 2017, a significant increase in VRE BSI isolates that are non-typeable using MLST was observed (9.8% to 62.1%).
• Among VRE BSI isolates, a significant increase in resistance to nitrofurantoin (18.7% to 44.8%) and HL-Gentamicin (17.3% to 38.8%) has been identified from 2013-2017.

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

• CPE infection rates have remained stable from 2013 to 2017 (0.03 per 10,000 patient days).  However, CPE colonization rates have significantly increased from 2014 (0.03 per 10,000 patient days) to 2017 (0.14 per 10,000 patient days), largely due to an increase in colonized cases in central Canada.
• CPA rates in Canada remain extremely low, with the exception of a 2013 outbreak attributed to one hospital in the Central region.
• Among CPEs, KPC and NDM continue to be the predominant carbapenemases, while OXA-23 continues to be the predominant carbapenemase for CPA.

Escherichia coli Antibiogram (E. coli)

• In 2015, CNISP initiated a pilot project to assess the feasibility of collecting hospital antibiogram data for Escherichia coli (E. coli). In 2016, surveillance using standardized antibiogram data collection was conducted. These data are presented for the first time in this report and indicate minimal changes in E. coli resistance patterns between 2015 and 2016.

Antimicrobial Use (AMU)

• Antimicrobial use among adult inpatients on ICU wards is significantly higher than antimicrobial use on other hospital wards; defined daily doses of antibiotics are 2.5 to 3 times higher on ICU wards compared to non-ICU wards.
• Among adult inpatients, cephalosporins were the most common class of antibiotics and represented approximately one quarter of all defined daily doses.

Results

1. Clostridioides difficile Infection (CDI)

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

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

	2013	2014	2015	2016	2017
National
No. of HA-CDI cases	3,160	2,870	2,895	2,814	2,721
Rate per 1,000 pt admissions	3.99	3.43	3.30	3.13	2.99
Rate per 10,000 pt days	5.19	4.39	4.28	4.05	3.85
No. of reporting hospitals	54	60	62	63	64
West
No. of HA-CDI cases	1,198	1,121	1,303	1,254	1,180
Rate per 1,000 pt admissions	3.61	3.10	3.31	3.10	2.91
Rate per 10,000 pt days	4.82	4.10	4.36	4.05	3.82
Central
No. of HA-CDI cases	1,732	1,506	1,3382	1,290	1,237
Rate per 1,000 pt admissions	4.56	3.89	3.39	3.22	3.00
Rate per 10,000 pt days	6.07	5.13	4.56	4.35	3.97
East
No. of HA-CDI cases	230	243	254	270	304
Rate per 1,000 pt admissions	2.86	2.75	2.89	2.90	3.27
Rate per 10,000 pt days	3.07	2.81	3.03	3.07	3.57

Figure 1.1 - Text description

Graph 1.1 Text Description

Year	Region	Rate
2013	West	4.82
2013	Central	6.07
2013	East	3.07
2013	National	5.19
2014	West	4.10
2014	Central	5.13
2014	East	2.81
2014	National	4.39
2015	West	4.36
2015	Central	4.56
2015	East	3.03
2015	National	4.28
2016	West	4.05
2016	Central	4.35
2016	East	3.07
2016	National	4.05
2017	West	3.82
2017	Central	3.97
2017	East	3.57
2017	National	3.85

Table 1.2 Attributable mortality rate 30 days after date of first positive CDI test in adults with HA-CDI from CNISP reporting hospitals only^{Footnote 1}

Year	Number of deathsFootnote 4	Attributable mortality rate per 100 cases (%)
2013	21	3.9
2014	22	4.3
2015	16	3.8
2016	12	3.0
2017	14	3.2

Table 1.3 Number and proportion of select HA-CDI from CNISP reporting hospitals only^{Footnote 1} NAP strain types^{Footnote 5}

Strain Type	2013	2014	2015	2016	2017
	No. (%)	No. (%)	No. (%)	No. (%)	No. (%)
NAP4	90 (17.5)	92 (19.1)	103 (20.6)	91 (20.1)	107 (21.6)
NAP1	152 (29.6)	114 (23.6)	115 (23.0)	53 (11.8)	83 (16.7)
NAP11	33 (6.4)	62 (12.9)	50 (10.0)	73 (16.2)	68 (13.7)
Other NAP typesFootnote 6	91 (17.8)	84 (17.4)	94 (18.8)	72 (16.0)	88 (17.7)
Other-not assigned	147 (28.7)	130 (27.0)	138 (27.6)	162 (35.9)	150 (30.2)
Total	513	482	500	451	496

Table 1.4 Antimicrobial resistance of HA-CDI from CNISP reporting hospitals only^{Footnote 1} isolates^{Footnote 5}

Antibiotics	2013	2014	2015	2016	2017
	No. (%)	No. (%)	No. (%)	No. (%)	No. (%)
Clindamycin	156 (30.5)	209 (43.1)	122 (24.4)	99 (22.0)	104 (21.0)
Moxifloxacin	166 (32.4)	137 (28.2)	138 (27.6)	72 (16.0)	89 (17.9)
Rifampin	13 (2.5)	5 (1.0)	10 (2.0)	7 (1.6)	13 (2.6)
Total isolates tested	512	482	500	451	496

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

Table 1.5 Number of CA-CDI^{Footnote 7} cases and incidence rates per 1,000 patient admissions and 10,000 patient days

	2013	2014	2015	2016	2017
National
No. of CA-CDI cases	N/A	N/A	1,035	961	1,053
Rate per 1,000 pt admissions	N/A	N/A	1.56	1.39	1.49
Rate per 10,000 pt days	N/A	N/A	2.03	1.81	1.91
No. of reporting hospitals	N/A	N/A	49	51	53
West
No. of CA-CDI cases	N/A	N/A	254	243	287
Rate per 1,000 pt admissions	N/A	N/A	1.15	1.07	1.24
Rate per 10,000 pt days	N/A	N/A	1.55	1.44	1.65
Central
No. of CA-CDI cases	N/A	N/A	675	613	634
Rate per 1,000 pt admissions	N/A	N/A	1.91	1.64	1.65
Rate per 10,000 pt days	N/A	N/A	2.57	2.22	2.18
East
No. of CA-CDI cases	N/A	N/A	106	105	132
Rate per 1,000 pt admissions	N/A	N/A	1.20	1.15	1.45
Rate per 10,000 pt days	N/A	N/A	1.27	1.19	1.55

Table 1.6 Number and proportion of select community associated C. difficile^Footnote7 NAP strain types^Footnote5

Strain Type	2013	2014	2015	2016	2017
	No. (%)	No. (%)	No. (%)	No. (%)	No. (%)
NAP4	N/A	N/A	49 (17.4)	49 (19.4)	48 (22.7)
NAP11	N/A	N/A	40 (14.2)	28 (11.1)	37 (17.5)
NAP1	N/A	N/A	35 (12.4)	25 (9.9)	14 (6.6)
Other NAP typesFootnote6	N/A	N/A	50 (17.7)	51 (20.2)	32 (15.2)
Other-not assigned	N/A	N/A	108 (38.3)	99 (39.3)	80 (37.9)
Total	N/A	N/A	282	252	211

Table 1.7 Antimicrobial resistance of community associated C. difficile^{Footnote 7} isolates^{Footnote 5}

Antibiotics	2013	2014	2015	2016	2017
	No.(%)	No. (%)	No. (%)	No. (%)	No. (%)
Clindamycin	N/A	N/A	73 (25.9)	60 (23.8)	40 (19.0)
Moxifloxacin	N/A	N/A	40 (14.2)	25 (9.9)	18 (8.5)
Rifampin	N/A	N/A	3 (1.1)	1 (0.4)	1 (0.5)
Total isolates tested	N/A	N/A	282	252	211

2. Methicillin-Resistant Staphylococcus aureus (MRSA)

Table 2.1 Number of total^{Footnote 8} MRSA infections and incidence rates per 1,000 patient admissions and 10,000 patient days

	2013	2014	2015	2016	2017
National
No. of MRSA infections	1,849	1,969	2,049	2,237	2,313
Rate per 1,000 pt admissions	2.12	2.12	2.18	2.30	2.35
Rate per 10,000 pt days	2.83	2.89	2.93	3.11	3.17
No. of reporting hospitals	53	58	59	61	62
West
No. of MRSA infections	898	949	1,117	1,268	1,303
Rate per 1,000 pt admissions	2.48	2.33	2.63	2.88	2.95
Rate per 10,000 pt days	3.40	3.29	3.54	3.90	4.06
Central
No. of MRSA infections	739	801	732	784	851
Rate per 1,000 pt admissions	1.79	1.91	1.75	1.82	1.94
Rate per 10,000 pt days	2.48	2.68	2.47	2.60	2.68
East
No. of MRSA infections	212	219	200	185	159
Rate per 1,000 pt admissions	2.15	2.19	2.03	1.77	1.53
Rate per 10,000 pt days	2.34	2.33	2.24	1.98	1.74

Figure 2.1 - Text description

Graph 2.1 Text Description

Year	Region	Rate
2013	West	3.40
2013	Central	2.48
2013	East	2.34
2013	National	2.83
2014	West	3.29
2014	Central	2.68
2014	East	2.33
2014	National	2.89
2015	West	3.54
2015	Central	2.47
2015	East	2.24
2015	National	2.93
2016	West	3.90
2016	Central	2.60
2016	East	1.98
2016	National	3.11
2017	West	4.06
2017	Central	2.68
2017	East	1.74
2017	National	3.17

Table 2.2 Number of Healthcare associated (HA) MRSA^{Footnote 9} infections and incidence rates per 1,000 patient admissions and 10,000 patient days

	2013	2014	2015	2016	2017
National
No. of HA-MRSA infections	1,141	1,171	1,193	1,206	1,202
Rate per 1,000 pt admissions	1.31	1.26	1.27	1.24	1.22
Rate per 10,000 pt days	1.75	1.72	1.70	1.67	1.65
No. of reporting hospitals	53	58	59	61	62
West
No. of HA-MRSA infections	554	535	631	676	637
Rate per 1,000 pt admissions	1.53	1.31	1.48	1.54	1.44
Rate per 10,000 pt days	2.10	1.86	2.00	2.07	1.99
Central
No. of HA-MRSA infections	404	459	405	381	447
Rate per 1,000 pt admissions	0.98	1.09	0.97	0.89	1.02
Rate per 10,000 pt days	1.36	1.53	1.37	1.26	1.41
East
No. of HA-MRSA infections	183	177	157	149	118
Rate per 1,000 pt admissions	1.85	1.77	1.59	1.43	1.14
Rate per 10,000 pt days	2.02	1.89	1.76	1.59	1.29

Table 2.3 Number of community associated (CA) MRSA^{Footnote 10} infections and incidence rates per 1,000 patient admissions and 10,000 patient days

	2013	2014	2015	2016	2017
National
No. of CA-MRSA infections	547	653	729	921	993
Rate per 1,000 pt admissions	0.63	0.70	0.77	0.94	1.01
Rate per 10,000 pt days	0.84	0.96	1.04	1.28	1.36
No. of reporting hospitals	53	58	59	61	62
West
No. of CA-MRSA infections	321	380	449	569	637
Rate per 1,000 pt admissions	0.89	0.93	1.06	1.29	1.44
Rate per 10,000 pt days	1.21	1.32	1.42	1.75	1.99
Central
No. of CA-MRSA infections	205	241	245	322	324
Rate per 1,000 pt admissions	0.50	0.57	0.59	0.75	0.74
Rate per 10,000 pt days	0.69	0.81	0.83	1.07	1.02
East
No. of CA-MRSA infections	21	32	35	30	32
Rate per 1,000 pt admissions	0.21	0.32	0.35	0.29	0.31
Rate per 10,000 pt days	0.23	0.34	0.39	0.32	0.35

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

	2013	2014	2015	2016	2017
National
No. of MRSA-BSI	365	450	490	605	608
Rate per 1,000 pt admissions	0.42	0.48	0.52	0.62	0.62
Rate per 10,000 pt days	0.56	0.66	0.70	0.84	0.83
No. of reporting hospitals	53	58	59	61	62
West
No. of MRSA-BSI	131	166	215	278	282
Rate per 1,000 pt admissions	0.36	0.41	0.51	0.63	0.64
Rate per 10,000 pt days	0.50	0.58	0.68	0.85	0.88
Central
No. of MRSA-BSI	191	240	224	281	278
Rate per 1,000 pt admissions	0.46	0.57	0.54	0.65	0.63
Rate per 10,000 pt days	0.64	0.80	0.76	0.93	0.88
East
No. of MRSA-BSI	43	44	51	46	48
Rate per 1,000 pt admissions	0.44	0.44	0.52	0.44	0.46
Rate per 10,000 pt days	0.48	0.47	0.57	0.49	0.52

Figure 2.2 - Text description

Graph 2.2 Text Description

Year	Region	Rate
2013	West	0.50
2013	Central	0.64
2013	East	0.48
2013	National	0.56
2014	West	0.58
2014	Central	0.80
2014	East	0.47
2014	National	0.66
2015	West	0.68
2015	Central	0.76
2015	East	0.57
2015	National	0.70
2016	West	0.85
2016	Central	0.93
2016	East	0.49
2016	National	0.84
2017	West	0.88
2017	Central	0.88
2017	East	0.52
2017	National	0.83

Table 2.5 All-cause mortality rate 30 days after date of positive culture per 100 MRSA-BSI cases

Year	Number of deathsFootnote 11	All-cause mortality rate per 100 MRSA-BSI cases
2013	93	25.5
2014	103	24.4
2015	95	20.3
2016	111	19.0
2017	99	16.3

Table 2.6 Number and proportion of select MRSA strain types identified^{Footnote 12}

Strain Type	2013	2014	2015	2016	2017
	No. (%)	No. (%)	No. (%)	No. (%)	No. (%)
CMRSA 10	214 (36.5)	266 (38.7)	303 (42.3)	408 (46.2)	398 (45.2)
CMRSA 2	278 (47.4)	302 (43.9)	266 (37.2)	279 (31.6)	284 (32.3)
CMRSA 7	24 (4.1)	41 (6.0)	48 (6.7)	72 (8.1)	68 (7.7)
Other strain typesFootnote 13	65 (11.1)	70 (10.2)	76 (10.6)	92 (10.4)	88 (10.0)
Unassigned	6 (1.0)	9 (1.3)	23 (3.2)	33 (3.7)	42 (4.8)
Total	587	688	716	884	880

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.

Table 2.7 Antimicrobial resistance identified for MRSA isolates^{Footnote 12}

Antibiotics	2013	2014	2015	2016	2017
	No. (%)	No. (%)	No. (%)	No. (%)	No. (%)
Erythromycin	495 (88.7)	535 (84.4)	576 (80.9)	624 (78.0)	689 (79.8)
Ciprofloxacin	479 (85.8)	228 (84.1)Footnote 14	85 (81.7)Footnote 14	609 (76.1)	659 (76.3)
Clindamycin	349 (83.5)Footnote 15	374 (65.4)Footnote 15	385 (54.1)	335 (41.9)	361 (41.8)
Fusidic acid	57 (10.2)	91 (14.4)	126 (17.7)	148 (18.5)	174 (20.1)
Mupirocin HLR	15 (2.7)	30 (4.7)	40 (6.6)Footnote 16	Not tested in 2016	Not tested in 2017
Tetracycline	25 (4.5)	34 (5.4)	37 (5.2)	54 (6.8)	56 (6.5)
TMP/SMX	25 (4.5)	14 (2.2)	14 (2.0)	20 (2.5)	12 (1.4)
Rifampin	3 (0.5)	3 (0.5)	3 (0.4)	10 (1.3)	10 (1.2)
Tigecycline	25 (4.5)	17 (2.7)	6 (0.8)	0 (0.0)	0 (0.0)
Daptomycin	2 (0.4)	2 (0.3)	5 (0.7)	5 (0.6)	5 (0.6)
Total	558	634	712	800	864

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.

3. Vancomycin-Resistant Enterococci (VRE)

Table 3.1 Number of total VRE infections and incidence rates per 1,000 patient admissions and 10,000 patient days

	2013	2014	2015	2016	2017
National
No. of VRE infections	322	297	271	299	387
Rate per 1,000 pt admissions	0.39	0.33	0.30	0.32	0.42
Rate per 10,000 pt days	0.52	0.45	0.41	0.43	0.57
No. of reporting hospitals	48	56	53	56	56
West
No. of VRE infections	154	153	142	146	181
Rate per 1,000 pt admissions	0.52	0.45	0.40	0.40	0.51
Rate per 10,000 pt days	0.72	0.65	0.56	0.54	0.71
Central
No. of VRE infections	161	143	127	145	201
Rate per 1,000 pt admissions	0.37	0.32	0.29	0.31	0.42
Rate per 10,000 pt days	0.51	0.44	0.41	0.45	0.61
East
No. of MRSA-BSI	7	1	2	8	5
Rate per 1,000 pt admissions	0.08	0.01	0.02	0.08	0.05
Rate per 10,000 pt days	0.08	0.01	0.02	0.09	0.05

Figure 3.1 - Text description

Graph 3.1 Text Description

Year	Region	Rate
2013	West	0.72
2013	Central	0.51
2013	East	0.08
2013	National	0.52
2014	West	0.65
2014	Central	0.44
2014	East	0.01
2014	National	0.45
2015	West	0.56
2015	Central	0.41
2015	East	0.02
2015	National	0.41
2016	West	0.54
2016	Central	0.45
2016	East	0.09
2016	National	0.43
2017	West	0.71
2017	Central	0.61
2017	East	0.05
2017	National	0.57

Table 3.2 Number of healthcare associated VRE infections^{Footnote 17} and incidence rates per 1,000 patient-admissions and 10,000 patient days

	2013	2014	2015	2016	2017
National
No. of VRE infections	N/A	274	258	272	356
Rate per 1,000 pt admissions	N/A	0.31	0.29	0.29	0.38
Rate per 10,000 pt days	N/A	0.42	0.39	0.39	0.52
No. of reporting hospitals	N/A	56	53	56	56
West
No. of VRE infections	N/A	143	138	131	165
Rate per 1,000 pt admissions	N/A	0.42	0.39	0.35	0.47
Rate per 10,000 pt days	N/A	0.61	0.54	0.48	0.64
Central
No. of VRE infections	N/A	130	118	133	186
Rate per 1,000 pt admissions	N/A	0.29	0.27	0.28	0.39
Rate per 10,000 pt days	N/A	0.40	0.38	0.41	0.56
East
No. of MRSA-BSI	N/A	1	2	8	5
Rate per 1,000 pt admissions	N/A	0.01	0.02	0.08	0.05
Rate per 10,000 pt days	N/A	0.01	0.02	0.09	0.05

From 2014 to 2017, 94.3% of VRE infections were reported as healthcare associated, while only 5.7% were community associated infections.

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

	2013	2014	2015	2016	2017
National
No. of VRE-BSI infections	98	94	89	121	157
Rate per 1,000 pt admissions	0.12	0.10	0.10	0.13	0.17
Rate per 10,000 pt days	0.16	0.14	0.14	0.18	0.23
No. of reporting hospitals	48	56	53	56	56
West
No. of VRE-BSI infections	31	36	35	45	48
Rate per 1,000 pt admissions	0.11	0.10	0.10	0.12	0.14
Rate per 10,000 pt days	0.15	0.15	0.14	0.17	0.19
Central
No. of VRE-BSI infections	67	58	53	75	108
Rate per 1,000 pt admissions	0.15	0.13	0.12	0.16	0.23
Rate per 10,000 pt days	0.21	0.18	0.17	0.23	0.33
East
No. of VRE-BSI infections	0	0	1	1	1
Rate per 1,000 pt admissions	0.00	0.00	0.01	0.01	0.01
Rate per 10,000 pt days	0.00	0.00	0.01	0.01	0.01

Figure 3.2 - Text description

Long description goes here

Graph 3.2 Text Description

Year	Region	Rate
2013	West	0.15
2013	Central	0.21
2013	East	0.00
2013	National	0.16
2014	West	0.15
2014	Central	0.18
2014	East	0.00
2014	National	0.14
2015	West	0.14
2015	Central	0.17
2015	East	0.01
2015	National	0.14
2016	West	0.17
2016	Central	0.23
2016	East	0.01
2016	National	0.18
2017	West	0.19
2017	Central	0.33
2017	East	0.01
2017	National	0.23

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

Isolate Type	2013	2014	2015	2016	2017
	No. (%)	No. (%)	No. (%)	No. (%)	No. (%)
vanA, Enterococcus faecium	72 (96.0)	70 (100.0)	75 (100.0)	88 (96.7)	111 (95.7)
vanB, Enterococcus faecium	3 (4.0)	0 (0.0)	0 (0.0)	3 (3.3)	5 (4.3)
Total	75	70	75	91	116

Table 3.5 Distribution of VRE-BSI multi-locus sequence types (MLST) identified in E. faecium.

Sequence Type	2013	2014	2015	2016	2017
	No. (%)	No. (%)	No. (%)	No. (%)	No. (%)
ST117	26 (34.7)	16 (22.9)	13 (17.3)	23 (25.3)	11 (9.5)
ST18	15 (20.0)	20 (28.6)	11 (14.7)	14 (15.4)	3 (2.6)
ST412	14 (18.7)	7 (10.0)	12 (16.0)	12 (13.2)	5 (4.3)
ST203	1 (1.3)	5 (7.1)	6 (8.0)	5 (5.5)	7 (6.0)
ST734	4 (5.3)	2 (2.9)	13 (17.3)	4 (4.4)	8 (6.9)
OthersFootnote 18	13 (17.3)	20 (28.6)	16 (21.3)	23 (25.3)	10 (8.6)
Untypeable	2 (2.7)	0	4 (5.3)	10 (11.0)	72 (62.1)
Total	75	70	75	91	116

Table 3.6 Antimicrobial resistance identified for VRE-BSI isolates

Antibiotics	2013	2014	2015	2016	2017
	No. (%)	No. (%)	No. (%)	No. (%)	No. (%)
Ampicillin	75 (100)	70 (100)	75 (100)	91 (100)	116 (100)
Levofloxacin	75 (100)	70 (100)	75 (100)	91 (100)	116 (100)
Penicillin	75 (100)	70 (100)	75 (100)	91 (100)	116 (100)
VancomycinFootnote 19	75 (100)	70 (100)	74 (98.7)	88 (96.7)	111 (95.7)
HL-Gentamicin	13 (17.3)	7 (10.0)	6 (8.0)	13 (14.3)	45 (38.8)
HL- Streptomycin	28 (37.3)	29 (41.4)	27 (36.0)	32 (35.2)	39 (33.6)
Nitrofurantoin	14 (18.7)	15 (21.4)	25 (33.3)	35 (38.5)	52 (44.8)
Chloramphenicol	0 (0.0)	0 (0.0)	0 (0.0)	2 (2.2)	11 (9.5)
DaptomycinFootnote 20	5 (6.7)	0 (0.0)	0 (0.0)	7 (7.7)	10 (8.6)
Linezolid	1 (1.3)	0 (0.0)	0 (0.0)	1 (1.1)	0 (0.0)
Tigecycline	0 (0.0)	2 (2.9)	0 (0.0)	0 (0.0)	0 (0.0)
Total isolates tested	75	70	75	91	116

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

Table 4.1 Number of CPE infections and incidence rates per 1,000 patient admissions and 10,000 patient days

	2013	2014	2015	2016	2017
National
No. of CPE infections	19	22	17	20	17
Rate per 1,000 pt admissions	0.02	0.02	0.02	0.02	0.02
Rate per 10,000 pt days	0.03	0.03	0.03	0.03	0.03
No. of reporting hospitals	45	58	58	58	59
West
No. of CPE infections	9	10	10	6	11
Rate per 1,000 pt admissions	0.03	0.03	0.03	0.02	0.03
Rate per 10,000 pt days	0.05	0.04	0.03	0.02	0.04
Central
No. of CPE infections	9	12	5	14	5
Rate per 1,000 pt admissions	0.02	0.03	0.01	0.03	0.01
Rate per 10,000 pt days	0.03	0.04	0.02	0.04	0.02
East
No. of CPE infections	1	0	2	0	1
Rate per 1,000 pt admissions	0.01	0.00	0.02	0.00	0.01
Rate per 10,000 pt days	0.01	0.00	0.02	0.00	0.01

Table 4.2 Number of CPE colonizations and incidence rates per 1,000 patient admissions and 10,000 patient days

	2013	2014	2015	2016	2017
National
No. of CPE colonizations	23	20	33	69	92
Rate per 1,000 pt admissions	0.03	0.02	0.04	0.07	0.10
Rate per 10,000 pt days	0.04	0.03	0.05	0.10	0.14
No. of reporting hospitals	45	58	58	58	59
West
No. of CPE colonizations	12	2	9	15	18
Rate per 1,000 pt admissions	0.05	0.01	0.02	0.04	0.05
Rate per 10,000 pt days	0.06	0.01	0.03	0.05	0.07
Central
No. of CPE colonizations	11	18	24	54	74
Rate per 1,000 pt admissions	0.03	0.04	0.06	0.12	0.16
Rate per 10,000 pt days	0.04	0.06	0.08	0.17	0.23
East
No. of CPE colonizations	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

Figure 4.1 - Text description

Graph 4.1 Text Description

Year	Classification	Rate
2013	Infection	0.03
2013	Colonization	0.04
2014	Infection	0.03
2014	Colonization	0.03
2015	Infection	0.03
2015	Colonization	0.05
2016	Infection	0.03
2016	Colonization	0.10
2017	Infection	0.03
2017	Colonization	0.14

Table 4.3 Number of CPA infections and incidence rates per 1,000 patient admissions and 10,000 patient days

	2013	2014	2015	2016	2017
National
No. of CPA infections	9	3	2	9	3
Rate per 1,000 pt admissions	0.012	0.003	0.002	0.010	0.003
Rate per 10,000 pt days	0.016	0.005	0.003	0.013	0.004
No. of reporting hospitals	45	58	58	58	59
West
No. of CPA infections	0	1	2	2	3
Rate per 1,000 pt admissions	0.000	0.003	0.005	0.005	0.008
Rate per 10,000 pt days	0.000	0.004	0.007	0.007	0.011
CentralFootnote 21
No. of CPA infections	9	2	0	7	0
Rate per 1,000 pt admissions	0.022	0.005	0.000	0.016	0.000
Rate per 10,000 pt days	0.030	0.006	0.000	0.022	0.000
East
No. of CPA infections	0	0	0	0	0
Rate per 1,000 pt admissions	0.000	0.000	0.000	0.000	0.000
Rate per 10,000 pt days	0.000	0.000	0.000	0.000	0.000

Table 4.4 Number of CPA colonizations and incidence rates per 1,000 patient admissions and 10,000 patient days

	2013	2014	2015	2016	2017
National
No. of CPA colonizations	17	0	3	5	7
Rate per 1,000 pt admissions	0.022	0.000	0.003	0.005	0.007
Rate per 10,000 pt days	0.029	0.000	0.004	0.007	0.010
No. of reporting hospitals	45	58	58	58	59
West
No. of CPA colonizations	2	0	3	0	2
Rate per 1,000 pt admissions	0.008	0.000	0.008	0.000	0.005
Rate per 10,000 pt days	0.010	0.000	0.010	0.000	0.008
CentralFootnote 21
No. of CPA colonizations	15	0	0	5	5
Rate per 1,000 pt admissions	0.036	0.000	0.000	0.011	0.011
Rate per 10,000 pt days	0.050	0.000	0.000	0.016	0.015
East
No. of CPA colonizations	0	0	0	0	0
Rate per 1,000 pt admissions	0.000	0.000	0.000	0.000	0.000
Rate per 10,000 pt days	0.000	0.000	0.000	0.000	0.000

Table 4.5 All-cause mortality rate 30 days after date of positive culture per 100 CPE and CPA inpatient infected cases

Year	Number of deathsFootnote 22	All-cause mortality rate per 100 infected cases
2013	6	21.4
2014	5	20.0
2015	4	22.2
2016	3	10.7
2017	5	20.8

Table 4.6 Number and proportion of main CPE and CPA pathogens identified^{Footnote 23}

Pathogen	2013	2014	2015	2016	2017
	No. (%)	No. (%)	No. (%)	No. (%)	No. (%)
Klebsiella pneumoniae	27 (28.4)	27 (38.0)	30 (35.7)	49 (35.8)	44 (26.7)
Escherichia coli	5 (5.3)	11( 15.5)	22 (26.2)	24 (17.5)	42 (25.5)
Enterobacter cloacae complexFootnote 24	4 (4.2)	12 (17.0)	10 (11.9)	23 (16.8)	37 (22.4)
Acinetobacter baumannii	37 (39.0)	8 (11.3)	9 (10.7)	17 (12.4)	14 (8.5)
Serratia marcescens	11 (11.6)	6 (8.5)	3 (3.6)	3 (2.2)	3 (1.8)
OthersFootnote 25	11 (11.6)	7 (9.9)	10 (11.9)	21 (15.3)	25 (15.2)
Total	95	71	84	137	165

Table 4.7 Number and proportion of resistance to specific antimicrobials identified for CPE^{Footnote 23}

Antibiotics	2013	2014	2015	2016	2017
	No. (%)	No. (%)	No. (%)	No. (%)	No. (%)
Piperacillin-Tazobactam	52 (91.2)	56 (88.9)	69 (92.0)	91 (76.5)	126 (96.9)Footnote 26
Cefotaxime	46 (80.1)	56 (88.9)	68 (90.1)	113 (95.0)	140 (92.7)
Meropenem	53 (93.0)	59 (93.7)	66 (88.0)	106 (89.1)	139 (92.1)
Ceftazidime	46 (80.1)	56 (88.9)	66 (88.0)	109 (91.6)	137 (90.7)
Trimethoprim-sulfamethoxazole	39 (68.4)	42 (66.7)	57 (76.0)	79 (66.4)	94 (62.3)
Ciprofloxacin	29 (50.1)	35 (55.6)	49 (65.3)	75 (63.0)	93 (61.6)
Tobramycin	29 (50.9)	40( 63.5)	41 (54.7)	62 (52.1)	67 (44.4)
Gentamicin	26 (45.6)	32 (50.8)	39 (53.4)	51 (42.9)	55 (36.4)
Amikacin	18 (31.6)	17 (27.0)	23 (30.7)	44 (37.0)	32 (21.2)
Tigecycline	10 (17.5)	11 (17.5)	13 (17.3)	28 (23.5)	18 (11.9)
Total no. of Isolates	57	63	75	119	151

All isolates were resistant to Ampicillin, and all but one to Cefazolin. All CPO isolates were screened for the mcr-type gene which is an acquired gene associated with colistin resistance.

Table 4.9 Number and proportion of carbapenemases identified for CPE^{Footnote 28}

Carbapenemase	2013	2014	2015	2016	2017
	No. (%)	No. (%)	No. (%)	No. (%)	No. (%)
KPC	30 (52.6)	31 (49.2)	26 (34.7)	62 (52.1)	69 (45.7)
NDM	14 (24.6)	17 (27.0)	29 (38.7)	38 (31.9)	55 (36.4)
OXA-48	6 (10.5)	7 (11.1)	14 (18.7)	17 (14.3)	23 (15.2)
NMC/IMI	1 (1.8)	2 (3.2)	0 (0.0)	2 (1.6)	4 (2.6)
VIM	0 (0.0)	1 (1.6)	1 (1.3)	1 (0.8)	3 (2.0)
SME Footnote 29	6 (10.5)	5 (7.9)	3 (4.0)	1 (0.8)	2 (1.3)
GES-5	1 (1.8)	1 (1.6)	3 (4.0)	0 (0.0)	0 (0.0)
IMP	0 (0.0)	1 (1.6)	0 (0.0)	0 (0.0)	0 (0.0)
Total no. of Isolates	57Footnote 30	63Footnote 30	75Footnote 30	119Footnote 30	151Footnote 30

Table 4.10 Number and proportion of carbapenemases identified for CPA^{Footnote 27}

Carbapenemase	2013	2014	2015	2016	2017
	No. (%)	No. (%)	No. (%)	No. (%)	No. (%)
OXA-23	5 (13.2)	5 (62.5)	8 (88.9)	6 (33.3)	11 (78.6)
NDM	0 (0.0)	0 (0.0)	1 (11.1)	0 (0.0)	2 (14.3)
OXA-24	4 (10.5)	0 (0.0)	0 (0.0)	3 (16.7)	1 (7.1)
OXA-235	0 (0.0)	0 (0.0)	0 (0.0)	9 (50.0)	0 (0.0)
OXA-58	0 (0.0)	0 (0.0)	1(11.1)	0 (0.0)	0 (0.0)
OXA-237	29 (76.3)	3 (37.5)	0 (0.0)	0 (0.0)	0 (0.0)
IMP	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Total no. of Isolates	38	8	9Footnote 31	18	14

5. Escherichia coli Antibiogram (E. coli)

Figure 5.1 - Text description

Graph 5.1 Text Description

	2015	2016
Antibiotic	% Non-susceptible E.coli isolates	% Non-susceptible E.coli isolates
Ampicillin	43.7	43.6
TMP-SMX	22.3	22.8
Ciprofloxacin	18.4	18.6
Amoxicillin Clavulanate	16.8	16.5
Ceftriaxone	8.5	8.9
Tobramycin	7.4	8.9
Piperacillin-Tazobactam	5.3	4.7
Nitrofurantoin	4.9	2.8
Ertapenem	0	0.4
Meropenem	0.5	0.1

6. Antimicrobial Use (AMU)

Table 6.1 Defined daily doses (DDDs) and DDDs per 1,000 patient days^{Footnote 35}

	2014Footnote 36	2015	2016
National
DDDs	1,681,652	1,680,080	1,925,259
DDDs per 1,000 patient days	534	482	555
No.of reporting hospitals	21	21	22
West
DDDs	631,443	692,567	726,943
DDDs per 1,000 patient days	570	492	594
No. of reporting hospitals	5	7	6
Central
DDDs	852,196	809,677	1,020,994
DDDs per 1,000 patient days	587	567	682
No. of reporting hospitals	12	11	13
East
DDDs	198,013	177,835	177,322
DDDs per 1,000 patient days	453	466	453
No. of reporting hospitals	4	3	3
ICUFootnote 37
DDDs	196,371	208,147	215,543
DDDs per 1,000 patient days	1282	1320	1353
No. of reporting hospitals	18	18	19
Non-ICUsFootnote 37
DDDs	1,485,281	1,471,930	1,597,835
DDDs per 1,000 patient days	496	442	514
No.of reporting hospitals	21	21	21

Figure 6.1 - Text description

Graph 6.1 Text Description

DDD's per 1,000 patient days	2014	2015	2016
Overall	534	482	555
Non-ICU	496	442	514
ICU	1282	1320	1353

Figure 6.2 - Text description

Graph 6.2 Text Description

Antibiotic class	2014 DDDs	2015 DDDs	2016 DDDs	2014 patient days	2015 patient days	2016 patient days	2014 rates	2015 rates	2016 rates
Cephalosporins	446084	466860	494387	3149830	3485875	3470454	141.62	133.93	142.46
Penicillin and β -lactamase inhibitor combos	206871	210913	280422	3149830	3485875	3470454	65.68	60.51	80.80
Fluoroquinolones	262753	245481	250603	3149830	3485875	3470454	83.42	70.42	72.21
Penicillins	204612	210983	243192	3149830	3485875	3470454	64.96	60.53	70.08
Glycopeptide	126769	126221	141992	3149830	3485875	3470454	40.25	36.21	40.91
Carbapenems	69611	76064	102828	3149830	3485875	3470454	22.10	21.82	29.63
Nitroimidazole derivatives	113109	99782	92120	3149830	3485875	3470454	35.91	28.62	26.54
Macrolide	67543	67149	82297	3149830	3485875	3470454	21.44	19.26	23.71
Tetracyclines	34891	37696	65850	3149830	3485875	3470454	11.08	10.81	18.97
Sulfonamides and trimethoprim combos	60819	57689	65196	3149830	3485875	3470454	19.31	16.55	18.79

Appendix A: Hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP), as of December 2017

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
• Health Sciences Centre, Winnipeg, MB
• 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
• Bridgepoint Active Healthcare, 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
• Health Sciences North, 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, 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: Summary of hospitals participating in CNISP, 2017

Appendix B: Summary of hospitals participating in CNISP, 2017

Region	Western	Central	Eastern	National
Total number of hospitals	26	28	12	66
By hospital type
AdultFootnote 44	11	17	4	32
Mixed	12	7	7	26
Pediatric	3	4	1	8
By hospital size
Small (1-200 beds)	7	6	5	18
Medium (201-499 beds)	13	16	6	35
Large (500+ beds)	6	6	1	13
Total number of beds	8,840	9,610	3,097	21,547
Total number of admissions	452,390	475,375	103,644	1,031,409
Total number of patient days	3,261,626	3,460,831	914,818	7,637,275

Surveillance of HAIs 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 HAI surveillance is based on funding, 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.

Appendix C: 2017 Surveillance Case Definitions and Eligibility Criteria

1. Clostridioides difficile Infection (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 diagnosis of a previous episode in the same patient.

A patient is identified as having CDI if:

•  the patient has 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

• the patient has 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)

Exclusion

• Any patients age less than 1 year.
• Any pediatric patients (aged 1 year to less than 18 years) with alternate cause of diarrhea found (i.e. rotavirus, norovirus, enema or medication etc.) are excluded even if C. difficile diagnostic test result is positive.

CDI case classification

Once a patient has been identified with CDI, the infection will be classified further based on the following criteria^{Footnote 45} and the best clinical judgment of the healthcare and/or infection prevention and control practitioner (ICP).

 Healthcare associated (from CNISP reporting hospitals only) CDI case definition

• Related to the current hospitalization
  • The patient’s CDI symptoms occur in your healthcare facility 3 or more days (or ≥72 hours) after admission.
• Related to a previous hospitalization
  • Inpatient: The patient’s CDI symptoms occur less than 3 days after the current admission (or <72 hours) AND the patient had been previously hospitalized at your healthcare facility and discharged within the previous 4 weeks.
  • Outpatient: The patient presents with CDI symptoms at your ER or outpatient location^{Footnote 46} AND the patient had been previously hospitalized at your healthcare facility and discharged within the previous 4 weeks.
• Related to a previous healthcare exposure^{Footnote 47} at your facility
  • Inpatient: The patient’s CDI symptoms occur less than 3 days after the current admission (or <72 hours) AND the patient had a previous healthcare exposure ^{Footnote 47} at your facility within the previous 4 weeks.
  • Outpatient: The patient presents with CDI symptoms at your ER or outpatient location^{Footnote 46} AND the patient had a previous healthcare exposure ^{Footnote 47} at your facility within the previous 4 weeks.

  Community associated CDI case definition

  • Inpatient: The patient’s CDI symptoms occur less than 3 days (or <72 hours) after admission, with no history of hospitalization or any other healthcare exposure^{Footnote 47} within the previous 12 weeks.
  • Outpatient: The patient presents with CDI symptoms at your ER or outpatient location with no history of hospitalization or any other healthcare exposure ^{Footnote 47}within the previous 12 weeks.

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^{Footnote 48}

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 infections.  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)
• MRSA infection identified at a new (different) site in a patient  with a MRSA infection identified in a previous surveillance (calendar) year^{Footnote 49}

AND

• meets the criteria for MRSA infection as determined using the January 2017 CDC/NHSN surveillance definitions^{Footnote 50} 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 or a new/different site of MRSA infection).

Healthcare associated (HA) case definition:

Healthcare associated is defined as an inpatient who meets the following criteria and in accordance with 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 51}

OR

• Patient is on calendar day 3^{Footnote 52} of their hospitalization

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 52} in the past 12 months^{Footnote 49} .

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 (PDF: 960 KB), 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

3. Vancomycin-Resistant Enterococci (VRE)

VRE infection case definition:

• Isolation of Enterococcus faecalis or faecium 

AND

• Vancomycin MIC ≥ 8 μg/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 2017 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.

CDC/NHSN Surveillance Definitions for Specific Types of Infections (PDF: 960 KB)

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 is defined as an inpatient who meets the following criteria and in accordance with 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 53}

OR

• Patient is on calendar day 3^{Footnote 54} of their hospitalization

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

Any patient admitted to a participating CNISP hospital 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 55}

4.1 CLSI criteria for both Enterobacteriacae and Acinetobacter

Table 4.1a. CLSI criteria for Enterobacteriacae

At least ONE of the following:	Enterobacteriaceae:
	MIC (μg/ml)	Disk diffusion (mm)
Imipenem	≥ 4	≤ 19
Meropenem	≥ 4	≤ 19
Doripenem	≥ 4	≤ 19
Ertapenem	≥ 2	≤ 18

Disk diffusion is using a 10 µg disk of the appropriate antimicrobial

Table 4.1b. CLSI criteria for Acinetobacter:

At least ONE of the following:	Acinetobacter:
	MIC (μg/ml)	Disk diffusion (mm)
Imipenem	≥ 8	≤ 18
Meropenem	≥ 8	≤ 14
Doripenem	≥ 8	≤ 14

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.

The data presented in this report include Enterobacteriaceae spp. and Acinetobacter spp. that are resistant to carbapenems through the production of a carbapenemase. The first positive isolate from an inpatient identified as colonized or infected with CPE or CPA is eligible. Subsequent positive isolates from the same patient in the same calendar year are eligible only if the patient tests positive for a different carbapenemase.  If the patient was initially colonized and subsequently develops an infection with the same gene, within the same calendar year, only the infection is eligible for inclusion in surveillance.  Data from previous years included in this report have been adjusted to reflect this change in reporting.

5. Escherichia coli (E. coli) Antibiogram

Eligibility to participate

1. Hospitals that are part of the CNISP network or affiliated with a CNISP site (and hence contributing to that institution’s annual antibiogram data)
2. Able to submit annual antibiogram data for the target organism E.coli (non-screening specimen isolates)
3. Able to indicate whether the antibiogram data is from one of the following categories:
   1. Inpatient and outpatient combined, i.e., inpatients and patients seen at hospital clinics or emergency department who might or might not have been admitted
   2. Inpatient only
   3. Outpatient only
4. Able to indicate antibiogram data specimen type is ‘all specimen types’ or ‘all urine’

Inclusion criteria

• All E. coli bacterial isolates (non-screening specimen isolates with duplicates removed) included in the annual antibiogram data.
• A minimum of 30 isolates per reported antibiotic are required in order to submit antibiogram data. 

6. Antimicrobial Use (AMU)

Participating hospitals provide total adult inpatient hospital antimicrobial usage, separated by ward or ward category. Adult AMU data are collected in defined daily doses (DDDs). Hospitals additionally provide patient-day denominator data broken down by ward categories.

Inclusion criteria:

• Acute adult in-patient antibiotic use includes all systemic antibacterials (J01), metronidazole oral (ATC code: P01AB01) and vancomycin oral (ATC code: A07AA10).
• Only antibiotic use by medical, surgical, combined (medical/surgical), ICU or other wards that are comprised of inpatients are included.

Calculation of defined daily doses:

For adult AMU, national, regional, and ward-specific DDD quantities were calculated by antibiotic and antibiotic class. Total antibiotic use was calculated. Standardized rates per 1,000 patient days were calculated. Where DDD were not provided by the hospital site, WHO ATC/DDD Index 2016 was used to convert grams to DDD equivalents.

The following antimicrobials are special cases:

• For co-trimoxazole (J01EE01), also known as sulfamethoxazole-trimethoprim, 1.6 g per DDD was used for conversion based on Health Canada Drug Product Database (WHO does not provide DDD conversion).
• For benzylpenicillin (J01ECE01),  also known as  penicillin G, and benzathine benzylpenicillin (J01CE08), data received in million units (MU) was converted to grams (where 0.6 g = 1 MU), before conversion to DDDs using WHO values.

Appendix D: Antibiotics included in antibiotic class categories^{Footnote 56Footnote 57}

Appendix D.a) Antibiotics included in antibiotic class categories

Cephalosporins	Penicillin and β-lactamase inhibitor combos	Fluoroquinolones	Penicillins	Glycopeptides
Cefaclor	Amoxicillin and clavulanic acid	Ciprofloxacin	Amoxicillin	Vancomycin
Cefadroxil	Amoxicillin and other enzyme inhibitor	Levofloxacin	Ampicillin
Cefazolin	Ampicillin and enzyme inhibitor	Moxifloxacin	Ampicillin, combinations
Cefixime	Piperacillin and enzyme inhibitor	Norfloxacin	Cloxacillin
Cefotaxime	Piperacillin and tazobactam	Ofloxacin	Penicillin g
Cefotetan	Ticarcillin and clavulanic acid		Penicillin v
Cefoxitin	Ticarcillin and enzyme inhibitor		Piperacillin
Cefprozil			Ticarcillin
Ceftazidime
Ceftobiprole
Ceftriaxone
Ceftriaxone combinations
Cefuroxime
Cephalexin

Appendix D.b) Antibiotics included in antibiotic class categories

Carbapenems	Nitroimidazole derivatives	Macrolides	Tetracyclines	Sulfonamides and trimethoprim combos
Doripenem	Metronidazole	Azithromycin	Combinations of tetracyclines	Sulfadiazine and tetroxoprim
Ertapenem		Clarithromycin	Demeclocycline	Sulfadiazine and trimethoprim
Imipenem		Erythromycin	Doxycycline	Sulfadimidine and trimethoprim
Imipenem and cilastatin		Erythromycin ethylsuccinate	Minocycline	Sulfamerazine and trimethoprim
Meropenem			Tetracycline	Sulfamethoxazole and trimethoprim
			Tigecycline	Sulfametrole and trimethoprim
				Sulfamoxole and trimethoprim