Introduction

Hospitals are the source of increasingly serious drug resistant infections. Five to ten percent of patients entering the hospital acquire an infection they did not have before admission. An increasing proportion of these hospital-acquired (nosocomial) infections are resistant to treatment by antibiotics, resulting in extended and costly hospital stays, serious illness and death.

The CDC estimates that 90,000 people die each year from hospital-acquired infections, and that it costs $4.6 billion per year to treat such infections.

Complex healthcare systems that share services and facilitate inter-institutional patient transfers provide an increased opportunity for the rapid transmission of such infections.

Few healthcare systems, however, are organized for timely recognition of the emergence of drug resistant infections and prompt action to stop their spread. There is inadequate communication among hospitals regarding outbreaks as they are occurring. And there is no effective means for coordinating the multi-hospital intervention strategies that may be needed to contain the spread of an outbreak.

Failure to address these problems with a multi-hospital approach has grave consequences:

• The percentage of resistant strains will continue to rise.
  
• Antibiotics that worked today will not work tomorrow.
  
• Lengthy hospital stays and treatment with expensive antibiotics will continue to add to escalating hospital costs.
  
• Certain invasive medical procedures like heart bypasses and transplants may be compromised due to increased risk of post-surgical infection.
  

In 1998, the Public Health Research Institute (PHRI), working with the New York City Partnership, began the New York Antimicrobial Resistance Project (NYARP) to track and combat drug resistant hospital infections in New York City. This project was funded by the New York State Department of Health, the New York Community Trust, and the New York City Partnership.

In 2001, PHRI received a $1 million appropriation from the New Jersey State Legislature (through the New Jersey Department of Health and Senior Services) to begin a similar program in New Jersey.

PHRI's Dr. Barry Kreiswirth, Program Co-Director, is one of the world's leading practitioners of DNA fingerprinting and other molecular typing of infectious organisms.

Co-Director Suzanne Lutwick, RN, MPH, has extensive experience as an infectious disease epidemiologist, and was Director of Infection Control for 10 years at Maimonides Medical Center in Brooklyn.

Additional funding will be needed to achieve sustainable results in lives saved and costs avoided.




Program Elements

PHRI's New Jersey program has five major elements:

• Molecular Outbreak Center
• Electronic Surveillance System
• Education Programs
• Research Collaborations
• Cost Analysis of Potential Savings

Molecular Outbreak Center - FULLY IMPLEMENTED
Molecular epidemiology is the use of DNA-based typing techniques to track the spread of infectious organisms. Typing can determine genetic relatedness and therefore help to uncover transmission from one patient to another and the presence or absence of an outbreak.

The Molecular Outbreak Center is a service that is provided free-of-charge to all New Jersey hospitals.

PHRI's Outbreak Center staff interacts with hospital infection control physicians and nurses, infectious disease physicians and directors of hospital microbiology laboratories to provide infection control information while maintaining hospital and patient confidentiality.

• If a hospital suspects an outbreak, a designated staff member contacts PHRI to discuss the problem and the nature of strains that are available for analysis.
• The hospital laboratory ships the strains and provides data and patient demographics in a manner which maintains both patient and hospital confidentiality.
• Upon receipt, strains are sub-cultured, stocked and genotyped and the resulting data is analyzed.
• The results are communicated to the hospital contacts and suggested "next steps" are discussed.

Approximately 30% of New Jersey hospitals are currently using the Outbreak Center for molecular typing of infectious isolates. It is expected that this number will increase substantially in 2003.

Electronic Surveillance System - PILOT SYSTEM TO BE IMPLEMENTED IN 2003
During 2003, PHRI will establish a real-time computerized surveillance system supported by our molecular epidemiology expertise to monitor the emergence of antibiotic resistance in New Jersey. The information generated will be used to develop evidence-based interventions for containment and control. This system will allow information to be generated in a timely and efficient manner and will drive more cost effective prevention and control activities.

PHRI has such a system currently in place in New York City in collaboration with six major hospital centers: Beth Israel Medical Center, Maimonides Medical Center, Montefiore Medical Center, Mount Sinai Medical Center, Memorial Sloan Kettering Cancer Center and New York and Presbyterian Hospital.

The pilot in New Jersey will begin with six hospitals, and ultimately, the New Jersey program will include all 84 hospitals in the State.

PHRI will focus initially on selected problem organisms including methicillin resistant Staphylococcus aureus (MRSA), vancomycin resistant Enterococci (VRE), quinolone resistant E. coli, imipenim resistant Pseudomonas and Acinetobacter and Klebsiella resistant to third generation cephalosporins. PHRI will also be prepared to identify and monitor new problem organisms as they arise.

Initial data gathered will include information about each isolate, patient demographic information and drug susceptibility information. Isolates will be numbered and coded and no patient names will be used. When the data comes in, PHRI will consolidate it into consistent files and examine trends in antibiotic susceptibility patterns. PHRI will conduct all data analysis and contact each hospital for consultations. These will include reviews of specific findings and conditions that could impact them.

Hospitals will be able to examine their own data online and they will also receive aggregate data without hospital names to preserve confidentiality. PHRI will prepare regular reports and specific updates as needed.

The surveillance network and the linkages it provides are identical to those needed to accumulate information and/or to identify pathogens used in bioterrorist attacks, and PHRI will design the system to be able to track both infectious outbreaks and bioterrorist events. The PHRI Electronic Surveillance System will thus be a valuable asset in our efforts to achieve a higher level of bioterrorism preparedness.

Education Programs
An integral part of the Project is the development of education programs that will give all health care professionals a better understanding of reservoirs of infection and modes of transmission. As the Outbreak Center accumulates information about infectious outbreaks, and researchers learn more about combating them, Project staff will work with hospitals as well as professional organizations to develop education programs that meet the needs of a wide variety of healthcare workers.

PHRI is planning a one-day Symposium on community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Since two cases of CA-MRSA were identified in Newark last year, other instances have been identified in the NY-NJ area, both isolated cases as well as clusters of infections among specific at-risk groups. The healthcare community within the state has little of the information they need to help them recognize CA-MRSA and to guide them in making decisions regarding treatment and control. The one-day Symposium will take place in Summer 2003 and target healthcare professionals and others involved in or concerned with the control and treatment of infections.

Research Collaborations
PHRI is actively developing collaborative research partnerships based on findings generated by the Molecular Epidemiology Outbreak Center. For example, in May 2002, a community-acquired methicillin-resistant strain of S. aureus that had previously been identified in Minnesota was identified in two patients in Newark. PHRI researchers are working with two major medical centers in Newark to determine to what extent the organism is present in Newark. They are reviewing laboratory information from patients who were cultured positive with this strain of S. aureus and collecting microbiology and patient demographic data.