Title: Enhanced Detection of Staphylococcus aureusrelated Hospitalizations Using Administrative Databases,
1Enhanced Detection of Staphylococcus
aureus-related Hospitalizations Using
Administrative Databases, United States1999-2005
- Jhung MA, Banerjee SN, Fridkin S, Tenover FC,
McDonald LC
- Division of Healthcare Quality Promotion
- Centers for Disease Control and Prevention
Presented at the 18th annual scientific meeting
of the Society for Healthcare Epidemiology of
America on April 6, 2008
2Background
Staphylococcus aureus National Estimates
- Administrative Data
- ICD-9-CM discharge diagnoses
- Nationwide Inpatient Sample (NIS)
- National Hospital Discharge Survey (NHDS)
- Other Data Sources
- Sentinel surveillance of HAIs (NHSN)
- Population based surveillance (ABCs)
- Prevalence survey (APIC)
3Background
Staphylococcus aureus National Estimates
- Administrative Data
- Relatively available, reliable and inexpensive
- May be inconsistent and lack data elements
- Variable sensitivity and positive predictive value
4Background
Staphylococcus aureus National Estimates
- Common features of recently published estimates
using administrative data
- Varied in database, methodology, results
- Few ICD-9-CM codes
- Single estimate for each infection type
- Comparison to other estimates lacking
5Objectives
- Determine national estimates of S. aureus-related
hospitalizations
- Pilot enhanced detection algorithm
- Establish a range of estimates
- Explore reasons for incidence trends
- Compare to other analyses
Staphylococcus aureus
6Methods
- Nationwide Inpatient Sample (NIS) dataset
- The Surveillance Network (TSN) for resistance
- Categories of S. aureus infections
- Bloodstream infections (septicemia)
- Respiratory infections (pneumonia)
- Skin infections
- All other
- Conservative, Moderate, Liberal estimates
- Case definitions include healthcare and
community associated disease
7MethodsICD-9-CM Diagnosis Codes
S. aureus Specific Codes
- 041.11 Staphylococcus aureus
- 482.41 Staphylococcus aureus pneumonia
- 038.11 Staphylococcus aureus septicemia
-
Non-S. aureus Specific Codes
Respiratory Infection Codes 482.40 Staphylococc
us pneumonia, unspecified 486 Pneumonia 510 Emp
yema 513 Abscess of lung and mediastinum Bloods
tream Infection Codes 038.1 Staphylococcus septic
emia 038.9 Unspecified septicemia 790.7 Bactere
mia
Skin Infection Codes 680 Carbuncle and furuncle
681 Cellulitis and abscess of finger and toe
682 Other cellulitis and abscess
684 Impetigo 686.9 Unspecified infection of skin
704.8 Other specified diseases of hair and hair
follicles 707 Chronic ulcer of skin 998.3 Disrup
tion of operation wound 998.5 Post-operative infe
ction 998.83 Non-healing surgical wound
8ICD-9-CM Diagnosis CodesConservative Estimate
S. aureus Specific Codes
- 041.11 Staphylococcus aureus
- 038.11 Staphylococcus aureus septicemia
- 482.41 Staphylococcus aureus pneumonia
Non-S. aureus Specific Codes
Respiratory Infection Codes 482.40 Staphylococc
us pneumonia, unspecified 486 Pneumonia 510 Emp
yema 513 Abscess of lung and mediastinum Bloods
tream Infection Codes 038.1 Staphylococcus septic
emia 038.9 Unspecified septicemia 790.7 Bactere
mia
Skin Infection Codes 680 Carbuncle and furuncle
681 Cellulitis and abscess of finger and toe
682 Other cellulitis and abscess
684 Impetigo 686.9 Unspecified infection of skin
704.8 Other specified diseases of hair and hair
follicles 707 Chronic ulcer of skin 998.3 Disrup
tion of operation wound 998.5 Post-operative infe
ction 998.83 Non-healing surgical wound
9ICD-9-CM Diagnosis CodesModerate Estimate
S. aureus Specific Codes
- 041.11 Staphylococcus aureus
- 482.41 Staphylococcus aureus pneumonia
- 038.11 Staphylococcus aureus septicemia
Non-S. aureus Specific Codes
Respiratory Infection Codes 482.40 Staphylococc
us pneumonia, unspecified 486 Pneumonia 510 Emp
yema 513 Abscess of lung and mediastinum Bloods
tream Infection Codes 038.1 Staphylococcus septic
emia 038.9 Unspecified septicemia 790.7 Bactere
mia
Skin Infection Codes 680 Carbuncle and furuncle
681 Cellulitis and abscess of finger and toe
682 Other cellulitis and abscess
684 Impetigo 686.9 Unspecified infection of skin
704.8 Other specified diseases of hair and hair
follicles 707 Chronic ulcer of skin 998.3 Disrup
tion of operation wound 998.5 Post-operative infe
ction 998.83 Non-healing surgical wound
10ICD-9-CM Diagnosis CodesLiberal Estimate
S. aureus Specific Codes
- 041.11 Staphylococcus aureus
- 482.41 Staphylococcus aureus pneumonia
- 038.11 Staphylococcus aureus septicemia
Non-S. aureus Specific Codes
Respiratory Infection Codes 482.40 Staphylococc
us pneumonia, unspecified 486 Pneumonia 510 Emp
yema 513 Abscess of lung and mediastinum Bloods
tream Infection Codes 038.1 Staphylococcus septic
emia 038.9 Unspecified septicemia 790.7 Bactere
mia
Skin Infection Codes 680 Carbuncle and furuncle
681 Cellulitis and abscess of finger and toe
682 Other cellulitis and abscess
684 Impetigo 686.9 Unspecified infection of skin
704.8 Other specified diseases of hair and hair
follicles 707 Chronic ulcer of skin 998.3 Disrup
tion of operation wound 998.5 Post-operative infe
ction 998.83 Non-healing surgical wound
11S. aureus Infections Increase over Time
S. aureus Infections by Type and Year
(Conservative Estimate)
Rate / 10,000 Discharges
All infections increased over time period,
Poisson regression p
12S. aureus Skin Infections Contribute Substantially
639,000
S. aureus Infections by Type and Year
(Conservative Estimate)
275,000
Rate / 10,000 Discharges
All infections increased over time period,
Poisson regression p
133 Major Skin Infection Classes
2004 Skin Infection Distribution
- 2
- Carbuncle and Furuncle
- Impetigo
- Diseases of hair and follicles
- Other local skin subcutaneous infections
Surgical Site Infection 26
Chronic Ulcer 8
Cellulitis and Abscess 64
14Cellulitis and Abscess Increasingly Important
Cochran-Armitage test for trend p infection types
15Cellulitis and abscess in Younger Age Groups
Proportion of S. aureus Cellulitis and Abscess by
Age Group
Age Group
Percentage
Cochran-Armitage test for trend p
16S. aureus Septicemia Increases from Conservative
to Liberal Estimates
2005 S. aureus Septicemia Estimates
x MRSA (TSN) 98,299 94,360
ABCs estimate invasive MRSA
Discharge Count
21
54
Conservative
Moderate
Liberal
Klevens, et al. JAMA, October 2007.
17NIS Estimate Larger than NHDS Estimate
NIS 15 Diagnosis Codes NHDS 7 Diagnosis
Codes
Klein, et al Emerg Infect Dis. December 2007.
18Summary
- Staphylococcus aureus-related discharges have
increased significantly from 1999-2005
- Estimates based on this algorithm are higher than
other published estimates
- Septicemia liberal estimates may be more accurate
than conservative
- Majority of increase in Staphylococcus
aureus-related discharges is due to skin
infections (cellulitis and abscess) in patients 45 years of age - Community associated disease?
19Limitations
- Administrative data
- Not primarily intended for surveillance
- Unable to distinguish community from healthcare
onset
- Unit of analysis is discharge not patient
- Analysis
- Codes may not represent S. aureus
20Conclusions
- Surveillance Using Administrative Data
- Multiple codes and a range of estimates may yield
the most useful results
- A database with a large number of diagnosis
fields may increase sensitivity
- Further study needed to determine appropriate
estimate for pneumonia and skin infections
21Acknowledgments
- Division of Healthcare Quality Promotion
- Centers for Disease Control and Prevention
- Katherine Ellingson
- Rachel Gorwitz
- Jeffrey Hageman
- John Jernigan
- Melissa Schaefer
- Agency for Healthcare Quality and Research
- Anne Elixhauser
The findings and conclusions in this presentation
are those of the authors and do not necessarily
represent the views of the Centers for Disease
Control and Prevention
22Citations for Published Estimates
- Elixhauser A. Infections with Methicillin-Resistan
t Stapyhlococcus aureus (MRSA) in US Hospitals,
1993-2005. In AHRQ/HCUP Statistical Brief 35
20071-10 - Jarvis WR. National prevalence of
methicillin-resistant Staphylococcus aureus in
inpatients at US health care facilities, 2006. Am
Jour of Infect Cont. 2007 Dec35(10)631-7. - Klein E. Hospitalizations and deaths caused by
methicillin-resistant Staphylococcus aureus,
United States, 1999-2005. Emerg Infect Dis. 2007
Dec13(12)1840-6. - Klevens RM. Invasive methicillin-resistant
Staphylococcus aureus infections in the United
States. JAMA. 2007 Oct 17298(15)1763-71.
- Kuehnert MJ. Methicillin-resistant-Staphylococcus
aureus hospitalizations, United States. Emerg
Infect Dis. 2005 Jun11(6)868-72.
- Noskin GAl. The burden of Staphylococcus aureus
infections on hospitals in the United States an
analysis of the 2000 and 2001 Nationwide
Inpatient Sample Database. Arch Intern Med. 2005
Aug 8-22165(15)1756-61. - Noskin GA. National trends in Staphylococcus
aureus infection rates impact on economic burden
and mortality over a 6-year period (1998-2003).
Clin Infect Dis. 2007 Nov 145(9)1132-40. - Styers D. Laboratory-based surveillance of
current antimicrobial resistance patterns and
trends among Staphylococcus aureus 2005 status
in the United States. Ann of Clin Micro and
Antimicrobials. 200652