# Presentation: 777133

## Methicillin Resistant Staphylococcus aureus (MRSA): Proposed Revision of ICD-9 Codes

**Rachel Gorwitz, MD, MPH**
**Division of Healthcare Quality Promotion**
**Centers for Disease Control and Prevention**

## Staphylococcus aureus

**Common human colonizer**
**Common cause of skin infections**
**Potential to cause severe / invasive infections**
**Transmission: Direct contact**

## Methicillin-Resistant Staphylococcus aureus (MRSA)

**Resistant to all currently available ****β****-lactam antibiotics (penicillins, cephalosporins)**
**Accounts for majority of *****S. aureus***** infections in healthcare settings**
**Associated with increased morbidity, mortality, and healthcare costs as compared to methicillin-susceptible *****S. aureus***** (MSSA) **
**1990s: Emerged as a community pathogen**
**Mainly skin infections**
**Occasionally severe / life-threatening**

## HAI = healthcare-associated infection

**HAI = healthcare-associated infection**

## Sources of MRSA Surveillance Data

**Active Bacterial Core Surveillance Project**
**National Healthcare Safety Network (NHSN)**
**National surveys using ICD-9 codes**
**Specialized Projects**
***EMERGE*****ncy ID Net**
**National Health and Nutrition Examination Survey**

## Active Bacterial Core Surveillance Areas (Invasive MRSA)

**Active Bacterial Core Surveillance Areas (Invasive MRSA)**

**Total Population: ~ 16.3 million**

**Oregon**

**California**

**Colorado**

**Tennessee**

**Georgia**

**Maryland**

**Connecticut**

**New York**

**Minnesota**

**Notes:**
These are the 9 sites participating in this collaboration, this surveillance project is population based, that is all residents of these areas are under surveillance; the green circles indicate that certain counties are included, whereas in CT, surveillance is state wide. 

## ABCs MRSA Case Categorization

**Healthcare-associated:**
**Hospital-onset:**** Cases with positive culture obtained >48 hrs after hospital admission (may also have risk factors)**
**Community-onset:**** Cases with at least 1 of the following risk factors:**
**Invasive device at time of admission; h/o MRSA infection or colonization; h/o surgery, hospitalization, dialysis, or residence in a LTC facility in 12 mos preceding culture**
**Community-associated:**** Cases with community-onset and none of above risk factors documented**

## Methods of Invasive MRSA Surveillance

**Medical Record Review**

**Methods of Invasive MRSA Surveillance**

**MRSA + Isolates from invasive site**

**Healthcare Risk Factors**

**Healthcare-Associated**

**Community-Associated**

**Notes:**
All sites use a standard protocol. To be included as a case, laboratories conducting tests for residents of the participating areas report on MRSA positive isolates from invasive sites. The health departments follow up to remove duplicates and conduct investigations of unique patients with MRSA through medical record reviews. During record reviews, they collect information on healthcare exposures known risk factors for MRSA (I’ll specify which in the next slide). Before that, I’ll mention that in 2005, we initiated collection of isolates for a sample of cases.

## ABCs Invasive MRSA Surveillance 2005

**Klevens et al JAMA 2007;298:1763-71**

**14%**

**59%**

**28%**

**National estimates:**
**94,360 infections; 18,650 deaths**

## National Healthcare Safety Network (NHSN)

**Voluntary, confidential, internet-based system for monitoring healthcare-associated events and processes (including HAIs)**
**Purposes:**
**Provide national estimates of magnitude of adverse events, trends**
**Provide risk-adjusted data for interfacility comparisons**
**Assist facilities in developing surveillance and analysis methods**
**Facility-associated infection:**
**No evidence infection was present or incubating at time of admission  (as assessed by trained infection control professional) **

## Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections

**Nationally representative surveys of hospitalizations and ambulatory care visits**
**Utilize:**
**Specific *****S. aureus***** infection codes (038.11 septicemia, 482.41 pneumonia)**
***S. aureus***** organism code (041.11)**
**Codes for syndromes typical of *****S. aureus***** (e.g., 682 cellulitis and abscess)**
**Methicillin resistance data from V codes (V09.0) or external data sources**

## Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections

**Kuehnert et al, Emerg Infect Dis 2005**
**291,542 annual hospital discharges with *****S. aureus***** infection-related diagnoses 1999-00**
**125,969 MRSA**
**Klein et al, Emerg Infect Dis 2007**
**62% ******** in *****S. aureus*****-related hospitalizations 1999-2005; >2-fold ******** in MRSA-related hospitalizations**
**McCaig et al, Emerg Infect Dis 2006**
**11.6 million annual ambulatory care visits for skin infections typical of *****S. aureus***** 2001-03**

## Use of ICD-9 Data to Monitor Burden and Trends in S. aureus Infections: Challenges

**With exception of septicemia and pneumonia, *****S. aureus***** organism code not linked to clinical syndrome**
**Resistance code (V09.0) not linked to clinical syndrome or *****S. aureus***** organism code (041.11)**
**National surveys contain a limited number of ICD-9 fields ****→ organism codes and resistance codes may be deleted**
**Current resistance code (V09.0) not specific for *****S. aureus***** or for methicillin-resistance**
**Currently no colonization code specific for *****S. aureus***** or MRSA (falls under V02.59 – Other specified bacterial diseases)**

## Proposal: Modification of ICD-9 Codes for MRSA

**Pages 17-18 of agenda**

## Acknowledgements

**Kate Ellingson**
**Scott Fridkin**
**Jeffery Hageman**
**Michael Jhung**
**John Jernigan**
**Monina Klevens**
**Cliff McDonald**
**Cathy Rebmann**
**Chesley Richards**
**Melissa Schaefer**
**Arjun Srinivasan**

## Legislative Activity for Public Reporting of Healthcare-Associated Infections

**IL**

- NY
- Jan-2007

- MS

**OR**

- ID

- MT

**NV**

- AZ

- CO
- Jan-2008

- NM

- OK
- Jul-2008

**MO**

- AR
- 2008

**TX**

- LA

- ND

- SD

- IA

**NE**

- DC

- KY

- ME

- NJ Jan-2009?

- MD Jul-2008

- TN
- Jan-2008

- WY

- MI

- SC
- Jul-2007

**FL**

- HI

- AK

- MA Jul-2008

- VT
- Feb-2007

- WA
- Jul-2008

- CA
- Jan-2008

- WI

- PA
- Feb-2008

- VA
- Jul-2008

**NH**

- AL

- GA

- UT

- KS

**MN**

- OH

- NC

- RI

- DE Feb-2008

- WV

- IN

- CT Jan-2008

- *

- Mandates Public Reporting,Using NHSN

- Mandates Public Reporting

- Pending Legislation

- * Voluntary reporting using NHSN

- 2/13/2008

**Legislative Activity for Public Reporting of Healthcare-Associated Infections**