Download Understanding the Enemy: Calming the Panic When New

Understanding the Enemy:
Calming the Panic When
New Organisms Enter Our
World
Jim Gauthier, MLT, CIC
Senior Clinical Advisor,
Infection Prevention
Objectives
Outline the difficulty of killing some of our common
pathogens
Look at the panic over some of these organisms
Discuss mode of transmission
Provide suggestions on communicating with senior
leadership
The Enemy?
www.usatoday.com
Who is the Enemy?
Bacteria
• Staphylococcus aureus
− MRSA
• E. coli, Klebsiella pneumoniae
− ESBL, CRE
• Enterococcus
− VRE
• Clostridium sp.
− CDI, Gas Gangrene
Who is the Enemy?
Enveloped Viruses
• HIV, Hepatitis
Non-Enveloped Viruses
• Norovirus, Rotavirus
Fungi
• Aspergillus, Tinia sp. (Athlete’s Foot)
• Black mould
Who Was/Is the New Enemy?
SARS-CoV
pH1N1 Influenza A
MERS-CoV
Ebola
Zika
Elizabethkingia anopheles
Panic1 [pan-ik]
noun
1. a sudden overwhelming fear, with or without cause, that
produces hysterical or irrational behavior, and that often
spreads quickly through a group of persons or animals.
www.dictionary.reference.com
Panic
History of Panic
“My heart is in anguish within me; the terrors of death have
fallen on me. Fear and trembling have beset me; horror has
overwhelmed me”
• Psalm 55:4-5
Not That Long Ago
Severe Acute Respiratory Syndrome
• Guangdong Province China
• Hong Kong
• Toronto
11
Courtesy Kingston General Hospital Archive
12
Courtesy Kingston General Hospital Archive
Penicillin Resistance
Staphylococcus aureus
Mortality before 1940 for bacteremia >80%
Penicillin mass produced in 1938
Resistance seen in 1942
• By late 1960’s, >80% resistant to penicillin
(Lowy 2003)
Penicillin molecule
Beta lactam ring
Methicillin
Methicillin Resistance
Semi-synthetic penicillin (along with Cloxacillin)
Developed in 1961
Resistance seen by 1962
Spread was rapid through Europe
First reported case in US was 1968 (NIAID)
First outbreak in Canada was reported in 1981
(Simor 1997)
Human Immunodeficiency Virus
1981 reports of Karposi’s sarcoma and Pneumocystis
carinii in homosexual men
(MMWR 1981 June, July)
Led to Universal Precautions, Body Substance Precautions
and most recently: Standard Precautions
VRE
First seen in 1986, reported in 1988 (Uttley 1988)
• Cluster, probably related to the use of Vancomycin and
Ceftazidime as treatment of acute undiagnosed sepsis
Spread went worldwide
VRE Around the World
East Asia and the Pacific
• 1992 Korea
• 1996 Japan
Europe and Central Asia
• 1996 Poland
• 2001 Turkey
• 2004 Serbia (reported in article)
(Mir 2010)
VRE Around the World
Latin America and Caribbean
• 1996 Brazil
• 1996 Argentina
• 1998 Columbia
• 2000 Peru
• 2001 Ecuador
VRE Around the World
Middle East and North Africa
• ~2002 Iran
• ~1999 Egypt
• ~2001 Kuwait
South Africa
• 1999
Clostridium difficile
First identified in culture in 1935
First reported as cause of pseudomembranous colitis in
1974
Has toxin mediated issues
Spore allows long environmental survival
(Bartlett 1994)
vaccinenewsdaily.com
Clostridium difficile
Fekety 1980
• Hands and fecally contaminated items
• Low infective dose in hamsters in presence of antibiotics
• Over 1000 cfu orally did not colonize nor infect
unchallenged hamsters
• Looked at relationship with Lactobacilli and other gut flora
24
Clostridium difficile
(Lucado 2009)
Ontario
Ministry of Health and Long Term Care, Ontario
Gram Negative Resistance
Extended spectrum beta lactamase (ESBL)
• Breaks down the beta lactam ring
• Emerges and changes as our antibiotics change (third
and fourth generation Cephalosporins)
(Bradford 2001)
Gram Negative Resistance
Carbapenemase
• Enzyme attacks carbapenem antibiotics: meropenem,
imipenem, ertapenem
• CPE: carbapenemase producing Enterobacteriaceae
• CRE: carbapenem resistant Enterobacteriaceae
• CPO: carbapenemase producing organism
Gram Negative Resistance Spread
South America
• 2004 ESBL E. coli Bolivia and Peru
Latin America
• 1997-2000 ESBL E. coli (6.7%) K. pneumo (47.3%)
Carbapenemase Resistance
• Turkey, Brazil, Columbia and Taiwan (2005-2007)
(Mir 2010)
So?
There are always going to be new organisms
Look at horizontal Infection Prevention and Control, not
vertical
Horizontal vs Vertical Infection Control
Wenzel 2010
31
Vertical
Focus on a single pathogen or anatomic site
Pathogen specific
• MRSA
• VRE
• ESBL
• CRE
• Acinetobacter
• Candida
32
Horizontal
Reduce rates of all infections for all pathogens
Hand hygiene program
Decolonization therapies (Chlorhexidine bathing)
Board to ward (Nat Audit Office 2009)
Antibiotic Stewardship Programs
Standardized cleaning and disinfection
33
34
http://diseasedetectives.wikia.com/wiki/Chain_of_Transmission
Reservoir
The organism/area where the infectious agents reside
Humans
Animals
Food Chain
Environment
35
Reservoir – Breaking the Link
Hand Hygiene – remove the organism before it is placed
near or on another person or surface, or infect ourselves
Disinfection – kill the organism on the surface
Pre-operative skin prep – remove and kill organisms
Mode of Transmission
Method by which the pathogen gets from the reservoir to
the new host
37
Mode of Transmission - Contact
Direct
• Contact between infectious agent and susceptible host
Indirect
• Contact of a fomite (surface) then contact of susceptible host
Mode
• Equipment
• Hands
• Sex
38
Mode of Transmission –
Percutaneous
Needlestick
39
Mode of Transmission – Droplet
Particle size >5um
Cough
Sneeze
40
Mode of Transmission–Airborne
Particle size <5um
Cough
Sneeze (rare)
Singing, talking
41
Mode of Transmission –
Common Vehicle
Food
Water
Medication vial
42
Mode of Transmission-Vector
Flies, mosquitos, ticks, lice
Not as common in healthcare facilities in first world
countries
Lyme Disease, Malaria, Plague, Trench Fever, Zika, etc.
Mode of Transmission –
Breaking the Link
Direct/Indirect
• Hand Hygiene
• Environmental disinfection
• Personal Protective Equipment (PPE)
• Isolation of infected patients
• Not in contact with others when ill/contagious
Droplet/Airborne
• Face protection (mask, respirator, goggles, shield)
• Airflow (Airborne Infection Isolation Room)
Chain of Transmission
Helps explain the risk
Helps calm some of the panic
What Broke the Chain?
Disinfectants
• Variety of kill ability
• Low Level to High Level
• Sporicidal
• Label Claim
− Surrogate organisms
− Marker organisms
− Can’t have ‘em all!
The main buckets of microorganisms
Bacteria
Gram Positive
Gram Negative
Staphylococcus
E. coli
Spores
Resistant form of bacteria Clostridium difficile,
Bacillus anthracis
Viruses
Envelope or Nonenvelope
Influenza, Rhinovirus,
HIV, HBV, Norovirus
Fungi
Multicellular
Trichophyton,
Aspergillus
Effect of Disinfectants on Microorganisms
R^
Organism
Bucket
Examples
Bacterial Spores
Spore
Bacillus anthracis, Clostridium
difficile
Mycobacteria
Bacteria
M. tuberculosis
Small non-enveloped
virus
Virus
Polio, Norovirus
Fungi and fungal spores
Fungus
Aspergillus, Penicillium
Gram negative bacteria
Bacteria
E. coli, Klebsiella including
CRE, Pseudomonas,
Acinetobacter
Large Virus (nonenveloped)
Virus
Adenovirus, Rotavirus
Gram positive bacteria
Bacteria
Staphylococcus including MRSA
Enterococcus including VRE
Virus (enveloped)
Virus
Influenza, HIV, HBV, HCV
S*
^Resistant
*
Sensitive
Resistant Organisms
Antibiotic resistance does NOT confer disinfectant
resistance!
• E. coli is E. coli whether it can produce a beta lactamase
or a carbapenemase
Antibiotics are more “Lock and Key”
Disinfectants are more “Dynamite”
(Weber 2006, Rutala 1997)
Communication
Difficult during panic
• Facility Outbreaks
• New Organisms
• Pandemic Problems
How to Communicate
Get the facts
• Reliable sources
Get the facts out there
• Newsletters
• Bulletins
• Huddles or Town Hall Meetings
Cultural Differences
IPAC is essentially a behavioural science (Borg 2014)
Hofstede’s model of cultural dimensions
Culture is “the collective programming of the mind that
distinguishes the members of one group or category of
people from another”
Uncertainty Avoidance (UAI)
What extent a society tolerates uncertainty and ambiguity,
and it shows how comfortable its members feel in
unstructured situations which are novel, unknown,
surprising or different from usual
Power Distance (PDI)
The extent to which the less powerful members of
organizations and institutions accept and expect that power
is distributed unequally
Masculinity (MAS)
The distribution of roles between the genders.
Masculine cultures emphasize
• ego needs
• assertiveness
• success
In feminine cultures, caring for the weak and quality of life
are more important.
Culture
MRSA rates significantly associated with UAI, PDI and
MAS
Explained nearly half of MRSA differences in Europe
Five European countries with the highest MRSA
proportions all possess very high UAI scores
Culture
UK and Ireland: Both countries scored low for UAI but high
for MAS.
In this mindset, targets work well.
Summary
There are always going to be new problems – DON’T
PANIC
Keep in mind Chain of Transmission and horizontal
infection control
• Doing activities that protect patients from all organisms
− Appropriate use of disinfectants
− Patient hand hygiene
Appreciate some activities in your facility may not be
appealing based on “Culture”
References
Bartlett J. Clostridium difficile: History of its role as an enteric pathogen
and the current state of knowledge about the organism. Clin Infect Dis
1994;18(Suppl 4):S265-72
Bradford PA. Extended-spectrum –beta lactamases in the 21st century:
characterization, epidemiology, and detection of this important
resistance threat. Clin Micro Rev 2001;14(4):933-951
Borg MA. Cultural determinants of infection control behaviour:
understanding drivers and implementing effective change. J Hosp
Infect 2014;86:161-168
Fekety R, Kim KH, Brown D, et al. Epidemiology of antibioticassociated colitis: isolation of Clostridium difficile from the hospital
environment. Am J Med 1981; 70:906–8.
References
Lucado J, Gould C, Elixhauser A. Clostridium difficile infections (CDI) in
hospital stays, 2009. HCUP Statistical Brief #124. January 2012.
Agency for Healthcare Research and Quality, Rockville, MD.
http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.pdf
Lowy FD. Antimicrobial resistance: the example of Staphylococcus
aureus. J Clin Invest 2003;111:1265-73
National Institute of Allergy and Infectious Diseases. Methicillin
Resistant Staphylococcus aureus (MRSA).
https://www.niaid.nih.gov/topics/antimicrobialresistance/examples/mrsa/
Pages/history.aspx Accessed on March 5, 2016
References
Ministry of Health and Long Term Care (Ontario).
http://www.hqontario.ca/public-reporting/patientsafety?_ga=1.214855314.462030773.1452205540 Accessed March 5,
2016
Mir F, Zaidi A. Hospital infections by antimicrobial-resistant organisms
in developing countries. Antimicrobial Resistance in Developing
Countries. Springer New York, 2010
MMWR Weekly Pneumocystis Pneumonia- Los Angeles. 1981;June 5,
30(21); 1-3
References
MMWR Weekly. Kaposi's sarcoma and Pneumocystis pneumonia
among homosexual men- New York City and California 1981;July 4,30
(4);305-308
Rutala WA, Weber DJ. Cleaning, Disinfection, and Sterilization. In:
APIC Text of Infection Control and Epidemiology. 2014
Rutala WA, et al. Susceptibility of antibiotic-susceptible and antibioticresistant hospital bacteria to disinfectants. ICHE 1997;18(6):417-21
Santé et Services sociaux Quebec.
http://msssa4.msss.gouv.qc.ca/en/document/publication.nsf/0/9ee1199
1af5fce358525753c00650c88?OpenDocument . Accessed March 21,
2015
References
Simor A, Ofner-Agostini M, Paton S. The Canadian Nosocomial
Infection Surveillance Program: Results of the first 18 months of
surveillance for methicillin-resistant Staphylococcus aureus in
Canadian hospitals. Can Commun Dis Rep. 1997;23:41–5
Weber DJ, Rutala WA. Use of germicides in the home and the
healthcare setting: is there a relationship between germicide use and
antibiotic resistance? ICHE 2006;27(10):1107-19
Wenzel RP, Edmond MB. Infection control: the case for horizontal
rather than vertical interventional programs. Int J Infect Dis
2010;14(supp 4);S3-S5
References
www.gotquestions.org/Bible-panic-attacks.html#ixzz3TTAjrMQK
Assessed March 4, 2015
Uttley A, Collins C, Naidoo J, et al. Vancomycin resistant enterococci.
Lancet 1988;1(8575-6):57–8.