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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.