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Transcript
Updates on Isolation Precautions by by Tariq Ahmed Madani, MBBS, FRCP(Canada) Professor of Internal Medicine & Infectious Diseases Chairman, Infection Control Committee Department of Medicine, Faculty of Medicine, King Abdulaziz University, University Jeddah, Jeddah Saudi Arabia KAUH 05.01.09 Updates on Isolation Precautions z z Chain of infection New Isolation Categories z z z z z Standard Precautions Transmission-Based Precautions Empiric E i i (syndromic) ( d i ) isolation i l ti Examples A new proposal for Isolation Precautions Chain of Infection Organism Source Mode of T Transmission i i Host Chain of Infection Organism Source Mode of Transmission Host Mode of Transmission z z z z z Contact C t t Droplet Airborne Common Vehicle Vector borne New Isolation Precautions, 1996 “Standard” and “T “Transmission-Based i i B dP Precautions” ti ” Standard Precautions z Consider all patients and their bodily fluids (except sweat) to be potentially infectious. z Use appropriate barrier precautions when there is a risk of exposure to blood, body fluids secretions fluids, secretions, excretions excretions, mucous membranes and non-intact skin. Standard Precautions z z z z z Hand hygiene Gloves Masks Eye protection Gowns Standard Precautions z z z Used needles and sharps should be disposed of safely (in puncture proof sharp boxes) Needles should NOT be recapped All health care workers should receive the HBV vaccine Standard Precautions z Patients with known or suspected infections are NOT to have their medical records labeled as "infectious". z Specimens of patients with known or suspected infections are NOT to be labeled as "infectious" infectious . All specimens are to be treated in the same safe manner. Hand Hygiene z Hand hygiene is the single most important practice to reduce the transmission of infectious agents in healthcare settings z The term “hand hygiene” includes: z handwashing with either plain or antisepticcontaining soap and water z use of alcohol-based products (gels, rinses, foams) containing an emollient that do not require the use of water Hand Hygiene z In the absence of visible soiling g of hands, approved alcohol-based products for hand disinfection are preferred over handwashing with water and antimicrobial or plain soap because of their superior microbiocidal activity, y reduced drying y g of the skin, and convenience When to wash hands z z z z z z Before and immediately after patient contact (examination feeding (examination, feeding, bathing bathing, carrying out aseptic and/or invasive procedures …etc). Between different procedures on the same patient. After contact with mucous membranes, blood and body fluids, secretions and excretions. After removing gloves. After touching objects or surfaces contaminated with blood or body fluids. Before preparing or serving food. Handwashing Healthcare Infection Control Practices Advisory Committee (HICPAC) former recommendations z Plain soap and water was recommended for routine handwashing z Antimicrobial soaps (e.g.: chlorhexidine) was recommended for z Patients under contact precautions z During instances of epidemic or hyperendemic spread of infections Handwashing HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force latest recommendations (MMWR October 25, 2002) Alcohol based hand rub or handwashing with water and antimicrobial soap should be used for routine hand h i hygiene as wellll as ffor patients ti t under d contact t t precautions Waterless Hand Hygiene Antiseptic Waterless Hand Gel Hand Hygiene z In observational studies of opportunities for handwashing in health care workers in USA z The overall compliance was 40% (range 5 - 81%) z Compliance was highest among nurses and gp physicians, y , in intensive care units,, lowest among and when required intensity of care was greater Boyce JM, et al. MMWR Recomm Rep 2002;51(RR-16):1-45 Handwashing study in Riyadh Medical Complex-General Hospital z 312 handwashing opportunities for 230 Health Care Workers in five medical (88 beds) and five surgical (117 beds) wards z z z z z 110 nurses 76 6 residents es de ts 23 medical students 11 interns 10 consultants Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4. Handwashing study in Riyadh Medical Complex-General Hospital z Females : 56% z Nationality z z Saudi : 51.3% z Phillipine: 25.7% 25 7% z India: 16.5% Sink – bed ratio: 1 : 6-7 Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4. Handwashing study in Riyadh Medical Complex-General Hospital z Overall frequency of handwashing z 23.7% after patient contact z 6 7% before patient contact 6.7% Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4. Handwashing study in Riyadh Medical Complex-General Hospital z Frequency of handwashing by profession z Medical students: 70.0% z Interns: 69.2% z Nurses: 18.8% z Residents: 12.5% z Consultants: 9.1% Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4. Handwashing study in Riyadh Medical Complex-General Hospital z Duration of handwashing by profession z Medical students :6.1 seconds z Interns: 5.4 seconds z Nurses: 4.1 seconds z Residents: 3.1 seconds z Consultants: 3.0 seconds Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4. Handwashing study in Riyadh Medical Complex-General Hospital z F Frequency off hanwashing h hi by b tasks t k z After wound care: 52.4% z After inserting peripheral iv lines: 40.0% z Aft examining After i i patients: ti t 31.6% 31 6% z After emptying of urine bags: 21.4% Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4. Handwashing study in Riyadh Medical Complex-General Hospital z Frequency of wearing gloves when indicated: 75.5% z Frequency of handwashing after removing gloves: 48.8% Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4. Gloves for Barrier Precautions Disposable Gloves 6.00 SR 5.00 SR Fluidshield Mask & a SplashGuard Visor Gowns and other protective apparel (eg. aprons) z Indications z z if contact with blood and body fluid is likely For patients under Contact Precautions Gowns and other protective apparel (eg. aprons) z The practice of routine gowning upon entrance into an intensive care or other high-risk area does not prevent colonization or infection of p patients. Therefore,, CDC recommendations for this practice have been rescinded Transmission-Based Precautions z Three categories of Transmission-based Transmission based precautions: z Contact Precautions z Droplet Precautions z Airborne Precautions Transmission-Based Precautions z More than M th one category t may be b used d for f diseases that have multiple routes of transmission (e.g., SARS, chickenpox) z When used either singularly or in combination, they are always to be used in addition to Standard Precautions Contact Transmission z Contact C t t transmission t i i (direct (di t and d indirect) i di t) is the most important and frequent mode of transmission of nosocomial infections. z Includes exposure to blood, other body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membrane covered by Standard Precautions. Contact Transmission z Examples of organisms spread by contact: z Multi-drug-resistant organisms in the gastrointestinal tract, sputum, or wounds (MRSA, MDR Gram -ve, VRE) z Clostridium difficile z Herpes simplex virus (mucocutaneous) z Scabies Contact Transmission z Examples of direct contact transmission in healthcare settings include: z blood directly enters a caregiver’s body z scabies z herpetic whitlow Contact Transmission z Examples of indirect contact transmission: z Hands H d off h healthcare lth personnell ttouch h an iinfected f t d or colonized body site on one patient or a contaminated inanimate object, and then subsequently touch another patient without performing hand hygiene between patient contacts. z Shared toys become a vehicle for transmitting respiratory viruses (e.g., RSV or pathogenic bacteria) to pediatric patients. Contact Transmission z Examples of indirect contact transmission: z Patient-care P ti t d i devices ((e.g., electronic l t i thermometers, glucose monitoring devices) contaminated with blood or body fluids shared between patients without cleaning and disinfecting between patients. z Instruments that are inadequately cleaned between patients (e.g., endoscopes or surgical instruments) or that have manufacturing defects that interfere with the effectiveness of reprocessing Contact Precautions z Private room preferred; cohorting allowed if necessary z The door of the room may remain open z Gloves: z z upon entering room z change gloves after contact with contaminated secretions z should be removed before leaving the room Gown: z if clothing may come into contact with the patient or environmental surfaces z should be removed before leaving the room Contact Precautions z Wash hands with antimicrobial soap before leaving the patient’s patient s room z Minimize risk of environmental contamination during patient transport (e.g. patient can be placed in a gown) z Patient’s care devices (e.g., thermometer, BP cuffs, stethoscopes) should be dedicated to use for a single patient if possible, otherwise, they should be rigorously cleansed and disinfected before use for other patients Droplet Transmission z z Respiratory droplets are large particles (>5 micron) expelled during z coughing z sneezing z talking z during procedures such as suctioning and bronchoscopy Droplets travel < 1.5 meter from the source patient Droplet Transmission z Because of their "large" size (> 5 microns), droplets do not remain suspended in the air and are therefore not spread by air currents z In order for transmission to take place, there must be a relatively close proximity between the infected person and the host Droplet Transmission z Major organisms spread as respiratory droplets: z Neisseria meningitidis z Haemophilus influenzae type b (invasive) z Streptococcus pyogenes (group A streptococcus) z Mycoplasma pneumoniae z Bordetella pertussis z Influenza virus z Adenovirus z Rhinovirus Rhi i z Rubella virus z Mumps z SARS-associated coronavirus z Multi-drug resistant organisms in the respiratory tract Droplet Precautions z Private room preferred; cohorting allowed if necessary z Special air handling and ventilation are unnecessary z The door of the room may remain open z Wear a mask when within 1 meter of the patient z Mask the patient during transport Airborne Transmission z Airborne spread depends upon aerosolization of VPDOO SDUWLFOHV 5 micron) of the infectious agent that VPDOOSDUWLFOHV5 can then travel over long distances through the air z Most common nosocomial pathogens transmitted by this route: z Mycobacterium tuberculosis z V i ll Varicella-zoster t virus i (Chickenpox) (Chi k ) z Measles z Smallpox z ? SARS Airborne Precautions z Place the patient in a negative pressure room with at least 6-12 air exchanges per hour z Room exhaust must be be appropriately discharged outdoors or passed through a HEPA (high-efficiency particulate aerator) filter before recirculation within the hospital z The door of the room should be kept closed Airborne Precautions z A certified respirator (Particulate Masks e e.g.: g: N95) must be worn when entering the room of a patient with diagnosed or suspected TB z Susceptible individuals should not enter the room of patients with confirmed or suspected measles or chickenpox z Transport of the patient should be minimized; the patient should be masked if transport within the hospital is unavoidable N95 Particulate Masks Type and Duration of Precautions Needed for Selected Infections and Conditions Infection/ Condition Precautions Duration Abscess, Draining, major Draining, minor C S AIDS S DI Type and Duration of Precautions Needed for Selected Infections and Conditions Infection/Condition Adenovirus infection Precautions Duration D&C Amoebiasis S Anthrax (pulmonary or cutaneous) S DI Type and Duration of Precautions Needed for Selected Infections and Conditions Infection/Condition Chickenpox Precautions Duration A&C Until all lesions are crusted Dengue S Epiglottitis, due to Haemophilus influenzae D Until 24h after starting therapy Type and Duration of Precautions Needed for Selected Infections and Conditions Infection/Condition ect o /Co d t o Gastroenteritis: Campylobacter, Vibrio E. coli, Giardia lamblia Rotavirus, Salmonella Shigella, Viral, Yersinia Clostridium difficile Precautions ecaut o s Duration u at o S (Apply Contact precautions for diapered or incontinent pts for duration of illness) C DI Type and Duration of Precautions Needed for Selected Infections and Conditions Infection Precautions Duration German measles (rubella) D Until 7 days after onset of rash M Measles l ((rubeola) b l ) A DI Influenza D DI Type and Duration of Precautions Needed for Selected Infections and Conditions Infection Hepatitis (viral) Hepatitis A B, C, D, E Precautions Duration S (Apply Contact - <3 y: for duration of stay precautions for - 3-14 y: until 2 wk after onset of illness diapered or co e pts) p s) - O Others: e s until u 1 wk a after e incontinent onset of illness S Type and Duration of Precautions Needed for Selected Infections and Conditions Infection/Condition Meningitis: Aseptic Fungal Haemophilus influenzae y g Listeria monocytogenes Neisseria meningitidis Pneumococcal TB Other bacteria Precautions S S D S D S S S Duration Until 24h after starting therapy Until 24h after starting therapy Type and Duration of Precautions Needed for Selected Infections and Conditions Infection ect o Tuberculosis Extrapulmonary Pulmonary or laryngeal Precautions ecaut o s Duration u at o S A Discontinue precautions only when TB patient is on effective therapy, is improving clinically, and has 3 consecutive –ve sputum smears collected on different days. TRANSMISSION-BASED PRECAUTIONS CONTACT DROPLET AIRBORNE 1. HANDS MUST BE WASHED BEFORE & AFTER PATIENT CONTACT 2. GLOVES NO YES 3. GOWN NO YES REGULAR NO YES REGULAR 4. MASK WATERPROOF N95 (AIRBORNE) 5. DOOR MUST BE KEPT CLOSED NO YES COMMENTS: …………………………………………………………………….. Please do not indicate patient diagnosis NOTE THE ABOVE ARE IMPLEMENTED IN ADDITION TO STANDARD PRECAUTIONS Syndromic or empiric application of Expanded Precautions Condition Potential pathogen Empiric precautions Meningitis Neisseria meningitidis Droplet for first 24 hrs of antimicrobial therapy Enteroviruses Contact for infants and children Neisseria meningitidis Droplet for first 24 hrs of antimicrobial therapy Petechial/ecchymotic rash with fever Syndromic or empiric application of Expanded Precautions Condition Potential pathogen Empiric p precautions Generalized vesicular rash Varicella, smallpox, or vaccinia virus Airborne Infection Isolation plus Contact; Contact if vaccinia Generalized maculopapular generalized rash with cough, coryza and fever Rubeola (measles) virus Airborne Infection Isolation Syndromic or empiric application of Expanded Precautions Condition Potential pathogen Empiric precautions Cough/fever/upper lobe pulmonary infiltrate in an HIV negative patient or a patient at low risk for HIV infection TB Airborne Infection Isolation; add Contact plus eye protection if there is history of exposure to SARS SARS Cough/fever/pulmonary TB infiltrate in any lung location in an HIV-infected patient or a patient at high risk for HIV infection Airborne Infection Isolation Syndromic or empiric application of Expanded Precautions Condition Potential pathogen Empiric precautions Respiratory infections, particularly bronchiolitis and pneumonia in infants and young children RSV, parainfluenza, adenovirus, influenza virus Contact plus Droplet; Droplet may be discontinued when adenovirus and influenza have been ruled out Acute diarrhea with a lik l infectious likely i f ti cause in i an incontinent or diapered patient Enteric pathogens Standard plus Contact ( di t i and (pediatrics d adult) d lt) Abscess or draining wound that cannot be covered Staphylococcus aureus, group A streptococcus Contact Latest Proposal for Isolation Precautions, 2004-2005 “Standard” and “Expanded Precautions” Latest Proposal for Isolation Precautions 2004-2005 z Ch Changes or clarifications l ifi ti in i terminology t i l z “Nosocomial infection” has been replaced by “Healthcare-associated infection” (HAI) z “Transmission-based Precautions” has been p by y “Expanded p Precautions” replaced z “Airborne Precautions” has been replaced with “Airborne Infection Isolation” Latest Proposal for Isolation Precautions 2004-2005 z z Respiratory Hygiene/Cough Etiquette added to Standard Precautions A new category of isolation precautions “Protective Environment” is added to the Expanded Precautions Latest Proposal for Isolation Precautions 2004-2005 z a new emphasis on the importance of administrative involvement in development and support of infection control programs z a unified infection control approach to MDROs replacing prior pathogen-specific recommendations (e.g., VRE, VISA) Standard Precautions z Respiratory Hygiene/Cough Etiquette z prevent transmission of respiratory infections at the first point of contact within a healthcare setting (e.g., reception and triage areas in ER and OPD) Standard Precautions z Elements of Respiratory Hygiene/Cough Etiquette: z education of healthcare facility staff, patients, and visitors z posted signs in language appropriate to the population served with instructions to patients and accompanying family members or friends Standard Precautions z Elements of Respiratory Hygiene/Cough Etiquette z source control measures e.g.: z covering the mouth/nose with a tissue when coughing or sneezing and disposing of used tissues z using surgical masks on the coughing person when tolerated and appropriate Standard Precautions z Elements of Respiratory Hygiene/Cough Etiquette z hand hygiene after contact with respiratory secretions z spatial separation separation, ideall ideally >1 meter, meter of persons with respiratory infections in common waiting areas when possible Expanded Precautions (Transmission-Based Precautions) z Expanded Precautions, 4 categories z Contact Precautions z Droplet Precautions z Airborne Infection Isolation z Protective Environment Protective Environment z meant to prevent the patient from acquiring fungal infections from the environment z designed for allogeneic hematopoietic stem cell transplant (HSCT) patients to minimize fungal spore counts in the air z no published reports support the benefit of placing solid organ transplants or other immunocompromised patients in a PE Protective Environment z The need for such controls has been demonstrated in z studies of outbreaks of aspergillosis associated with construction z molecular typing yp g studies that have found identical strains of Aspergillus terreus in patients with hematologic malignancies and in potted plants in the vicinity of the patients Protective Environment z Improving p g air quality q y for HSCT patients p z HEPA filtration of incoming air z directed room air flow z positive room air pressure relative to the corridor (Pressure differential of >2.5 Pa [0.01” water gauge]) z well-sealed rooms (including sealed walls, floors, ceilings, windows, electrical outlets) to prevent infiltration of air from the outside Protective Environment z Improving air quality for HSCT patients z ventilation to provide >12 air changes per hour z strategies to lower dust, e.g., z z scrubbable surfaces rather than carpet and upholstery z routinely i l cleaning l i crevices i and d sprinkler i kl heads h d prohibiting dried and fresh flowers and potted plants and fresh flowers in the rooms of HSCT patient. Protective Environment z The desired Th d i d quality lit off air i may be b achieved hi d without the inconvenience or expense of laminar airflow z To prevent inhalation of respirable particles in the presence of construction, placement off an N95 respirator i t on the th patient ti t is i advised when patients leave the PE for diagnostic studies or treatments elsewhere in the facility OLD NEW Standard Precautions for all Isolation when indicated + TBP when indicated Thank You