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Preventing and Controlling
Infectious Agents
APIC Fall
Seminar 2012
Stephen P. Blatt MD FACP
Medical Director Infectious Diseases TriHealth
HAIs - Overview
• 1.7 million infections/yr in US hospitals
• 99,000 deaths/yr
• Cost: $5-10 Billion/yr
– Some estimates as high as $30 billion/yr
• Occur in 5% of hospitalized patients
• Adds at least 4 days to length of stay
Outline
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Procedures and Devices
Isolation Precautions
Cleaning, Disinfection, Sterilization
Risks of Construction
Frequency of Infection Types
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UTIs 32%
Surgical Site 22% ($10,500/case)
Pneumonia 15% ($23,000/case)
Bloodstream 14% ($25,000/case)
• Average annual hospital cost for HAIs is
$572,000
Procedures and Devices
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Surgical Site Infections
Intravascular Devices
Urinary Catheters
Ventilator Associated Pneumonia
Surgical Site Infection - Background
• 1840s Semmelweis recognized
importance of hand hygiene in preventing
Puerperal Fever
• 1860s Germ Theory advanced by Pasteur
and Koch
• 1870 Lister identified importance of
antiseptics in preventing wound infection
SSI - Background
• 30 million surgical procedures in US/yr
• Account for 22% of all hospital acquired
infections
• SSI doubles the risk for death and
increases risk of readmission by 5 times
• SSI dramatically increases the cost of
medical care in the US
Pathogenesis of Surgical Site Infection
• Inoculum of bacteria – wound
contamination
– Colon most heavily colonized site
• Virulence of organism
– Staph aureus (MRSA), Grp A Strep,
Clostridium perfringens most virulent
• Microenvironment of wound
-blood, foreign bodies, necrotic tissue
Host Defenses – Immune suppression
SSI – Classification System
• American College of Surgeons Classification
System
– Class I – Clean wound: No inflammation, no
contaminated spaces encountered
– Class II – Clean-contaminated: Respiratory,
urinary, GI, or genital tract involved under
controlled conditions
– Class III – Contaminated wound: Open fresh
wound, may have contamination from GI tract,
infected urine
– Class IV – Dirty, infected wound: fecal
contamination, devitalized tissue
National Nosocomial Infection Survey NNIS
• Standardized scoring system for infection
risk using:
– Simplified scoring system from 0-3
– Based on following 3 indicators:
• ACS score of contaminated or dirty (III or IV)
• ASA (American Society of Anesthesia) score >= 3
• Prolonged procedure time > 75th percentile for all
similar surgeries
NNIS SSI Definitions
• Superficial incisional SSI
– Involves only skin or subcut tissue
– Purulent drainage or + culture or signs of
inflammation or Dr dx of wound infection
• Deep incisional SSI
– Involves deep soft tissue – fascia or muscle
• Organ space SSI
– Involves any part of the anatomy other than
the incision that was involved in the operation
Prevention of SSIs
• Reducing bacteria at the surgical site
– Clip don’t shave
– Surgical skin prep
• Povidone iodine traditionally used
• Increasing data that chlorhexidine-alcohol may be
superior
– Appropriate air handling in OR
– Sterilized surgical instruments
– Reducing traffic in and out of OR
Prevention of SSIs
• Prophylactic antibiotic therapy
– Antibiotic should be active against bacteria
found at the site of surgery
– Must be given pre-op and highest
concentration should be in the tissue at the
time of incision (ideally given 30-60 minutes
prior to incision)
– Antibiotics should be discontinued within 24
hours of surgery
Prevention of SSIs – Host Factors
• Normothermia – hypothermia increases
risk for infection
• Normal blood sugar – multiple studies
reveal hyperglycemia is assoc with
increased risk of infection
SUSCEPTIBLE
HOST
A person who
cannot resist a
microorganism
invading the body,
multiplying, and
resulting in infection.
The host is
susceptible to the
disease, lacking
immunity or physical
resistance to
overcome the
invasion by the
pathogenic
microorganism.
INFECTIOUS AGENT
A microbial organism with the ability to cause disease.
The greater the organism's virulence (ability to grow
and multiply), invasiveness (ability to enter tissue) and
pathogenicity (ability to cause disease), the greater the
possibility that the organism will cause an infection.
RESERVOIR
A place within which
microorganisms can
thrive and reproduce.
PORTAL OF EXIT
A place of exit providing
a way for a
microorganism to leave
the reservoir.
PORTAL OF ENTRY
An opening allowing
the microorganism to
enter the host.
MODE OF TRANSMISSION
Method of transfer by which the organism moves or is carried from one place to another.
Case 1
• 48 yo male with pneumonia in ICU with
resp failure on Rocephin and Levaquin
• Day 5 of ICU stay develops T 102
• Exam: still intubated
– Chest few rhonchi
– Heart RRR no murmur
– Abd soft/NT
– R IJ TLC looks OK
Case 1
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CXR – clearing RLL infiltrate vs admission
UA – 5-10 WBC/HPF (from foley)
Blood cultures sent
Sputum cultures sent
Case 1
• Sputum culture: mixed flora
• Urine culture: negative
• Blood culture from central line and
peripheral site: GPC clusters
CLABSI
Central Line-associated Blood Stream Infection
• Commonly known as “Line Sepsis”
• Definition: Recognized pathogen cultured
from one or more blood cultures and not
related to infection at another site (ie UTI
or pneumonia) in a patient with a central
line in place
• Or 2 positive blood cultures of a common skin
organism (ie coag neg Staph) in a patient with
signs/symptoms of infection
CLABSI Risk Factors
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Femoral line site
Prolonged hospitalization
Prolonged duration of catheterization
Heavy microbial colonization at insertion
site
Femoral > IJ > Subclav/PICC
Neutropenia
Prematurity
TPN
CLABSI Bundle
• Education in insertion, care and maintenance of
central lines
• Use a catheter insertion “Checklist” for every
insertion
• Hand hygeine prior to insertion
• Avoid femoral site
• Maximal sterile barriers (cap, gown, gloves,
drape)
• Chlorhexidine based skin prep (not iodine)
• Standardized dressing change protocol
CLABSI Additional Approaches
if rates remain high
• Bathe ICU patients with Chlorhexidine on
a daily basis
• Use antiseptic or antibiotic impregnated
Central lines
• Use chlorhexidine-containing sponge
dressing on insertion site (Biopatch)
• Use antimicrobial lock therapy
Approaches NOT to Use
• Do not use systemic antimicrobial
prophylaxis
– “just leave the patient on vanco until the line
comes out”
– Do not routinely replace central lines in the
absence of infection
Performance Measures
• Compliance with the Insertion Bundle
Checklist
• Daily assessment of need for central line
• Compliance with dressing change protocol
• CLABSI rate: infection/1000 catheter days
– Current national rate: 2.1/1000
HCAP – Health care associated
Pneumonia
• 20-50% Mortality in some studies
• 15% of all hospital deaths
• Mortality with Pseudomonas = 70%
HCAP Risk Factors
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Intubation
ICU admission
Antibiotic therapy
Surgery – esp Abdominal, chest surgery
Chronic lung disease
Advanced age
Immunosuppression
HCAP Diagnosis
• Difficult in ICU patients
• New infiltrate on CXR with
– Fever, leukocytosis (>12) or confusion and
– 2 of: worsening sputum, cough or dyspnea,
rales, worsening oxygenation
– Positive cultures
• New Definitions begin 2013:
– VAC – ventilator assoc condition
– IVAC – Infection-related VAC
– Possible VAP, Probable VAP
VAP Prevention
Ventilator-associated Pneumonia
• Conduct active surveillance for VAP and
measure rates
• Maintain head of bed up at 35 degrees
• Perform frequent antiseptic mouth care
• Promote the use of non-invasive
ventilation
• Extubate as soon as possible – Daily SBT
• Special approaches: ET tubes with in-line
subglottic suctioning system
VAP Prevention
What not to do
• IVIG
• WBC colony stimulating factors
(Filgrastim)
• Chest physiotherapy
• Prophylactic inhaled or IV antibiotics
Case 2
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46 yo WF 4 days s/p abd hysterectomy
T 102, nausea, vomiting
Exam: Clear lungs
Mild tenderness around wound, no
erythema or drainage, mild suprapubic
tenderness, Foley remains in place
UA with 1+ pro, 2+ LE, 40-60 WBCs
WBC count 15,000
Bugs?
Drugs?
CA-UTI
Catheter-associated UTI
• Most common HAI
• 80% due to Foley catheter
• 12-16% of all hospitalized patients will get
a UTI
• 3-7% of patients/day with a Foley in place
CA-UTI Risk Factors
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Duration of catheterization
Female sex
Older age
Lack of maintenance of closed drainage
system
CA-UTI Prevention
• Use Foley catheter only when necessary:
– Perioperative for certain surgical procedures
– Urine output monitoring in critically ill patients
– Acute urinary retention and obstruction
– Assistance in pressure ulcer healing
• Standardized, aseptic insertion technique
• Perform surveillance for infection rates
– National ICU rate: 3.4/1000 Foley days
– GSH MSICU rate: 1.6/1000
CA-UTI Prevention
• Properly secure catheter to prevent
trauma
• Maintain a sterile, closed drainage system
• Keep the bag below the level of the
bladder to prevent backflow
• Remove the Foley when no longer
needed!
CA-UTI Prevention
Methods not to use
• Do not routinely use silver coated or
antibiotic impregnated catheters
• Do not screen for asymptomatic
bacteriuria
• Do not treat asymptomatic bacteriuria
– Except before invasive urinary procedures
• Avoid catheter irrigation
• Do not use systemic antibiotic prophylaxis
• Do not change catheters routinely
Standard Precautions
• If it’s wet and it’s not yours, don’t touch it!
• Applicable to all patients
• What Personal Protective Equipment (PPE)
to use:
– What are my patient’s signs and symptoms?
– What am I doing to my patient?
• Use barriers (gown, gloves, face protection)
• Protect skin, clothing, mucous membranes (eye,
nose, mouth – T-zone)
Hand Hygiene
• Key to reducing HAIs
• Improved hand hygiene compliance has
been shown to decrease HAI rates
• Education of HCWs on need for and
methods for hand hygiene is required
• Monitoring of hand hygiene compliance is
critical
Indications for Hand Hygiene
• Soap and water:
– Hands visibly soiled
– Before eating
– After using the restroom
– When contact with spore forming organisms is
suspected (C diff)
Indications for Hand Hygiene
• Soap/water or alcohol based hand gel:
– Before and after direct patient care
– Before donning sterile gloves
– Before inserting invasive devices
– After removing gloves
– After contact with equipment in the patient’s
immediate vicinity
– When moving from a contaminated body site
to a clean body site during patient care
Alcohol Hand Rub/Gel
• When NOT to use alcohol:
1. When hands are visibly soiled
2. When caring for a patient with undiagnosed
diarrhea, suspect or confirmed Clostridium
difficile, Norovirus, or other enteric viruses
• Must allow it to air dry
• 1 full squirt is enough
• Is an adjunct to soap and water, not a
replacement
Methods to Monitor Hand
Hygiene
• Direct observation – “secret shopper”
– Allows both quantitative (% compliance) and
qualitative (soap or gel, duration of washing)
evaluation
• Monitor volume of hand product used
• Monitor adherence to artificial fingernail
policy
Contact Precautions
Reduces the risk of transmitting
microorganisms by :
• direct contact (skin to skin) or
• indirect contact (susceptible host to
contaminated/colonized object).
Private room or cohort patients with the same
organism
Gloves and gowns are worn when entering the
room
Contact Precautions
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MRSA
VRE
C. difficile
MDROs – multi-drug resistant organisms
RSV in infants
Contact Precautions
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Limit patient transport: minimize the risk of
transmission and contamination of
environmental surfaces.
Dedicate the use of non-critical
equipment.
Stethoscope, BP cuff, thermometer
All equipment in the patient’s room must
be cleaned and disinfected
“C Diff ”…A New Threat
From an Old Enemy
• Gram positive anaerobic, bacillus
• Spore former: resistant to typical cleaning
strategies requiring:
Environment – bleach
Hand hygiene - soap and water
• Resides: GI tract (normal floral usually
keep the bacteria to a minimum)
• Risk factors: antibiotic therapy
>90% of C difficile HAIs occur after or
during antimicrobial therapy.
Hyper virulent strain of Clostridium difficile
» New strain produces up to 20 times more toxin
Complications:
• CDAD- C.diff associated diarrhea
• Pseudo membranous colitis
• Toxic mega colon
• Perforations of the colon
• Sepsis
• Death – Mortality rate up to 20% in the frail elderly
C. difficile Interventions
• Antibiotic Stewardship
• Isolate patients with diarrhea and
C.difficile immediately
• Wear PPE gowns and gloves
• Hand hygiene with soap and water
– Not alcohol hand gel
• Clean room surfaces and equipment with
bleach
12 Steps to Prevent Antimicrobial Resistance
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Prevent infection
 Vaccinate
 Get invasive devices out ASAP
Diagnose and Treat Effectively
 Target the pathogen
 Access the experts
Use Antimicrobials Wisely
 Practice antimicrobial control
 Treat infection, not colonization
 Stop treatment when infection is cured or
unlikely
Prevent Transmission
 Isolate the pathogen
 Break the chain of infection
*from CDC slide set
Newest Tools in the Arsenal
• UVC devices
– Kill spores
including C.diff
• Ozone and
chemical gas
generation
devices also
available
MDROs – Multidrug
Resistant Organisms
• MRSA (VISA, VRSA)
– Methicillin-resistant Staph aureus
• ESBL-producing Gram Negatives
– Extended-spectrum beta-lactamases
• KPCs
– Carbepenamase producing Klebsiella
• NDM-1
– New Delhi Metallobetalactamase producers
• Acinetobacter
• VRE – vancomycin resistant Enterococcus
Multi Drug Resistant Organism (MDRO)
Interventions
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Administrative support: Fiscal and
Human Resources
Judicious use of antibiotics
Education: facility-wide, unittargeted
Monitor the MDRO infection rates
Appropriate isolation
Fundamental Interventions
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Assess hand hygiene practices
Contact Precautions
Identify previously colonized patients
Rapidly report MDRO lab results
Provide MDRO education for health care
providers
Impact of MRSA: 2008-2011
 49-65 % of health-care associated S.
aureus infections reported to National
Healthcare Safety Network (NHSN) are
MRSA
 National population based estimates of
invasive MRSA infections
 94,360 MRSA infections annually
 Associated 18,650 deaths each year
 86% of all invasive MRSA infections are HAIs
Evolution of Antimicrobial
Resistance
Penicillin
S. aureus
Methicillin
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Penicillin-resistant
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Methicillin-resistant
[1950s]
S. aureus
[1980s]
S. aureus (MRSA)
Vancomycin
[1997]
[1990s]
VancomycinResistant
S. aureus
[ 2002 ]
Vancomycin
Vancomycin-resistant
(glycopeptide) -
enterococcus (VRE)
intermediate
resistant
S. aureus
*from CDC slide set
Supplemental Measures
 Active surveillance testing
 Surgical patients receiving implantable
devices i.e., joints, sternal wires, hardware
 Unit specific to identify colonized patients:
ICU patients
 Decolonization
 Mupirocin ointment intra-nasal
 Chlorhexidine (CHG) wipes and CHG
surgical skin prep for surgical procedures
Where do Organisms Hide?
VRE
VRE is colonized in the gastrointestinal
tract.
 Rectal swab cultures can be used to
identify carriers or determine if a patient
who was previously VRE+ is still a carrier
 Contact isolation as long as the patient is
a VRE carrier
 Ongoing shedding of VRE is the likely
reservoir of VRE in the hospital
Multi Drug Resistant Gram-negative Rods
• Resistant to 3 or more classes of these
antibiotics*:
Cephalosporins
Aminogylocosides
Carbapenems
Quinolones
Penicillins
• Resistance caused by mutation or gene
sharing
*As used at TriHealth, no national consensus
Extended Spectrum Beta Lactamase producers
• ESBL
• Beta lactamase enzyme
• Bacteria destroys all penicillins,
cephalosporins, and aztreonam
• Generally treat with carbapenems
– Ertapenem (Invanz)
– Imipenem/cilastatin (Primaxin)
– Meropenam (Merrem)
Carbapenem-resistant Enterobacteriaceae
• CRE - colonized in the GI tract
• Often are pan-resistant
• Treatment options: tigecycline, colistin,
polymixin B
• Not seen in US until 1992;
• First identified in Klebsiella pneumoniae
• New Delhi Metallo-Beta-Lactamase is
most recent
CRE
• Now carbapenemase producing bacteria
are found throughout the US
• Infections cause death 40-50% of the
time
• Gene can spread from one bacteria to the
next
• CDC-Recommendations to decrease
transmission of CRE
Multi Drug Resistant Gram-negative Rods
• Once colonized, may remain colonized for
a long time
• Screening is not practical
• Use Contact Precautions to prevent
spread within the hospital
-Duration of isolation is controversial
• *Hand Hygiene remains the single most
important means to reduce transmission
and spread
Interventions
• “The single most important means to
effectively reduce the transmission and
horizontal spread of enterobacteriaceae
and other microorganisms in all healthcare
settings is compliance with the Centers for
disease Control and Prevention (CDC) or
the World Health Organization (WHO)
handwashing guidelines”
Association for Professionals in Infection Control & Epidemiology Text,
2009.
Droplet Precautions
• For transmission of pathogens spread
by close respiratory or mucous
membrane contact
(sneezing, coughing, talking/ coughinducing procedures)
• Larger, heavier – weighted droplets
within 6 ft. of the patient
• Influenza or bacterial meningitis
• Private room
• Surgical mask
Meningitis
•
18 year old male patient admitted from urgent care center for treatment of
meningitis.
One week hx of Fever to 103.2, headache, neck pain and stiffness
Denied recent infections, but did complain of a “heat rash” on and off
No sick contacts, does play football and practiced while ill
Diagnostic Findings:
Spinal tap- CSF cell count 14,200 WBCs, 400 RBCs, 90% neutrophils
CSF culture gram stain- gram negative diplococci
Culture final was Neisseria meningitidis
What is the diagnosis?
Yes
Is it Contagious?
Droplet Precautions, antibiotics & supportive care
What should we do?
Should contacts be prophylaxed? Yes; family members, sports contacts,
those in close contact prior to instituting Droplet
Precautions.
Meningitis 5 types: Bacterial/Viral/Parasitic/Fungal/Non-infectious
Bacterial - caused by bacteria like:
Haemophilus influenza – DROPLET Precautions
Streptococcus pneumoniae - NO Precautions
Group B streptococcus - NO Precautions
Listeria monocytogenes - NO Precautions
Neisseria meningitidis - DROPLET Precautions
Viral (Aseptic) - caused by viruses like Enteroviruses and Herpes simplex
Parasitic - caused by parasites like Naegleria (amoeba found in lake/pond water)
Fungal - caused by fungi like Cryptococcus and Histoplasma
Non-infectious: Not contagious; causes- cancer, lupus, head injury, drugs,
brain surgery
Airborne Precautions
• Used to prevent spread of pathogens that
remain suspended in the air and travel
great distances.
• Measles, chickenpox, pulmonary
tuberculosis, zoster (shingles) in an
immunocompromised patient, and for
disseminated zoster in any patient.
Airborne Precautions
• Airborne isolation room with negative air
pressure relative to the hall
• 6-12 air exchanges with direct exhaust of air
to the outside
• Keep the door(s) shut
Airborne Precautions
• Fit tested N-95 Respirator
• Fit check before entering
• Limit transport to essential
medical purposes
• Surgical mask on the patient if
transport required
• Assist with respiratory hygiene
by providing tissues, disposal
bag, & hand gel at bedside
Cleaning, Disinfection, and
Sterilization
• Contact between medical devices and
human tissue carries the risk of
transmitting infectious agents
• Numerous outbreaks have occurred and
continue to occur due to inadequate
cleaning and sterilization procedures
• CDC “Guideline for Disinfection and
Sterilization in Healthcare Facilities, 2008”
Instrument Categories for Risk
Assessment
• Critical items – high risk of infection if any
microbial contamination including bacterial
spores
– Instruments that enter sterile body cavities
– Surgical instruments, cardiac and urinary
catheters, implants
– Items must be purchased sterile or be
sterilized
Semi-critical Items
• Will contact mucous membranes and nonintact skin
-Resp therapy equipment, some
endoscopes, laryngoscope blades, others
-Must be free of all vegetative organisms
but may have small numbers of spores
-Requires high level disinfection
Non-critical Items
• Contact with intact skin but not mucous
membranes
• Examples: BP cuff, bedpan, bed rails etc.
Methods of Sterilization
Destroys all microbes including spores
• High Temperature: Steam sterilization
– Used for heat tolerant Critical and Semicritical items
• Low Temperature: Ethylene oxide gas
– Used for heat intolerant Critical and Semicritical items
• Liquid Immersion: Chemical sterilants
– Used for heat intolerant Critical and Semicritical items that can be immersed in liquid
High Level Disinfection
• Destroys all vegetative organisms but may
leave a few viable spores
• Methods:
– Heat- automated: Pasteurization
– Liquid immersion: Chemical agents
• Used for Semi-critical items:
– RT equipment, GI endoscopes,
bronchoscopes
Intermediate Level Disinfection
• Destroys vegetative bacteria,
mycobacteria, fungi and viruses but not
spores
• Method: EPA registered hospital
disinfectants with antituberculocidal
activity
– Phenolics, chlorine based products
• Use: Noncritical patient care items ie BP
cuff or surface with visible blood
Low Level Disinfection
• Destroys vegetative bacteria, fungi,
viruses but not mycobacteria or spores
• EPA registered disinfectants with no
tuberculocidal claim
– Chlorine based, phenolics or quarternary
ammonium compounds
• Used for non-critical patient care items or
surfaces with no visible blood
Cleaning
• Must be performed before processing for
sterilization or disinfection
• Utilizes water and detergents or enzymatic
cleaners in order to remove foreign
material – organic or inorganic salts
Construction and Renovation
• Background
– Construction projects have the potential to
disrupt normal air and water flow into patient
care areas
– This risk for exposure to contaminated air and
water has resulted in multiple outbreaks
– The Joint Commission includes evaluation of
construction projects in their Environment of
Care (EOC) standards
Basic Principles
• Infection Preventionists need to be
involved in construction projects from the
beginning
– Involvement with facility management staff is
key to identifying necessary support needed
to prevent infections in the healthcare
environment
– CDC Guideline for Environmental Infection
Control in Health Care Facilities
Basic Principles
• ICRA: Infection Control Risk Assessment
– Conducted by a panel with expertise in
infection control, patient care, risk
management, facility design and construction
– Provides documentation of risk assessment
and mitigation strategies throughout the
construction process
– The owner shall provide monitoring of the
mitigation strategies
ICRA Building Design Elements
• Number and location of protective
environment rooms
• Location of special ventilation HVAC units
• Ventilation and air handling needs in
surgical services, labs etc where particular
air exchanges are recommended
• Water systems to limit Legionella growth
• Finishes and surfaces that allow for
adequate cleaning and disinfection
ICRA Construction Elements
• Impact of disrupting essential services to
patients and staff (ie water flow)
• Determination of specific hazards and
required protection levels
• Location of patients based on infection risk
• Impact of potential outages or movement
of debris
• Location of known hazards
ICRMR Preparation
• ICRMR – Infection Control Risk Mitigation
Recommendations
– Patient placement and relocation
– Standards for barriers to protect patients
– Temporary provisions for providing safe air
and water
– Protection of occupied patient areas during
demolition
– Measures to educate healthcare workers and
construction workers on mitigation plans
Construction Related Infections
• Infections related to contaminated air
sources:
– Aspergillus
– Rhizopus, Mucor
– Penicillium
– MRSA
– Stachybotrys
Construction Related Infections
• Infections related to contaminated water
sources:
– Pseudomonas
– Mycobacterium fortuitim
– Legionella – multiple outbreaks
– Acinetobacter
– Aspergillus
– Burkholdaria
– KPC – Carbepenemase producing Klebsiella
Construction and Renovation
Policy
• Serves as the foundation for educating the
healthcare facilities leadership on the role
of the ICRA and responsibilities of all
members
• Ensures timely notification of the IP in
order to get the ICRA done prior to
initiation of the project
• Supports a systematic approach to project
management
APIC On-line Text
• Provides excellent detail on every phase
of construction and renovation projects
• Reviews mitigation strategies for hazards
that may be encountered
Conclusion
• Infection Prevention will become even
more important in the coming years
– Health systems will be “at risk” for infection
– Consumers will select healthcare on the basis
of outcome data
– More regulation will require well trained IPs to
implement and monitor Infection Prevention
programs
• “Let’s be careful out there!”
– Sgt Phil Esterhaus, Hillstreet Blues