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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 • • • • Procedures and Devices Isolation Precautions Cleaning, Disinfection, Sterilization Risks of Construction Frequency of Infection Types • • • • 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 • • • • 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 • • • • 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 • • • • • • • • 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 • • • • • • • 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 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 • • • • 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 • • • • • MRSA VRE C. difficile MDROs – multi-drug resistant organisms RSV in infants Contact Precautions 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 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 Administrative support: Fiscal and Human Resources Judicious use of antibiotics Education: facility-wide, unittargeted Monitor the MDRO infection rates Appropriate isolation Fundamental Interventions 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 Penicillin-resistant 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