48th annual meeting history...presentation objectives describe the role of isolation in preventing...
TRANSCRIPT
7/20/2014
1
48th Annual Meeting
Navigating the Oceans of Opportunity
Infection Prevention
Florian Daragjati, Pharm.D, BCPS
Disclosure
I do not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation
Objectives
Describe the role of isolation in preventing the spread of certain infections
Describe each type of isolation with examples of diseases and treatment options
Explain the significance of correct sequence of donning and removing PPE.
Describe the significance of antibiotic resistant organisms seen in hospitals
Ignaz Philipp Semmelweis
History
• Hungarian obstetrician at the Maternity Hospital in Vienna
• Credited with first discovering that healthcare workers can transmit disease
• In 1847 noted higher rates of maternity mortality among patients cared for by obstetricians and medical students than among those cared for by midwives
Noakes et al. Epidemiol Infect 2008;136:1-9
Maternal Mortality RatesFirst and Second Obstetric Clinics
General Hospital of Vienna, 1841-1850
02
46
810
1214
1618
1841 1842 1843 1844 1845 1846 1847 1848 1849 1850
Mat
ern
al M
ort
alit
y
FirstSecond
InterventionMay 15, 1847
Semmelweis IP, 1861Noakes et al. Epidemiol Infect 2008;136:1-9
What is Infection Prevention?
Infection prevention and control measures aim to ensure the protection of those who might be vulnerable to acquiring an infection both in the general community and while receiving care due to health problems, in a range of settings.
The basic principle of infection prevention and control is hygiene.
http://www.who.int/topics/infection_control/en/
7/20/2014
2
Infection Prevention Programs
SENIC Study 4 essential components of infection prevention program Surveillance with feedback of intervention control rates to
hospital staff
Enforcement of preventative practices
Supervising IP to collect and analyze surveillance data
Involvement of a physician or microbiologist
Programs with these elements reduces rates of the four most common hospital-acquired infections (HAIs) by 32%
Joint Commission, CMS, OSHA, SHEA
Haley et al. AM J Epidemiol 1980;111:472-485.Haley et al. Am J Epideomiol 1985;121:182-205.
Hughes et al. Chemotherapy 1988;34:553-561
Penalties associated with HAIs
CMSRequires hospitals to submit data on 10
quality measures Including measures to prevent HAIs
Withholding reimbursement for catheter-associated urinary tract infections, central line-associated bloodstream infections, surgical site infections
Principle of infection prevention
35-50% of all healthcare-associated infections are associated with only 5 patient care practices:
Use and care of urinary catheters Use and care of vascular access lines Therapy and support of pulmonary functions Surveillance of surgical procedures Hand hygiene and standard precautions
Haley RW AM J Epidemiol 1985;121(2):182-205
Chain of Infection
http://faculty.ccc.edu/tr-infectioncontrol/chain.htm
Routes of Transmission
Direct Contact
Indirect Contact
Droplet Contact
Airborne
Common Vehicle Transmission
http://www.health.qld.gov.au
Nosocomial Infections
Develops when a patient is staying at a healthcare facility AND was not present when the patient was admitted to the facility
At least 5% of patients hospitalized each year in the United States develop nosocomial infections. 90,000 deaths per year
5th leading cause of death in acute-care hospitals
Many are preventable
Horan et al. Am J Infect Control 2008;36:309-332.Burke et al. N Engl J Med 2003;348:651-656.
Stone et al. Am J Infect Control 2005;33:501-509.
7/20/2014
3
Antibiotic Resistant Microorganisms
Problem exists because of overuse and inappropriate use
Resistant to multiple antibiotics Reduced options for treatment Require isolation precautions Examples: MRSA, VRE, MDR TB Solutions: more appropriate antibiotic use, better
infection control and prevention
1. Klevens et al. Public Health Rep. 2007;122(2):160-166. 2. Stone et al. Am J Inf Control. 2005;33(9);542-547.
Impact of Antimicrobial Resistance
Each year an estimated 1.7 million patients in U.S. hospitals acquire an infection resulting in 100,000 deaths1
This results in an additional $6.5 billion in health care expenditures2
1. Klevens et al. Public Health Rep. 2007;122(2):160-166. 2. Stone et al. Am J Inf Control. 2005;33(9);542-547.
Impact of Antimicrobial Resistance
Infection and Causative Organism
Increased Risk of Death (OR)
Attributable Length of Stay (days)
Attributable Cost ($)
MRSA bacteremia 1.9 2.2 6,916
MRSA surgical infection 3.4 2.6 13,901
VRE infection 2.1 6.2 12,766Resistant Pseudomonas infection
3.0 5.7 11,981
Resistant Enterobacter infection
5.0 9 29,379
>$30 billion are spent annually on antimicrobial resistance.
Cosgrove SE. Clin Infect Dis. 2006; 42(Suppl 2):S82-9.
Cost of Healthcare-Associated Infections
Kuper K. et al. Am J Health-Sys Pharm 2009 66;488-94
Drivers of Resistance
Bug• Intrinsic
• Acquired
• β-lactamase
• Efflux pumps
• Altered binding site
• Porin change
Drug• Underdosage
• Pharmacokinetics
• Pharmacodynamics
Patient• Neonate
• Advanced age
• Extended LOS
• Immunocompromised
Risk factors for MDR pathogens
Nosocomial and Community-acquired infectionRisk Factors
Antimicrobial therapy in preceding 90 days
Current hospitalization of 5 days or more
High frequency of resistance in the community or hospital unit
Presence of risk factors for health care-associated pneumonia•Hospitalization for 2 days or more in the preceding 90 days•Residence in a nursing home•Home infusion therapy•Chronic dialysis within 30 days•Home wound care•Family member with MDR pathogen
Immunosuppresive disease and/or therapy
ATS; IDSA Am J Respir Crit Care Med 2005;171(4):388-41.Baughman RP. J Intensive Care Med 2009;24(4):230-241.
7/20/2014
4
Antimicrobials in the Pipeline
IDSA. Clin Infect Dis. 2009;48:1Boucher HW et al. Clin Infect Dis. 2009;48:1-12
HAND WASHING
Proper hand washing is the single most important step to prevent and reduce infections
Wash and rinse hands for 15 seconds, using a dry paper towel to turn off faucet
Alcohol-based hand wash is also available in all patient care areas
Dubberke et al. Infect Control Hosp Epidemiol 2008;29(1):S81-S-92.Sax et al. J Hosp Infect 2007;67:9-21.
http://www.healthunit.org/handwash/index.html
Hand Washing
FOAM IN/ FOAM OUT
Use a golf ball size
Rub hands thoroughly until dry.
Standard Precautions
Guidelines for preventing exposure to blood, body fluids, secretions, excretions (except sweat), broken skin, or mucous membranes
Based on the concept that body fluids from ANY patient can be infectious
Should be used on every patient
Use necessary PPE for protection CDC guidelines requires us to use category-specific isolation (ex –
TB isolation) in addition to Standard Precautions when a patient is known or suspected to have an infection
Saiman et al. Infect Control Hosp Epidemiol 2003;24:S6-S52.
CONTACT ISOLATION
used to prevent transmission of microorganisms spread by direct/indirect contact with the source
examples: MRSA VRE C. diff contagious skin infections… Lice & Scabies
Huang et al. J Infect Dis 2007;195:330-338.Salgado et al. Infect Control Hosp Epidemiol 2006;27:116-121.
7/20/2014
5
• Gloves every time you go into the room
• Gowns every time you go into the room
• Foam/ Hand Washing before entering and when leaving the room
Patients placed on ContactPrecautions
OR
Contact Precautions
University of California, San Francisco Infection Prevention Department
MRSA in the Hospital and Community
Close to 60% of S. aureus isolates from hospitalized patients are methicillin resistant1
MRSA is isolated from 59% of patients with community-acquired skin and skin structure infections2
1. Styers D et al. Ann Clin Microbiol Antimicrob. 2006;5:2.2. Moran GJ et al. N Engl J Med. 2006;355:666-674.
51% to 57%54% to 59%
59% to 63%
51% to 57%54% to 59%
59% to 63%~60%
50% to 52%
54%54%
51%51%
60%60% 60%60%
67%67%
74%74%
39%39%15%15%
55%55%
68%68%
72%72%
54%54%
51%51%
60%60% 60%60%
67%67%
74%74%
39%39%15%15%
55%55%
68%68%
72%72%
54%54%
51%51%
60%60% 60%60%
67%67%
74%74%
39%39%15%15%
55%55%
68%68%
72%72%
Methicillin-Resistant S. aureus (MRSA)
Colonized in nares and skin of normal humans
Higher rates of colonization among those with diabetes mellitus, IV drug use, patient undergoing hemodialysis, immunocompromised (HIV/AIDS)
Causes infections ranging from skin infections to bloodstream infections, pneumonia, meningitis, endocarditis, and toxic shock syndrome
Increased mortality, length of hospitalization, costs vs. MSSA
Cosgrove et al. Infect Control Hosp Epidemiol 2005;26:166-174.Cosgrove et al. Clin Infect Dis 2003;36:53-59.
Weinke et al. Eur J Clin Microbiol Infect Dis 1992;11:985-989.
Treatment of MRSA
Vancomycin Drug of choice for MRSA infections
15-20 mg/kg IV every 8-12 hours
IV- serious MRSA infections (pneumonia, endocarditis, osteomyelitis, cellulitis)
Trough concentrations must be monitored to ensure safety and efficacy (target 10-20 mcg/mL)
Adverse events: “red man” syndrome, nephrotoxicity (when administered concurrently with other nephrotoxic drugs, such as aminoglycosides, IV contrast, tacrolimus, etc.)
Trimethoprim/Sulfamethoxazole, Doxycycline, Minocycline, Clindamycin
Liu et al. Clin Infect Dis 2011;52(3):285-92.Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Accessed May 30, 2014.
Treatment of MRSA cont.
Other agents Daptomycin- treats serious MRSA and VRE infections, except
pneumonia (inactivated in the lung) Monitor creatinine phosphokinase levels
Ceftaroline- treats cellulitis and community-acquired pneumonia, where MRSA is suspected (not FDA-approved for MRSA pneumonia)
Tigecycline- treats cellulitis and intra-abdominal infections (covers MRSA, VRE, gram negative organisms)
Linezolid- treats serious MRSA and VRE infections
Newer agents Telavancin, Dalbavancin
Liu et al. Clin Infect Dis 2011;52(3):285-92.Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Accessed May 30, 2014.
7/20/2014
6
Treatment of Clostridium difficile infections
Mild to Moderate disease Metronidazole 500mg by mouth three times daily for 10-14 days
Severe Disease Vancomycin 125mg by mouth four times daily for 10-14 days
500mg by mouth four times daily PLUS metronidazole 500mg IV three times daily ± vancomycin 500mg per rectal administration four times daily for fulminant disease
Recurrent Infection Fidaxomicin 200mg by mouth twice daily x 10 days
Prevention Antimicrobial Stewardship, probiotics, hand-washing, private
rooms, environmental decontamination with bleach, education, probiotics
Dubberke ER. Infect Control and Hosp Epidemiol 2014; 35(6): 628-645.Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Accessed May 30, 2014.
AIRBORNE ISOLATION
used to prevent transmission of microorganisms spread on very small particles that drift on air currents (droplet nuclei, dust)
examples:
pulmonary Tuberculosis
varicella
measles
Airborne Precautions
University of California, San Francisco Infection Prevention Department
AIRBORNE ISOLATION
BASIC COMPONENTS: negative air pressure isolation room
door remains closed
fit-tested N95 respirator Should be performed annually for healthcare workers
yes… HANDWASHING!
• N-95 Mask before ENTERING room and wear at ALL times while in room
• Patient is in a negative pressure room
• Foam/ Hand Washing before entering and when leaving the room
Patients are placed on AIRBORNE Precautions
OR
FOAM
OR
Caused by Mycobacterium tuberculosis
can linger for up to 30 min in the air in poorly ventilated areas
First-line therapy
Rifampin, Isoniazid, Pyrazinamide, Ethambutol
Second-line therapy
Streptomycin, levofloxacin, moxifloxacin, amikacin
Resistance emerging
6-9 months of treatment
Treatment of Tuberculosis
Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Accessed May 30, 2014
7/20/2014
7
Vaccines
MMWR Immunization Schedule 2014;61(4):1-7
DROPLET ISOLATION
used to prevent transmission of microorganisms spread by large, moist droplets inhaled by or landing on the mucous membranes of the susceptible host
examples:
Influenza
Neisseria meningitidis
some pneumonias
vaccine preventable diseases: rubella, mumps, pertussis
Vaccines
MMWR Immunization Schedule 2014;61(4):1-7
Droplet Precautions
University of California, San Francisco Infection Prevention Department
• Mask before ENTERING room and wear at ALL times while in room
• Take mask off before leaving room
• Foam/ Hand Washing before entering and when leaving the room
Patients are placed on DROPLETPrecautions
OR
• Mask before ENTERING room and wear at ALL times while in room
• Take mask off before leaving room
• Foam/ Hand Washing before entering and when leaving the room
Patients are placed on special precautions
OR
OR
7/20/2014
8
Hand Washing Pearls
• How to wash your hands..Get your hands wet Put soap on your hands Rub your hands together
Germs don’t hop off when they see water coming. It is the friction that removes the germs
Remember you have backs to your hands & in between your fingers
Rub and scrub
While you rinse continue to rub and scrub Take the paper towel and dry your hands well Drying prevents dry cracked skin Gets off germs you missed in you hurry because drying is friction
Take the paper towels you just dried your hands with and turn the faucet off
Throw the paper towel away If you don’t do the last 2 steps...you might as well not have washed
your hands Your hands were dirty when you touched the faucet The faucet was dirty when you got there
If you don’t want to open up the door Get a clean paper towel to open the door and then discard it
Hand Washing Pearls cont.
REMEMBER
Germs love anything that makes your hands rough Dry skin
Callous
Warts
It gives the germs something to hold on to
Germs love jewelry
Germs love long fingernails and acrylic nails
Patient “medication bags” from home• Always dump the contents of the bag out – NEVER
reach blindly into the bag to retrieve patients home medications
• Do this to prevent needle/lancet sticks
• You never know what is in the bag
Gloves
• Purpose – patient care, environmental services, other
• Glove material – vinyl, latex, nitrile, other
• Sterile or nonsterile
• One or two pair
• Single use or reusable
PPE Use in Healthcare Settings
Do’s and Don’ts of Glove Use
• Work from “clean to dirty”
• Limit opportunities for “touch contamination” - protect yourself, others, and the environment– Don’t touch your face or adjust PPE with
contaminated gloves
– Don’t touch environmental surfaces except as necessary during patient care
PPE Use in Healthcare Settings
7/20/2014
9
Key Points About Personal Protective Equipment (PPE)
Don before contact with the patient, generally before entering the room
Use carefully – don’t spread contamination
Remove and discard carefully, either at the doorway or immediately outside patient room; remove respirator outside room
Immediately perform hand hygiene
Sequence for Donning PPE
Gown first
Mask or respirator
Goggles or face shield
Gloves
How to Safely Use PPE
Keep gloved hands away from face
Avoid touching or adjusting other PPE
Remove gloves if they become torn; perform hand hygiene before donning new gloves
Limit surfaces and items touched
Sequence for Removing PPE
Gloves
Face shield or goggles
Gown
Mask or respirator
Where to Remove PPE
At doorway, before leaving patient room or in anteroom*
Remove respirator outside room, after door has been closed*
*Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub
Removing Isolation Gown
Unfasten ties
Peel gown away from neck and shoulder
Turn contaminated outside toward the inside
Fold or roll into a bundle
Discard
7/20/2014
10
Removing a Mask
Untie the bottom, then top, tie
Remove from face
Discard
Hand Hygiene
Perform hand hygiene immediately after removing PPE.• If hands become visibly contaminated during PPE
removal, wash hands before continuing to remove PPE
Wash hands with soap and water or use an alcohol-based hand rub
*Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub
For Direct Caregivers
Artificial nails/ nail tips should not be worn
Natural nails should be no more than ¼
inch from the fingertip.
Regarding jewelry:
Wedding bands are acceptable.
Other rings, dangling earrings and bracelets are discouraged.
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
12 Contain your contagion11 Isolate the pathogen
10 Stop treatment when cured9 Know when to say “no” to vanco
8 Treat infection, not colonization7 Treat infection, not contamination
6 Use local data5 Practice antimicrobial control
4 Access the experts3 Target the pathogen
2 Get the catheters out1 Vaccinate
Prevent Transmission
Use Antimicrobials Wisely
Diagnose and Treat Effectively
Prevent Infection
CDC Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
Questions