APIC Fall

Seminar 2012

Stephen P. Blatt MD FACP

Medical Director Infectious Diseases TriHealth

Preventing and Controlling Infectious Agents

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

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.

RESERVOIRA place within which microorganisms can thrive and reproduce.

PORTAL OF EXITA place of exit providing a way for a microorganism to leave the reservoir.

MODE OF TRANSMISSIONMethod of transfer by which the organism moves or is carried from one place to another.

PORTAL OF ENTRYAn opening allowing the microorganism to enter the host.

SUSCEPTIBLE HOSTA 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.

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

CLABSICentral 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 Approachesif 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 PreventionVentilator-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 PreventionWhat 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-UTICatheter-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 PreventionMethods 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 soiled2. 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, unit-

targeted 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

S. aureus

Penicillin

[1950s]

Penicillin-resistant

S. aureus

Methicillin

[1980s]

Methicillin-resistant

S. aureus (MRSA)

Vancomycin-ResistantS. aureus

Vancomycin-resistant

enterococcus (VRE)

Vancomycin

[1990s]

[1997]

Vancomycin

(glycopeptide) -

intermediate

resistant

S. aureus

[ 2002 ]

*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

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

Where do Organisms Hide?VRE

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/ cough-inducing 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

What is the diagnosis?

Is it Contagious?

What should we do?

Should contacts be prophylaxed?

Culture final was Neisseria meningitidisYes

Droplet Precautions, antibiotics & supportive care

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 non-intact 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 SterilizationDestroys all microbes including spores

• High Temperature: Steam sterilization– Used for heat tolerant Critical and Semi-

critical items

• Low Temperature: Ethylene oxide gas– Used for heat intolerant Critical and Semi-

critical items

• Liquid Immersion: Chemical sterilants– Used for heat intolerant Critical and Semi-

critical 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