by dr. sherif ibrahim 1. office of epidemiology and preventive services division of infectious...
TRANSCRIPT
Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Review epidemiology of MDROs◦ Reservoir◦ Mode of transmission ◦ Type of infection ◦ Role of environment
Review specific MDROs Prevention strategies Contact Precautions Exercise
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Definition: ◦ microorganisms, predominantly bacteria, that are
resistant to one or more classes of antimicrobial agents
Importance: ◦ Limited options for treatment ◦ Increase the length of stay and cost of hospitalization ◦ Increase admission to and stay in ICU◦ High mortality rates
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Transmission: ◦ Mainly person to person through hands of healthcare
personnel (HCP)◦ Contact with contaminated environmental surfaces
◦ Transmission depends on Availability of vulnerable patients Antimicrobial pressure Colonization pressure Adherence to infection control measures Frequent movement among healthcare facilities
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Reservoirs◦ Infected and colonized patients ◦ Contaminated environmental surfaces & patient care
equipment
Risk factors ◦ Colonization, age > 65, ICU admission, long hospital
stay, frequent hospitalizations, invasive procedures, indwelling devices, underlying diseases, enteral feeding, LTCFs, antimicrobial exposure
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Infected: a person who has culture-positive for an MDRO and displays signs or symptoms of infection
Colonized: a person who has culture-positive for an MDRO but has no signs or symptoms of infection
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Enterococcus faecium (VRE)
Staphylococcus aureus (MRSA)
Clostridium difficile (C. Diff)
Acinetobacter baumannii
Pseudomonas aeruginosa
Enterobacteriaceae (CRKP/CRE)
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Methicillin‐Resistant Staphylococcus aureus (MRSA)
Vancomycin‐Resistant Enterococci (VRE)
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Staph aureus (SA) resistant to beta‐lactams.
Nasal colonization general population ◦ 25-30 % for SA◦ < 2% for MRSA
Other colonization sites: rectum, axilla, throat, wounds
Higher carriage among HCP, dialysis patients, diabetics, IV drug users
Reservoirs: ……. and……...
Transmission…… and………
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
49-65 % of HA-Staph infections NHSN ◦ 94,360 invasive MRSA infections annually/US◦ 18,650 associated deaths◦ 86% of all invasive MRSA are HAIs
Staphylococcus aureus ◦ Intrinsic virulence◦ Cause a wide range of life threatening infections◦ Adapt to different environmental conditions◦ Can survive in the environment 1-56 days
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
MRSA colonization generally precedes infection
Risk of developing MRSA infection among colonized individuals is 29% in 18 months
Rationale for prevention ◦ Prevent transmission from colonized to un-colonized
individuals ◦ Prevent infection in colonized individuals
MRSA-specific strategies (Decolonization) Non MRSA-specific strategies (reduce device-
associated infections)
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Aerobic Gram positive cocci that inhabitant of GI tract and female genital tract
Endemic in most U.S. hospitals
25% all enterococcal isolates are VRE
Resistance is commonly seen in isolates of E. faecium than E. faecalis
Risk factors (Host, Healthcare facility, Antimicrobial exposure)
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Reservoirs: ….. and ……..
Transmission: ……and ……
Common sites of infection: urinary tract, surgical wound, blood stream
Mortality rate is 2 times higher in VRE than VSE infections
Survives on environment days – weeks
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Glucose fermenter (Enterobacteriaceae)◦ Foodborne (Salmonella, Shigella)◦ Healthcare-associated Enterobacter species (E.
cloacae)◦ Community and Healthcare-associated
Klebsiella species (K. pneumoniae) Escherichia coli
Non–glucose fermenters◦ Acinetobacter baumannii ◦ Pseudomonas aeruginosa
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Normal human gut flora
Environment (soil & water)
Important cause of community and HA infections
Wide range of infections (UTI, Bacteremia, pneumonia, wound infection)
E. coli most common cause of outpatient UTIs
E coli and Klebsiella accounted for 15% all HAIs reported to NHSN 2007
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
B lactamases resistant to B-lactams for decades
Extended spectrum B-lactamases (ESBL) resistant to 3rd generation cephalosporins, monobactams ◦ Usually nosocomial however 34% from patients with
no healthcare contact ◦ Carbapenems the last line of defense for treatment
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Carbapenem-Resistant Enterobacteriaceae (CRE)
◦ Resistance production of a carbapenemase also known as KP carbapenemase (KPC)
◦ Resides on transferable plasmids wide spread transmission
◦ Limits options for treatment (Polymyxins problems with nephrotoxicity)
◦ Reservoirs: ……..and …..
◦ Transmission; …..and ……
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2001
Geographical Distribution of KPC-Producers
Sporadic isolate(s)
Centers for Disease Control and Prevention.
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Widespread
Sporadic isolate(s)
2006
Geographical Distribution of KPC-Producers
Centers for Disease Control and Prevention.
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2010
Geographical Distribution of KPC-Producers
Sporadic and Widespread isolate(s)
Centers for Disease Control and Prevention.
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Antimicrobial Interpretation Antimicrobial Interpretation
Amikacin I Chloramphenicol R
Amox/clav R Ciprofloxacin R
Ampicillin R Ertapenem R
Aztreonam R Gentamicin R
Cefazolin R Imipenem R
Cefpodoxime R Meropenem R
Cefotaxime R Pipercillin/Tazo R
Cetotetan R Tobramycin R
Cefoxitin R Trimeth/Sulfa R
Ceftazidime R Polymyxin B MIC >4mg/ml
Ceftriaxone R Colistin MIC >4mg/ml
Cefepime R Tigecycline S
0
10
20
30
40
50
60
Overall Mortality AttributableMortality
Pe
rce
nt
of
sub
ject
s CRKPCSKP
p<0.001
p<0.001
2048 1238
OR 3.71 (1.97-7.01)OR 4.5 (2.16-9.35)
Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Few clinical cases large reservoir of colonized patients in LTCFs.
Colonization rate was as high as 49% in one outbreak
Recipe for CRKP outbreaks: ◦ Infection control breaches (lack of compliance)◦ Unrecognized colonized residents serving as
reservoirs for transmission
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Non-motile gram negative bacteria (32 species)
Ubiquitous widely distributed in nature (soil, water, food, sewage) & the hospital environment
MDR-Ab is primarily a nosocomial pathogen
Long survival time on inanimate surfaces extensive environmental contamination
Transmission …. and…… Reservoirs: …… and …..
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Most common gram negative carried by skin of HCPMost common gram negative carried by skin of HCP
Frequently colonizes tracheostomy site
Chlorohexidine resistance
Respiratory care equipment
Bed rails, Bedside tables, Mattresses, Pillows Curtains, door handles Keyboards Floor mops, sinks
Air humidifiers Patient care items Wound care procedures Equipment carts, Infusion pumps Patient monitors and X-
ray board
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Widespread environmental contamination
Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
MDR- Acinetobacter mainly causes HAIs◦ Pneumonia (Ventilator-associated pneumonia)◦ Urinary tract ◦ Bacteremia◦ Meningitis◦ Skin/wound infections
MDR- Acinetobacter infections◦ Acute care (ICUs) traditionally, associated with outbreaks ◦ LTAC & LTCFs◦ Injured military personnel◦ Outbreaks mortality rates up to 75%
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Aerobic gram-negative rods
Ubiquitous in soil and water
Moist environment (hydrophilic) (e.g. sink drains, vegetables, river water, etc.)
P. aeruginosa is an opportunistic infection rarely colonize healthy individuals
At Risk individuals: ◦ Immuno-compromised◦ Burn patients ◦ Patients on mechanical ventilation◦ Cystic fibrosis patients
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
10% of all hospital-acquired infections
Often cause severe life threatening HAIs
Can be found everywhere
Can be community acquired
In healthcare facilities: respiratory equipment, food, sinks, taps, toilets, weak disinfectants, showers and mops, uncooked vegetables, flower water
Transmission …..and ………. Reservoirs ……. and …………
Colonization precedes infection in 50% of cases
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Core Measures Administrative supportSurveillancePatient placement Patient/staff cohortingHand hygieneContact precautionsProtocol for lab notificationDedicated equipment Device useEnvironmental measuresMonitor compliance Education Antimicrobial stewardship
Supplemental Measures Preemptive isolation Active surveillance culture Chlorohexidine bathing
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Gram positive spore forming bacillus (rods) Obligate anaerobe Part of the GI Flora in
◦ 1-3% of healthy adult◦ 70% of children < 12 months
Some strains produce toxins A & B Toxins-producing strains cause C. diff Infection
(CDI) CDI ranges from mild, moderate, to severe and
even fatal illness
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Transmission Fecal – oral route
◦ Contaminated hands of healthcare workers◦ Contaminated environmental surfaces.
Person to person in hospitals and LTCFs
Reservoir: ◦ Human: colonized or infected persons ◦ Contaminated environment
C. diff spores can survive for up 5 months on environmental surfaces.
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
A common cause of nosocomial antibiotic-associated diarrhea (AAD)
Most common infectious cause of acute diarrheal illness in LTCFs
The only nosocomial organism that is anaerobic and forms spores
Infective dose is < 10 spores
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Number of annual cases
Cost Number of annual deaths
Hospital-onset, hospital acquired (HO-HA)
165,000 $ 1.3 B 9000
Nursing home-onset 263.000 $ 2.2 B 16,500
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Illness caused by toxin-producing strains of C. difficile ranges from ◦Asymptomatic carriers = Colonized◦Mild or moderate diarrhea ◦Pseudo membranous colitis that can be fatal
A median time between exposure to onset of CDI symptoms is of 2–3 days
Risk of developing CDI after exposure ranges between 5-10 days to 10 weeks
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
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Antimicrobial stewardship
Admitted to healthcare facility
Antimicrobials
C Diff exposure & acquisition
Colonized no symptoms
Infected Symptomatic
Optimizing Environmental cleaning and Hand Hygiene
Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Supplemental Measures Extend (CP) beyond duration
of diarrhea (48 hours) Presumptive isolation for
symptomatic patients Implement soap and water for
HH before exiting room of a patient with CDI
Implement universal glove use on units with high CDI rates
Use sodium hypochlorite (bleach) - containing agents for environmental cleaning
Implement an antimicrobial stewardship program
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Core MeasuresSurveillanceContact Precautions (CP) for duration of diarrheaHand hygiene (HH) Dedicated equipment Cleaning and disinfection of equipment and environmentLaboratory-based alert system for immediate notification Educate HCP, housekeeping, admin staff, patients, families, visitors, about CDI Monitor compliance
Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Patient placement (factors to consider) Hand hygiene (HH) Gloves
◦ Don gloves upon room entry◦ Change gloves after contact with infectious materials ◦ Change gloves when moving from contaminated to non contaminated site◦ Remove gloves and HH before leaving the room or caring for another patient
Gowns ◦ Don gown upon room entry◦ Remove and discard gloves before removing gown ◦ Discarding gown before exiting the room
After gown and gloves removal HH make sure not to touch any potentially contaminated environmental surface in the room
Dedicated equipment (BP cuff, stethoscope, thermometer, etc.)
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Challenges of implementing CP in LTCFs Contact Precautions should be used for the following
residents with MDROs◦ Dependent on HCP in their activities of daily life◦ Ventilator-dependent◦ Incontinent of stool◦ Wound with difficult to contain discharge
Contact Precautions can be relaxed for all others residents with MDROs (consider resident’s mental status and personal hygiene)
Standard precautions should be observed all times Dedicated equipment Signage for HCP and visitors
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
MDROs represent a major clinical and infection control challenge particularly in LTCFs
You cannot do it alone Regional approach Aggressive infection control approach works Appropriate antimicrobial use Training and education (HCP, Patients,
Families) Communications (intrafacility and
interfacilities)
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
During morning rounds you were assigned rooms 103 and 107 for the day
Room 103 ◦ Under contact precautions ◦ Has 2 patients
Patient #1 was recently treated for CRKP UTI, has a Foley catheter and is stool incontinent
Patient # 2 is CRKP colonized and has a deep bedsore in the right buttock
Room # 107 ◦ Has two residents admitted for short term rehabilitation S/P total
knee replacement. One of them is stool incontinent
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
What type of precautions would you use upon entering Room 103 and why?
How is this type of organism transmitted? What type of precautions will you be using for room 107 and why?
Do you think it is a good practice to provide care for these two rooms in the same day? Please explain why and what is the best practice in this situation?
Patient # 2 in room 103 is ambulatory and he wants to go to the activity room. What would you do?
In the schedule, all four patients are due for bathing. Specify who would go first.
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
Questions
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Office of Epidemiology and preventive Services Division of Infectious Disease Epidemiology
SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility http://www.dhhr.wv.gov/oeps/disease/AtoZ/Documents/SHEA%20Guide%20to%20LTCF%20Infection%20Control%20Jul08.pdf
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006 http://www.cdc.gov/hicpac/pdf/MDRO/MDROGuideline2006.pdf
DIDE Website http://www.dhhr.wv.gov/oeps/disease/HAI/Pages/default.aspx
CDC Healthcare-Associated Infections http://www.cdc.gov/hai/ CDC SHEA “Train the Trainer” May 2011 Epidemiology and Prevention of Common Emerging MDROs
“Alex Kallen, MD, MPH” DHQP, CDC
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