DAVID R . WOODARDMSC, CIC, CPHQ, CLS

Hospital Ecology

What is it all about

What is “normal”What is unusualWhat is totally weirdWhat is OMG

Usual or Normal

Organisms that are encountered with some degree of frequency

Antimicrobial susceptibilities that are common

Usual organisms in usual places ICU Rehab MRSA

MRSA and VRE

Are all MRSA equal? Community acquired Hospital acquired

VRE Faecium Faecalis

CohortScreen

Unusual

Organisms that you know occur infrequently in your populations

Organisms with uncommon susceptibilities but you recognize

Common organisms in unusual settings

Totally weird

Organisms with names you cannot pronounceOrganisms that Micro calls you aboutOrganisms in places they shouldn’t be –

Salmonella in spinal fluid Chyrsobacterium in sputum

OMG

Lots of the same bug in an inappropriate setting 6 sputum cultures positive for Echinobacteria all in

the same day All AFB from the same day all positive for M.

gallinariumBugs you have never heard of or were just on

“Good Morning America”

Antibiotics

Know your antibiogram Is amikacin resistant E. coli “normal in your hospital How many carbepenemase producing Klebsiella do

you see in a time intervalInduceable clindamycin resistance in MRSAPan-resistant organisms

ANTIBIOGRAM

A cumulative table comparing bacteria to the antibiotics that are used for testing

Expressed a % susceptibleCompare year over year when possiblePrepared by microbiology/infection

control/pharmacy

Antibiotic susceptibility

Standards are published by CLSIBreakpoints

The point (concentration) where an antibiotic is determined to be no longer effective

Change per CLSIEffect isolation practices –

2010 Cephalosporin/enterobacteriaceae major changes

So what

Do you have a good communication system with your lab

Critical values Bugs Drugs

Authority Confidence

Authority

Implement isolation protocolsEnforce isolation protocolsHand hygieneConsequences

Confidence

Know and understand your programKnow and access your resources

Library Internet State

Carry your expertise – just in time education

Where do bugs come from

Sources of organisms Patients normal flora Patient’s transient flora

Other units/hospitals Outside facilities

Environment Equipment Supplies

Patients own flora

GutPrior hospital exposure

Medical Tourist (KPC) Delhi metallo-enzyme

Antimicrobial resistant strains from far away places with strange sounding names

Imported flora

Acinetobacter calocaceticusKlebsiella pneumoniae (KPC)Salmonella sps (food)Living in unusual environments

Peace corps Military

Equipment

Equipment is mobile Rental Vendor/total joints Specialty procedures

Rectal probes Eye instruments

Follow-up to outside cases

Exogenous stuff

Fried RicePlantsFountainsAnimals

Feral cats Turtles

Stuff

Endogenous stuff

FingernailsSkin and soft tissuesBack packsOR capsClothing and other attire

Environmental Biology

Labs not qualified to do testingWater –

Dialysis Drinking

Equipment and medicinesAir? What is normal

Supplies

Manufacturer’s contamination Alcohol pads – Bacillus cereus IV solutions Heparin flushes – Serratia marcescens Pseudomonas aeruginosa & mouthwash

Equipment Sutures Dressing

Recalls

Hospital recall systemProducts that maybe contaminatedInternal processingTracking and looking

Hoarders! Hidden cabinets Procedure carts (locked)

Questions