Infection Prevention 2012: In Defiance of the Post-Antibiotic Era

March 15, 2012Cynosure Health ‘Beyond SCIP’ Meeting

Allan J. Morrison, Jr., MD, MSc, FACP, FIDSA FSHEAInova Health System Epidemiologist

Chairperson, Infection Control CommitteeInova Fairfax Hospital

Professor and Distinguished Senior FellowSchool of Public Policy, George Mason University

Clinical Assistant Professor of MedicineGeorgetown University Hospital

DISCLOSURES

• Speaker’s Bureau with the following entities: Care Fusion, Cubist, Glaxo-SmithKline, Pfizer, Ortho-McNeil, Merck, Sage

• No mention of investigational nor off-label usage will be employed in this

program

NOSOCOMIAL INFECTIONS

• Historical derivation– Nosocome: Rabelais (circa 1340) “ . . . so they took the wounded soldiers to

the great nosocome . . . ”– “Castle-acquired” infections

Ann Int Med 2002;137:665

MOST PREVALENTUrinary Tract

33%

S urgical S ite23%

Primary Bloodstream

19%

Other25%

Weinstein RA. Nosocomial infection update. Emerg Infect Dis. 1998;4(3):416-420.

CRBSIs and SSIs: occur when skin is incised

INFECTION CONTROL IN THE MODERN ERA: HISTORY

• 1970s: “KARDEX” system– Whole house/body site surveillance– Data prospectively gathered, retrospectively analyzed– Created objective methodology

• SENIC study– First large study to demonstrate characteristics of “efficacious” IC program– ICP/250 beds, organized surveillance, SSI feedback to surgeons, trained epidemiologist

NOSOCOMIAL INFECTIONS : PREVENTABLES

• SENIC (1971-1976)– 6% NI preventable by minimal infection control efforts– 32% NI preventable by well-organized and highly

effective infection control programsAm J Epid 1985;121:182

• Meta-analysis of interventional studies (N=25)– 66% reduction (15.1 8.3/1000 C-D)

CIN Perf Qual Hlth Care 1998;6:172– 46% reduction (3217.4/1000 C-D)

Am J Inf Control 1999;27:402;J Hosp Inf 2003;54:258

INFECTION CONTROL IN THE MODERN ERA: HISTORY

• 2000 - 2010– Emergence of evidence-based data leading to

“bundles”– VAP, CRBSI, Sepsis, CDAD– (Variably) implemented but NI rates

• 2011 - FutureWhere do we go from here?

HUMAN: BACTERIAL INTERFACE

• Total human cells/person ~ 1013

• Total colonizing microbes ~ 1014

. . . We are outnumbered 10:1!

NEJM 2010;362:75

VRE VSE

Bacteremia2 n=683 n=931 OR, 2.52*

MRSA MSSA

Bacteremia3 11,8% (n=382) 5,1% (n=433) p<.001

KPN-ESBL+ KPN-ESBL-

Bacteremia4 52% (n=48) 31% (n=99) p<0.05

AB (IMP-R) AB (IMP-S)

Bacteremia5 57,5% (n=40) 27,5% (n=40) p=0.007

MDR-Pae No-MDR-Pae

Bacteremia6 21% (n=40) 12% (n=40) p=0.08

EB (IMP-R) EB (IMP-S)

Serious infections7 33% (n=33) 9% (n=33) p=0.0388

““ESKAPE” PathogensESKAPE” Pathogens11

Clinical Outcomes Clinical Outcomes

J Infect Dis; 2008; 41:327

INFECTION CONTROL IN THE MODERN ERA:

BLUEPRINT FOR FAILURE• Current paradigm:

MDRO (community, nosocomial)

Transmission within facilities

Colonization, infection, mortality ABX pressure

• Hand hygiene: poor compliance• Respect for isolation protocols/barriers

INFECTION PREVENTION: (FOUR) PILLARS

* De-populate the patient

* De-populate the space

* De-instrument the patient

* De-escalate the ABX

fole

Infection Control: The Symmetry of Science

INFECTION PREVENTION: (FOUR) PILLARS

* De-populate the patient

* De-populate the space

* De-instrument the patient

* De-escalate the ABX

fole

INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

• CENTRAL VENOUS CATHETERS• PERIPHERAL VENOUS CATHETERS• PATIENT BATHING PROTOCOLS• PREOPERATIVE PATIENT SHOWER• OPERATIVE TEAM HAND SCRUB• BLOOD CULTURE SKIN PREP• OPERATIVE SITE SKIN PREP

CHG :”Great White” of Skin Antisepsis

PREVENTION OF CATHETER-RELATED INFECTIONS IN THE ICU: A PROSPECTIVE RANDOMIZED TRIAL OF 2% CHG/70% IPA VERSUS 10%

POVIDONE-IODINE

0

5

10

15

1 2

PVP-I 2% CHG/70% IPA

1.3

7.710.6

1.3

Catheter-Related Bloodstream Infections

N = 82

Primary Bloodstream Infections

N = 82

Infe

ctio

n R

ate

s per

100

0 C

ath

ete

r D

ays

P= 0.05 P= 0.015

Catheter-related bloodstream infection: Isolation of identical organisms from blood cultures and semi-quantitative catheter cultures with no other identified source of infection. CDC primary bloodstream infection: Pathogen cultured from one or more blood cultures; organism cultured from blood is not related to an infection at another site. Patient has at least one of the following signs and symptoms: fever (>38°C). chills, or hypotension and positive skin contaminant found in blood cultures, OR positive antigen test with signs and symptoms of infection not related to another site.

Kelly R, et al. Prevention of infections related to central venous catheters and arterial catheters in intensive care patients: a prospective randomized trial of chlorhexidine gluconate (CHG) versus povidone iodine (PI). 15th Annual Scientific Meeting of the Society for Healthcare Epidemiology of America; April 9-12, 2005; Los Angeles, CA. Abstract 165.

CHG: CENTRAL VENOUS CATHETER (CVC)

P/R trial of CVC insertion (IJ, SC) 5% Povidone-Iodine/70% ethanol 0.25% CHG/4% benzylic alcohol 2 x 30 second application (pre-insertion) then Q 72o @

dressing change Results: PI-A CHG-A P-value

N 242 239Catheter colonization 22.2% 11.6%0.002CR-BSI 4.2% 1.7% 0.09

RF for catheter colonization IJ site, PI

Arch Int Med 2007;167:2066

INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

• CENTRAL VENOUS CATHETERS• PERIPHERAL VENOUS CATHETERS• PATIENT BATHING PROTOCOLS• PREOPERATIVE PATIENT SHOWER• OPERATIVE TEAM HAND SCRUB• BLOOD CUTLTURE SKIN PREP• OPERATIVE SITE SKIN PREP

CHG PREP: PERIPHERAL IVs

• P/R trial comparing:– 2% chlorhexidine gluconate - plus 70%

isopropyl alcohol (CHG-IA)– 70% isopropyl alcohol (IA)

• Results:CHG-IA IA P-value

N 91 79 --X dwell 2.3D 2.2D NSTip Cx 20% 49% <.001

• Skin disinfection with CHG-IA prior to PIV insertion associated with TIP CX

ICHE 2008;29:963

INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

• CENTRAL VENOUS CATHETERS• PERIPHERAL VENOUS CATHETERS• PATIENT BATHING PROTOCOLS• PREOPERATIVE PATIENT SHOWER• OPERATIVE TEAM HAND SCRUB• BLOOD CUTLTURE SKIN PREP• OPERATIVE SITE SKIN PREP

CHG Bathing: ICU

• 52 wk/cross-over trial– 22-bed MICU (Cook County Hospital)– Daily CHG bathing (impregnated washcloth) vs.

soap/water• Results:

Soap/Water CHG P-valueN (pt-days) 2119 2210Primary BSI 10.4 4.1 <.01(per 1000 pt-days)

Arch Int Med 2007;167:2073

CHG Bathing: ICU

• ICU (N=6): Daily Bathing Protocol Six Months ‘Regular’, Six Months CHG

• MRSA acquisition decreased 32% (p<.05)

• VRE acquisition decreased 50% (p<.01)

• VRE Bacteremia decreased (p=.02)

Crit Care Med 2008;37:185

CHG Bathing: Non-ICU

• N= 4 Hospital wards– 94 Beds; Rhode Island (>70K pt-days)– Daily CHG bathing (impregnated washcloth) vs.

soap/water• Results:

Soap/Water CHG P-valueN (pts) 7102 7699 ----MRSA VRE HAIs 64% .01Clostridium difficile…..no effect

ICHE 2011;32:238

CHG Bathing : Meta-Analysis

• N= 12 studies; 137,392 patient-days

• Studies screened for methodological rigor • Results: p-value CRBSI/BSI reduction <.00001

Inf Ctrl Hosp Epid 2012;33:257

SURGICAL SITE INFECTION

INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

• CENTRAL VENOUS CATHETERS• PERIPHERAL VENOUS CATHETERS• PATIENT BATHING PROTOCOLS• PREOPERATIVE PATIENT SHOWER• OPERATIVE TEAM HAND SCRUB• BLOOD CULTURE SKIN PREP • OPERATIVE SITE SKIN PREP

CHLORHEXIDINE: PREOPERATIVE SHOWERS

• CDC recommends preoperative showering with CHG1

• CHG more effective than PI & triclocarban

• Lower rates of intra-operative wound contamination1. Mangram AJ et al. The hospital infection control

practices advisory committee. Guidelines for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

2. Garibaldi RA. Prevention of intraoperative wound contamination with chlorhexidine shower and scrub. J Hosp Infect. 1988;11(suppl B):5-9.

The Ultimate Pre-op Shower

INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

• CENTRAL VENOUS CATHETERS• PERIPHERAL VENOUS CATHETERS• PATIENT BATHING PROTOCOLS• PREOPERATIVE PATIENT SHOWER• OPERATIVE TEAM HAND SCRUB• BLOOD CULTURE SKIN PREP• OPERATIVE SITE SKIN PREP

“

History repeats itself; that's one of the things

that's wrong with history."

Clarence DarrowUS Defense Lawyer

CHG: SURGICAL SCRUB

• CHG superior to povidone-iodine– Reduced hand bacterial counts at scrub– Reduction maintained 6 hours later

Orthopedics 2006:29:329Surg Gynecol Obstet 1981;132:677

Ostrander RV, et al. J Bone Joint Surg Am. 2005;87-A:980-985.

Bacterial Colony Counts/Site/Prep

2% CHG/70% IPA vs 0.7% Iodine 74% IPA; Hallux

(P<0.01)

2% CHG/70% IPA vs 0.7% Iodine 74% IPA; Toe

(P<0.05)

2% CHG/70% IPA vs 3% Chloroxylenol; Control

(P<0.01)

Control = anterior tibia, 12 cm proximal to the ankle joint

INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

• CENTRAL VENOUS CATHETERS• PERIPHERAL VENOUS CATHETERS• PATIENT BATHING PROTOCOLS• PREOPERATIVE PATIENT SHOWER• OPERATIVE TEAM HAND SCRUB• BLOOD CULTURE SKIN PREP• OPERATIVE SITE SKIN PREP

Blood Culture Results: Truth or Dare

* Blood Culture Contamination (BCC): Rate estimated at 0.6 - 6.0% * Results in unnecessary Lab costs, hospital

admissions, LOS, antibiotics J Hosp Med 2006;1:272

Clin Microbiol Rev 2006;19:788

BCC: Efficacy of CHG-Alcohol

• P/Trial: ER (60% BC drawn in ER)• Compared Iodine vs. CHG-A skin prep• Results: Iodine CHG-Alcohol p-value BCC 3.5% 2.2% <.0001

J Nurse Care Qual 2008;23:272

Blood Culture Contamination: Can it be Reduced ?

• Randomized/Crossover/Sterile Gloves• Results: Routine Optional p-value N 5265 5255 N/ABCC,possible 0.6% 1.1% .009BCC,likely 0.5% 0.9% .007 Ann Int Med 2011;154:145

Blood Cx Contamination: THE NEWEST BUNDLE?

Training in proper BC collection: Requirement for annual competency

? Time for a Blood Culture Bundle?

Ann Int Med 2011;154:202

INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS

• CENTRAL VENOUS CATHETERS• PERIPHERAL VENOUS CATHETERS• PATIENT BATHING PROTOCOLS• PREOPERATIVE PATIENT SHOWER• OPERATIVE TEAM HAND SCRUB• BLOOD CULTURE SKIN PREP• OPERATIVE SITE SKIN PREP

SSI: DOES CHOICE OF PREP MATTER?

• P/R trial comparing CHG-Alcohol (CA) and Povidine-Iodine (PI)– Clean-contaminated surgery (N = 849)– Pre-op prep, follow-up 30D post-op

• Results CA PI P-value

N 409 440SSI (total) 9.5% 16.1% .004Superficial 4.2% 8.6% .008Deep 1% 3% .05

NEJM 2010;362:18

SSI: DOES CHOICE OF PREP MATTER?

• P/R trial comparing CHG-Alcohol and Povidine-Iodine– Clean-contaminated surgery (N = 849)– Pre-op prep, follow-up 30D post-op

• Results (continued):

7 patients died (4 = CA; 3 = PI). None of CA deaths had SSI. All 3 PI deaths due to Sepsis from SSI.

NEJM 2010;362:18

Caesarean Section: SSI

CHG-Alcohol: C-Sections

• 2005: 4M live births in US annually• C-Sections account for 30% (>1M)• P/Trial (2006-2007): Pre-op CHG cloths and

CHG-A operative prep• Results: Pre-Interv Interv p-value SSI 7.5% 1.2% <.001Projected cost savings: $25,546 per SSI Am J Inf Control 2010;38:319

Preoperative Skin Antisepsis: CHG vs. Iodine : Meta-Analysis

Cost benefit decision analytic model N=1508 screened: 9 met criteria Summary: “Use of CHG for preoperative skin

antisepsis is associated with a 36% reduction in the number of SSIs…Although CHG is more costly than Iodine, this dramatic reduction in the number of SSIs will likely result in greater overall cost savings with chlorhexidine use”

Am J Inf Control 2010;31:1219

SSI: Efficacy of CHG-A Skin Prep

• …..In summary, the weight of evidence suggests that chlorhexidine alcohol should replace povidone-iodine as the standard for preoperative surgical scrubs.

NEJM 2010;362:1

INFECTION PREVENTION: (FOUR) PILLARS

* De-populate the patient

* De-populate the space

* De-instrument the patient

* De-escalate the ABX

fole

ENVIRONMENTAL CONTAMINATION: VRE

• VRE persists through an average of 2.8 standard room cleanings

ICHE 1998;19:261

ENVIRONMENTAL CLEANING: MDR CONTROL?• Purpose

– To assess the efficacy of environmental cleaning protocols for reduction of VRE, C. difficile

Baseline Post-Routine Post-Bleach Cx Cleaning Cleaning

VRE (N = 17) 94% 71% 0 (p < .001)

C. diff (N = 9) 100% 78% 11% (p = .03)

. . . Implications . . .

BMC Inf Dis 2007;7:61

ENVIRONMENTAL CONTAMINATION: VRE

• 14 month study; N = 1330 ICU admissions– Weekly environmental Cx– Twice weekly pt Cx

• 8% at-risk patients acquired VRE• Risk factors for VRE acquisition

– Prior VRE occupant (p = .007)– Prior VRE environmental Cx (p < .001)

CID 2008;46:678

INFECTION PREVENTION: (FOUR) PILLARS

* De-populate the patient

* De-populate the space

* De-instrument the patient

* De-escalate the ABX

fole

CA-UTI: NURSE-LED MODEL

• Urinary catheters (UC) vs unnecessary urinary catheters (UUC)

• 2006-2007; 10 hospital units (N=4,963 PD)– 18% UC days

• Results: UC UUC (per 1000 PD) P-value (per 1000 PD) P-value

Pre-interv. 203 102 .002 .001

Intervention 162 64 .05 .01

Post-interv. 187 91ICHE 2008;29:815ICHE 2008:29:820

INFECTION PREVENTION: (FOUR) PILLARS

* De-populate the patient

* De-populate the space

* De-instrument the patient

* De-escalate the ABX

fole

Antibiotic Stewardship Issues

Empiric ABX Order Set: Computer Physician Order Entry (CPOE) CID 2007; 44: 159 VAP De-escalation (8 Days of ABX)

JAMA 2003;290:2588 Bacteremia vs. Fungemia (example)

CAUTI: CID 2010;50:625

Institutional Antibiogram

INFECTION PREVENTION: (FOUR) PILLARS

* De-populate the patient

* De-populate the space

* De-instrument the patient

* De-escalate the ABX

fole

INFECTION CONTROL IN THE MODERN ERA: BLUEPRINT FOR SUCCESS

MDRO case finding = ASC isolation

CHG 10% bleach

Colonization Infection Death

De-instrument ABX pressure De-escalate the patient the ABX

MDRO

? LOS/? Improved antibiogram