Transcript Infection Control - What`s New in Medicine

Healthcare-Associated Infections
and Infection Control
Timothy H. Dellit, MD
Associate Professor
University of Washington School of Medicine
Associate Medical Director
Harborview Medical Center
Disclosure:
Dr. Dellit has no financial interest in any of the products or manufacturers mentioned.
An observation...
Ignaz Semmelweis
1818-1865
And an intervention...
Patient Safety and Infection Control

Prevention, monitoring, and feedback
◦ Healthcare-associated infections
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Catheter-associated bloodstream infections
Catheter-associated UTI
Ventilator-associated pneumonia
Surgical site infections
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MRSA
VRE
Carbapenem-resistant Acinetobacter
ESBL-producing organisms → MDR Enterobacteriaceae
Carbapenem-resistent Enterobacteriaceae (CRE, KPC, NDM-1...)
C. difficile
Aspergillus in burn and immunocompromised populations
Influenza/respiratory viruses
Tuberculosis
◦ Transmission of multidrug-resistant/marker organisms
Increasing Regulation and Reporting

CMS and “preventable events”
◦ FY2008
 Catheter-associated urinary tract infection
 Vascular catheter-associated infections
 Mediastinitis after CABG
◦ FY2009
 SSI following select orthopedic procedures
 Spinal fusion
 Elbow and shoulder arthroplasty
 SSI following bariatric surgery

Mandatory reporting of healthcare-associated infections (HB 1106)
◦ Central line infections in ICU: July 2008
◦ Ventilator-associated pneumonia: January 2009
◦ Selected surgical site infections: January 2010
 Cardiac surgery
 Total hip and knee arthroplasty
 Hysterectomy
2012: CMS
Colon and abd hysterectomy
2013: HB 1471
Remove VAP
Expand CLA-BSI housewide
How are we doing?
N Engl J Med 2014;370:1198-1208
Antimicrobial
Resistant
Pathogens and
HAI
Infect Control Hosp Epidemiol 2013;34:1-14
“MDRO Bundle”
– Catheter-associated BSI
– Ventilator-associated
pneumonia
– Catheter-associated UTI
– SCIP measures
• Active surveillance cultures
• Chlorhexidine baths
• Antimicrobial stewardship
Increased Hand Hygiene Associated with
Decreased MRSA Transmission
100
2.5
90
Hand hygiene
80
MRSA Transmission rate
2
70
60
1.5
50
40
1
30
20
0.5
10
0
0
1994
1998
Lancet 2000;356:1307-12
Transmission per 10,000 patient-days
Hand Hygiene
Contact precautions
Education
Minimize shared equipment
Environmental cleaning
Healthcare-associated
infections preventive bundles
Hand Hygiene Adherance
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Stethoscopes and Finger Tips
MRSA
Mayo Clin Proc 2014;89:277-280
Strategies to
control MRSA:
vertical vs. horizontal
Infect Control Hosp Epidemiol 2014;35:772-796
Infect Control Hosp Epidemiol 2014;35:797-801
Targeted vs Universal Decolonization to
Prevent ICU Infection
43 Hospitals Randomized
• Group 1: Nasal surveillance
cultures and contact precautions
• Group 2: Similar to group 1 plus 5
day decolonization with mupirocin
and CHG baths for those with MRSA
• Group 3: No screening, contact
precautions used, all patients
received 5 day colonization with
mupirocin and CHG baths
N Engl J Med 2013;368:2255-2265
Daily Chlorhexidine Baths:
ICU MDRO Reduction
Baseline
CHG Baths
P
MRSA acquisition*
5.04
3.44
0.046
VRE acquisition*
4.35
2.19
0.008
VRE bacteremia*
2.13
0.59
0.0006
*per 1000 pt-days
Crit Care Med 2009;37:1858-1865
Downside to Contact Precautions?
Unintended Consequences
• Reduced time with patients
• Reduced patient satisfaction
• More preventable adverse events
Tracked 15 interns for 3 months
Isolation
Nonisolation
P
Visits per day
2.3
2.5
<0.001
Time per visit
2.2 min
2.8 min
<0.001
Total time
5.2
6.9
<0.001
JAMA Intern Med 2014;174:814-815
Compliance with Contact Precautions
1013 observations in 11 hospitals
Compliance
Hand
Hygiene
Before
Gowning
Gloving
Doffing
Hand
Hygiene
After
Overall
37.2%
74.3%
80.1%
80.1%
61.0%
28.9%
Infect Control Hosp Epidemiol 2014;35:213-221
Role of Environmental Contamination
Bed Linen
Contact Contamination
Patient Gown
100
90
Overbed Table
Percent positive
80
BP Cuff
Side Rails
Bath Door Handle
IV Pump Button
Contact with patient
Contact with environment
70
60
50
40
30
20
10
0
Room Door Handle
Gowns
0
20
40
60
80
Percent of Surfaces Positive for MRSA
Infect Control Hosp Epidemiol 1997;18:622-627
Gloves
100
Environmental Contamination
%
Who was in this room before me?
100
80
78
60
60
ENVIRONMENT ANY
CALL BUTTON
BED RAIL
TABLE
TELEPHONE
40
30
20
0
Patients with CDAD
Asymptomatic
Carriers
Non carriers
Infect Control Hosp Epidemiol 2010;31:21-7
Carriers source for 29% of HA-CDI
Clin Infect Dis 2013;57:1094-1102
Infect Control Hosp Epidemiol
2011;32:201-6
Rationale for considering extending isolation
beyond duration of diarrhea
Clin Infect Dis 2008;46:447-50
UV-C Decontamination and
Clostridium difficile
Infect Control Hosp Epidemiol 2011;32:737-742
Copper Surfaces:
Passive reduction in organism burden
82% reduction
Infect Control Hosp
Epidemiol 2013;34:479-486
Infect Control Hosp
Epidemiol 2013;34:530-533
National Reduction in CLA-BSI
JAMA 2009;301:727-36
Infect Control Hosp Epidemiol 2013;34:893-899
Prevention of CLA-BSI
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IHI “Central line bundle”
◦ Hand hygiene
◦ Chlorhexidine skin prep
◦ Maximal barriers
 Full drape
 Mask, hair cover, sterile gown, sterile gloves
◦ Optimal catheter site selection
Standardization of CVC education
 Standardized use of central line carts and checklist
 Maintenance and prompt removal
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Bundle in Action: Keystone Project
Median Bloodstream Infections
per 1000 Catheter-Days
3.0
Overall
Teaching Hospital
Non-teaching Hospital
< 200 beds
> 200 beds
2.5
2.0
1.5
1.0
0.5
0.0
Baseline
0-3
4-6
7-9
10-12
13-15
16-18
Months After Implementation
Reduction in mean rate from 7.7 to 1.4 per 1000 catheter-days
N Engl J Med 2006;355:2725-32
Daily CHG baths and CLA-BSI
• Multicenter, clusterrandomized, nonblinded
crossover trial in six hospitals
• Nine ICU and bone marrow
transplant units
• 7727 patients enrolled
Include as basic strategy
Infect Control Hosp Epidemiol 2014;35:753-771
Intervention
Control
P
Hospital-acquired BSIa
4.78
6.60
0.007
CLA-BSIb
1.55
3.30
0.004
aRate
per 1000 pt-days
bRate per 1000 catheter-days
N Engl J Med 2013;368:533-42
Alcohol-impregnated hub caps
799 patients with PICCs
Am J Infect Control 2013;41:33-38
Beyond the bundle
Feedback/RCA
Muldidisciplinary team reenforcing bundle
• Antimicrobial catheters
• CHG dressings
VRE cluster
EVS
CHG
bathing
Critical Care 2013;17:R41
Disrupting the Lifecycle of the Urinary Catheter
1. Preventing Unnecessary and Improper Placement
Bladder
scanners
4. Preventing
Catheter
Replacement
Defined indications
Condom catheters?
Straight cath?
1
2
4
2. Maintaining
Awareness &
Proper Care of
Catheters
Reminders
Nurse-driven protocols
3
Closed system
Transportation
Dependent loops
3. Prompting Catheter Removal
(Meddings. Clin Infect Dis 2011)
Modified from Sanjay Saint
Catheter-Associated UTI
Duration of catheterization is primary risk
 Providers unaware of catheter status
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◦
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Students
Interns
Residents
Attendings
21%
22%
27%
38%
Daily assessment of need, especially when
transferred from ICU to floor
Am J Med 2000;109:476-80
Reminders and Stop-Orders
Meta-analysis of 14 studies
• Reduced CA-UTI by 52%
• Reduced duration of catheterization by 37%, resulting in 2.61
fewer days per patient
Clin Infect Dis 2010;51:550-560
Bladder Bundle and State Collaborative
JAMA Intern Med 2013;173:874-879
What not to do!
Do not routinely use antimicrobial catheters
 Do not screen for asymptomatic bacteriuria
 Do not treat asymptomatic bacteriuria except before
invasive urologic procedures
 Avoid catheter irrigation
 Do not use systemic antimicrobial prophylaxis
 Do not change catheters routinely
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Infect Control Hosp Epidemiol 2014;35:464-479
19 y o woman with h/o asthma is admitted with four days of
fever 40 C, sore throat, cough, myalgias, and SOB.
Which of the following is MOST correct regarding influenza?
A. A negative rapid point of care influenza test in the office rules
out influenza due to high sensitivity of the assay.
B. Patient should be placed in droplet precautions with use of
mask and eye protection.
C. Patient should be placed in airborne isolation with use of N95
respirator.
D. Patient should not be treated with oseltamivir since she has
presented more than 48 hours after symptom onset
Importance of Early Recognition and
Clinical Judgment
Early treatment associated with better outcomes
 15 deaths in King County
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◦ Time from symptom onset to treatment
 Mean 5.8 days (2-12 days)
◦ 5 patients with predisposing risk factors presented with ILI and were
not treated initially
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Testing challenges
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◦
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Rapid point of care tests 10-50% sensitive
FA and “inconclusive results”
Movement towards PCR testing
Upper vs. lower tract testing
Epi-Log Dec 2009: Public Health Seattle & King County
Critical Care 2009;13:R148
J Infect Dis 2011;203;1739-47
What are the appropriate precautions and
room placement for the following patients?
A. 40 y o woman h/o Non-Hodgkin lymphoma undergoing
chemotherapy who presents with fever and a diffuse
vesicular rash involving trunk and extremities.
B. 40 y o woman h/o Non-Hodgkinslymphoma undergoing
chemotherapy who presents with painful vesicular rash
across her right flank.
C. 70 y o man painful vesicular rash across his right flank.
CDC Recommendations
Condition
Precaution
Placement
Mask or Respirator?
Varicella Zoster
(Primary)
Airborne
and
Contact
Negative
Pressure
No clear recommendation
for immune HCW (i.e.
surgical mask or
respirator)
Disseminated
zoster
Airborne
and
Contact
Negative
Pressure
No clear recommendation
for immune HCW (i.e.
surgical mask or
respirator)
Localized zoster in
immunocompromised
Airborne
and
Contact
Negative
Pressure
No clear recommendation
for immune HCW (i.e.
surgical mask or
respirator)
Localized zoster in
immunocompetent
Standard
Single room
No recommendation
• Susceptible HCW should not enter room
• Exclude exposed susceptible HCW from day 8-21 after exposure
Airborne Transmission of Localized Herpes Zoster?
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VZV DNA in saliva in 54/54 patients with localized herpes zoster
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Outbreak in long-term care facility (J Infect Dis 2008;197;646-53)
(J Infect Dis 2008;197:654-7)
2
49 y o man with
cerebral palsy
86 y o woman with HZ in
contact precautions with
lesions covered
1
29 y o HCW
changed linens –
primary varicella
92 y o female
with Alzheimer
0
12
3/
14
3/
16
3/
18
3/
20
3/
3/
22
24
3/
3/
26
28
3/
30
3/
1
4/
3
4/
Environmental samples positive in all patient rooms and staff locker (dust)
3 y o boy returns from Philapines with
fever, conjuctivitis, coryza, cough, and
rash that began on his head.
What are the recommended
precautions?
A. Place patient in airborne isolation
and use N95 respirator with eye
protection.
B. Place patient in airborne
isolation. No need for N95
respirator if immune.
C. Place patient in droplet
precautions with use of mask and
eye protection.
D. No special precautions needed
due to high rates of MMR
vaccination.
http://www.immunize.org/photos/measlesphotos.asp
Measles in the U.S.
What is immunity?
• written documentation of vaccination with
2 doses of live measles or MMR vaccine
administered at least 28 days apart,
• laboratory evidence of immunity,
• laboratory confirmation of disease, or
• birth before 1957.¶
¶ The majority of persons born before 1957 are likely to
have been infected naturally and may be presumed
immune, depending on current state or local
requirements. For unvaccinated personnel born before
1957 who lack laboratory evidence of measles
immunity or laboratory confirmation of disease, healthcare facilities should recommend 2 doses of MMR
vaccine during an outbreak of measles.
35 year old Vietnamese man presents to emergency
department with three week history of worsening nonproductive cough, fever, night sweats, and right-sided
chest pain.
Thoracentesis is performed
• 1200 WBC 88% lymphocytes
• Total protein 5.4
• LDH 358
44 y o Vietnamese man with 6
month h/o pain and swelling of
left medial thigh associated with
fevers and night sweats
Which of the following is most correct?
A.
B.
C.
D.
Pleural TB is extrapulmonary and hence, no risk of
transmission.
Patients with extrapulmonary TB and a drain do not
need airborne isolation if sputum is AFB negative.
Surgical debridement of TB should be done is a
negative pressure OR.
All patients with extrapulmonary TB should be
evaluated for pulmonary involvement.
Pulmonary Involvement in
Extrapulmonary TB
• 72 patients with XPTB
36 lymph nodes
12 pleura
6 CNS
6 GI
• 57 had sputum collection
25%
20%
15%
10%
5%
0%
• Weight loss associated
with positive sputum cx
OR 4.3 (1.01-18.72)
49% had abnormal CXR
Chest 2008;134:589-94
Summary
Great strides in reducing HAI, but many
unanswered questions
 MDRO bundle

◦ Vertical vs. horizontal approach
◦ Importance of the environment
◦ Role of antimicrobial stewardship
Moving beyond the “bundle for device-related
infections
 Respiratory pathogens
