Transcript HEPATITIS C: THE SILENT EPIDEMIC January 31, 2000
Infection Prevention 2012: In Defiance of the Post-Antibiotic Era
March 15, 2012 Allan J. Morrison, Jr., MD, MSc, FACP, FIDSA FSHEA Inova Health System Epidemiologist Chairperson, Infection Control Committee Inova Fairfax Hospital Professor and Distinguished Senior Fellow School of Public Policy, George Mason University Clinical Assistant Professor of Medicine Georgetown 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
O ther 25%
MOST PREVALENT
Urinary Tract 33% P rimary B loods tream 19% S urg ical S ite 23%
CRBSIs and SSIs: occur when skin is incised Weinstein RA. Nosocomial infection update. Emerg Infect Dis . 1998;4(3):416-420.
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 efforts preventable by minimal infection control
•
32% NI preventable by well-organized and highly effective infection control programs Am 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 (32
17.4
/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 - Future Where do we go from here?
HUMAN: BACTERIAL INTERFACE
Total human cells/person ~ 10
13
Total colonizing microbes ~ 10
14
. . . We are outnumbered 10:1!
NEJM 2010;362:75
Bacteremia 2 Bacteremia 3 Bacteremia 4 Bacteremia 5 Bacteremia 6 Serious infections 7
“ESKAPE” Pathogens
1 Clinical Outcomes VRE n=683 MRSA 11,8% (n=382) KPN-ESBL+ 52% (n=48) AB (IMP-R) 57,5% (n=40) MDR-Pae 21% (n=40) EB (IMP-R) 33% (n=33)
8
VSE n=931 MSSA 5,1% (n=433) KPN-ESBL 31% (n=99) AB (IMP-S) 27,5% (n=40) No-MDR-Pae 12% (n=40) EB (IMP-S) 9% (n=33) OR, 2.52* p<.001
p<0.05
p=0.007
p=0.08
p=0.038
ESKAPE Reference:
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
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
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 PVP-I 2% CHG/70% IPA 15 10 5 0
7.7
P= 0.05
1 1.3
10.6
2
P= 0.015
1.3
Catheter-Related Bloodstream Infections N = 82 Primary Bloodstream Infections N = 82 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 not related to another site. ° C). chills, or hypotension and positive skin contaminant found in blood cultures, OR positive antigen test with signs and symptoms of infection Kelly R, et al. Prevention of infections related to central venous catheters and arterial catheters in intensive care patients: a 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 72 o @ dressing change
Results: PI-A CHG-A P-value N Catheter colonization 242 239 22.2% 11.6% 0.002
CR-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
•
isopropyl alcohol (CHG-IA) 70% isopropyl alcohol Results: (IA) CHG-IA IA 70% P-value N X dwell Tip Cx
91 2.3D
79 2.2D
- NS 20% 49% <.001
Skin disinfection with CHG-IA insertion associated with
prior to PIV 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 CULTURE SKIN PREP
OPERATIVE SITE SKIN PREP
CHG Bathing: ICU
52 wk/cross-over trial
• •
22-bed MICU (Cook County Hospital) Daily CHG bathing vs. soap/water (impregnated washcloth)
Results: N (pt-days) Primary BSI Soap/Water CHG P-value 2119 2210 (per 1000 pt-days) 10.4 4.1
<.01
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 Daily CHG bathing vs. soap/water ( >70K pt-days ) (impregnated washcloth)
Results: N (pts) Soap/Water CHG P-value 7102 7699 --- MRSA VRE HAIs 64% .01
Clostridium difficile…..no effect ICHE 2011;32:238
CHG Bathing : Meta-Analysis
N= 12 studies; 137,392 patient-days Studies screened for methodolgic rigor Results: CRBSI/BSI reduction p-value <.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 CHG 1 CHG more effective than PI & triclocarban Lower rates of intraoperative wound contamination 1. Mangram AJ et al. The hospital infection control practices advisory committee. Guidelines for prevention of surgical site infection. 2. Garibaldi RA. Prevention of intraoperative wound contamination with chlorhexidine shower and scrub. J Hosp Infect Infect Control Hosp Epidemiol . 1988;11(suppl B):5-9.
. 1999;20(4):250-278.
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 Darrow US Defense Lawyer
CHG: SURGICAL SCRUB
CHG superior to povidone-iodine
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Reduced hand bacterial counts at scrub
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Reduction maintained 6 hours later Orthopedics 2006:29:329 Surg Gynecol Obstet 1981;132:677
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
Ostrander RV, et al.
J Bone Joint Surg Am
. 2005;87-A:980-985.
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/A BCC,possible 0.6% 1.1% .009
BCC,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 C HG A lcohol (CA) and P ovidine I odine (PI)
• •
Clean-contaminated surgery (N = 849) Pre-op prep, follow-up 30D post-op Results CA PI P-value N SSI (total) Superficial Deep 409 9.5% 4.2% 1% 440 16.1% 8.6% 3% .004
.008
.05
NEJM 2010;362:18
SSI:
DOES
CHOICE
OF PREP MATTER?
P/R trial comparing
•
CHG-Alcohol and P ovidine Clean-contaminated surgery (N = 849) I odine
•
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% <.001
Projected 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 iodine as the standard povidine 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
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% (p < .001) 71% 0 C. diff (N = 9) 100% (p = .03) 78% 11% . . . 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
Prior VRE
occupant (p = .007) 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
CA-UTI: NURSE -LED MODEL
U rinary c atheters (UC) vs u nnecessary u rinary c atheters (UUC)
2006-2007; 10 hospital units (N=4,963 PD)
•
18% UC days
Results: UC UUC (per 1000 PD) Pre-interv. 203 P-value (per 1000 PD) 102 .002
Intervention 162 64 .05
Post-interv. 187 91 P-value .001
.01
ICHE 2008;29:815 ICHE 2008:29:820
INFECTION PREVENTION: (FOUR) PILLARS
*De-populate the patient *De-populate the space *De-instrument the patient *
De-escalate the ABX
Antibiotic Stewardship Issues
Empiric ABX Order Set: C omputer P hysician O rder E ntry ( 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
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