Transcript Health care facility design, construction and renovation

Prevention of
Healthcareassociated
Gastrointestinal
Infections
1. List the types of microorganisms that can cause
gastrointestinal infections (GI) associated with
health care facilities.
2. Define diarrhoea.
3. Identify risk factors for GI infections.
4. Outline methods to prevent GI infections.
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Learning objectives
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• 45 minutes
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Time involved
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• Many microbes cause GI problems
• Most outbreaks caused by viruses
• Norovirus
• Bacterial gastroenteritis associated with food and/or water
• Another cause - toxigenic strains of Clostridium difficile
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Introduction
• Food-borne infections occur
• Especially in low resource countries during warmer months
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• Critical elements for prevention and control:
• Isolation
• Contact Precautions
• Decontamination of spillages
• Antibiotic stewardship essential to prevent
Clostridium difficile infections
• Hand hygiene with soap and water in outbreaks
• In food production - temperature control
• Inspection and auditing often reveal deficiencies
in practices
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Key points
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• Diarrhoea
• 2 or more episodes of watery stools (Bristol Stool
Type 7) or
• 3 or more episodes of loose stools (Bristol Stool
Type 6)
• Over a period of 24 hours
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Definitions
• All cases of acute diarrhoea and/or vomiting
regarded as potentially infectious
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• Exclude when investigating infections
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laxative use
allergic reactions
chemical and physical agents
nasogastric feeding
inflammatory bowel disease
surgery on the gastrointestinal tract
constipation associated with faecal impaction
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Non-infectious causes of
diarrhoea
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• Considered when two or more
persons who have consumed
the same food develop
gastroenteritis within 24 hours
• Cases occur in the same ward in
short time
• Causes
• Common vehicle
• Poor hygiene and non-compliance
of practices
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Food-borne outbreak
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• Norovirus, Adenovirus, Rotavirus
• Vomit major symptom
• Sudden and projectile
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Viral gastroenteritis - 1
• Elderly most affected
• Often resolves spontaneously
• Immunosuppressed shed viruses longer
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• Noroviruses highly
infectious
• Transmission
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Viral gastroenteritis - 2
• Direct
• Hand contact
• Indirect
• Contamination of
environment, and subsequent
contamination of hands
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• Characteristic of outbreaks
• Short incubation period
• 15 to 48 hours
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Viral gastroenteritis - 3
• Limited duration of illness
• 12 to 60 hours
• Vomiting the key symptom
• Affect both patients and staff
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• Admissions with GI symptoms isolated or
cohorted immediately
• Gloves and apron for all contacts
• patients and environment
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Prevention of outbreaks - 1
• Hand washing with soap and water after every
contact
• Alcohol-based hand rub should not be used
• No masks
• Bed linen and clothing changed daily
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• Environmental cleaning
• Perform at least once a day
• Disinfect (e.g., 1,000 ppm chlorine)
• Special attention to toilets, bathroom, and bedpans
• Attention to horizontal and frequently touched
surfaces
• Decontamination of all spillages of vomit and faeces
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Prevention of outbreaks - 2
• Cohorting of staff and patients
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• Wear personal protective equipment
• Disposable gloves, apron, visor or mask
• Absorb by paper towels
• Wash area
discard
discard
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Decontamination of all
spillages of vomit and faeces
• Hot water and detergent then disinfect with fresh
chlorine solution at 10,000 ppm
• Hand washing
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• Staff from wards with cases must not work in
unaffected areas until 48 hours have elapsed
from the last case
• Affected staff should be excluded until they have
been symptom-free for 48 hours
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Cohorting of staff and patients
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• Monitor compliance with IP&C practices
• If cases continue despite intervention, consider
closing ward and stopping new admissions
• Do not transfer patients to unaffected wards
unless urgent
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Prevention of outbreaks - 3
• If so consult IP&C staff
• Visitors
• Restrict
• Gown or apron
• Hand hygiene while visiting and hand washing on
leaving
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• IP&C team determines when over
• Expert opinion: two complete incubation periods
without a new case
• Terminal disinfection and changing of bed
curtains
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End of outbreaks
• Special attention to bathrooms and toilets
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• Diarrhoea common complication in patients
• Disruption of the flora in intestine
• Can colonise with Clostridium difficile
• Can produce exotoxins resulting in mucosal
injury and inflammation
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Antibiotic-associated
Gastroenteritis
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• Symptoms from mild diarrhoea to
pseudomembranous colitis and perforation
• Risk increases with health care stay
• Antibiotic use major pre-disposing factor
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C. difficile infections
• All antibiotics, especially wider spectrum, can
predispose
• Antibiotic stewardship initiatives crucial for
prevention
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• IP&C measures promptly enforced
• Hygienic interventions
• Hand hygiene with soap
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Prevention of Antibioticassociated Gastroenteritis - 1
• Lack of activity of alcohol on spores
• Gloves and disposable gowns or aprons
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•Programme of Cleaning
• Critical to reduce environmental contamination with
spores
• Chlorine-based compounds main product
• Recently, hydrogen peroxide mist has been used for
terminal decontamination
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Prevention of Antibioticassociated Gastroenteritis - 2
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• Isolation of patients as soon as possible in a
single room with toilet
• If not achievable, cohort
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Prevention of Antibioticassociated Gastroenteritis - 3
• Screening or decolonisation not recommended
• Single use items preferred or thorough
cleaning/disinfection between patients
• Disposable rectal thermometers
• Antibiotic Stewardship
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Contact Precautions
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• Prevalence of healthcare-associated Salmonella
and Shigella infections 3% and 2.5% respectively
• Hepatitis A, Campylobacter, Yersinia also cause
food-related illness
• The role of IP&C Teams depends on facility
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Prevention of Food-borne
Gastroenteritis
• Simple supervision to a more significant contribution
• IP&C personnel need to have a clear
understanding of effective food hygiene
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• Food pathogens survive and multiply within the
temperature danger zone
• 6°C to 63°C
• Cold food must be served as soon as possible
after removal from refrigeration
• Heating food to 75°C for 1-2 minutes guarantees
destruction of any biological hazard
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Food Hygiene
• Cooling of cooked food must be rapid
• Maintain temperature control until food is
served
• Maintain hot holding temperatures above 63°C
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• Preparing food more than a half day in advance
• Storage at room temperature
• Inadequate cooling
• Inadequate reheating
• Undercooking
• Cross contamination from raw to cooked food
• Contamination from food handlers
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Common causes of food-borne
infections
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• Training should include
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Conditions for temperature and time
Effective personal hygiene
Environmental hygiene
Potential sources of contamination
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Food Hygiene
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• Pioneered in the 1960s by USA’s National
Aeronautics and Space Administration program
• Incorporated into legislation of food safety both
in USA and the EU
• Evaluates food production to determine hazards
that may contaminate food
• Identifies critical control points after which any
contamination cannot be reversed
• Preventive measures monitored and corrected
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Hazard Analysis Critical
Control Points (HACCP)
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• Regular equipment cleaning and maintenance
• Provision of effective hygiene facilities
• Systems to control insects and other pests
• Temperature control
• Regular training for staff on food hygiene
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Elements of HACCP
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Process
Reception
Storage
Preparation
Cooking
Concern
Prevention Methods
Growth of
Temperature control.
pathogens.
Toxin production. Stored covered and dated
Contamination. Rotate stock
Ensure a pest free environment.
Limit exposure to ambient temperatures.
Prepare with clean equipment
Separate cooked and raw foods.
Wash hands before handling food.
Cook food to 􏰀75°C in thickest part two minutes.
Cooling
Cool foods as quickly as possible. Refrigerate within 90 minutes. Do
not leave at room temperature.
Chilled
storage
Temperature control.
Check expiration dates. Consume within three days
Store 6 inches above the floor and away from the wall.
Use in rotation.
Keep food hot at >63°C.
Hot holding/
Distribution
Reheating
Serving
Avoid if possible. Reheat to >75°C.
Serve as soon as possible
Ensure hands and equipment clean.
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Adapting HACCP to health care
food production
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• Not required to monitor food safety
• May be occasions when is useful
• Confirmation of microbiological quality and safety
• Educational tool for behaviour changes among food
handlers
• Semi-quantitative testing of production area
simple and low cost
• E. coli a good indicator to identify poor hygienic
food production practices
• Routine testing of food handlers not indicated
(e.g. faeces)
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Testing of food, environment,
and individuals
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What’s on YOUR hands??!
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Bobulsky G et al, CID 2007; Farr et al, LID 2001
• Kept clean
• Refrigerators away from direct heat or sunlight
• Temperature monitoring
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Ward kitchens precautions
• Items should be labelled, dated, and used within
72 hours
• Separation between raw and cooked items
• Place cooked above if in the same refrigerator
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• Checklists for every day documentation of critical
points
• Auditing of kitchen practices
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Kitchen auditing
• Including points related to causes of foodborne illness
• Critical points
• Temperature control
• Compliance with hygiene practices
• Itemised audit sheet
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• There are many risks of GI infections in health
care
• Can be produced by bacteria and viruses
• Can be associated with incorrect IP&C practices,
excessive antibiotic use and poor food/or water
hygiene
• Most outbreaks caused by viruses and spread by
contact
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Summary
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1. Lewis SJ, Heaton KW. Stool form scale as a useful guide
to intestinal transit time. Scand J Gastroenterol 1997; 32
(9): 920–4.
http://informahealthcare.com/doi/abs/10.3109/003655
29709011203 And Bristol Stool Scale
http://en.wikipedia.org/wiki/Bristol_Stool_Scale
2. Koopmans M. Noroviruses in healthcare settings: a
challenging problem. J Hosp Infect 2009; 73:331-7.
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References
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1. Chadwick PR, Beards G, Brown D, et al. Management of
hospital outbreaks of gastro-enteritis due to small round
structured viruses. J Hosp Infect 2000; 45:1-10.
http://www.hpa.org.uk/infections/topics_az/norovirus/h
ospital_norovirus.pdf
2. World Health Organisation. Five keys to Safer Food
Manual [online]. 2006.
http://www.who.int/foodsafety/publications/consumer/
manual_keys.pdf
3. Food and Agriculture Organization of the United Nations.
Food Quality and Safety Systems - A Training Manual on
Food Hygiene and the Hazard Analysis and Critical
Control Point (HACCP) System 1998.
http://www.fao.org/docrep/W8088E/W8088E00.htm
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References
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1.
Which of the following is effective to prevent food borne
infections?
a)
b)
c)
d)
2.
Which of the following is NOT a strategy to prevent transmission
of diarrhoea by Clostridium difficile?
a)
b)
c)
d)
3.
Adopting a HACCP system in food production
Ensuring stringent temperature control when storing food
Avoiding preparing food too far in advance
All of the above
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Quiz
Antimicrobial prophylaxis for all surgical operations
Using narrow spectrum antibiotics where possible
Contact precautions for all cases of diarrhoea
Education of staff in infection prevention and antibiotic stewardship
Laboratory testing of food handlers is indicated when?
a)
b)
c)
d)
Never
To create awareness in workers
To know epidemiology and causes of infections
To identify potential risks
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• IFIC’s mission is to facilitate international networking in
order to improve the prevention and control of
healthcare associated infections worldwide. It is an
umbrella organisation of societies and associations of
healthcare professionals in infection control and related
fields across the globe .
• The goal of IFIC is to minimise the risk of infection within
healthcare settings through development of a network of
infection control organisations for communication,
consensus building, education and sharing expertise.
• For more information go to http://theific.org/
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International Federation of
Infection Control
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