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Healthcare-Associated Infections and Infection Control

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:

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Healthcare-Associated Infections and Infection Control

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  1. 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.

  2. An observation... Ignaz Semmelweis 1818-1865

  3. And an intervention...

  4. Patient Safety and Infection Control • Prevention, monitoring, and feedback • Healthcare-associated infections • Catheter-associated bloodstream infections • Catheter-associated UTI • Ventilator-associated pneumonia • Surgical site infections • Transmission of multidrug-resistant/marker organisms • MRSA • VRE • Carbapenem-resistant Acinetobacter • ESBL-producing organisms → MDR Enterobacteriaceae • Carbapenem-resistentEnterobacteriaceae (CRE, KPC, NDM-1...) • C. difficile • Aspergillusin burn and immunocompromised populations • Influenza/respiratory viruses • Tuberculosis

  5. 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

  6. How are we doing? N Engl J Med 2014;370:1198-1208

  7. Antimicrobial Resistant Pathogens and HAI Infect Control Hosp Epidemiol 2013;34:1-14

  8. “MDRO Bundle” • Hand Hygiene • Contact precautions • Education • Minimize shared equipment • Environmental cleaning • Healthcare-associated infections preventive bundles • Catheter-associated BSI • Ventilator-associated pneumonia • Catheter-associated UTI • SCIP measures • Active surveillance cultures • Chlorhexidine baths • Antimicrobial stewardship Lancet 2000;356:1307-12

  9. Stethoscopes and Finger Tips MRSA Mayo Clin Proc 2014;89:277-280

  10. Strategies to control MRSA:vertical vs. horizontal Infect Control Hosp Epidemiol 2014;35:772-796 Infect Control Hosp Epidemiol 2014;35:797-801

  11. 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

  12. Daily Chlorhexidine Baths: ICU MDRO Reduction *per 1000 pt-days Crit Care Med 2009;37:1858-1865

  13. Downside to Contact Precautions? • Unintended Consequences • Reduced time with patients • Reduced patient satisfaction • More preventable adverse events Tracked 15 interns for 3 months JAMA Intern Med 2014;174:814-815

  14. Compliance with Contact Precautions 1013 observations in 11 hospitals Infect Control Hosp Epidemiol 2014;35:213-221

  15. Role of Environmental Contamination Contact Contamination Percent positive Percent of Surfaces Positive for MRSA Infect Control Hosp Epidemiol 1997;18:622-627

  16. Who was in this room before me? 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

  17. Rationale for considering extending isolation beyond duration of diarrhea Clin Infect Dis 2008;46:447-50

  18. UV-C Decontamination and Clostridium difficile Infect Control Hosp Epidemiol 2011;32:737-742

  19. 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

  20. National Reduction in CLA-BSI JAMA 2009;301:727-36 Infect Control Hosp Epidemiol 2013;34:893-899

  21. Prevention of CLA-BSI • 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

  22. Bundle in Action: Keystone Project Median Bloodstream Infections per 1000 Catheter-Days 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

  23. Daily CHG baths and CLA-BSI • Multicenter, cluster-randomized, 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 aRate per 1000 pt-days bRate per 1000 catheter-days N Engl J Med 2013;368:533-42

  24. Alcohol-impregnated hub caps 799 patients with PICCs Am J Infect Control 2013;41:33-38

  25. Beyond the bundle VRE cluster EVS Feedback/RCA CHG bathing • Muldidisciplinary team re-enforcing bundle • Antimicrobial catheters • CHG dressings Critical Care 2013;17:R41

  26. Disrupting the Lifecycle of the Urinary Catheter 1. Preventing Unnecessary and Improper Placement Defined indications Condom catheters? Straight cath? 1 Bladder scanners 2. Maintaining Awareness & Proper Care of Catheters 4. Preventing Catheter Replacement 2 4 Closed system Transportation Dependent loops Reminders Nurse-driven protocols 3 3. Prompting Catheter Removal Modified from Sanjay Saint (Meddings. Clin Infect Dis 2011)

  27. Catheter-Associated UTI • Duration of catheterization is primary risk • Providers unaware of catheter status • Students 21% • Interns 22% • Residents 27% • Attendings 38% • Daily assessment of need, especially when transferred from ICU to floor Am J Med 2000;109:476-80

  28. 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

  29. Bladder Bundle and State Collaborative JAMA Intern Med 2013;173:874-879

  30. 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 Infect Control Hosp Epidemiol 2014;35:464-479

  31. 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 negative rapid point of care influenza test in the office rules out influenza due to high sensitivity of the assay. • Patient should be placed in droplet precautions with use of mask and eye protection. • Patient should be placed in airborne isolation with use of N95 respirator. • Patient should not be treated with oseltamivir since she has presented more than 48 hours after symptom onset

  32. Importance of Early Recognition and Clinical Judgment • Early treatment associated with better outcomes • 15 deaths in King County • 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 • Testing challenges • 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

  33. What are the appropriate precautions and room placement for the following patients? • 40 y o woman h/o Non-Hodgkin lymphoma undergoing chemotherapy who presents with fever and a diffuse vesicular rash involving trunk and extremities. • 40 y o woman h/o Non-Hodgkinslymphoma undergoing chemotherapy who presents with painful vesicular rash across her right flank. • 70 y o man painful vesicular rash across his right flank.

  34. CDC Recommendations • Susceptible HCW should not enter room • Exclude exposed susceptible HCW from day 8-21 after exposure

  35. Airborne Transmission of Localized Herpes Zoster? 49 y o man with cerebral palsy 86 y o woman with HZ in contact precautions with lesions covered 29 y o HCW changed linens – primary varicella 92 y o female with Alzheimer Environmental samples positive in all patient rooms and staff locker (dust) VZV DNA in saliva in 54/54 patients with localized herpes zoster (J Infect Dis 2008;197:654-7) Outbreak in long-term care facility(J Infect Dis 2008;197;646-53)

  36. 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/measles-photos.asp

  37. 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, health-care facilities should recommend 2 doses of MMR vaccine during an outbreak of measles.

  38. 35 year old Vietnamese man presents to emergency department with three week history of worsening non-productive cough, fever, night sweats, and right-sided chest pain. Thoracentesis is performed • 1200 WBC 88% lymphocytes • Total protein 5.4 • LDH 358

  39. 44 y o Vietnamese man with 6 month h/o pain and swelling of left medial thigh associated with fevers and night sweats

  40. Which of the following is most correct? • 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.

  41. Pulmonary Involvement in Extrapulmonary TB • 72 patients with XPTB 36 lymph nodes 12 pleura 6 CNS 6 GI • 57 had sputum collection • Weight loss associated with positive sputum cx OR 4.3 (1.01-18.72) 49% had abnormal CXR Chest 2008;134:589-94

  42. 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

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