1. CIP Consulting LLCBasic and Intermediate Infection Prevention Michele Barr, RN, BSN, CIC Jennifer Perry, RN, BSN, CIC, CPHRM

2. Common Survey Questions

3. Basic Infection Prevention Training Microbiology Review

4. Stain…. will identify • To visualize microbes the lab can stain them using two common staining methods. 1. Gram stain Gram + Purple Gram – Red Gram Stain – allows identification of four basic groups of bacteria, and provide early suggestion of empiric antibiotics to use and possible initiation of isolation precautions. 2. Acid-fast stain

5. Stains…. • Acid-fast stain – The cells of some bacteria and parasites are impervious to crystal violet and other dyes, so heat or detergents are used to force dye into this type of cell. • If smear +, look closely at the patient to determine if airborne isolation is needed. • S/S of TB? • Look at most recent chest x-ray.

6. How are microbes cultured? • Nutrient – type of plate • Optimal temperature - 35 – 37 degrees C. • Atmosphere – does the microbe need oxygen or carbon dioxide? • Collection – (Do you have a specimen collection policy? Check with lab, and educate your people) • Tissue culture – Some viral pathogens are more difficult to grow than bacteria, so non culture methods are used for their identification.

7. MIC studies (Minimum inhibitory concentration studies) • MIC studies help determine antimicrobial susceptibility to antibiotics. • The lowest concentration of an antimicrobial that will inhibit the visible growth of a microorganism after incubation. (examples of disk diffusion) Other methods to determine MIC are broth dilution, E-test, and automated systems.

8. MIC • The zone sites are looked up on a standardized chart to give a result of • Sensitive • Intermediate • Resistant The charts have a corresponding column which gives the minimum inhibitory concentration for that drug. (Example of E-test)

9. R, I, S, designations For instance this culture report – the Ampicillin zone of inhibition was > 32, according to the CLSI guidelines that the lab uses, that zone of inhibition should be reported as “R”

10. Antibiogram • Done annually by the Microbiology lab. • Helps guide antibiotic usage, very specific to the facility. • See example in packet – let’s review!

11. Direct antigen testing • In addition to traditional culturing methods, there are non-culture methods to detect microbes. • EIA (Enzyme immunoassay) This procedure uses known specific antibodies which are reacted with a patient specimen. If the unknown patient antigen reacts with the antibody, a visible result can be observed by an enzymatic reaction. (i.e., Influenza A virus antibody, HIV, Strep kit) • Advantage – rapid testing, agents that are difficult to grow, very specific identification.

12. DNA Probes – another non-culturing method • Matches DNA from an unknown agent, with nucleic acid segments from a known agent. • Lab frequently uses this method for genital specimens to detect Neisseria gonorrhea and Chlamydia.

13. PCR – Polymerase Chain Reaction - another non-culture detection method. • PCR enzymatically enhances the number of nucleic acid molecules to the point that they can be detected. • Used to detect Toxoplasmosis, Enteroviruses, RSV, Pneumocystic carinii, and MTB. • Disadvantage – does not allow the testing of antimicrobial susceptibility testing.

14. Pulse field Gel Electrophoresis • PFGE technique can be used with remarkable precision to determine relatedness of isolates from an outbreak…

15. Environmental testing • “Can we culture the ice machine, I don’t think they clean them, and I see some black sludge on the dispenser” • Microbiological environmental testing is not generally recommended. In most cases no standards for comparison exist, so what are you going to do with the information? • Just clean the ice machine and make sure that there is a scheduled cleaning procedure.

16. Fungi Some are well adapted human pathogens, but most are accidental pathogens that we acquire through decaying organic matter or airborne spores. • Two groups • Yeasts – i.e. Candida species, Cryptococcus • Molds – i.e. Aspergillus species, histoplasma capsulatum What type of host plays an important part! Construction on an oncology ward higher risk than construction on a medical surgical unit.

17. Viruses – • Cannot multiply on their own, need living cells to live and grow • Multiplication occurs in 5 steps • Attachment • Penetration • Replication • Maturation • Release

18. Parasites • Vary in size and complexity, i.e. may be single celled microscopic protozoa or complex worms over 10 feet in length! • Flukes, tapeworms, roundworms, and ectoparasites such as lice and scabies.

19. Staphylococcus aureus – most frequently seen microbe in human infections. • Gram positive cocci, easily grown in the micro-lab. • Normal flora on skin. • Common pathogen – possesses numerous invasive enzymes which aid its pathogenicity. • Frequently resistant to the penicillin group of antibiotics, including the oxacillin-like agents (methicillin)

20. Staphylococcus aureus – most frequently seen microbe in human infections • Commonly seen as “R” to Oxacillin on the culture report. • MRSA – cannot be taken lightly! • MRSA was first isolated in the United States in 1968. By the early 1990s, MRSA accounted for 20%-25% of Staphylococcus aureus isolates from hospitalized patients. • 1999, MRSA accounted for >50% of S. aureus isolates from patients in ICUs in the (NNIS) system. • in 2003, 59.5% of S. aureus isolates in NNIS ICUs were MRSA.

21. Pseudomonas aeruginosa • Gram negative bacilli. • Most commonly associated with water. • Frequently a colonizing organism in patients. • “Opportunistic pathogen”, takes advantage of lowered defense systems of the host. • Can be commonly resistant to multiple antimicrobial agents. • Associated with outbreaks on healthcare systems.

22. Mycobacterium Tuberculosis • Referred to as an acid fast bacillus. • Slow growing (can take 4-6 weeks to grow) • Spread by the airborne route – so if + acid fast smear +, consider negative airflow. • If smear +, reportable to Oklahoma State health department.

23. Herpes Simplex Virus • Not seen by gram staining – it is a virus. • Requires tissue culture to grow. • Can a Healthcare worker (HCW) with a herpes lesion on their lip work? • What if they work in the NICU or oncology? • What if the HCW has a herpetic whitlow? • How do you find the answers? (CDC healthcare worker guidelines)

24. Basic Infection prevention terminology

25. Infection VS Colonization with normal flora • Colonization – presence of microorganisms with multiplication but without tissue invasion or damage. (urine culture E-coli < 20,000 cfu, patient with no symptoms) • Infection – entry and multiplication of an infectious agent in the tissues of a host. (urine culture E-coli >100,000 cfu, patient has fever, frequency, dysuria)

26. Exogenous VS Endogenous • Exogenous organisms are those that come from outside the host. • Endogenous organisms are those that come from the host’s own flora.

27. Aerobic VS Anaerobic • Aerobic • needs oxygen, Containing oxygen; referring to an organism, environment, or cellular process that requires oxygen. • Anaerobic • Lacking oxygen; referring to an organism, environment, or cellular process that lacks oxygen and may be poisoned by it.

28. Other terms • ASEPSISFreedom from infection or infectious material. • BACTERIOSTATICArresting the growth or multiplication of bacteria. An antibiotic may be classified as a bacteriostatic medication.

29. WBC count and differential • Normal WBC count is 5,000 – 10,000 • White blood cells originate in the bone marrow. • Types of WBC • Phagocytic – ingest and destroy bacteria, protozoa, cells and cellular debris. (neutrophils, eosinophils, basophils, monocytes, and macrophages) • Non-phagocytic – important to immune function and produce antibody. (T and B lymphocytes)

30. Hand Hygiene

31. 2003 Hand Hygiene Guidelines • This gentleman insisted his students clean their hands with a chlorine solution between each patient. He practiced in the 1800. Who is he? • Oliver Wendell Holmes • Jack the Ripper • Ignaz Semmelweis • Joseph Lister

32. HANDWASHING • The most important measure you can use to prevent the spread the spread of infection.

33. 2003 Hand Hygiene Guidelines • When washing hands with soap and water, hands should be rub together vigorously for: • 6 seconds • 15 seconds • 20 seconds • 3 minutes

34. 2003 Hand Hygiene Guidelines • When hands are visibly dirty or contaminated with proteinaceous material, hands should be wash with: • Antimicrobial soap • Non-antimicrobial soap • A chlorine solution • Both A and B

35. 2003 Hand Hygiene Guidelines • It is not necessary to decontaminate your hands if you are only touching intact skin. • True • False

36. 2003 Hand Hygiene Guidelines • Soap dispensers should be refilled: • When 2/3 full • When ¾ full • Never • Only when completely empty

37. 2003 Hand Hygiene Guidelines • Natural nail tip length should be: • Less than ¼ inch • Less than ½ inch • Bitten to nubs • Nails can be any length as long as they are natural

38. 2003 Hand Hygiene Guidelines • It is not the responsibility of the facility to provide lotion to the HCW, but the facility should encourage the use of lotion to minimize the occurrence of dermatitis. • True • False

39. 2003 Hand Hygiene Guidelines • When performing surgical hand antisepsis one should: • Remove rings, watches and bracelets before beginning the hand scrub • Leave all jewelry on during hand scrub so you can clean the jewelry and hands at the same time. • Remove only items that will be damaged by the water.

40. Hand Washing Wash hands to prevent transfer of microorganisms : • Before & after patient contact • After gloves are removed • Between task on the same patient to prevent cross-contamination of different body sites

41. 2003 Hand Hygiene Guidelines • If your hands have been exposed to Bacillus anthracis, you should: • Wash your hands with antimicrobial soap • Wash your hands with non-antimicrobial soap • Wash your hands with an iodophor • A and B • Cry

42. Clean hands are happy, healthy hands!!!!!“Foam in Foam out”

43. It is December!Give the gift of good healthto our patients and yourself!“Foam in Foam out” If visibly soiled, wash with soap, water and friction

44. Hand hygiene compliance • Who collects the data at your facility? • Audit tool (review sample tools) • Calculation of Hand hygiene compliance rates • # of “yes” observations/Total # of observations X 100 • Communicate the data to the HCW’s.

45. Hand hygiene compliance rates

46. Dr. _______ says…. Got Foam???? Use it! Before and after patient care or contact with the patient environment. Hand hygiene matters!!!!! Thank you Dr. ____

47. Dr. ___________ is sending Subliminal Messages during rounds…. Infection prevention dept. loves it! Thank you Dr. ______ 

48. Hand hygiene - Keep it Fun! Ideas to keep the ball rolling…. • “Glow Germ” at staff meetings • Hand hygiene “huddles” • Hand hygiene videos to show at staff meetings, orientation, advocate meetings, patient videos. • Pictures of staff washing hands! http://www.cdc.gov/handhygiene/Patient_materials.html http://www.hhs.gov/ash/initiatives/hai/training/partneringtoheal.html http://web.me.com/danielwlieu/Hands/Infection_Prevention_and_Control.html

49. Hand hygiene - Keep it Fun! • Mandatory annual hand hygiene education http://www.cdc.gov/handhygiene/training/interactiveeducation/ • Small prizes or tickets for free food when you catch a HCW performing hand hygiene. (OFMQ – “thank you pocket card, be a life saver pocket card”

50. Hand hygiene - Keep it Fun! • Wear Hand hygiene apron when out on IC rounds, make some for hospital managers. • iScrub - iScrub Lite is available free from the iTunes App Store. Search for iScrub in the App Store • Face book/Twitter • Web page buttons –