CIP Consulting LLCBasic and Intermediate Infection Prevention Michele Barr, RN, BSN, CIC Jennifer Perry, RN, BSN, CIC, CPHRM
Basic Infection Prevention Training Microbiology Review
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
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.
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.
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.
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)
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”
Antibiogram • Done annually by the Microbiology lab. • Helps guide antibiotic usage, very specific to the facility. • See example in packet – let’s review!
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.
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.
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.
Pulse field Gel Electrophoresis • PFGE technique can be used with remarkable precision to determine relatedness of isolates from an outbreak…
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.
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.
Viruses – • Cannot multiply on their own, need living cells to live and grow • Multiplication occurs in 5 steps • Attachment • Penetration • Replication • Maturation • Release
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.
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)
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.
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.
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.
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)
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)
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.
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.
Other terms • ASEPSISFreedom from infection or infectious material. • BACTERIOSTATICArresting the growth or multiplication of bacteria. An antibiotic may be classified as a bacteriostatic medication.
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)
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
HANDWASHING • The most important measure you can use to prevent the spread the spread of infection.
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
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
2003 Hand Hygiene Guidelines • It is not necessary to decontaminate your hands if you are only touching intact skin. • True • False
2003 Hand Hygiene Guidelines • Soap dispensers should be refilled: • When 2/3 full • When ¾ full • Never • Only when completely empty
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
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
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.
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
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
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
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.
Dr. _______ says…. Got Foam???? Use it! Before and after patient care or contact with the patient environment. Hand hygiene matters!!!!! Thank you Dr. ____
Dr. ___________ is sending Subliminal Messages during rounds…. Infection prevention dept. loves it! Thank you Dr. ______
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
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”
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 –