DR.T.V.RAO MD 1

Dr.T.V.Rao MD

HEALTH CARE PRECAUTIONS DEALING MULTIDRUG RESISTANT INFECTED

PATIENTS

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MULTIDRUG-RESISTANT ORGANISMS (MDROS)

• MDROs are defined as microorganisms – predominantly bacteria – that are resistant to one or more classes of antimicrobial agents. Although the names of certain MDROs suggest resistance to only one agent (e.g., methicillin-resistant Staphylococcus aureus [MRSA], vancomycin resistant enterococcus [VRE]), Extended spectrum Betalactamse, carbapenemases resistant bacteria, these pathogens are usually resistant to all but a few available antimicrobial agents.

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IMPORTANT MRDO,S IN HOSPITAL PRACTICE

• Streptococcus pneumonia (MDRSP) which is resistant to penicillin and other broad-spectrum agents such as macrolides and fluoroquinolones, multidrug-resistant gram-negative bacilli (MDR- GNB), especially those producing extended spectrum beta-lactamases (ESBLs); and strains of S. aureus that are intermediate or resistant to vancomycin (i.e., VISA and VRSA)

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MDROs that are considered to be epidemiologically important and deserve special attention in healthcare facilities

WHY MULTIDRUG RESISTANT BACTERIA ARE IMPORTANT

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• MDROs are transmitted by the same routes as antimicrobial susceptible infectious agents. Patient-to-patient transmission in healthcare settings, usually via hands of HCWs, has been a major factor accounting for the increase in MDRO incidence and prevalence, especially for MRSA and VRE in acute care facilities

TRANSMISSION OF MDRO’S

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• Multidrug-resistant organisms (MDRO’s)may require more stringent protection, such as methicillin resistant Staphylococcus aureus (MRSA).ESBL ( Extended spectrum Beta lactamases, Multidrug drug resistant bacteria and Pan resistant bacterial pathogens

PATIENT ISOLATION PRECAUTIONS FOR HOSPITALS-

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PATIENT ISOLATION PRECAUTIONS FOR HOSPITALS-

• Standard Precautions (Basic level)• Are used for care of ALL patients in a hospital all of the time

regardless of diagnosis or infection status• Combine the major features of universal, and body

substance precautions, terms formerly used• Applied to blood, body fluids, excretions and secretions

regardless of whether they contain visible blood, mucous membranes and non-intact skin

• All other transmission-based precautions include (are in addition to) Standard Precautions

• Level of use depends on anticipated contact with patient

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Isolation Precautions

Patient Transport

Linen & laundry Waste Management

Decontamination

PPE

Hand hygiene

Patient placement

Isolation Precautions

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PATIENT ISOLATION PRECAUTIONS FOR HOSPITALS-

• Other Transmission-Based Precautions Commonly Used in Hospitals Consist of: • Direct and Indirect Contact Precautions• Airborne Precautions• Droplet Precautions

• These may be used in combinations depending on whether the microorganisms and infection in question have multiple routes of transmission with barrier nursing.

• Special adaptations may be needed for multidrug resistant organisms and Category A agents of bioterrorism.

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• Unit staff should be educated and updated frequently as to appropriate infection control for patients on their unit.

• If possible, dedicate same patient care staff to care of infected patient(s) during their stay.

NURSING EDUCATION IS MOST IMPORTANT TOOL IN CONTROLLING INFECTION

GENERAL MEASURES• The general hospital

environment and "permanent" equipment need to be protected

• Appropriate sharp/needle precautions should be followed as should proper disposal of clinical waste and laundry

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PATIENT ISOLATION PRECAUTIONSSTANDARD PRECAUTIONS

• Hand hygiene after patient contact

• Wear clean, non-sterile protective gloves when touching blood, body fluids, secretions, excretions and contaminated items

• Wear mask, eye protection or facial shield and gown during procedures likely to generate splashes or spray of blood, body fluids, secretions or excretions. Use depends on anticipated exposure and safe injection practices as well

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CONTACT PRECAUTIONSCONSISTS OF STANDARD PRECAUTIONS

• Intended to prevent spread of microorganisms from an infected patient through direct means (touching the patient) and indirect means (touching surfaces or objects that have been in contact with the patient). These objects include chairs, bedrails, telephones, IV pumps, light switches and so on.

• Placing the patient in a private room is preferred or when not available, it is recommended that a set of principles be followed such as cohorting with someone with the same infection.

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• Three new elements have been added to standard precautions. These are: • Respiratory

hygiene/cough etiquette• Safe injection practices• Use of masks for

insertion of catheters or injection into spinal or epidural areas

EXTENDED STANDARD PRECAUTIONS

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CONTACT PRECAUTIONS• Leak resistant bag for linens should be at

bedside.• Dedicated thermometer, B/P apparatus and

stethoscopes are preferred unless unavoidable and then must be cleaned and completely disinfected before using with other patient.

• Indirect contact transmission can occur when a susceptible patient is in contact with an intermediate inanimate object in the patient’s environment.

HANDWASHING AND HAND HYGIENE

One of the most important ways to protect against transmission of microbes and disease is hand hygiene

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1. Perform hand hygiene:Before and after patient contactAfter removing gloves or any other PPE itemAfter touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are wornAfter contact with patient surroundings

2. Routine hand hygiene by alcohol hand rub (preferably) or by washing hands with soap and water

3. Perform hand hygiene after touching surgical mask/ N 95 respirator or before touching the face

Hand hygiene

DEALING WITH USED GLOVES

1. When expose to blood, body fluids, secretions, excretions, mucous membranes and non-intact skin, and contaminated items

3. Perform hand hygiene immediately after glove removal

2. Change gloves when heavily contaminated

4. Disposable glove should not be reused

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EPA-REGISTERED DISINFECTANTS OR DETERGENTS/DISINFECTANTS

• EPA-registered disinfectants or detergents/disinfectants that best meet the overall needs of the healthcare facility for routine cleaning and disinfection should be selected . In general, use of the existing facility detergent/disinfectant according to the manufacturer’s recommendations for amount, dilution, and contact time is sufficient to remove pathogens from surfaces of rooms where colonized or infected individuals were housed. This includes those pathogens that are resistant to multiple classes of antimicrobial agents (e.g., C. difficile,

• VRE, MRSA, MDR-GNB

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COMMON CLEANERS FROM EPA LIST:

• 1. Lysol Brand Deodorizing Disinfectant Cleaner

• 2. Lysol Brand Pre-Moistened Touch-Ups Disinfecting Cleaning Wipes

• 3. Lysol Brand Disinfectant Direct Multi-Purpose Cleaner

• 4. Mr. Clean Multi-Surfaces Antibacterial

• 5. Ultra Clorox Brand Regular Bleach

• 6. Clorox Disinfecting Spray III

• 7. Hydrogen Peroxide

• 8. Pine Oil

• 9. Bio Clean

• 10.Ready-To-Use Bathroom Cleaner and Disinfectant

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HANDWASHING AND HAND HYGIENE-

• Should be done: • Before gloving, • After removing gloves• After touching blood, body fluids, tissues, secretions, excretions

or any contaminated items. If not visibly soiled can use alcohol- based but if visibly soiled or contaminated with proteinacious material use soap and wash hands.

• Between patients

• After procedures on some patients to prevent cross-contamination of different body sites

• After contact with patients intact skin or inanimate objects near the patient

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HAND WASHING AND HAND HYGIENE-

• Wash with soap and water at least 15 seconds when hands are visibly soiled and follow institutional procedures

• Use friction

• Can use alcohol-based rubs to decontaminate hand, if soiled

• Fingernails should be short, clean and free from polish

• Artificial nails should be avoided

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HAND WASHING AND HAND HYGIENE-

• Rings should not be worn• Watches and bracelets should be removed• For alcohol-based rubs, apply to palm of one hand

and rub hand together covering all surfaces of hand and fingers until hands are dry

• Paper towels should be used to dry hands. Do not touch faucet handles with hands after washing

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INFECTED PATIENT TRANSPORT WITHIN INSTITUTION

• If patient has airborne or droplet transmitted infection should only leave room, if essential

• Patient should wear mask during transport• Transport personnel should wear appropriate PPE• Transport route should avoid populated areas• Receiving personnel should be aware of what PPE and

infection control procedures are needed and when patient is coming

• Protect stretchers or wheelchairs appropriately• Appropriate hand hygiene should be used

TRANSPORT OF SUSPECTED OR CONFIRMED PATIENT

3. Inform the receiving service/department of concern beforehand

4. Clean / disinfect transport vehicles after use

1. Limit patient transport unless clinically indicated

2. Encourage patients to wear surgical mask if no contraindication

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• Disinfect all transport equipment and linens

• Patient should be in clean gown

• Patient should wear or use appropriate barriers such as impermeable dressings for wounds

• Let patients know how they can assist

INFECTED PATIENT TRANSPORT WITHIN INSTITUTION-

DECONTAMINATION - PATIENT CARE ITEMS

1. Dedicated non-critical patient care items for suspected and confirmed cases

2. Clean and disinfect reusable equipment before used on other patients.• Use 1,000 ppm of hypochlorite solution (i.e. add 1 part of 5.25% hypochlorite in

49 parts of water) to disinfect non-critical items• Use 70% alcohol on metallic surfaces

3. Reusable respiratory equipment should undergo high level disinfection before reused on other patients

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DECONTAMINATION - ENVIRONMENTAL CONTROL

Disinfect isolation and procedure rooms after use by a high risk patient

1. Clean and disinfect the environment regularly and additional session for frequently touched surfaces

2. Contaminated area should be disinfected by one part of hypochlorite solution add in 49 parts of water

3. If blood spills occur:• Use one part of hypochlorite solution add in 49 parts of

water for non-metallic and 70% alcohol for metallic items.• If spills involve large amount of blood, the blood should

be removed by disposable material soaked with one part of hypochlorite solution add in 4 parts of water before further cleaning and disinfection

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PATIENT TEACHING/COUGH ETIQUETTE -

• Instruction should include cont.:• Offering masks to persons who are coughing,

• Separating coughing persons at least 3 feet away from others in a waiting room or have separate locality.

• Instructing patients and providers not to touch eyes, nose, or mouth.

• Having health care personnel observe droplet precautions in addition to standard precautions.

• Health care workers should use standard precautions with all patients.

PRINCIPLES OF PRECAUTIONS FOR HIGH-RISK PROCEDURES IN MDRO’S

1. Limit unnecessary procedures2. Limit extent of procedure3. Limit number of persons involved 4. Effective decontamination of used items

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• Judicious antibiotic use, comprehensive surveillance for targeted MDROs, application of infection control precautions during patient care, environmental measures (e.g., cleaning and disinfection of the patient care environment and equipment, dedicated single-patient-use of non-critical equipment), and decolonization therapy when appropriate.

PRACTICE RATIONALISM OF ANTIBIOTIC USAGE

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PREVENTION AND TRANSMISSION IS A COMPLEX PROBLEM

• Preventing the emergence and transmission of these pathogens requires a comprehensive approach that includes administrative involvement and measures (e.g., nurse staffing, communication systems, performance improvement processes to ensure adherence to recommended infection control measures), education and training of medical and other healthcare personnel,

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• The prevention and control of MDROs is a national priority - one that requires that all healthcare facilities and agencies assume responsibility and participate in community-wide control programs

CONTROL OF MDRO’S IS A NATIONAL PRIORITY

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MULTIDRUG RESISTANT STRAINS ARE A GLOBAL PROBLEM WE ARE ALL CONCERNED

• Antibiotic resistance has both medical and financial costs. It causes longer and more serious illnesses, lengthening people’s stays in hospital and complicating their treatment. Sometimes people die unnecessarily. . At the moment, resistant bacteria threaten mostly children, the old, cancer patients and the chronically ill. Nearly 450,000 new cases of multidrug-resistant tuberculosis are recorded each year; one-third of these people die from the disease. More than a quarter of new cases of TB identified recently in parts of Russia were of this troublesome kind.

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• Programme created by Dr.T.V.Rao MD for Medical and Health care Workers in the

Developing World • Email

• doctortvrao@gmail.com