healthcare-associated infections and infection control

Healthcare-Associated Infections and Infection Control

Timothy H. Dellit, MDAssociate ProfessorUniversity of Washington School of MedicineAssociate Medical DirectorHarborview Medical CenterDisclosure: Dr. Dellit has no financial interest in any of the products or manufacturers mentioned.

An observation...

Ignaz Semmelweis1818-1865

And an intervention...

Patient Safety and Infection ControlPrevention, 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-resistent Enterobacteriaceae (CRE, KPC,

NDM-1...) C. difficile Aspergillus in burn and immunocompromised populations Influenza/respiratory viruses Tuberculosis

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: CMSColon and abd hysterectomy

2013: HB 1471Remove VAPExpand CLA-BSI housewide

How are we doing?

N Engl J Med 2014;370:1198-1208

Antimicrobial Resistant Pathogens and HAI

Infect Control Hosp Epidemiol 2013;34:1-14

“MDRO Bundle”

Increased Hand Hygiene Associated with Decreased MRSA Transmission

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• 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

Mayo Clin Proc 2014;89:277-280

Stethoscopes and Finger Tips

MRSA

Strategies to control MRSA:vertical vs. horizontal

Infect Control Hosp Epidemiol 2014;35:772-796Infect Control Hosp Epidemiol 2014;35:797-801

Targeted vs Universal Decolonization to Prevent ICU Infection

N Engl J Med 2013;368:2255-2265

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

Daily Chlorhexidine Baths: ICU MDRO Reduction

Baseline CHG Baths P

MRSA acquisition* 5.04 3.44 0.046

VRE acquisition* 4.35 2.19 0.008

VRE bacteremia* 2.13 0.59 0.0006

Crit Care Med 2009;37:1858-1865*per 1000 pt-days

Downside to Contact Precautions?

Tracked 15 interns for 3 months

Isolation Nonisolation

P

Visits per day

2.3 2.5 <0.001

Time per visit

2.2 min 2.8 min <0.001

Total time 5.2 6.9 <0.001JAMA Intern Med 2014;174:814-815

Unintended Consequences•Reduced time with patients•Reduced patient satisfaction•More preventable adverse events

Compliance with Contact Precautions

Hand Hygiene Before

Gowning

Gloving Doffing Hand Hygiene After

Overall

Compliance

37.2% 74.3% 80.1% 80.1% 61.0% 28.9%


1013 observations in 11 hospitals

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Room Door Handle

IV Pump Button

Bath Door Handle

Side Rails

BP Cuff

Overbed Table

Patient Gown

Bed Linen

Percent of Surfaces Positive for MRSA


Role of Environmental Contamination

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Contact with environment

Contact Contamination

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Patients with CDAD AsymptomaticCarriers

Non carriers

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ENVIRONMENT ANYCALL BUTTONBED RAILTABLETELEPHONE


Carriers source for 29% of HA-CDI Clin Infect Dis 2013;57:1094-1102

Who was in this room before me?

Rationale for considering extending isolation beyond duration of diarrhea

Clin Infect Dis 2008;46:447-50

UV-C Decontamination and Clostridium difficile


Copper Surfaces: Passive reduction in organism burden



82% reduction

National Reduction in CLA-BSI

JAMA 2009;301:727-36


Prevention of CLA-BSIIHI “Central line bundle”

◦ Hand hygiene◦ Chlorhexidine skin prep◦ Maximal barriers

Full drape Mask, hair cover, sterile gown, sterile gloves

◦ Optimal catheter site selectionStandardization of CVC educationStandardized use of central line carts

and checklistMaintenance and prompt removal

Bundle in Action: Keystone Project

Reduction in mean rate from 7.7 to 1.4 per 1000 catheter-days

N Engl J Med 2006;355:2725-32

Months After Implementation

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Baseline 0-3 4-6 7-9 10-12 13-15 16-18

Overall

Teaching Hospital

Non-teaching Hospital

< 200 beds

> 200 beds

Daily CHG baths and CLA-BSI

Intervention Control

P

Hospital-acquired BSIa

4.78 6.60 0.007

CLA-BSIb 1.55 3.30 0.004aRate per 1000 pt-daysbRate per 1000 catheter-days

• Multicenter, cluster-randomized, nonblinded crossover trial in six hospitals

• Nine ICU and bone marrow transplant units

• 7727 patients enrolled

N Engl J Med 2013;368:533-42

Include as basic strategyInfect Control Hosp Epidemiol 2014;35:753-771

Alcohol-impregnated hub caps

799 patients with PICCs

Am J Infect Control 2013;41:33-38

Beyond the bundle

Muldidisciplinary team re-enforcing

bundle• Antimicrobial

catheters• CHG dressings

Feedback/RCA

VRE cluster

EVS

CHG bathing

Critical Care 2013;17:R41

Disrupting the Lifecycle of the Urinary Catheter

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1. Preventing Unnecessary and Improper Placement

2. Maintaining Awareness & Proper Care of Catheters

3. Prompting Catheter Removal

4. Preventing Catheter Replacement

(Meddings. Clin Infect Dis 2011) Modified from Sanjay Saint

Defined indicationsCondom

catheters?Straight cath?

Bladder scanner

s

RemindersNurse-driven

protocols

Closed system

Transportation

Dependent loops

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

Reminders and Stop-OrdersMeta-analysis of 14 studies

Clin Infect Dis 2010;51:550-560

• Reduced CA-UTI by 52%• Reduced duration of catheterization by 37%, resulting in 2.61 fewer days per patient

Bladder Bundle and State Collaborative

JAMA Intern Med 2013;173:874-879

What not to do!Do not routinely use antimicrobial cathetersDo not screen for asymptomatic bacteriuriaDo not treat asymptomatic bacteriuria

except before invasive urologic proceduresAvoid catheter irrigationDo not use systemic antimicrobial

prophylaxisDo not change catheters routinely


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. A negative rapid point of care influenza test in the office rules out influenza due to high sensitivity of the assay.

B. Patient should be placed in droplet precautions with use of mask and eye protection.

C. Patient should be placed in airborne isolation with use of N95 respirator.

D. Patient should not be treated with oseltamivir since she has presented more than 48 hours after symptom onset

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 CountyCritical Care 2009;13:R148J Infect Dis 2011;203;1739-47

A. 40 y o woman h/o Non-Hodgkin lymphoma undergoing chemotherapy who presents with fever and a diffuse vesicular rash involving trunk and extremities.

B. 40 y o woman h/o Non-Hodgkinslymphoma undergoing chemotherapy who presents with painful vesicular rash across her right flank.

C. 70 y o man painful vesicular rash across his right flank.

What are the appropriate precautions and room placement for the following patients?

CDC RecommendationsCondition Precaution Placement Mask or Respirator?

Varicella Zoster (Primary)

Airborne andContact

Negative Pressure

No clear recommendation for immune HCW (i.e. surgical mask or respirator)

Disseminated zoster

Airborne andContact

Negative Pressure


Localized zoster in immuno-compromised

Airborne and Contact

Negative Pressure


Localized zoster in immunocompetent

Standard Single room No recommendation

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

Airborne Transmission of Localized Herpes Zoster?

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)

86 y o woman with HZ in contact precautions with lesions covered

29 y o HCW changed linens – primary varicella

49 y o man with cerebral palsy

92 y o female with Alzheimer

Environmental samples positive in all patient rooms and staff locker (dust)

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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

Measles in the U.S.

• 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.

What is immunity?

Thoracentesis is performed• 1200 WBC 88% lymphocytes • Total protein 5.4• LDH 358

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.

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

Which of the following is most correct?

A. Pleural TB is extrapulmonary and hence, no risk of transmission.

B. Patients with extrapulmonary TB and a drain do not need airborne isolation if sputum is AFB negative.

C. Surgical debridement of TB should be done is a negative pressure OR.

D. All patients with extrapulmonary TB should be evaluated for pulmonary involvement.

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)Chest 2008;134:589-94

49% had abnormal CXR

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

healthcare-associated infections and infection control

Documents

associated infections

mrsa group

contact precautions

icu infectionn engl

central line infections

patient safety

day decolonization

vre acquisition