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48th Annual Meeting

Navigating the Oceans of Opportunity

Infection Prevention

Florian Daragjati, Pharm.D, BCPS

Disclosure

I do not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation

Objectives

Describe the role of isolation in preventing the spread of certain infections

Describe each type of isolation with examples of diseases and treatment options

Explain the significance of correct sequence of donning and removing PPE.

Describe the significance of antibiotic resistant organisms seen in hospitals

Ignaz Philipp Semmelweis

History

• Hungarian obstetrician at the Maternity Hospital in Vienna

• Credited with first discovering that healthcare workers can transmit disease

• In 1847 noted higher rates of maternity mortality among patients cared for by obstetricians and medical students than among those cared for by midwives

Noakes et al. Epidemiol Infect 2008;136:1-9

Maternal Mortality RatesFirst and Second Obstetric Clinics

General Hospital of Vienna, 1841-1850

02

46

810

1214

1618

1841 1842 1843 1844 1845 1846 1847 1848 1849 1850

Mat

ern

al M

ort

alit

y

FirstSecond

InterventionMay 15, 1847

Semmelweis IP, 1861Noakes et al. Epidemiol Infect 2008;136:1-9

What is Infection Prevention?

Infection prevention and control measures aim to ensure the protection of those who might be vulnerable to acquiring an infection both in the general community and while receiving care due to health problems, in a range of settings.

The basic principle of infection prevention and control is hygiene.

http://www.who.int/topics/infection_control/en/

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Infection Prevention Programs

SENIC Study 4 essential components of infection prevention program Surveillance with feedback of intervention control rates to

hospital staff

Enforcement of preventative practices

Supervising IP to collect and analyze surveillance data

Involvement of a physician or microbiologist

Programs with these elements reduces rates of the four most common hospital-acquired infections (HAIs) by 32%

Joint Commission, CMS, OSHA, SHEA

Haley et al. AM J Epidemiol 1980;111:472-485.Haley et al. Am J Epideomiol 1985;121:182-205.

Hughes et al. Chemotherapy 1988;34:553-561

Penalties associated with HAIs

CMSRequires hospitals to submit data on 10

quality measures Including measures to prevent HAIs

Withholding reimbursement for catheter-associated urinary tract infections, central line-associated bloodstream infections, surgical site infections

Principle of infection prevention

35-50% of all healthcare-associated infections are associated with only 5 patient care practices:

Use and care of urinary catheters Use and care of vascular access lines Therapy and support of pulmonary functions Surveillance of surgical procedures Hand hygiene and standard precautions

Haley RW AM J Epidemiol 1985;121(2):182-205

Chain of Infection

http://faculty.ccc.edu/tr-infectioncontrol/chain.htm

Routes of Transmission

Direct Contact

Indirect Contact

Droplet Contact

Airborne

Common Vehicle Transmission

http://www.health.qld.gov.au

Nosocomial Infections

Develops when a patient is staying at a healthcare facility AND was not present when the patient was admitted to the facility

At least 5% of patients hospitalized each year in the United States develop nosocomial infections. 90,000 deaths per year

5th leading cause of death in acute-care hospitals

Many are preventable

Horan et al. Am J Infect Control 2008;36:309-332.Burke et al. N Engl J Med 2003;348:651-656.

Stone et al. Am J Infect Control 2005;33:501-509.

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Antibiotic Resistant Microorganisms

Problem exists because of overuse and inappropriate use

Resistant to multiple antibiotics Reduced options for treatment Require isolation precautions Examples: MRSA, VRE, MDR TB Solutions: more appropriate antibiotic use, better

infection control and prevention

1. Klevens et al. Public Health Rep. 2007;122(2):160-166. 2. Stone et al. Am J Inf Control. 2005;33(9);542-547.

Impact of Antimicrobial Resistance

Each year an estimated 1.7 million patients in U.S. hospitals acquire an infection resulting in 100,000 deaths1

This results in an additional $6.5 billion in health care expenditures2

1. Klevens et al. Public Health Rep. 2007;122(2):160-166. 2. Stone et al. Am J Inf Control. 2005;33(9);542-547.

Impact of Antimicrobial Resistance

Infection and Causative Organism

Increased Risk of Death (OR)

Attributable Length of Stay (days)

Attributable Cost ($)

MRSA bacteremia 1.9 2.2 6,916

MRSA surgical infection 3.4 2.6 13,901

VRE infection 2.1 6.2 12,766Resistant Pseudomonas infection

3.0 5.7 11,981

Resistant Enterobacter infection

5.0 9 29,379

>$30 billion are spent annually on antimicrobial resistance.

Cosgrove SE. Clin Infect Dis. 2006; 42(Suppl 2):S82-9.

Cost of Healthcare-Associated Infections

Kuper K. et al. Am J Health-Sys Pharm 2009 66;488-94

Drivers of Resistance

Bug• Intrinsic

• Acquired

• β-lactamase

• Efflux pumps

• Altered binding site

• Porin change

Drug• Underdosage

• Pharmacokinetics

• Pharmacodynamics

Patient• Neonate

• Advanced age

• Extended LOS

• Immunocompromised

Risk factors for MDR pathogens

Nosocomial and Community-acquired infectionRisk Factors

Antimicrobial therapy in preceding 90 days

Current hospitalization of 5 days or more

High frequency of resistance in the community or hospital unit

Presence of risk factors for health care-associated pneumonia•Hospitalization for 2 days or more in the preceding 90 days•Residence in a nursing home•Home infusion therapy•Chronic dialysis within 30 days•Home wound care•Family member with MDR pathogen

Immunosuppresive disease and/or therapy

ATS; IDSA Am J Respir Crit Care Med 2005;171(4):388-41.Baughman RP. J Intensive Care Med 2009;24(4):230-241.

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Antimicrobials in the Pipeline

IDSA. Clin Infect Dis. 2009;48:1Boucher HW et al. Clin Infect Dis. 2009;48:1-12

HAND WASHING

Proper hand washing is the single most important step to prevent and reduce infections

Wash and rinse hands for 15 seconds, using a dry paper towel to turn off faucet

Alcohol-based hand wash is also available in all patient care areas

Dubberke et al. Infect Control Hosp Epidemiol 2008;29(1):S81-S-92.Sax et al. J Hosp Infect 2007;67:9-21.

http://www.healthunit.org/handwash/index.html

Hand Washing

FOAM IN/ FOAM OUT

Use a golf ball size

Rub hands thoroughly until dry.

Standard Precautions

Guidelines for preventing exposure to blood, body fluids, secretions, excretions (except sweat), broken skin, or mucous membranes

Based on the concept that body fluids from ANY patient can be infectious

Should be used on every patient

Use necessary PPE for protection CDC guidelines requires us to use category-specific isolation (ex –

TB isolation) in addition to Standard Precautions when a patient is known or suspected to have an infection

Saiman et al. Infect Control Hosp Epidemiol 2003;24:S6-S52.

CONTACT ISOLATION

used to prevent transmission of microorganisms spread by direct/indirect contact with the source

examples: MRSA VRE C. diff contagious skin infections… Lice & Scabies

Huang et al. J Infect Dis 2007;195:330-338.Salgado et al. Infect Control Hosp Epidemiol 2006;27:116-121.

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• Gloves every time you go into the room

• Gowns every time you go into the room

• Foam/ Hand Washing before entering and when leaving the room

Patients placed on ContactPrecautions

OR

Contact Precautions

University of California, San Francisco Infection Prevention Department

MRSA in the Hospital and Community

Close to 60% of S. aureus isolates from hospitalized patients are methicillin resistant1

MRSA is isolated from 59% of patients with community-acquired skin and skin structure infections2

1. Styers D et al. Ann Clin Microbiol Antimicrob. 2006;5:2.2. Moran GJ et al. N Engl J Med. 2006;355:666-674.

51% to 57%54% to 59%

59% to 63%

51% to 57%54% to 59%

59% to 63%~60%

50% to 52%

54%54%

51%51%

60%60% 60%60%

67%67%

74%74%

39%39%15%15%

55%55%

68%68%

72%72%

54%54%

51%51%

60%60% 60%60%

67%67%

74%74%

39%39%15%15%

55%55%

68%68%

72%72%

54%54%

51%51%

60%60% 60%60%

67%67%

74%74%

39%39%15%15%

55%55%

68%68%

72%72%

Methicillin-Resistant S. aureus (MRSA)

Colonized in nares and skin of normal humans

Higher rates of colonization among those with diabetes mellitus, IV drug use, patient undergoing hemodialysis, immunocompromised (HIV/AIDS)

Causes infections ranging from skin infections to bloodstream infections, pneumonia, meningitis, endocarditis, and toxic shock syndrome

Increased mortality, length of hospitalization, costs vs. MSSA

Cosgrove et al. Infect Control Hosp Epidemiol 2005;26:166-174.Cosgrove et al. Clin Infect Dis 2003;36:53-59.

Weinke et al. Eur J Clin Microbiol Infect Dis 1992;11:985-989.

Treatment of MRSA

Vancomycin Drug of choice for MRSA infections

15-20 mg/kg IV every 8-12 hours

IV- serious MRSA infections (pneumonia, endocarditis, osteomyelitis, cellulitis)

Trough concentrations must be monitored to ensure safety and efficacy (target 10-20 mcg/mL)

Adverse events: “red man” syndrome, nephrotoxicity (when administered concurrently with other nephrotoxic drugs, such as aminoglycosides, IV contrast, tacrolimus, etc.)

Trimethoprim/Sulfamethoxazole, Doxycycline, Minocycline, Clindamycin

Liu et al. Clin Infect Dis 2011;52(3):285-92.Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Accessed May 30, 2014.

Treatment of MRSA cont.

Other agents Daptomycin- treats serious MRSA and VRE infections, except

pneumonia (inactivated in the lung) Monitor creatinine phosphokinase levels

Ceftaroline- treats cellulitis and community-acquired pneumonia, where MRSA is suspected (not FDA-approved for MRSA pneumonia)

Tigecycline- treats cellulitis and intra-abdominal infections (covers MRSA, VRE, gram negative organisms)

Linezolid- treats serious MRSA and VRE infections

Newer agents Telavancin, Dalbavancin

Liu et al. Clin Infect Dis 2011;52(3):285-92.Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Accessed May 30, 2014.

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Treatment of Clostridium difficile infections

Mild to Moderate disease Metronidazole 500mg by mouth three times daily for 10-14 days

Severe Disease Vancomycin 125mg by mouth four times daily for 10-14 days

500mg by mouth four times daily PLUS metronidazole 500mg IV three times daily ± vancomycin 500mg per rectal administration four times daily for fulminant disease

Recurrent Infection Fidaxomicin 200mg by mouth twice daily x 10 days

Prevention Antimicrobial Stewardship, probiotics, hand-washing, private

rooms, environmental decontamination with bleach, education, probiotics

Dubberke ER. Infect Control and Hosp Epidemiol 2014; 35(6): 628-645.Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Accessed May 30, 2014.

AIRBORNE ISOLATION

used to prevent transmission of microorganisms spread on very small particles that drift on air currents (droplet nuclei, dust)

examples:

pulmonary Tuberculosis

varicella

measles

Airborne Precautions

University of California, San Francisco Infection Prevention Department

AIRBORNE ISOLATION

BASIC COMPONENTS: negative air pressure isolation room

door remains closed

fit-tested N95 respirator Should be performed annually for healthcare workers

yes… HANDWASHING!

• N-95 Mask before ENTERING room and wear at ALL times while in room

• Patient is in a negative pressure room

• Foam/ Hand Washing before entering and when leaving the room

Patients are placed on AIRBORNE Precautions

OR

FOAM

OR

Caused by Mycobacterium tuberculosis

can linger for up to 30 min in the air in poorly ventilated areas

First-line therapy

Rifampin, Isoniazid, Pyrazinamide, Ethambutol

Second-line therapy

Streptomycin, levofloxacin, moxifloxacin, amikacin

Resistance emerging

6-9 months of treatment

Treatment of Tuberculosis

Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Accessed May 30, 2014

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Vaccines

MMWR Immunization Schedule 2014;61(4):1-7

DROPLET ISOLATION

used to prevent transmission of microorganisms spread by large, moist droplets inhaled by or landing on the mucous membranes of the susceptible host

examples:

Influenza

Neisseria meningitidis

some pneumonias

vaccine preventable diseases: rubella, mumps, pertussis

Vaccines

MMWR Immunization Schedule 2014;61(4):1-7

Droplet Precautions

University of California, San Francisco Infection Prevention Department

• Mask before ENTERING room and wear at ALL times while in room

• Take mask off before leaving room

• Foam/ Hand Washing before entering and when leaving the room

Patients are placed on DROPLETPrecautions

OR

• Mask before ENTERING room and wear at ALL times while in room

• Take mask off before leaving room

• Foam/ Hand Washing before entering and when leaving the room

Patients are placed on special precautions

OR

OR

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Hand Washing Pearls

• How to wash your hands..Get your hands wet Put soap on your hands Rub your hands together

Germs don’t hop off when they see water coming. It is the friction that removes the germs

Remember you have backs to your hands & in between your fingers

Rub and scrub

While you rinse continue to rub and scrub Take the paper towel and dry your hands well Drying prevents dry cracked skin Gets off germs you missed in you hurry because drying is friction

Take the paper towels you just dried your hands with and turn the faucet off

Throw the paper towel away If you don’t do the last 2 steps...you might as well not have washed

your hands Your hands were dirty when you touched the faucet The faucet was dirty when you got there

If you don’t want to open up the door Get a clean paper towel to open the door and then discard it

Hand Washing Pearls cont.

REMEMBER

Germs love anything that makes your hands rough Dry skin

Callous

Warts

It gives the germs something to hold on to

Germs love jewelry

Germs love long fingernails and acrylic nails

Patient “medication bags” from home• Always dump the contents of the bag out – NEVER

reach blindly into the bag to retrieve patients home medications

• Do this to prevent needle/lancet sticks

• You never know what is in the bag

Gloves

• Purpose – patient care, environmental services, other

• Glove material – vinyl, latex, nitrile, other

• Sterile or nonsterile

• One or two pair

• Single use or reusable

PPE Use in Healthcare Settings

Do’s and Don’ts of Glove Use

• Work from “clean to dirty”

• Limit opportunities for “touch contamination” - protect yourself, others, and the environment– Don’t touch your face or adjust PPE with

contaminated gloves

– Don’t touch environmental surfaces except as necessary during patient care

PPE Use in Healthcare Settings

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Key Points About Personal Protective Equipment (PPE)

Don before contact with the patient, generally before entering the room

Use carefully – don’t spread contamination

Remove and discard carefully, either at the doorway or immediately outside patient room; remove respirator outside room

Immediately perform hand hygiene

Sequence for Donning PPE

Gown first

Mask or respirator

Goggles or face shield

Gloves

How to Safely Use PPE

Keep gloved hands away from face

Avoid touching or adjusting other PPE

Remove gloves if they become torn; perform hand hygiene before donning new gloves

Limit surfaces and items touched

Sequence for Removing PPE

Gloves

Face shield or goggles

Gown

Mask or respirator

Where to Remove PPE

At doorway, before leaving patient room or in anteroom*

Remove respirator outside room, after door has been closed*

*Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub

Removing Isolation Gown

Unfasten ties

Peel gown away from neck and shoulder

Turn contaminated outside toward the inside

Fold or roll into a bundle

Discard

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Removing a Mask

Untie the bottom, then top, tie

Remove from face

Discard

Hand Hygiene

Perform hand hygiene immediately after removing PPE.• If hands become visibly contaminated during PPE

removal, wash hands before continuing to remove PPE

Wash hands with soap and water or use an alcohol-based hand rub

*Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub

For Direct Caregivers

Artificial nails/ nail tips should not be worn

Natural nails should be no more than ¼

inch from the fingertip.

Regarding jewelry:

Wedding bands are acceptable.

Other rings, dangling earrings and bracelets are discouraged.

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

12 Contain your contagion11 Isolate the pathogen

10 Stop treatment when cured9 Know when to say “no” to vanco

8 Treat infection, not colonization7 Treat infection, not contamination

6 Use local data5 Practice antimicrobial control

4 Access the experts3 Target the pathogen

2 Get the catheters out1 Vaccinate

Prevent Transmission

Use Antimicrobials Wisely

Diagnose and Treat Effectively

Prevent Infection

CDC Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Questions