Basic Infection Prevention Training

1. Basic Infection Prevention Training CIP Consulting LLC

2. Basic Infection Prevention Training Role of the ICP

3. Father of Hand Hygiene:Dr. Ignaz Semmelweis

4. Role of the ICP • Infection Prevention and control expert • Mentor staff • Role model for Infection Prevention and Control • Resource for the staff • Design and implement effective programs

5. Role of the ICP • Liaison to public health • Liaison in emergency preparedness • Promote zero tolerance for HAIs • Collect and analyze infection data • Develop and review policies • Consult on infection risk assessments, prevention and control strategies

6. Role of the ICP • Educate and direct interventions to reduce infection risk • Implement change mandated by regulatory bodies • Evaluate Product changes • Evaluate Chemical changes • Development of IC Surveillance plan and annual evaluation (review and discuss a sample infection control surveillance plan with the group)

7. Basic Infection Prevention Training Microbiology Review

8. 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

9. 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.

10. 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.

11. 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.

12. 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.

13. 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”

14. Antibiogram • Done annually by the Microbiology lab. • Helps guide antibiotic usage, very specific to the facility.

15. Multi-drug resistant organisms - MDRO • CDC MDRO definition Bacteria that is resistant to one or more classes of antibiotics • Discuss annual MDRO risk assessment (calculation of MDRO rates discussed in “data and analysis”) • Past and current hospital surveillance data is the core of the MRSA risk assessment. • MRSA risk assessment is developed annually, whenever there is a change based on continuing surveillance, and when change of populations or services occurs. • Information from the MRSA risk assessment drives improvement processes.

16. MDRO • Prevention is key! • Use contact isolation (gowns and gloves before entering room, remove before leaving the room) • Educate the patients and family members with hospital MDRO literature (kept on each unit) • Hand washing before and after patient care • Wipe down equipment shared between patients with hospital approved disinfectant.

17. 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. Review ICRA with the group

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

19. 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.

20. 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.

21. 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 gonorrhoeae and Chlamydia.

22. 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.

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

24. 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)

25. 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.

26. 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.

27. 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)

28. 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.

29. 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.

30. 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.

31. 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)

32. 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)

33. CSF Normal CSF Bacterial Aseptic WBC < 5 > 1,000 5 – 500 Protein < 50 > 100 30 –150 Glucose 2/3 serum glucose < 40 < 30 - 70 Meningitis – Cerebral spinal fluid • Lumbar puncture – The results of the CSF fluid; WBC count, protein, and glucose are important in diagnosis between Bacterial (septic) and Viral (aseptic) meningitis

34. Meningitis OverviewInflammation of the meninges, which surrounds the brain and spinal cord. The inflammation may have infectious or non-infectious causes. Presentation – both viral and bacterial present the same (fever, neck stiffness, altered mental status, headache photophobia, nausea, skin rash in meningococcal meningitis). • Bacterial – often called septic meningitis, it has an identified bacterial cause. (Streptococcus, Neisseria, Haemophilus, Listeria) • Viral – often called aseptic meningitis, which refers to all non bacterial causes of the meningitis, such as viruses, fungi, parasitic, medication related, and malignancies.

35. Diagnostic Tests • CSF Culture • Blood Cultures • CSF and Blood Cultures take time. • Antigen Testing (Serology) Main advantage is speed. The quicker the appropriate antibiotics are given for bacterial meningitis the better!

36. Basic Infection Prevention Training Components of Surveillance

37. Components of Surveillance • Surveillance Methods • Facility wide • Periodic (Quarterly) • Targeted • Outbreak Thresholds • CDC/NHSN definitions of HAI and criteria for specific types of infections in the acute care setting. (introduction to the CDC document, more intense review in intermediate and advance courses)

38. Surveillance • Collecting Relevant Data • Managing Data • Analyzing and Interpreting Data • Communicating Results

39. Reports • Announcements that need to be recorded in the minutes • News related to Infection Prevention • Updates from any construction projects • Reports from regular surveillance • Reports from Employee Health • Reports from Dialysis water cultures • Reports from IC Rounding

40. Annual Review • Evaluate program annually • Highlight accomplishments • Evaluate goals • Set new goals based on risk assessment • Review a sample program evaluation

41. MRSA incidenceIncidence = the number of new cases (1st lab ID specimen) of a given disease in a given time period. Analysis – “Past and current hospital surveillance data is the core of the MRSA risk assessment”.

42. Healthcare associated MRSACDC definition – Lab ID specimen collected > 3 days after admission to the facility (i.e. on or after day 4) Analysis – Based on annual data, HA MRSA goal is < 1 per 1000 patient days.

43. Healthcare associated VRE

44. Healthcare associated C-difficile

45. Breakdown of SSI culturesDecember 2010 – January 2010

46. Annual TB risk assessment 2009 2010 (rates per 100,000) • Oklahoma county TB rate 3.3 3.8 • State TB rate 2.8 2.3 • National TB rate 3.8 3.6 In 2011, The hospital continues to be low risk according to the CDC risk classification of inpatient hospitals with < 200 beds, and outpatient clinics (both must have < 3 confirmed TB patients per year) Issues found during risk assessment and 11/2010 state health visit. 1. Only 1 ICP got immediate notification via email when PPD placed – this was fixed and now both ICP’s get immediate notification, so that prompt assessment can be made regarding negative airflow.

47. TB Risk assessment 2. ACH in negative airflow rooms now checked quarterly and reported to EOC committee. Recommended ACH is 12. 3. Noted that compliance for annual fit testing not 100% as stated in TB control plan – Employee Health working on compliance issue. 4. “TB reference book” placed in nurse house supervisor office. This book has the list of “fit tested” team members and provides reference to reading TBST’s, discontinuation of airborne isolation and references TB control plan.

48. Basic Infection Prevention Training Infection Control Risk assessments

49. ICRA • Multi-disciplinary Risk Assessment • Construction Risk Assessment • TB Risk assessment • Multi-drug resistant Risk Assessment

50. Basic Infection Prevention Training Disease Transmission and isolation