Infection Control C. Diff, MRSA, VRE

1. Infection ControlC. Diff, MRSA, VRE Karyn Leible, RN, MD Chief clinical Officer Pinon Management Medical Director Colorado State Veterans Home, Fitzsimons

2. 483.65 Infection ControlF Tag 441 • F-Tag 441 (R) - Facility must: • establish and maintain an Infection Control Program • provide a safe, sanitary, comfortable environment • Help prevent development and transmission of disease and infection

3. Diarrhea Outbreak • Your facility has a significant diarrhea outbreak: • Your Inf Cntrl program is working (the medical director is supposed to be notified of possible outbreaks). The ICP calls to inform you that the facility has had 16 cases of diarrhea in the last two days. (No surprise, staff absenteeism is up too). • Are there any recommendations to prevent spread you would like to make?

4. Diarrhea outbreak • The ICP reminds you that the facility was cited at the last survey for non-compliance with F-Tag 444 - Handwashing [F-Tag 444 is also under 483.65 Infection Control] • You remember giving an inservice on handwashing as part of the Plan of Correction (POC)

5. F-Tag 444 Hand washing • ( R) The facility must require staff to wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice. • (IG) Procedures must be followed to prevent cross contamination, including handwashing or changing gloves after providing personal care, or…. • IG) Facilities for hand washing must be available

6. Case 2: Diarrhea outbreak • You recommend isolation (remain in room, meals in room) for residents with diarrhea • This is of course in addition to your ongoing “universal precautions” policy • standard precautions • Your social worker says you can’t do that, it violates residents’ rights

7. F-Tag 442 Preventing the spread of infection • ( R ) When the infection control program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident • ( IG ) Isolate appropriately to reduce the risk of transmission

8. F-Tag 442 Preventing the spread of infection • (IG) Isolate residents only to the degree needed to isolate the infecting organism • (IG) Method should be the least restrictive possible while maintaining the integrity of the process

9. Diarrhea outbreak • This example is “real” • In South Dakota between October 2, 2002 and January 8, 2003, 14% of 6093 residents became ill with acute gastrointestinal symptoms • In the facility, 56% of residents had gastrointestinal symptoms within a 9 day period at the end of December 2002

10. Diarrhea outbreak • Investigation by the state health department strongly suggested that the majority of these cases were related to Norovirus infection • This is the same virus implicated in diarrheal outbreaks on cruise ships

11. Norovirus • High attack rates (68% in one study) • Can shed up to two weeks after sx’s resolve • Low infectious dose (< 100 virons) • High persistence of agent in the environment • Potential for multiple modes of transmission • Percentage cases with vomiting > 50% • Absence of long-lasting immunity • Outbreaks can involve multiple strains www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus-fact sheet-htm

12. Surveillance

13. Infection ControlSurveillance Program • Infections present on the resident’s admission or readmission, or that develop within 48 hours* after admission, are NOT considered nosocomial * 48 hours may not be long enough in the case of C. difficile, but regs and their necessarily arbitrary definitions cannot account for this “outlier”

14. Infection ControlSurveillance Program • It is important and useful to have precise definitions • Be sure you know what definitions the ICP is utilizing • Be sure the ICP is compulsive in adhering to definitions

15. Infection ControlEpidemiological Definitions • General rules: A. Only NEW symptoms or acute changes in chronic symptoms should be considered B. Potential noninfectious causes of the symptoms and signs should always be considered before diagnosing infection C. Infection should be diagnosed based on several supporting data and not on a single finding. Microbiological and radiological findings should be used only to confirm clinical evidence of infection

16. MDS Section I-2 asks about infections

17. Infection Control • Rates of infection: • Calculation of rates • Review and trend monthly • Watch for patterns, outbreaks • Add your clinical knowledge to apparent statistical truth • Review of antibiotic usage is often an easily obtained and useful adjunct to ICP generated statistical data

18. Clostridium difficile • Diagnostic Criteria • Diarrhea • Evidence of CDAD (c. diff associated diarrhea) by any of the following • Positive assay • Pseudomembranous colitis • Positive stool culture

19. Clostridium difficile Diagnostic Tests • Cell Culture Cytotoxin Assay • Stool Culture • EIA

20. Clostridium difficile Facts • Leading cause of nosocomial enteric infection. • 3 million new cases/year in U.S. • 20 thousand new cases/year in U.S. outside hospital setting.

21. C. DIFF. C. DIFF. C. DIFF.

22. Clostridium difficile HEALTH CARE WORKER • Rarely have fecal carriage. • Carriage on stethoscopes, clothing and hands well documented. • Hand washing/gloves proven to decrease rates of infection. • One study, HCW hand culture rate was 59%.

23. Clostridium difficile PRIMARY PREVENTION • Antibiotic Control • Avoid antibiotic use. • Limit duration. • Antibiotics with and association • Cephalosporins (keflex, rocephin) • Clindamycin • Floroquinalones (Cipro, Levoquin)

24. Clostridium difficile PRIMARY PREVENTION • Hand washing and gloves. • Both proven to lower Clostridium difficile rates. • Simple tasks but compliance low. • Responsibility • As your mother said “WASH YOUR HANDS” • And use soap!

25. Clostridium difficile PRIMARY PREVENTION • What to wash with? • Study – liquid soap vs 4% chlorhexidine • Without gloves – no difference. • With gloves – liquid soap out-performed 4% chlorhexidine. • Wash with soap • Remember Mom says: “use soap!”

26. Clostridium difficile PRIMARY PREVENTION • “Cleaning” the Long Term Care Facility • Eliminate or reduce spores. • Spores are widespread and can persist for weeks-months. • Spores are resistant to most commonly used disinfectants. • 1:10 bleach and water solution • Cleaning reduces spore numbers.

27. Clostridium difficile PRIMARY PREVENTION • “Cleaning” the facility • As bed occupancy increases, time for cleaning decreases. • Frequent movement of patients from bed-to-bed. • Readmissions of asymptomatic carriers.

28. Clostridium difficile SECONDARY PREVENTION • Hand washing/gloves. • Gowns. • Thorough cleaning of all contaminated and potentially contaminated surfaces. • Isolation/private rooms (the greater the diarrhea, the greater the need).

29. Clostridium difficile • SECONDARY PREVENTION • Room contamination rates (McFarland, 1989). • C. diff. (-) patient = 8% • C. diff. Asymptomatic carrier = 29% • CDAD patient = 49%

30. Clostridium difficile • An outbreak is likely to be caused by the transmission of organisms by staff and a breakdown in the use of standard precautions. • Therefore an intense education program for staff should ensue with rigorous supervision of handwashing and use of gloves and gowns.

31. Resistant Organisms

32. Resistant Organisms The admissions coordinator wants to admit a patient whose labs indicate MRSA is growing in the sputum. The ICP calls to see if this is ok and to ask what precautions, if any, will be necessary.

33. Methicillin Resistant Staphylococcus aureus • What we think we know about MRSA • STAPHYLOCOCCUS AUREUS • 40% of healthy adults colonized with SA, half of those with nasal colonization carry it on their hands • 10-44% of NF residents may be colonized • Half-life of colonization estimated to be 40 months • Eradication of colonization rarely indicated • Re-colonization after treatment is stopped is common • Tend to select for resistant organisms

34. What we think we know about MRSA • Colonization rate increases with • Bedridden • Feeding tube, urinary catheter • Poor functional status • Hospitalization within 6 months • Fecal incontinence • Wounds • Dialysis

35. What we think we know about MRSA • Transmission • Contaminated environmental surfaces NOT felt to play a big role • Contact (person to person) • Role of airborne spread unclear • Medicated soaps or alcohol gels may remove SA from skin

36. MRSA in Wounds • Attempt to cohort with other MRSA residents • Avoid non-MRSA roommates who have unhealed wounds, indwelling catheters, or are immunosuppressed • If drainage can be contained in a dressing, resident may go out of room unless exhibiting behaviors likely to increase chance of transmission (e.g., picking at wound dressing, picking nose)

37. MRSA in Urine • MRSA in urine • Cohort with other MRSA patients • Avoid high risk roommates • If continent, may leave room • If incontinent, ICP and Medical Director should analyze whether isolation to room is necessary (usually not)

38. Respiratory MRSA • Active pneumonia or bronchitis • Private room • Standard surgical masks for all entering room • Respiratory tract colonization without signs of infection • Private room not necessary • Cohort • Avoid high risk roommates • At first sign of acute exacerbation, re-evaluate need for respiratory (droplet) isolation

39. MRSA • Housekeeping: standard practices appropriate • Barriers: • Gloves should be used, wash hands after removing gloves • Gown use if care activity likely to result in soiled clothing (i.e., gown not needed to take a temperature or give medication) • Masks needed only if aerosolization likely • Isolation carts likely to be helpful

40. MRSA in LTC • In LTC • Infection rates • (colonized =10%/yr; non colonized =2-4%/yr) • Colonization not clearly related to MRSA-induced morbidity • Non-MRSA mortality in colonized residents is 2-3 times higher than in non-colonized • probably reflecting functional status and underlying disease

41. MRSA: Emerging issues • Vancomycin Resistant Staphylococcus aureus • One case reported from Detroit in 2002 • One case reported from Pennsylvania in 2003 • One case reported from New York in 2004 (MMWR 4-23-2004) Many more since

42. MRSA Guidelines • Changes • Hibliclens baths and mupirocin to nares no longer required during treatment of MRSA infection. • Surveillance cultures and/or decolonization therapy should not be required for admission to a LTCF.

43. MRSA Guidelines • Outbreak • Increase in number of MRSA cases or a cluster of new cases (facility dependent) • Increase of 25% • 3 or more new healthcare associated cases • Decolonization of residents with MRSA • Only in consultation with medical director or infection control specialist. • Decolonization of healthcare workers • Only if linked to epidemic

44. MRSA Guidelines • Outbreak • Surveillance cultures • Skin breakdown, draining wounds, anterior nares • Other affected sites • Serial cultures weekly to document end of transmission • Focus on involved unit, indiv at high risk for MRSA, roommates • Remember only consider surveillance cultures in outbreak situations.

45. Resistant Organisms • What if the potential resident had a urine culture showing VRE? Would you approve admission?

46. What we think we know about VRE • ENTEROCOCCI, (E. faecalis & E. faecium) • normal inhabitants of the bowel • often resistant to aminoglycosides • when high resistance occurs to gentamycin and streptomycin, there is usually no reliably bactericidal regimen

47. What we think we know about VRE • Multiple genetic mechanisms for vancomycin resistance • Vancomycin resistance has been demonstrated to transfer between VRE and Staph aureus, Listeria, and Strep pyogenes • Death rates from VRE bacteremia may exceed 30%

48. What we think we know about VRE • RISK FACTORS FOR COLONIZATION • Recent treatment with oral or parenteral Vancomycin or cephalosporins • Recent treatment with anti-anaerobic drugs (metronidazole, clindamycin, imipenem) • Prolonged hospitalization • Proximity to patient colonized by VRE (not clearly demonstrated in LTC)

49. What we think we know about VRE • RISK FACTORS FOR COLONIZATION • Care by nurse who cares for another VRE patient • Longer ICU stay • Care in hospital with high VRE prevalence • Contamination from inanimate objects • Factors increasing environmental or skin contamination (e.g., diarrhea)

50. What we think we know about VRE • COLONIZATION • Fecal VRE an important source of infection as well as nosocomial spread • Skin colonization (even above the waist) is common • Duration of colonization variable (up to years)