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Challenges for Infection Prevention in the 21 st Century

Challenges for Infection Prevention in the 21 st Century. William A. Rutala, Ph.D., M.P.H. UNC Health Care and UNC School of Medicine, Chapel Hill, NC. Disclosure.

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Challenges for Infection Prevention in the 21 st Century

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  1. Challenges for Infection Prevention in the 21st Century William A. Rutala, Ph.D., M.P.H. UNC Health Care and UNC School of Medicine, Chapel Hill, NC

  2. Disclosure This educational activity is brought to you, in part, by Advanced Sterilization Products (ASP) and Ethicon. The speaker receives an honorarium from ASP and Ethicon and must present information in compliance with FDA requirements applicable to ASP.

  3. CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS • Changing population of hospital patients • Increased severity of illness • Increased numbers of immunocompromised patients • Shorter duration of hospitalization • More and larger intensive care units • Larger step-down units • Growing frequency of antimicrobial-resistant pathogens • Lack of compliance with hand hygiene and other infection preventive measures (e.g., endoscope)

  4. CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS • Limited infection prevention resources • Implementation of bundles demonstrated to reduce HAIs • Public reporting of HAIs • CMS non-reimbursement for HAIs • Health insurance reimbursement tied to quality goals • State and federal laws legislating care issues • Influenza immunization for staff • MRSA screening of patients and staff • Greater emphasis on infection prevention by The Joint Commission

  5. Tranquil Gardens Nursing Home HEALTHCARE SYSTEM OF THE PAST Home Care Outpatient/ Ambulatory Facility Acute Care Facility Long Term Care Facility

  6. Tranquil Gardens Nursing Home CURRENT HEALTHCARE SYSTEM Acute Care Facility Home Care Outpatient/ Ambulatory Facility Long Term Care Facility

  7. HEALTHCARE-ASSOCIATED INFECTIONS: IMPACT • 1.7 million infections per year • 98,987 deaths due to HAI • Pneumonia 35,967 • Bloodstream 30,665 • Urinary tract 13,088 • SSI 8,205 • Other 11,062 • 6th leading cause of death (after heart disease, cancer, stroke, chronic lower respiratory diseases, and accidents)1 1 National Center for Health Statistics, 2004

  8. MORTALITY RATE OF COMMON HAIs

  9. INCREMENTAL HOSPITAL DAYSDUE TO COMMON INFECTIONS

  10. RATES OF HEALTHCARE-ASSOCIATED INFECTIONS PER 1,000 PATIENT DAYS 69% Increase

  11. COST ESTIMATES FOR HEALTHCARE-ASSOCIATED INFECTIONS (HAIs) Anderson DJ, et al. ICHE 2007;28:767-773 Costs based on literature review 1985-2005; adjusted to US 1995 dollars

  12. CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS • Changing population of hospital patients • Increased severity of illness • Increased numbers of immunocompromised patients • Shorter duration of hospitalization • More and larger intensive care units • Larger step-down units • Growing frequency of antimicrobial-resistant pathogens • Lack of compliance with hand hygiene and other infection preventive measures (e.g., endoscope)

  13. HAZARDS IN THE ICU Weinstein RA. Am J Med 1991;91(suppl 3B):180S

  14. PREVALENCE: ICU (EUROPE) • Study design: Point prevalence rate • 17 countries, 1447 ICUs, 10,038 patients • Frequency of infections: 4,501 (44.8%) • Community-acquired: 1,876 (13.7%) • Hospital-acquired: 975 (9.7%) • ICU-acquired: 2,064 (20.6%) • Pneumonia: 967 (46.9%) • Other lower respiratory tract: 368 (17.8%) • Urinary tract: 363 (17.6%) • Bloodstream: 247 (12.0%) Vincent J-L, et al. JAMA 1995;274:639

  15. RISK FACTORS FOR ICU-ACQUIRED INFECTIONS (95% CI) (1.01-1.43) (1.16-1.57) (1.20-1.60) (1.19-1.69) (1.51-2.03) (1.75-2.44)

  16. RISK FACTORS FOR ICU-ACQUIRED INFECTIONS (95% CI) (1.56-4.13) (5.51-14.70) (9.33-24.14) (19.43-48.67) (37.90-96.25) (48.18-120.06)

  17. NOSOCOMIAL INFECTIONS IN THE UNITED STATES Burke JP. NEJM 2003;348:651

  18. AGING POPULATION, US

  19. CANCER: INCIDENCE & DEATHS, 2006 (estimated) American Cancer Society

  20. CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS • Changing population of hospital patients • Increased severity of illness • Increased numbers of immunocompromised patients • Shorter duration of hospitalization • More and larger intensive care units • Larger step-down units • Growing frequency of antimicrobial-resistant pathogens and emerging pathogen • Lack of compliance with hand hygiene and other infection preventive measures (e.g., endoscope)

  21. Penicillin [1940s] Methicillin [1960s] Methicillin-resistant S. aureus (MRSA) Penicillin-resistant S. aureus S. aureus Vancomycin [1997] Ciprofloxacin 1987 [2002] Vancomycin- resistant S. aureus Vancomycin (glycopeptide) intermediate-resistant S. aureus Vancomycin-resistant enterococcus (VRE) Evolution of Antimicrobial Resistancein Gram-positive Cocci CA-MRSA

  22. UNITED STATES • Enterobacter / Ceftazidime 21→19% • E. coli / ESBL phenotype 3→5% • E. coli / Ciprofloxacin 4→19% • Klebsiella / ESBL phenotype 6→15% • Klebsiella / Ciprofloxacin 4→13% • Klebsiella / Imipenem (2 μg/ml) <1→5 (3.7)%

  23. UNITED STATES • P. aeruginosa / Imipenem 9→8% • P. aeruginosa / Piperacillin-tazobactam 11→12% • P. aeruginosa / Ciprofloxacin 17→19% • Acinetobacter / Amikacin 11→16% • Acinetobacter / Ceftazidime 23→45% • Acinetobacter / Imipenem 3→7%

  24. Current concerns Vancomycin resistant Staphylococcus aureus Multidrug resistant gram negative pathogens Clostridium difficile (strains that hyperproduce toxin) Norovirus Prions XDR-TB Future concerns but planning required Influenza pandemic (H5N1?) Bioterrorism Gene transfer Xenotransplantation EMERGING INFECTIOUS AGENTS

  25. EMERGING INFECTIOUS DISEASES RELEVANT TO THE HOSPITAL • 1977 (US) – Legionnaire’s disease • 1978 (US) – Staphylococcal toxic shock syndrome • 1996 (England  US) – Variant Creutzfeld-Jakob disease (vCJD) • 2001 (US) - Anthrax (attack via letters)* • 2002 (US) – Vancomycin-resistant S. aureus* • 2002 (Canada  US) – Hypervirulent C. difficile* • 2003 (China  worldwide) - SARS* • 2003 (US) – Monkeypox* • 2004 (Asia) – Avian influenza (H5N1)* • 2006 (Worldwide) – XDR-TB* * HCWs at risk for infection

  26. Person-to-person transmission Andes hanta virus Anthrax* C. difficile Monkeypox Norovirus (G-II strain) Plague* Rabies Smallpox* Viral hemorrhagic fever* Fomite transmission Anthrax* C. difficile Norovirus Plague* Q fever* Smallpox* Lab risk Q fever* Monkeypox Smallpox* RISKS FROM EMERGINGINFECTIOIUS DISEASES * BT agent

  27. SARS

  28. Total SARS Cases and % Healthcare Workers by Country % HCW Total No. SARS Cases % HCW

  29. CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS • Changing population of hospital patients • Increased severity of illness • Increased numbers of immunocompromised patients • Shorter duration of hospitalization • More and larger intensive care units • Larger step-down units • Growing frequency of antimicrobial-resistant pathogens • Lack of compliance with hand hygiene and other infection preventive measures (e.g., endoscope)

  30. Lack of Compliance • Hand Hygiene • Endoscope reprocessing • SSI

  31. ASSOCIATION BETWEEN HAND HYGIENE COMPLIANCE AND HAI RATES HAI, healthcare-associated infections *Other infection control measures also instituted Boyce JM, Pitter D. MMWR 2002;51(RR-16)

  32. How Is Our Track Record on Handwashingin Healthcare Facilities? • A review of 34 published studies of handwashing adherence among healthcare workers found that adherence rates varied from 5% to 81% • The average adherence rate was only 40% Average Handwashing Adherence of Personnel in 34 Studies Average

  33. Hand Hygiene Adherence an Institutional Priority • Multidisciplinary Program • Administrative support (IOC, Executive Staff, Dept Heads) • Monitor HCWs adherence to policy and provide staff with information about performance • Provide HCWs with accessible hand hygiene (HH) products to include alcohol based hand rubs • Education regarding types of activities that result in hand contamination and indications for hand hygiene • Reminders in the workplace (e.g., posters) • Considering ways to include HH in management standards (loss of hospital privileges, tickets for non-compliance, coffee coupons)

  34. UNC Hospitals Intensive Care Units Hand Hygiene Compliance Pocket-sized alcohol based gel available  Evaluated hand hygiene products  Leadership presentations Collected baseline data      Implemented Infection Control Liaisons Staff HH compliance added to patient satisfaction survey Began quarterly compliance reports to ICUs Ongoing education

  35. GI ENDOSCOPES • Widely used diagnostic and therapeutic procedure • Endoscope contamination during use (109 in/105 out) • Semicritical items require high-level disinfection minimally • Inappropriate cleaning and disinfection has lead to cross-transmission • In the inanimate environment, although the incidence remains very low (35 cases of transmission from 1993-2002), endoscopes represent a risk of disease transmission

  36. Endoscope Reprocessing: Current Status of Cleaning and Disinfection • Guidelines • Society of Gastroenterology Nurses and Associates, 2000 • European Society of Gastrointestinal Endoscopy, 2000 • British Society of Gastroenterology Endoscopy, 1998 • Gastroenterological Society of Australia, 1999 • Gastroenterological Nurses Society of Australia, 1999 • American Society for Gastrointestinal Endoscopy, 2003 • Association for Professional in Infection Control and Epidemiology, 2000 • Multi-society Guideline for Reprocessing Flexible GI Endoscopes, 2003 • Centers for Disease Control and Prevention, 2004 (in press)

  37. Endoscope Reprocessing, Worldwide • Worldwide, endoscopy reprocessing varies greatly • India, of 133 endoscopy centers, only 1/3 performed even a minimum disinfection (1% glut for 2 min) • Brazil, “a high standard …occur only exceptionally” • Western Europe, >30% did not adequately disinfect • Japan, found “exceedingly poor” disinfection protocols • US, 25% of endoscopes revealed >100,000 bacteria Schembre DB. Gastroint Endoscopy 2000;10:215

  38. TRANSMISSION OF INFECTION • Gastrointestinal endoscopy • >300 infections transmitted • 70% agents Salmonella sp. and P. aeruginosa • Clinical spectrum ranged from colonization to death (~4%) • Number of reported infections is small, suggesting a very low incidence • Endemic transmission may go unrecognized • Bronchoscopy • 90 infections transmitted • M. tuberculosis, atypical Mycobacteria, P. aeruginosa Spach DH et al Ann Intern Med 1993: 118:117-128 and Weber DJ et al Gastroint Dis 2002;87

  39. ENDOSCOPE INFECTIONS • Infections traced to deficient practices • Inadequate cleaning (clean all channels) • Inappropriate/ineffective disinfection (time exposure, perfuse channels, test concentration) • Failure to follow recommended disinfection practices (drying, contaminated water bottles, irrigating solutions) • Flaws in design/manufacture of endoscopes or AERs

  40. ENDOSCOPE DISINFECTION • CLEAN-mechanically cleaned with water and enzymatic detergent • HLD/STERILIZE-immerse scope and perfuse HLD/sterilant through all channels for at least 12-20 min • RINSE-scope and channels rinsed with sterile, filtered or tap water followed by alcohol • DRY-use forced air to dry insertion tube and channels • STORE-prevent recontamination

  41. Surgical Site Infection SSIs third most common HAI, accounting for 14-23% of HAIs Among surgical patients, SSIs were most common accounting for ~40% of healthcare-associated infections 67% incisional infections (confined to incision) 33% organ/space infections Increase an average of 7 days to each hospitalization Increase >$10,000 (2005 $) to each hospitalization Appropriate preoperative administration of antibiotics and other prevention measures are effective in preventing infection Surgical Site Infections. Available at: http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/. Odom-Forren J. Nursing2006. 2006;36(6):58-63.

  42. Cost Estimates for Specific Healthcare-Associated Infections 2005 US dollars Anderson DJ, et al. ICHE 2007;28:767-773

  43. Clinical and Economic Impact Adapted from: Darouiche RO. N Engl J Med. 2004;350:1422-429. *Darouiche RO. Clin Infec Dis. 2001;38:1567-1572.

  44. Clinical and Economic Impact Adapted from: Darouiche RO. N Engl J Med. 2004;350:1422-429. *Darouiche RO. Clin Infec Dis. 2001;38:1567-1572.

  45. Surgical Site Infection • Advances in infection control practices • Improved operating room ventilation • Sterilization methods • Barriers • Surgical technique • Antimicrobial prophylaxis

  46. SSI: Pathogenesis Risk of surgical site infections = Dose of bacterial contamination x virulence (toxins) Resistance of the host

  47. SSI: Primary Risk Factors Endogenous microorganisms Skin-dwelling microorganisms Most common source S aureus most common isolate Fecal flora (gnr) when incisions are near the perineum or groin Exogenous microorganisms Surgical personnel (members of surgical team) OR environment (including air) All tools, instruments, and materials (extremely rare) Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

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