Preventing and Controlling Infectious Agents

1. Preventing and Controlling Infectious Agents APIC Fall Seminar 2012 Stephen P. Blatt MD FACP Medical Director Infectious Diseases TriHealth

2. HAIs - Overview • 1.7 million infections/yr in US hospitals • 99,000 deaths/yr • Cost: $5-10 Billion/yr • Some estimates as high as $30 billion/yr • Occur in 5% of hospitalized patients • Adds at least 4 days to length of stay

3. Outline Procedures and Devices Isolation Precautions Cleaning, Disinfection, Sterilization Risks of Construction

4. Frequency of Infection Types • UTIs 32% • Surgical Site 22% ($10,500/case) • Pneumonia 15% ($23,000/case) • Bloodstream 14% ($25,000/case) • Average annual hospital cost for HAIs is $572,000

5. Procedures and Devices Surgical Site Infections Intravascular Devices Urinary Catheters Ventilator Associated Pneumonia

6. Surgical Site Infection - Background 1840s Semmelweis recognized importance of hand hygiene in preventing Puerperal Fever 1860s Germ Theory advanced by Pasteur and Koch 1870 Lister identified importance of antiseptics in preventing wound infection

7. SSI - Background 30 million surgical procedures in US/yr Account for 22% of all hospital acquired infections SSI doubles the risk for death and increases risk of readmission by 5 times SSI dramatically increases the cost of medical care in the US

8. Pathogenesis of Surgical Site Infection • Inoculum of bacteria – wound contamination • Colon most heavily colonized site • Virulence of organism • Staph aureus (MRSA), Grp A Strep, Clostridium perfringens most virulent • Microenvironment of wound -blood, foreign bodies, necrotic tissue Host Defenses – Immune suppression

9. SSI – Classification System • American College of Surgeons Classification System • Class I – Clean wound: No inflammation, no contaminated spaces encountered • Class II – Clean-contaminated: Respiratory, urinary, GI, or genital tract involved under controlled conditions • Class III – Contaminated wound: Open fresh wound, may have contamination from GI tract, infected urine • Class IV – Dirty, infected wound: fecal contamination, devitalized tissue

11. National Nosocomial Infection Survey NNIS • Standardized scoring system for infection risk using: • Simplified scoring system from 0-3 • Based on following 3 indicators: • ACS score of contaminated or dirty (III or IV) • ASA (American Society of Anesthesia) score >= 3 • Prolonged procedure time > 75th percentile for all similar surgeries

12. NNIS SSI Definitions • Superficial incisional SSI • Involves only skin or subcut tissue • Purulent drainage or + culture or signs of inflammation or Dr dx of wound infection • Deep incisional SSI • Involves deep soft tissue – fascia or muscle • Organ space SSI • Involves any part of the anatomy other than the incision that was involved in the operation

13. Prevention of SSIs • Reducing bacteria at the surgical site • Clip don’t shave • Surgical skin prep • Povidone iodine traditionally used • Increasing data that chlorhexidine-alcohol may be superior • Appropriate air handling in OR • Sterilized surgical instruments • Reducing traffic in and out of OR

14. Prevention of SSIs • Prophylactic antibiotic therapy • Antibiotic should be active against bacteria found at the site of surgery • Must be given pre-op and highest concentration should be in the tissue at the time of incision (ideally given 30-60 minutes prior to incision) • Antibiotics should be discontinued within 24 hours of surgery

15. Prevention of SSIs – Host Factors Normothermia – hypothermia increases risk for infection Normal blood sugar – multiple studies reveal hyperglycemia is assoc with increased risk of infection

16. INFECTIOUS AGENTA microbial organism with the ability to cause disease. The greater the organism's virulence (ability to grow and multiply), invasiveness (ability to enter tissue) and pathogenicity (ability to cause disease), the greater the possibility that the organism will cause an infection. SUSCEPTIBLE HOSTA person who cannot resist a microorganism invading the body, multiplying, and resulting in infection. The host is susceptible to the disease, lacking immunity or physical resistance to overcome the invasion by the pathogenic microorganism. RESERVOIRA place within which microorganisms can thrive and reproduce. PORTAL OF EXITA place of exit providing a way for a microorganism to leave the reservoir. PORTAL OF ENTRYAn opening allowing the microorganism to enter the host. MODE OF TRANSMISSIONMethod of transfer by which the organism moves or is carried from one place to another.

17. Case 1 • 48 yo male with pneumonia in ICU with resp failure on Rocephin and Levaquin • Day 5 of ICU stay develops T 102 • Exam: still intubated • Chest few rhonchi • Heart RRR no murmur • Abd soft/NT • R IJ TLC looks OK

18. Case 1 • CXR – clearing RLL infiltrate vs admission • UA – 5-10 WBC/HPF (from foley) • Blood cultures sent • Sputum cultures sent

19. Case 1 • Sputum culture: mixed flora • Urine culture: negative • Blood culture from central line and peripheral site: GPC clusters

20. CLABSICentral Line-associated Blood Stream Infection • Commonly known as “Line Sepsis” • Definition: Recognized pathogen cultured from one or more blood cultures and not related to infection at another site (ie UTI or pneumonia) in a patient with a central line in place • Or 2 positive blood cultures of a common skin organism (ie coag neg Staph) in a patient with signs/symptoms of infection

21. CLABSI Risk Factors • Femoral line site • Prolonged hospitalization • Prolonged duration of catheterization • Heavy microbial colonization at insertion site • Femoral > IJ > Subclav/PICC • Neutropenia • Prematurity • TPN

22. CLABSI Bundle • Education in insertion, care and maintenance of central lines • Use a catheter insertion “Checklist” for every insertion • Hand hygeine prior to insertion • Avoid femoral site • Maximal sterile barriers (cap, gown, gloves, drape) • Chlorhexidine based skin prep (not iodine) • Standardized dressing change protocol

23. CLABSI Additional Approachesif rates remain high • Bathe ICU patients with Chlorhexidine on a daily basis • Use antiseptic or antibiotic impregnated Central lines • Use chlorhexidine-containing sponge dressing on insertion site (Biopatch) • Use antimicrobial lock therapy

24. Approaches NOT to Use • Do not use systemic antimicrobial prophylaxis • “just leave the patient on vanco until the line comes out” • Do not routinely replace central lines in the absence of infection

25. Performance Measures • Compliance with the Insertion Bundle Checklist • Daily assessment of need for central line • Compliance with dressing change protocol • CLABSI rate: infection/1000 catheter days • Current national rate: 2.1/1000

26. HCAP – Health care associated Pneumonia • 20-50% Mortality in some studies • 15% of all hospital deaths • Mortality with Pseudomonas = 70%

27. HCAP Risk Factors • Intubation • ICU admission • Antibiotic therapy • Surgery – esp Abdominal, chest surgery • Chronic lung disease • Advanced age • Immunosuppression

28. HCAP Diagnosis • Difficult in ICU patients • New infiltrate on CXR with • Fever, leukocytosis (>12) or confusion and • 2 of: worsening sputum, cough or dyspnea, rales, worsening oxygenation • Positive cultures • New Definitions begin 2013: • VAC – ventilator assoc condition • IVAC – Infection-related VAC • Possible VAP, Probable VAP

29. VAP PreventionVentilator-associated Pneumonia • Conduct active surveillance for VAP and measure rates • Maintain head of bed up at 35 degrees • Perform frequent antiseptic mouth care • Promote the use of non-invasive ventilation • Extubate as soon as possible – Daily SBT • Special approaches: ET tubes with in-line subglottic suctioning system

30. VAP PreventionWhat not to do • IVIG • WBC colony stimulating factors (Filgrastim) • Chest physiotherapy • Prophylactic inhaled or IV antibiotics

31. Case 2 • 46 yo WF 4 days s/p abd hysterectomy • T 102, nausea, vomiting • Exam: Clear lungs • Mild tenderness around wound, no erythema or drainage, mild suprapubic tenderness, Foley remains in place • UA with 1+ pro, 2+ LE, 40-60 WBCs • WBC count 15,000 • Bugs? • Drugs?

32. CA-UTICatheter-associated UTI • Most common HAI • 80% due to Foley catheter • 12-16% of all hospitalized patients will get a UTI • 3-7% of patients/day with a Foley in place

33. CA-UTI Risk Factors • Duration of catheterization • Female sex • Older age • Lack of maintenance of closed drainage system

34. CA-UTI Prevention • Use Foley catheter only when necessary: • Perioperative for certain surgical procedures • Urine output monitoring in critically ill patients • Acute urinary retention and obstruction • Assistance in pressure ulcer healing • Standardized, aseptic insertion technique • Perform surveillance for infection rates • National ICU rate: 3.4/1000 Foley days • GSH MSICU rate: 1.6/1000

35. CA-UTI Prevention • Properly secure catheter to prevent trauma • Maintain a sterile, closed drainage system • Keep the bag below the level of the bladder to prevent backflow • Remove the Foley when no longer needed!

36. CA-UTI PreventionMethods not to use • Do not routinely use silver coated or antibiotic impregnated catheters • Do not screen for asymptomatic bacteriuria • Do not treat asymptomatic bacteriuria • Except before invasive urinary procedures • Avoid catheter irrigation • Do not use systemic antibiotic prophylaxis • Do not change catheters routinely

37. Standard Precautions • If it’s wet and it’s not yours, don’t touch it! • Applicable to all patients • What Personal Protective Equipment (PPE) to use: • What are my patient’s signs and symptoms? • What am I doing to my patient? • Use barriers (gown, gloves, face protection) • Protect skin, clothing, mucous membranes (eye, nose, mouth – T-zone)

38. Hand Hygiene Key to reducing HAIs Improved hand hygiene compliance has been shown to decrease HAI rates Education of HCWs on need for and methods for hand hygiene is required Monitoring of hand hygiene compliance is critical

39. Indications for Hand Hygiene Soap and water: Hands visibly soiled Before eating After using the restroom When contact with spore forming organisms is suspected (C diff)

40. Indications for Hand Hygiene Soap/water or alcohol based hand gel: Before and after direct patient care Before donning sterile gloves Before inserting invasive devices After removing gloves After contact with equipment in the patient’s immediate vicinity When moving from a contaminated body site to a clean body site during patient care

41. Alcohol Hand Rub/Gel • When NOT to use alcohol: • When hands are visibly soiled • When caring for a patient with undiagnosed diarrhea, suspect or confirmed Clostridium difficile, Norovirus, or other enteric viruses • Must allow it to air dry • 1 full squirt is enough • Is an adjunct to soap and water, not a replacement

42. Methods to Monitor Hand Hygiene Direct observation – “secret shopper” Allows both quantitative (% compliance) and qualitative (soap or gel, duration of washing) evaluation Monitor volume of hand product used Monitor adherence to artificial fingernail policy

43. Contact Precautions Reduces the risk of transmitting microorganisms by : • direct contact (skin to skin) or • indirect contact (susceptible host to contaminated/colonized object). Private room or cohort patients with the same organism Gloves and gowns are worn when entering the room

44. Contact Precautions MRSA VRE C. difficile MDROs – multi-drug resistant organisms RSV in infants

45. Contact Precautions • Limit patient transport: minimize the risk of transmission and contamination of environmental surfaces. • Dedicate the use of non-critical equipment. Stethoscope, BP cuff, thermometer • All equipment in the patient’s room must be cleaned and disinfected

46. “C Diff ”…A New Threat From an Old Enemy • Gram positive anaerobic, bacillus • Spore former: resistant to typical cleaning strategies requiring: Environment – bleach Hand hygiene - soap and water • Resides: GI tract (normal floral usually keep the bacteria to a minimum) • Risk factors: antibiotic therapy >90% of C difficile HAIs occur after or during antimicrobial therapy.

47. Hyper virulent strain of Clostridium difficile • New strain produces up to 20 times more toxin Complications: • CDAD- C.diff associated diarrhea • Pseudo membranous colitis • Toxic mega colon • Perforations of the colon • Sepsis • Death – Mortality rate up to 20% in the frail elderly

48. C. difficile Interventions • Antibiotic Stewardship • Isolate patients with diarrhea and C.difficile immediately • Wear PPE gowns and gloves • Hand hygiene with soap and water • Not alcohol hand gel • Clean room surfaces and equipment with bleach

49. 12 Steps to Prevent Antimicrobial Resistance *from CDC slide set • Prevent infection • Vaccinate • Get invasive devices out ASAP • Diagnose and Treat Effectively • Target the pathogen • Access the experts • Use Antimicrobials Wisely • Practice antimicrobial control • Treat infection, not colonization • Stop treatment when infection is cured or unlikely • Prevent Transmission • Isolate the pathogen • Break the chain of infection

50. Newest Tools in the Arsenal • UVC devices • Kill spores including C.diff • Ozone and chemical gas generation devices also available