Isolation precautions. Patama Suttha M.D. 15 Dec 2015 Bamrasnaradura Infectious diseases Institute

Transcription

1 Isolation precautions Patama Suttha M.D. 15 Dec 2015 Bamrasnaradura Infectious diseases Institute

2 Isolation precautions: Aim Reduce direct or indirect transmission of HAI 3 mechanisms: - Contact transmission : Direct, Indirect - Droplets > 5 micron, travel < 1m - Airborne transmission : suspended in the air

3 Precautions to Prevent Transmission of Infectious Agents Standard precautions 1990s Recommended in care of all hospitalized patients Apply when contact with blood, other body fluids, nonintact skin, mucous membranes and secretions and excretions except sweat Transmission based precautions - Contact Precaution Direct contact Indirect contact - Droplets Precaution - Airborne Precautions

4

5 When should hand hygiene take place immediately? Removal of gloves Before and between pt contact Any time handles blood, body fluid, secretion or excretion or contaminated equipment

6 Isolation precautions 3 different types : Contact Isolation Precautions used for infections, diseases, or germs that are spread by touching the patient or items in the room (ex: MRSA, VRE, diarrheal illnesses, open wounds, RSV). Droplet Isolation Precautions used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (ex: pneumonia, influenza, Pertussis, Meningococcemia). Airborne Isolation Precautions used for diseases or very small germs that are spread through the air from one person to another (ex: TB, measles, chickenpox

7 Contact precautions Transmission by skin to skin contact Direct physical transfer of organisms : - EVD, Lassa, Marburg HF - Colonization or infection with MDR - C. difficile infection - Acute diarrhea in incontinent pt - Respiratory virus - Skin infection : Impetigo, decubitus, abscess, Cutaneous diphtheria - Scabies, Pediculosis, HSV, HZV

8 Contact precautions Private room if possible When not available, cohort pt with the same organism without other infection Nonsterile gloves, clean and nonsterile gown : Before entering pt room Hand hygiene Limit pt transportation Use equipment to a single patient

9 Contact precaution Direct contact Indirect contact Norwegian scabies Herpetic Whitlow Common:Children,Dentis ts, Med care providers

10 Contact Precautions Apply to patients with any of the following conditions and/or disease: Presence of stool incontinence (may include patients with norovirus, rotavirus, or Clostridium difficile) Draining wounds, uncontrolled secretions, pressure ulcers, or presence of ostomy tubes and/or bags draining body fluids Presence of generalized rash or exanthems

11 Contact Precautions Colonization of with MDR bacteria Enteric infections( C.diff,entero virus,e.coli Respiratory virus ( RSV, Rhinovirus, Influenza etc) Ebola viral diseases Skin infection: Scabies,Noncontained abcesses or decubitus ulcers

12 Contaminated Surfaces tested positive for VRE (+) in patient environment. Hayden M. ICAAC,2001, Chicago, IL

13 Droplet precautions Apply to pts known / suspected to be infected with a pathogen that transmitted by droplet route ( > 5 micron) during sneezing, coughing, talking or during invasive procedures eg Bronchoscopy Adenovirus, influenza, Bordetella pertusis, pharyngeal diphtheria For first 24 hrs of Rx meningococcemia, group A streptococcus, Scarlet fever in young children Mumps, Parvovirus B19, Rubellla Plague( Pneumonic), Mycoplasma pneumoniae

14 Droplet precautions Private room if possible Maintain seperation at least 1 meter between the pt and the others Special ventilation is unnecessary Surgical mask : Within < 1 m of the pt Limit pt transport : maintain isolation precaution during transportation

15 Airborne Precautions Apply to patients known or suspected to be infected with a pathogen ( < 5 um) that can be transmitted by airborne route Tuberculosis ( Pulmonary/Laryngeal TB) Measles Chickenpox (until lesions are crusted) Localized (in immunocompromised pt) or diss. herpes zoster (until lesions are crusted over) Patient enter through a separate entrance to the facility if available, to avoid the reception and registration area

16 Airborne Precautions Negative air pressure room ( AIIR) 6-12 ACH Keep door closed Respiratory protection : N95 ( Face seal leak < 10%) In outbreak situation : molded surgical mask may be effective TB : Maintain isolation until TB ruled out or Rx until smear neg AFB * 3 days MDR TB : Isolation throughout hospitalization

17 Airborne Precautions Once the patient leaves, the exam room should remain vacant for generally 1 hour before anyone enters; however, adequate wait time may vary depending on the ventilation rate of the room If staff must enter the room during the wait time, they are required to use respiratory protection

18 Fit check

19

20

21

22

23 Transmission - based Precautions for Hospitalized Patients Category of single room masks gown Gloves Precautions Air borne Yes, with negative Yes No No air pressure ( Particulate mask) ventilation Droplet Yes* Yes No No (surgical mask) Contact Yes* No Yes Yes * prefered but not required, cohorting patients with the same disease are acceptable

24 Category of Precautions Single room Mask Gown Gloves Air borne Yes, NPV Yes, Particulate mask Droplet Yes Yes ( Surgical mask) No No No No Contact Yes No Yes Yes * prefered but not required, cohorting patients with the same disease are acceptable

25 Empirical precautions

26 PREVENT TRANSMISSION OF EPIDEMIOLOGICALLY IMPORTANT PATHOGENS PENDING CONFIRMATION OF DIAGNOSIS*

27

28 Case discussion : Isolation precaution Isolation precaution Adjunctive measures Postexposure prophylaxis Immunoprophylaxis

29 Case 1 Thai male, 18 yrs Low graded fever with rash 1 days Pregnancy 16 wks HCWs exposed to the pt Varicella (Chickenpox)

30 Q; Diagnosis? Preg HCW! What do you do with this HCWs first? a. Prescribe antiviral prophylaxis b. Taking past history of varicella or immunization c. Prescribe Varicella IG d. Exclude from work facility from D 8-21 after exposure

31 Isolation precautions: VZV Isolation room : Negative pressure room; AIIR In limitted engineering resource masking patient, placing the patient in a private room with the door closed Susceptible HCW : N95 or mask if N95 mask not available ( Restrict suscep HCW) Pt with VZV : face mask Contact cases with index case :? Susceptible or not

32 Evidence of immunity to varicella Written documentation of varicella Prior lab evidence of immunity Prior Dx of VZV by a healthcare provider Self-reporting of past varicella history 10-30% of negative or uncertain history of varicella are found VZV seronegative.

33 Type of postexposure prophylaxis Active immunization : Vaccine Passive immunization : Varicella Ab

34 Postexposure prophylaxis Active immunization : Vaccine within 3-5 d of exposure to prevent infection and lessen disease severity in those become ill. Passive immunization : VariZIG in 4-10 d after exposure For high risk pt who have additional exposure to VZV > 3 wks after initial dose, another dose of VariZIg should be considered

35 Recommendation of Varicella IG ( VZIG) Pregnant women who lack immunity to varicella IC hosts, on immunosupressive drugs, Neoplastic disease Neonate whose mothers develop varicella within 5 days before and after 48 hr delivery or mothers have no history of varicella and/or a negative immune status, Premature infants < 28 Wks VariZIg might extend incubation period to from d to > 28 d

36 Role of antibiotic varicella PEP Acyclovir : Not routine preemptive use for healthy persons. No RCT Small study : ( 16% Vs 100 %) Varicella vaccine is preferred. Duration of isolation : Until lesions dry and crusted

37 Case 2 28 yr, fever with rash What is the diagnosis? Measles IC 10 days

38 Isolation precautions : Measles Isolation room : AIIR Duration of isolation : 4 d after rash or duration of illness if IC host Limit susceptible HCW to enter room Immune HCW : No recommend mask or N95 Susceptible HCWs : Mask or N 95? Post-exposure vaccine within 72 hrs. or IG within 6 days when available

39 Isolation precautions : Measles Exclude susceptible HCWs from duty from D 5 after (first exposure)- D 21 (last exposure), regardless of postexposure vaccine

40 Contraindication of MMR vaccine Pregnancy Immunocompromised hosts Hx of gelatin allergy MMR vaccination should delayed 6 or 7 mo after received PRC and plt

41 Case 3 24 yr old Thai male What is the diagnosis? How to treat this pt. and his family member(s)? Pharyngeal diphtheria

42 Isolation precautions: Isolation room : Yes ( Droplet precaution) PPE for pt. : surgical mask PPE for HCW: Surgical mask if work within 3 feet Duration of Isolation : Until 2 cultures taken 24 hrs. apart negative PEP: Nasal and pharygeal culture,if pos Rx Benz PGS,Erythromycin 7-10 d, Roxithromycin ( MOPH) Repeat C/S after complete of Rx 2 wks

43 Isolation precautions:diphtheria PEP vaccine < 3 doses or unknown : Complete primary series > 3 doses, last dose > 5 yrs :immediate booster dt > 3 doses, last dose < 5 yrs: not required except in children who need 4 th primary dose

44 Case 4 : 35 yr male fever and skin lesions Meningococcemia

45 Isolation precautions:meningococcemia Isolation room : Yes single room if possible PPE for pt. : mask PPE for close contact HCW : Surgical mask (Droplet precautions) for first 24 hr after antibiotic Mask and face protection for intubation

46 Meningococcemia : PEP For close contact : < 3 feet,> 8 hrs,contact oral secretions 7 d before onset of pt. s symptom until 24 hr after antibiotic therapy Et intubation, suction, intimate kissing Should administer early as soon as possible Not recommend PEP after 14 d exposure Surveillance of close contact at least 10 d after exposure

47 Meningococcemia : PEP regimen Adults : rifampicin 600 mg q 12 hr 2d ciprofloxacin 500 mg single dose ceftriaxone 250 mg IM single dose Children: < 1 mo 5mg/kg q 12 hr * 2 d > 1 mo 10 mg/kg q 12 hr * 2 d <15 yrs ceftriaxone 125 IM* 1 dose

48 Isolation precautions :

49 Isolation precautions :EVD Isolation room : Yes ; single pt room preferred or cohort ward PEP for HCW : glove,gown, goggles or face shield, mask, leg or shoe covers Emphasize: use of sharps safety devices and safe work N 95 respirator when performing aerosolgenerating procedures. Largest viral load in final Options for cleaning and laundry are limited. Duration of Isolation : Duration of illness

50 Guidance on PPE for Health Care Workers N95 for Airborned Generate Procedure Hand hygiene should be performed immediately after removal of PPE

51 Detection of Ebola Virus in Different Human Body Fluids over Time Highest Con VL off all fluid tested PCR tested prevent transmission in funerals 51

52

53

54

55