Healthcare Associated Infections (HAI) in LTC Principles of Transmission and Isolation

Transcription

1 Outline Hospital or Home? Infection Prevention in Long Term Care Mark Shelly, MD Associate Professor of Medicine, URMC Epidemiologist for Highland Hospital Principles of Infection Prevention Defining Infection in Long Term Care Facilities Special Case for attention: C difficile, MDRO, Antibiotic finger traps Healthcare Associated Infections (HAI) in LTC Principles of Transmission and Isolation 1.8 million residents in 16,500 nursing homes HAI rates of 3 to 7 per resident-care days (1.8 to 13.5) 2 to 4 million cases a year 1 to 2 per resident per year CDC Isolation Guideline 2007, 1.D.2.a

2 HAI in LTC LTC is home for many Guidelines for healthcare infection prevention often ignore LTC Application of hospital infection control guidelines to LTCF is often unrealistic... ICHE 2008; 29: Hospitals have greatly reduced infections Little data in LTC infection prevention Modes&of&Transmission Mode Vector Example Prevention Contact (direct) Contact (indirect) Hands Staph aureus Hand hygiene Environment Instruments Clostridium difficile Droplet Face-to-face Influenza Mask Gloves/gowns Hand hygiene Gowns/gloves Environ clean Airborne Cough; small particles Tuberculosis N95 Mask Blood borne Intimate contact Medical Interventions HIV Hepatitis B, C Ventilation Gloves Sterilization ICHE 2008; 29: Types of Isolation Ethics of Isolation Standard Contact Droplet Airborne Hand Hygiene Blood & Body Fluid Gown & Gloves Simple Mask N95 Respirators Negative Pressure No isolated patient benefits from isolation Isolated patients receive less care and may feel abandoned To justify this, Proven benefit to others? Best of available options?

3 Types of Isolation for LTC Standard Contact Droplet Hand Hygiene Blood & Body Fluid Gown & Gloves xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Simple Mask Defining Infection in LTCF 2012 Update Airborne N95 Respirators Negative Pressure xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx SHEA/CDC Position Paper McGeer Criteria: 1991 Updated with current evidence Still too weak to grade Provides surveillance definitions for common infections RTI, UTI, SSTI, GI BSI, some other definitions unchanged SHEA/CDC Position Paper Endorsed by American Medical Directors Assoc Assoc Prof in Infec Control (APIC) National Assoc of Dir of Nursing Admin in LTC Assoc Medical Micro and Infect Disease Canada Community and Hosp Infec Control Assoc Canada

4 Surveillance Clinical Dx Surveillance definitions are made to measure populations consistently (specificity) Clinical diagnosis is what determines care for the individual (sensitivity) Each should inform the other Most of the people being treated should meet surveillance definitions Surveillance shouldn t miss many cases 3 Conditions 1. New or acutely worse symptoms 2. Noninfectious causes ruled out first 3. Infections not based on a single piece of evidence i.e. Not just lab value OR provider dx Constitutional Criteria Fever Leukocytosis Acute Change in Mental Status Acute Functional Decline CC: Fever & WBC Fever T > 37.8 C (100.0 F) or Repeated T > 37.2 C (99.0 F) oral, >37.5 C (99.5 F) rectal or T > 1.1 C (2 F) over baseline Leukocytosis: >14,000 WBC or >6% bands

5 CC: Mental Status Change Acute change in mental status from baseline (ALL of these) Acute onset Fluctuating course Inattention Disorganized thinking or altered level of consciousness CC: Functional Decline New 3 point increase in ADL score Bed mobility Toilet Use Transfer Personal hygiene Locomotion w/i LTCF Eating Dressing 0 independent - 4 dependent Confusion Assessment Method (CAM), c/w CMS Minimum Data Set 3.0 CMS Minimum Data Set 3.0 Respiratory Tract Infection (RTI) Common Cold Influenza-like illness Pneumonia Lower Respiratory Tract Infection Influenza-like illness +Fever +at least 3 subcriteria Chills New headache or eye pain Myalgias or body aches Malaise or loss of appetite Sore throat New or increased dry cough No longer seasonal

6 RTI: Pneumonia RTI: Lower Resp Tract 1constitutional criteria and +CXR w/ pneumonia or new infiltrate + 1 respiratory sx New or increased cough New/increased sputum production O2 sat <94% on RA or down > 3% from baseline New/changed lung exam findings Pleuritic chest pain Resp rate 25/min Tracheobronchitis or bronchitis 1constitutional criteria and +CXR not done or unchanged 2 respiratory sx New or increased cough New/increased sputum production O2 sat <94% on RA or down > 3% from baseline New/changed lung exam findings Pleuritic chest pain Resp rate 25/min Urinary Tract Infections Definitions significantly changed Most fevers with positive cultures that do not meet these definitions are not UTI No catheter: localizing GU signs + positive culture Catheter: GU signs, or sepsis w/o other cause No pyuria = no UTI; pyuria does not rule in Urine Cultures Non-specific, but required for UTI dx Process promptly (<24h), refrigerate voided: >10 5 CFU/ml and 2 species straight cath: > 100 CFU/ml foley: >10 5 CFU/ml replace the catheter first if in place >14 days

7 UTI: No Catheter acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate Fever or leukocytosis, and 1 Sx, or 2 Sx CVA tenderness* Suprapubic pain Gross hematuria * not included if fever/leukocytosis is one sign new or marked increase in incontinence urgency frequency UTI: With Catheter Purulent discharge at catheter, or pain/swelling/ tenderness of the testes/epididymis/prostate New suprapubic pain or CVA tenderness/pain Fever, rigors, or hypotension with no other site Leukocytosis with no other site and either Mental status change or Functional decline GI Tract Infections Diarrhea: 3 or more liquid stools in 24h over normal for resident Vomiting: 2 or more episodes in 24h A positive culture for a pathogen with at least one sx: Nausea, vomiting, diarrhea or abdominal pain Surv Def in LTCF, ICHE 2012; 33(10): Norovirus Diarrhea or Vomiting AND Positive lab testing for Norovirus Kaplan Criteria (for clusters of cases) vomiting in more than 50% incubation 24-48h duration of illness 12-60h no bacterial pathogen in stool culture Surv Def in LTCF, ICHE 2012; 33(10):965-77

8 Clostridium difficile Infection Clinical picture Diarrhea: 3 liquid, watery stools above normal for resident or Toxic megacolon and Positive lab test EIA, toxin assay, or PCR Pseudomembranous colitis observed Surv Def in LTCF, ICHE 2012; 33(10): Surveillance Intervals admit d/c 4w 12w HCF HCF Associated HCF Onset HA-HO Incident cases per patient-days Comm Onset HA-CO Indeterminate Community Associated within 2 weeks: same episode within 8 weeks: recurrence Adapted from McDonald LC, Coignard B, et al, Infec Control Hosp Epidemiol 2007; 28(2): " C"diff"infec*on"2010" Special Cases 15" CDI"per" 10,000" 10" pa*ent"days" 5" 0" HH" RGH" SMH" Unity" NYS" Hosp"Onset" 10.3" 8.7" 13.3" 8.7" 8.2" Hosp"Assoc" 15.0" 12.2" 16.2" 14.0"

9 CDI in LTC Elderly CDI Hospitalization Rates, USA Variable rates in the literature LTAC: 31 /10kpd (Goldstein, Anaerobe 2009; 15(12):241) Subacute/Rehab: / p-d Nursing Home 1 / 10kpd (Laffan, JAGS 2006; 54:1068) Ohio: 6-8 / 10kpd in hospitals, 2-3 in nursing homes (ICHE 2009; 30(6):526) Jagai J, Naumova E. Emerg Infect Disease 2009; 15(2):online figure Age distribution of C. diff patients URMC 2009 C diff positive tests n= Years Hospital)Onset)CDI)per)10,000) pt*days) Hospital)Onset)CDI,)NYS)2010) 30" 25" 20" 15" 10" 5" 0" 0.00" 0.20" 0.40" 0.60" 0.80" 1.00" Incoming)CDI)per)1000)admits) 1.20" 1.40"

10 Diagnosing CDI Must have diarrhea ( 3 BM/d, loose) Enzyme assay is specific but will not detect all cases (80% sensitivity) More tests better Glutamate dehydrogenase (GDH) 96% sensitive A PCR is available, very sensitive and specific C diff testing x1 Diarrhea EIA for Toxins A & B GDH EIA EIA toxin GDH ( ) ( ) No Clostridium difficile (+) (+) 3 BM/d for 1-2 days Only unformed stools accepted for testing No more than 1 test every 3 days Positives not retested for a week Test of cure is not appropriate PCR (+) Clostridium difficile Infection New Lab Te s t ing URMC Micro Annals of Internal Medicine (3):176-9 Negative Predictive Value 99% Sensitivity 96% Specificity >90% From URMC Lab Memo, 2009 Nov 18 CDI per patient days R ICU Geriatrics Surgery Step Down Medicine Med/Surg ALC Risk varies between units in the same hospital Antibiotics (and Gastric Acid) No antibiotic is risk free Clindamycin is traditional culprit Broad spectrum increases risk Floroquinolones (new and old) are implicated in recent outbreaks 0.5 Surgery Proton Pump Inhibitors increase the risk 0 Maternity Highland Hospital, 10 Span method,

11 What should LTC do? Monitor the incidence of CDI Assure proper environmental cleaning Hand Hygiene for everyone, including residents Fecal Oral Transmission Use antibiotics wisely: timely, targeted treatment MRSA, VRE, ESBL Common&bugs&learn&resistance Extended'Spectrum'Beta0Lactamases'(ESBL)'win' against'many'favorites Carbapenems'to'the'rescue'.'.'. UnAl'carbapenemases' First'in'Klebsiella(pneumoniae((KPC) Shared'by'mobile'geneAc'element'with'other' organisms:'e.'coli,'enterobacter,'providenaa Carbapenem'Resistant'Enterobacteraceae'(CRE) Even&Worse New'Metalo0beta0lactamases'(MBL) Most'recent'is'the'strain'from'New'Delhi,' NDM01 Very'hard'to'treat,'with'any'anAbioAc

12 Extended&Spectrum&Beta<lactamase&(ESBL) Carbapenemase&NDM<1 What&to&do&about&MDRO&GNR? Like'VRE,'MRSA,'CDI'.'.'. Contact&isolaHon

13 Treatment&of&ESBL&or& AnAbioAc'treatment'may'be'limited'to' Tigecycline' but'this'doesn t'work'well'for'bacteremia ColisAn' this'old'drug'is'very'nephrotoxic ID'Consult'required Antibiotic Stewardship Antibiotic Stewardship 2.9 to 13.9 antibiotic courses per 1000 resident days CDC has a 12-step program for this Protocols have a role in improving care Do an antibiotic starts review: how many met definition Measure administration days, not purchasing (DDD) Think Twice, Treat Once Asymptomatic bacteriuria Upper respiratory tract infections Red leg(s) Chronic wounds

14 My Short List Alcohol hand gel everywhere Gloves easily available Wash hands before you eat Vaccinate every HCW (and patient) Avoid presentee-ism Treasure antibiotics Monitor & improve what is endemic What makes sense? Some infections can be prevented Hospital-style infection prevention doesn t always fit Routine pathogens don t warrant quarantine in the home Start measuring: Hand Hygiene, CDI, MDRO, Antibiotics Antibiotic stewardship will play a role Types of Isolation for LTC Standard Contact Droplet Hand Hygiene Blood & Body Fluid Gown & Gloves????????????????????????????????????????????????????????????? Airborne Simple Mask N95 Respirators Negative Pressure xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx References Stone ND, Ashraf MS, Calder J et al. Surveillance definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hospital Epi 2012; 33(10): Smith PW, Bennett G, Bradley S et al. SHEA/APIC Guideline: Infection prevention and Contol in the Long-Term Care Facility. Infect Control Hospital Epi 2008; 29(9): CDC website on Hospital Associated Infections in Long-Term Care. High KP, Bradley SF, Gravenstein S et al. Clinical Practice Guideline for the Evaluation of Fever and Infection in Older Adult Residents of Long-Term Care Facilities. Clinical Infectious Diseases. 2009;48: Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. Infect Control Hospital Epi 2008; 29(S1):S1-S