Round Robin Highlights of Infection Control Practices

Round Robin Highlights of Infection Control Practices Arkansas Department of Health Healthcare-Associated Infections Program Staff

To Isolate or Not To Isolate: That Is The Question Kelley Garner, MPH, MLS(ASCP) CM HAI Program coordinator/epidemiology Supervisor Arkansas department of Health

Isolation Isolation separates sick people with a contagious disease from people who are not sick. Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick.

Why?

Indications Route(s) of transmission of the known or suspected infectious agent Risk factors for transmission in the infected patient Risk factors for adverse outcomes resulting from a healthcare-associated infection (HAI) in other patients CDC. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). Available at: https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/index.html. Accessed on 12/04/2018.

Types Transmission based: Standard Contact Droplet Airborne Address the following syndromes or conditions: Diarrhea Meningitis Respiratory infections Skin or wound infections that cannot be covered CDC. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). Available at: https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/index.html. Accessed on 12/04/2018.

Standard Precautions and Hand Hygiene Standard Precautions were formally known as Universal Precautions Treat all patient contacts that involve blood, body fluids, secretions, excretions, and contaminated linens as potentially infectious As such, glove use and hand hygiene are the primary activities Add a gown if contact with blood and bodily fluids to clothing or exposed skin is anticipated Add mask and/or eye protection if splashes may occur or if aerosol-generating procedures will occur Hand hygiene remains a critical activity to prevent the transmission of infections within healthcare settings CDC. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). Available at: https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/index.html. Accessed on 12/04/2018.

Contact For persons that have an active infection that is spread through contact ( touch ) and can cause environmental contamination Precautions include: Placing in a single resident space, when available Using personal protective equipment (PPE) appropriately Gloves Gown Limiting the transport and movement of a resident to when medicallynecessary Contain or cover the infected areas during transport PPE should not be worn by staff during transport Clean PPE should be used when resident arrives at the destination Using disposable or dedicated resident-care equipment, if available If unavailable, clean and disinfect before use on another patient Prioritizing cleaning and disinfection of the rooms Performing Hand Hygiene CDC. Infection Control Transmission-Based Precautions. Available at: https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html. Accessed on 12/01/2018.

Droplet For persons that have an infection that is transmitted by respiratory droplets that are generated by a person who is coughing, sneezing, or talking Precautions include: Placing a resident in a single room, if possible. If not, on a caseby-case basis consider infection risks to other residents and available alternatives Using PPE appropriately Mask Limiting the transport and movement of a resident to when medically-necessary Resident should wear a mask when outside of room CDC. Infection Control Transmission-Based Precautions. Available at: https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html. Accessed on 12/01/2018.

Airborne For persons that have an infection that is transmitted by the airborne route (e.g. tuberculosis, measles, chickenpox, and disseminated herpes zoster) Precautions include: Ensuring appropriate placement of a resident in an airborne isolation room (AIIR) Using PPE appropriately Fit-tested N95 or higher level respirator Limiting transport and movement of the resident, unless medicallynecessary Resident should wear a mask during transport Restricting susceptible healthcare personnel from entering the room (if a vaccine preventable infection) Initiating immunization of susceptible persons with unprotected contact, if vaccine preventable CDC. Infection Control Transmission-Based Precautions. Available at: https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html. Accessed on 12/01/2018.

Deciding which type to use Low threshold to implement for acute on-set of symptoms Can be discontinued if symptoms resolve or culture results come back negative or not indicated Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Appendix A CDC. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Appendix A. Available at: https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/typeduration-precautions.html#s. Accessed on 12/04/2018.

Signage Pg. 58 of State Operations Manual Appendix PP Guidance to Surveyors for Long Term Care Facilities

Cohorting Cohort patients when single patient rooms are not available Like patients should be put together (i.e. GI illness with GI illness with the same pathogen, influenza, etc.) If not multiple illnesses, persons should be put with other persons that are less likely to develop illness Each person in the room should be considered separate in regards to changing PPE and hand hygiene

Judicious use Patients on isolation can have negative outcomes 50% less interaction from clinicians Twice as likely to experience adverse events such as falls and pressure ulcers Negative psychological effects: Loneliness Stigmatization Depression Anxiety Even when on isolation, consider ways for residents to still get adequate services Most isolation is not strict, can still leave the room for bathing and other purposes (case-by-case basis) Tran K, Bell C, Stall N, et al. The Effect of Hospital Isolation Precautions on Patient Outcomes and Cost of Care: A Multi-Site, Retrospective, Propensity Score-Matched Cohort Study. J Gen Intern Med. 2016;32(3):262-268.

Overview Isolation is a critical component to prevent the spread of infectious diseases Resources are available to aid in identifying the type and duration for isolation Transmission-based precautions include: Contact Droplet Airborne Isolation should be used with active infections and can be discontinued when the infection resolves Standard Precautions and Hand Hygiene are everyday activities that help prevent the spread of infections, regardless of type or organism.

Understanding Clostridioides difficle (C. diff) laboratory testing Trent Gulley, MPH Antimicrobial Resistance Epidemiologist

Clostridioides difficle (C. diff) Gram positive, anaerobic, toxin-producing, spore forming bacteria. 500,000 infection per year 29,000 deaths per year $4.8 billion in excess medical costs per year Risk Factors Exposure to antibiotics Accessing healthcare Nearly half a million Americans suffered from Clostridium difficile infections in a single year. https://www.cdc.gov/media/releases/2015/p0225-clostridium-difficile.html. Accessed December 12, 2018. Lessa FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile Infection in the United States. The New England Journal of Medicine. 2015;372:825-834

Testing Glutamate dehydrogenase (GDH) antigen Enzyme immunoassay (EIA) for toxin Cell cytotoxicity neutralization assay Nucleic acid amplification test (NAAT) Toxigenic Culture MDRO and CDI Prevention Process and Outcome Measures Monthly Reporting. https://www.cdc.gov/nhsn/forms/57.127_mdromonthlyreporting_blank.pdf. Accessed December 3, 2018

GDH antigen Test for GDH enzyme A protein produced by C. diff High sensitivity Can accurately rule out the presence of C. diff Quick turnaround (15-45 minutes) Inexpensive Does not test for toxin production Solomon, D.A., Milner, D.A. ID Learning Unit: Understanding and Interpreting Testing for Clostridium difficile. Open Forum Infect Dis. 2014;1(1):ofu007. Published 2014 May 16. doi:10.1093/ofid/ofu007

EIA for Toxin Test for toxin A and toxin B Moderate specificity Quick turnaround (15-45 minutes) Poor sensitivity A combination of Toxin A/+B can have negative results for toxin production Only test for toxin and not organism Should be used with another test Solomon, D.A., Milner, D.A. ID Learning Unit: Understanding and Interpreting Testing for Clostridium difficile. Open Forum Infect Dis. 2014;1(1):ofu007. Published 2014 May 16. doi:10.1093/ofid/ofu007

Cell cytotoxicity neutralization assay Gold standard Test for toxin activity Looking for cytotoxicity specific to C. diff High specificity Slow turnaround (>48 hours) Expensive Labor-intensive to perform Not all labs can perform this test Samples need be sent to the lab with 2 hours or refrigerated. Solomon, D.A., Milner, D.A. ID Learning Unit: Understanding and Interpreting Testing for Clostridium difficile. Open Forum Infect Dis. 2014;1(1):ofu007. Published 2014 May 16. doi:10.1093/ofid/ofu007

NAAT Examples: PCR and LAMP Test for tcdb and tcdc High sensitivity and specificity Can be used on it s own Expensive Does not test for active toxin production Cannot distinguish between active infection and asymptomatic carriage. PCR often remains positive after antibiotic therapy Solomon, D.A., Milner, D.A. ID Learning Unit: Understanding and Interpreting Testing for Clostridium difficile. Open Forum Infect Dis. 2014;1(1):ofu007. Published 2014 May 16. doi:10.1093/ofid/ofu007

Toxigenic culture Gold Standard High sensitivity and specificity Long turnaround time Can take 2-3 days for results Can not distinguish between colonization and infection Labor intensive Requires growing the bacteria and then detecting the presence of toxins. McDonald, L. C., Gerding, D. N., Johnson, S., Bakken, J. S., Carroll, K. C., Coffin, S. E.,... Wilcox, M. H. (2018). Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases, 66(7), 987-994. https://doi.org/10.1093/cid/ciy149

2017 C. diff guidelines

Algorithms Testing Criteria 1. >=3 unexplained unformed stools in a 24 hour period 2. Symptoms: patient reported abdominal pain or cramping McDonald, L. C., Gerding, D. N., Johnson, S., Bakken, J. S., Carroll, K. C., Coffin, S. E.,... Wilcox, M. H. (2018). Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases, 66(7), 987-994. https://doi.org/10.1093/cid/ciy149

Algorithms Sharp, S. Gilligan, P. A Practical Guidance Document for the Laboratory Detection of Toxigenic Clostridium difficile September 21, 2010*. American Society for Microbiology.

Algorithms Sharp, S. Gilligan, P. A Practical Guidance Document for the Laboratory Detection of Toxigenic Clostridium difficile September 21, 2010*. American Society for Microbiology.

Recap GDH testing for organism EIA for Toxin testing for toxin production Cell cytotoxicity neutralization assay (gold standard) testing for toxin production NAAT testing for toxin genes Toxigenic Culture (gold standard) testing for organism and toxin production

Contact info Trent Gulley, MPH Antimicrobial Resistance Epidemiologist Healthcare-Associated Infections Program Epidemiology Branch Arkansas Department of Health 4815 W Markham St, Slot 32 Little Rock, AR 72205 Phone: (501) 614-5362 Trenton.Gulley@Arkansas.gov

Competency-based Training Pain or Gain?! Margaret Holaway, BSN, RNP Infection Control Nursing Liaison December 13, 2018

Objectives Explore the different types of learning styles Review the CDC Infection Control Readiness Assessment (ICAR) elements for training and competency validation Present data from ICAR visits nationwide Define methods of training programs observed in the long-term care ICAR visits in Arkansas

Methods of Learning Auditory Visual Kinesthetic (active) Listen actively Pictures, videos, posters Real life examples Include discussions Take detailed notes Hands-on approaches Utilize an expert in the field (i.e. infection prevention nurse Color code material Role play/demonstration Require attendance Require attendance Require attendance https://academics.uafs.edu/academic-success/visual-learning-strategies

ICAR Elements for Learning Training and competency validation for all/appropriate personnel at time of employment Training and competency validation for all/appropriate personnel within the past 12 mos Skills to assess: Hand Hygiene Personal Protective Equipment Injection Safety Environmental Cleaning

Nursing Homes Assessment Findings (n=2044)

Nursing Homes Assessment Findings (n=2044)

Nursing Homes Assessment Findings (n=2044)

Nursing Homes Assessment Findings (n=2044)

Methods of Training for HCWs Orientation Program Annual Skills Fair Ø Hand Hygiene Ø Personal Protective Equipment Ø Injection Safety Ø Point of Care Testing Ø Environmental Cleaning

Pain or Gain???

TB Assessment in Long Term Care Facilities How to make sense of positive TB test results

Why test for TB? Communicable, reportable disease Most home grown (US-born) cases are reactivation of latent TB infection Risk factors for latent -> active disease Diabetes Renal failure Malignancy Weakened immune system Congregate setting becomes a risk factor Important to establish a baseline at admission (first 2 weeks)

But first, ask: Does patient have known history of Positive test in past document if possible TB treatment in past For latent or active TB? Important distinction! Treated when/where/how long document if at all possible If yes, don t retest but do a CXR and call us

Methods of testing TB skin test If initial test is negative or doubtful (<15 mm), retest to look for booster effect 2-3 weeks later (positive if >10 mm) If booster is negative, you re done False positives possible (cross reaction) IGRA (T spot or quantiferon gold) One-stop shopping Much less cross reactivity More expensive

Positive test now what??? False positive True positive could be Old (history is important here) Latent TB Active TB Need clinical correlation to distinguish! Report all positive tests to Department of Health

Symptoms of active TB Persistent fever Weight loss Night sweats Persistent cough > 2-3 weeks*** Swollen lymph nodes

Symptoms of latent TB [ ]

Chest X-ray

Call your local health unit for next steps TB-109 form We ll interpret the chest x-ray Sputa? Meds? We re here to help! The only stupid question is the one you should have asked but didn t L

Asymptomatic Bacteriuria Naveen Patil, MD, MHSA, MA, FIDSA Medical Director Infectious Diseases Branch Healthcare Associated Infections Antimicrobial Stewardship Initiative Arkansas Department of Health

Urinary Tract Infections (UTI s) UTI s is the most common infection in the long term care setting. Diagnosing UTI & deciding when to treat continues to be challenge. Widespread prevalence of ASB complicates the picture and lack of clinical or laboratory gold standards further blurs the horizon. High prevalence of cognitive impairment in the population further complicates decision making process..

Asymptomatic Bacteriuria

Asymptomatic Bacteriuria Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment. Screening for or treatment of asymptomatic bacteriuria is not recommended for the following persons: Premenopausal, nonpregnant women, diabetic women, older persons living in the community, elderly institutionalized subjects, persons with spinal cord injury, catheterized patients while the catheter remains in situ. Antimicrobial treatment of asymptomatic women with catheter-acquired bacteriuria that persists 48 hours after indwelling catheter removal may be considered though evidence is weak.

Acute Uncomplicated Cystitis Urinary Tract Infections (UTI) are the most common bacterial infections in woman and most are acute uncomplicated cystitis. Most common organism is E coli (86%). Others include S. saphrophyticus, Klebsiella, Proteus, Enterobacter, Citrobacter, Enterococcus. It causes discomfort for almost a week leading to approximately 7 million office visits with $1.6 billion in associated costs. Nitrites & leukocyte esterase are the accurate indicators of infection in symptomatic patients.

Acute Cystitis- Treatment

When to treat for UTI? Other causes of nonspecific signs and symptoms (fatigue, confusion): Inadequate sleep Loneliness Immobility Depression Overstimulation Address these etiologies before ordering urine specimens

Questions? ADH.HAI@Arkansas.gov