Talk 1 Healthcare-Associated Infections (HAIs): Common Questions Robert A. Weinstein, MD April 9, 2016 The C. Anderson Hedberg, MD Professor of Medicine Rush Medical College Chairman Emeritus Department of Medicine, Cook County Hospital Disclosures: Sage Inc (Remote) & CDC (Current) Funding
TOPICS 1. Pathogens What, Why, & How? 2. Protecting Patients Standard Precautions & Beyond 3. Prevention 12 Essentials & Results 4. Protecting Health Care Workers
1. PATHOGENS QUESTION #1 WHICH OF THE FOLLOWING IS THE MOST COMMON HEALTHCARE-ASSOCIATED PATHOGEN IN HOSPITALIZED PATIENTS? A. E. coli B. Clostridium difficile C. Candida D. Pseudomonas aeruginosa E. Staphylococcus aureus
CAUSATIVE PATHOGENS & TYPES OF INFECTION KEY POINTS 504 HAIs tallied, 183 hospitals, 10 states, 2011 #1 Pathogen C. difficile (12% of HAIs) Next Most Common Pathogens (% of HAIs): S. aureus (11) Klebsiella (10) E. coli (9) Enterococcus (9) P. aeruginosa (7) Candida (6) Examples of site tropisms S. aureus: Pneumonia, SSI, BSI Klebsiella; E. coli: UTI Candida; Coagulase-neg staph: BSI Magill et al, N Engl J Med 2014; 370:1198-1208.
HOW & WHY DO HAIS SPREAD? THE EPIDEMIOLOGY OF HEALTHCARE-ASSOCIATED INFECTIONS IS GENERALLY UNDERSTOOD Factors Cross-infection via hands of hospital personnel Relative contribution Gram (-) Gram (+) 30-40% 60-80% Antibiotic pressures 30-40% 10-20% Community acquired 20-25% 10-50% Other (contamination of environment, food, air: personnel carriers; unknown) 20+% 10-20+% IMPACT 100,000+ HOSPITAL DEATHS/YEAR
2. PROTECTING PATIENTS Alcohol is good for you After patient contact and before using alcohol gel After alcohol gel Clean your hands!
SOME INCONVENIENT TRUTHS ABOUT HAND HYGIENE We actually believe we are adherent But hand hygiene still is not practiced reliably And where would adherence get us? What to do?
Hand Hygiene Appealing to Our Basic Instincts to Control Healthcareassociated Infections
QUESTION #2 A nursing home reports that over the past 2 months 25% of its 100 residents have been diagnosed with suspected gastrointestinal infections. The symptoms low grade fever, nausea, vomiting, and occasional diarrhea resolved for most patients within 48-96 hours. Potential modes of transmission for the most likely pathogen include all of the following except: A. Droplet B. Common source C. Direct person-to-person spread D. Indirect person-to-person spread E. Airborne
NOROVIRUS (NORWALK-LIKE VIRUS) Non-enveloped single-stranded RNA viruses that cause acute, self-limited gastroenteritis Caliciviridae family (includes sapoviruses, also a cause of gastroenteritis) Multiple genotypes; reinfection possible Incubation 12-48 hrs; duration of illness 24-72 hrs Vomiting > diarrhea; low grade fever, headache, myalgia Highly contagious; infective inoculum 18 viral particles; spreads indirectly, directly, common source, droplet A major cause of foodborne outbreaks
ISOLATION CATEGORIES & PRECAUTIONS ARE BASED ON MODES OF TRANSMISSION Healthcare Worker Private Room Gloves Gown Mask Contact Yes* Yes Yes PRN Droplet Yes* PRN PRN W/in 3-6 ft Airborne AII PRN PRN N95 * When possible; cohort if not possible. Avoid rooming with immunosuppressed or high risk patients. AII = Airborne Infection Isolation: negative pressure with no air recirculation (unless HEPA-filtered); 6-12 ACH (air changes per hour). Hand hygiene yes for all; eye protection PRN for all.
ISOLATION PRECAUTIONS EXAMPLES OF INDICATIONS Standard All patients Droplet Bacterial meningitis, pertussis, mumps, seasonal influenza Contact Multidrug resistant bacteria, infectious diarrhea, Ebola, chickenpox Airborne Tuberculosis, measles, chickenpox Opportunistic Airborne* SARS, MERS-CoV, Pandemic influenza, Some BT agents, Ebola *e.g., increased transmission risk during aerosol generating procedures (such as intubation)
Airborne vs. Droplet spread Droplet generation. A flash photo of a human sneeze, showing the expulsion of droplets that may be laden with infectious pathogens. Sneezing can produce as many as 40 000 droplets of 0.5 12 μm. These particles can be expelled at a velocity of 100 m/s, reaching distances of several metres. Smaller droplets with less mass are less influenced by gravity, and can be transported as a cloud over greater distances by air flows. Larger droplets with more mass are more strongly influenced by gravity and less so by air flows, and move more ballistically, falling to the ground more quickly. Reproduced with the kind permission of Prof. Andrew Davidhazy, School of Photographic Arts and Sciences, Rochester Institute of Technology, Rochester NY, USA. Tang JW et al, J Hosp Infect 2006; 64:100-14.
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PREVENTING DEVICE AND PROCEDURE INFECTIONS: HAND HYGIENE Alcohol is good for you CVC-BSI CHG prep & maximum barrier precautions; CHG cleansing; CVC removal PIV Observe site daily; change post ED insertion & q 3 days VAP Oral CHG & sedation vacations (tube removal); positioning 45º UTI Closed system & catheter removal SSI Skin prep, antibiotic prophylaxis timing, & capable surgeon REPORT RATES 3. WHAT IS ESSENTIAL?* *Qualifier: RAW s views
Mandatory Reporting of Infections What s Measured Improves & Now National Data HAIs, Hospital-associated infections www.apic.org
IMPROVED CONTROL OF DEVICE & PROCEDURE-RELATED INFECTIONS (THOUGH SHORT OF NATIONAL GOALS) CDC, National and State Healthcare Associated Infections Progress Report, March 2015
Yah, but there is a slight drawback. Most patients here do NOT survive surgery. to get infected. See, this is where I should go!
4. PROTECTING HEALTH CARE WORKERS QUESTION #3 Emergency Department (ED) staff who cared the prior day for a patient with fever and headache have heard that the patient has meningococcal meningitis. None of the personnel wore personal protective equipment. You are asked which of the following individuals should receive post-exposure prophylaxis: A. Intern who did the lumbar puncture B. Nurse who took the patient s initial vital signs C. Transporter who brought patient from ED to inpatient ward D. Intern, nurse, & transporter E. Patient s roommate
HEALTHCARE WORKER POST EXPOSURE PROPHYLAXIS (PEP) Pathogen or Disease Mode of Transmission High-risk HCW PEP Modifying Factors HIV Percutaneous, splash Blood or sterile body fluid or bloody fluids Risk 0.3% Seronegative ARVs for 4 weeks; serologic follow-up for 6 months Sharp type, puncture depth, contaminating fluid, patient, VL & treatment, duration after exposure (24-36h or longer); pregnancy Hepatitis C Percutaneous Risk 3% Seronegative Pre-emptive therapy vs watchful waiting Serologic follow-up Hepatitis B Percutaneous Risk 30% Seronegative HBIG & vaccine Duration after exposure (24-48h)
HEALTHCARE WORKER PEP (CONTINUED) Pathogen or Disease Mode of Transmission High-risk HCW PEP Modifying Factors Hepatitis A Fecal-oral Seronegative Vaccine; IG Duration after exposure (14 days) Parvovirus B19 Pertussis Droplet, contact Droplet, contact Seronegative and pregnant, HIV, or hemoglobinopathy Seronegative or waned immunity No PEP Macrolide Exclude pregnant HCW from patient care Duration after exposure (3 weeks)
HEALTHCARE WORKER PEP (CONTINUED) Pathogen or Disease Mode of Transmission High-risk HCW PEP N. meningitidis Droplet Close contact Ciprofloxacin, rifampin, ceftriaxone, or azithromycin (or sulfa if S) VZV Tuberculosis Contact, airborne Airborne, rarely contact Negative VZV history or seronegative and immunocompromised or pregnant PPD- or IGRAnegative VZIG or valacyclovir; VZV vaccine (Furlough day 10-21 PE; 10-28 if VZIG used) INH (&/or rifampin) if PPD conversion Modifying Factors Duration & proximity of contact Duration of, and after, exposure PPD results (baseline;12 weeks post-exposure)
Take Home Messages Basic control measures can be very effective HAI rates are on the decline but far from zero Clostridium difficile is enemy number 1