Infection control in Aged Residential Care Facilities Dr Sally Roberts Clinical Advisor for IP&C Service, ADHB
Background Endemic infections Epidemic infections Managing outbreaks Administrative measures Staff Residents
Endemic Infections Patients in RCF are at increased risk of infection Aging-associated changes Comorbidities Functional impairment Institutional residence
Endemic Infections Urinary tract infections High prevalence of asymptomatic bacteriuria. Treat only those with localising symptoms Urinary infections in residents with long term IDC may present with fever without localising signs and symptoms
Endemic Infections Respiratory tract infections Minimise aspiration Discourage smoking Yearly Influenza vaccine Skin and soft tissue infections Optimal management of comorbid conditions Prevent trauma and injury
Influenza
Influenza Seasonal epidemic High rates in the young and the elderly 1% of >65yr get admitted annually with influenza Associated with significant mortality
Influenza Surveillance 30 April 2012-2 September Characteristics Admissions Assessed Non-SARI Cases (%) Non-SARI tested % of the tested cases Influenza positive cases % of flu +ve among tested Overall 59124 4417 1969 386 100 42 10.9 Age group (years) <1 2737 219 197 51.0 11 5.6 1 to 4 4836 56 41 10.6 3 7.3 5 to 19 7261 25 17 4.4 2 11.8 20 to 34 10496 14 12 3.1 4 33.3 35 to 49 9250 31 20 5.2 1 5.0 50 to 64 9419 48 36 9.3 9 25.0 65 to 79 8866 63 35 9.1 7 20.0 80 and over 6259 40 27 7.0 5 18.5 Unknown 2560 1473 1 0.3 0 0.0 Sex Female 31190 240 190 49.2 23 12.1 Male 27934 256 195 50.5 19 9.7 Unknown 0 2571 1473 1 0.3 0 0.0
Demographics SARI Cases (%) Cases per 1000 hospitalisations Influenza SARI cases positive (%*) SARI & influenza cases among ADHB & CMDHB residents SARI incidence Influenza Influenza incidence (per 100 000) Cases (per 100 000 Overall 59124 4417 2023 (45.8) 34.2 324 (22.7) 1705 203.5 288 34.4 (30.5, 38.6) Age group (years) <1 2737 398 145.4 41 (13.9) 357 2721.9 37 282.1 (198.7, 388.6) 1 to 4 4836 272 56.2 36 (18.6) 231 469.7 31 63.0 (42.8, 89.5) 5 to 19 7261 103 14.2 23 (29.1) 85 44.7 19 10.0 (6.0, 15.6) 20 to 34 10496 179 17.1 37 (31.4) 165 84.5 34 17.4 (12.1, 24.3) 35 to 49 9250 166 17.9 35 (27.8) 155 81.1 32 16.7 (11.5, 23.6) 50 to 64 9419 262 27.8 56 (29) 252 206.7 53 43.5 (32.6, 56.9) 65 to 79 8866 300 33.8 53 (23.8) 291 513.0 53 93.4 (70.0, 122.2) 80 and over 6259 173 27.6 31 (24.4) 166 821.3 29 143.5 (96.1, 206.0) Unknown 2560 170 12 (16.2) 3 0 Ethnicity Maori 8118 336 41.4 49 (18.7) 306 315.2 45 46.4 (33.8, 62.0) Pacific Peoples 13274 576 43.4 123 (27.6) 551 428.9 119 92.6 (76.7, 110.8) Asians 8029 169 21 33 (27.5) 158 98.0 31 19.2 (13.1, 27.3) European and others 29296 696 23.8 98 (19.6) 613 151.6 84 20.8 (16.6, 25.7) Unknown 407 2636 246 21 (20.4) 77 9 19.4 (8.9, 36.8) Hospitals ADHB 31819 2057 1122 (54.5) 35.3 146 (20.9) 941 232.6 125 30.9 (25.7, 36.8) CMDHB 27305 2354 900 (38.2) 33 177 (24.2) 764 176.4 163 37.6 (32.1, 43.9) Sex Characteristics Admissions Assessed SARI & influenza cases among all hospital patients Female 31190 898 28.8 160 (24.3) 827 192.6 149 34.7 (29.3, 40.7) Male 27934 944 33.8 150 (21.7) 865 211.9 137 33.6 (28.2, 39.7) Unknown 0 2571 181 14 (17.1) 13 2
Outbreak Management Administrative measures Policies and procedures Clinical and epidemiologic definitions Prevention Vaccinate all residents and staff Visitors policy Consider chemoprophylaxis
Outbreak Management Recognizing it Consider an outbreak if during the influenza season 2 residents manifest signs and symptoms of IL-I within 72 hours of each other Sore throat, breathing difficulties, myalgia and headache Seek advice from primary care/ip&c
Norovirus
Norovirus Transmitted by the faecal-oral route Consumption of contaminated food or water or personto-person spread. Tiny infecting dose 10 particles 5 billion particles per gram of faeces Incubation period 12-48 hours Acute onset vomting, non-bloody diarrhoea with abdominal cramps and nausea Low grade fever occasionally occurs Symptoms last 24 to 60 hours Asymptomatic infection may occur
Norovirus Probably contributes to about 50% of foodborne outbreaks Most outbreaks due to contamination of food by food handler immediately before consumption Diagnosis Molecular assays Expensive Not readily available in the community Immunity Strain-specific and lasts only a few months Elderly can shed virus for up to 28 days Elderly tend to remain symptomatic for longer
NZ Guidelines
Preventing transmission What favours spread in RCF? Shared bathroom facilities Prolonged shedding of virus Limited hand washing facilites Incontinent residents Recognizing Norovirus outbreak Sudden onset of vomiting and diarrhoea in 2 residents +/- staff
Prevention of transmission Hand hygiene Soap and water or ABHR (ethanol) Environment Remove soiling wearing PPE Bleach 0.1% for cleaning surfaces Mediwipes for shared equipment 70% alcohol, 0.5% CHG and a QAT Increased cleaning of patient and staff bathrooms Managing patients Contact Precautions Single room, PPE If transferring to hospital inform receiving hospital of potential outbreak in facility Reinforce hand hygiene before eating Oral rehydration
Signage
Managing staff Clinical staff Educate Reinforce hand hygiene Stop shared or communal food/meals Send home if become unwell at work Absent from symptoms for 48 hours before returning to work Food handlers Educate Reinforce hand hygiene Exclude from duty if develop symptoms of acute gastroenteritis. Exclude for a min of 48hrs after resolution of symptoms
Multiple antibiotic resistant pathogens MRSA ESBL MDR-Gram negative bacilli VRE Clostridium difficile
Revolving door Discharged to RCF Admitted to hospital Admitted to hospital Discharged to RCF
MRSA Colonisation leads to infection Infection of skin and soft tissue Can cause pneumonia or urinary tract infections Hand hygiene
ESBL Community-onset vs healthcare-associated Mainly associated with urinary tract infections Hand hygiene Environmental cleaning Shared bathroom facilities
Management Maintain surveillance Guidelines for management Policy around transfer to other HCF Review antimicrobial policy Standard Precautions
Clostridium difficile infection Commonest cause of hospital-acquired diarrhoea Self limiting severe colitis All antimicrobial agents are associated with disease 3G Cephs, amoxycillin, clindamycin, FQ, macrolides, tetracyclines, TMP-SMZ Contributing factors include: advanced age, severity of underlying illness, use of agents that alter normal GI motility
Management Diagnosis Stool specimen for testing Hand washing with soap and water (spores) Environmental cleaning Reduce antibiotic use
WHO 5 Moments for Hand Hygiene
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