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Infection Control and Antibiotic Stewardship
 

Infection Control and Antibiotic Stewardship

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Infection Control and Antibiotic Stewardship Symposia presented in Milot, Haiti at Hôpital Sacré Coeur. ...

Infection Control and Antibiotic Stewardship Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.

CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.

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  • Main Efficacy Main Efficacy Main Efficacy
  • Main Efficacy Main Efficacy Main Efficacy The key elements of postexposure management are listed here. Over the next few slides, wound management, exposure reporting, assessment of the infection risk by type and severity of exposure, determination of the bloodborne status of the source person, and appropriate treatment, follow-up, and counseling are explored in more detail.
  • Main Efficacy Main Efficacy Main Efficacy The first element in postexposure management is wound care. Wounds should be cleaned with soap and water. Mucous membranes should be flushed with water. Eyes should be flushed with eye irrigant or clean water. There is no evidence that application of antiseptics or disinfectants, or squeezing (or milking) puncture sites provides any benefit. The use of bleach and other agents that are caustic to the skin should be avoided.
  • Main Efficacy Main Efficacy Main Efficacy It is important to collect and record information about the exposure on an exposure report, and to maintain the confidentiality of both the worker and the source patient. An exposure report should include the date and time that the exposure occurred, as well as details of what procedure was being performed, where, how, and what device (if any) was involved. If a device was involved, OSHA requires that the brand and manufacturer of the device be recorded. Details such as the route of exposure, body substance involved, and volume or duration of contact also should be included. Additionally, information about the source person and exposed person, if known, is critical, along with exposure management details, which will be discussed later.
  • Main Efficacy Main Efficacy Main Efficacy As mentioned earlier, one factor to consider in assessing the risk of infection is the body substance to which healthcare personnel are exposed. This shows the concentration of HBV in various body fluids. On the left, in red, are the fluids with the highest concentration of virus. Moving from the left to the right side, the concentration decreases. Blood, for instance, has a higher virus concentration than urine or sweat.
  • Main Efficacy Main Efficacy Main Efficacy For the 50 documented cases of HIV infection associated with the 51 percutaneous injuries from the previous slide, the types of sharp objects implicated are shown on this pie chart. The largest portion of the pie, in red, represents hollow-bore needles. Other sharp objects represented on this chart include scalpels, in peach, and broken vials, in green. The purple slice represents cases where the sharp object causing the injury was unknown.
  • Main Efficacy Main Efficacy Main Efficacy The risk of HBV transmission after a percutaneous exposure to HBV-infected blood, without postexposure treatment, varies, depending on the e-antigen status of the source. If the source is e-antigen positive, the risk of transmission will be up to 30%, whereas if the source is e-antigen negative, the risk is from 1-6%. The average risk of HCV transmission after a percutaneous exposure to HCV-infected blood is 1.8%, with a range of 0-7%. The average risk of HIV infection after a percutaneous exposure to HIV-infected blood is 0.3%, or 1 in 300 exposures (with a 95% confidence interval of 0.2%-0.5%). The average risk is based on aggregate data, and may not apply to specific exposure events.
  • Main Efficacy Main Efficacy Main Efficacy In a retrospective case-control study of healthcare personnel who had percutaneous exposure to HIV-infected blood, an increased risk for HIV infection was associated with exposure to a larger quantity of blood from the source person as indicated by deep injury, visible blood on the device, or a procedure involving a needle placed in an artery or vein. An increased risk was also associated with exposure to blood from source persons with terminal illness, possibly reflecting either a higher titer of HIV in blood late in the course of AIDS or other factors. Postexposure use of zidovudine was associated with a decreased risk of HIV transmission.
  • Main Efficacy Main Efficacy Main Efficacy HIV exposures should be regarded as urgent medical concerns, and, if indicated after evaluating the source patient status and type and severity of the injury, postexposure prophylaxis should be initiated as soon as possible after exposure, i.e. within hours rather than days. The interval after which postexposure prophylaxis is no longer likely to be effective in humans is unknown. Initiating postexposure prophylaxis days or weeks after an exposure might be considered if warranted for a higher exposure risk.
  • Main Efficacy Main Efficacy Main Efficacy Preventing transmission of bloodborne viruses in healthcare settings requires a multifaceted approach, including promoting hepatitis B vaccination of all healthcare personnel who may have contact with blood, considering all patients as potentially infectious, using appropriate barriers to prevent blood and body fluid contact, and preventing percutaneous injuries, by eliminating unnecessary needle use, implementing safety devices (devices with safety features), using safe work practices when handling needles and other sharp devices, and safely disposing sharps and blood-contaminated materials.
  • Main Efficacy Main Efficacy Main Efficacy
  • Cut to the 1940s and the introduction of penicillin, discovered by Alexander Fleming. We now had a weapon against infection.
  • Unfortunately, as it turns out, the Introduction of every new class of antimicrobial drug is followed by emergence of resistance. By the 1950s, penicillin-resistant S. aureus were a major threat in hospitals and nurseries. Methicillin was developed. By the 1970s, methicillin-resistant S. aureus (or MRSA) had emerged and spread, a phenomenon that encouraged widespread use of vancomycin. In the 1990s, vancomycin-resistant enterococci emerged and rapidly spread; most of these organisms are resistant to other traditional first-line antimicrobial drugs. At the end of the century, the first S. aureus strains with reduced susceptibility to vancomycin (the so-called VISA) were documented, prompting concerns that S. aureus fully resistant to vancomycin may be on the horizon. In June 2002 the first case of vancomycin-resistant S. aureus was detected.
  • Here are some abbreviations that I will be using for those of you that are not familiar with these terms.
  • Progression of resistant Staphylococcus aureus Key Points: Changes in the epidemiology can be observed in both nosocomial and community-acquired infections caused by antimicrobial-resistant strains of S aureus Methicillin resistance is increasing in both nosocomial and community-acquired strains of S aureus The trend of increasing prevalence of methicillin resistance among S aureus strains mirrors the evolution observed with penicillin resistance following the introduction of penicillin If the trend continues, methicillin resistance may become widespread among S aureus strains in the hospital and community settings Reference: McDonald LC. Clin Infect Dis . 2006;42:S65-71.
  • The proportion of hospital-onset infections that are due to a resistant organism has increased at an alarming rate. The next four slides show trends in antimicrobial resistance among pathogens causing infections in ICU patients. These trends are based on data from the CDC’s National Nosocomial Infections Surveillance (NNIS) system. Shown on this slide are trends in the proportion of Staphylococcus aureus infections caused by methicillin-resistant strains. From 1995 through 2004, the percent of S. aureus infections caused by methicillin-resistant strains increased from approximately 40% to 60%.
  • Over the 10-year period from 1995-2004, the proportion of enterococcal infections among ICU patients that were resistant to vancomycin doubled from less than 15% to 30%.
  • During the same time period, there also was a significant increase in the proportion of gram-negative pathogens (e.g., Klebsiella spp. and Enterobacteriaceae) that had acquired extended-spectrum beta-lactamases (ESBLs). Shown above are trends in 3 rd generation cephalosporin resistance among Klebsiella pneumoniae . As of 2004, approximately 25% of K. pneumoniae isolates causing infections in ICUs were resistant to 3 rd generation cephalosporins.
  • Resistance to fluoroquinolones also has emerged among nosocomial pathogens. In 1995, approximately 15% of Pseudomonas aeruginosa infections in ICUs were due to fluoroquinolone-resistant strains, but by 2004, approximately 25% of such infections in ICU patients were resistant to fluoroquinolones.
  • Antibiotic treatment of nosocomial pneumonia is a balancing act. Clinicians need to treat patients with these potentially life-threatening infections with an appropriate initial antimicrobial regimen while also trying to minimize the emergence of resistant pathogens.
  • 1997: Initail goals CDC's campaign was the development and distribution of principles for appropriate antibiotic use for pediatric and adult upper respiratory tract infections produced a series of health education and behavioral change materials for both patients and providers to promote appropriate antibiotic use. CDC distributes federal funds to state and local health departments for the development, implementation, and evaluation of local
  • Since 2003 CDC has developed a national media campaign in partnership with the Food and Drug Administration (FDA) to provide a coordinated message on appropriate antibiotic use and create a foundation for local efforts across the country 4 HEDIS( Healthcare Effectiveness Data and Information Set) measures, incorporated into in 2004, are: Appropriate testing for children with pharyngitis Appropriate treatment for children with upper respiratory infection (URI) Avoidance of Antibiotic Treatment in Adults with Acute Antibiotic Utilization: This measure summarizes data on outpatient utilization of drug prescriptions, stratified by age.
  • Despite success sin the outpatient setting , antimicrobial resistance continues to increase in healthcare settings 50 % of patients in a hospital receive an antibiotic and of those about 50% are in appropriate or unnecessary. iOM report estimated that the total cost to U.S. society of antimicrobial resistance was at least $4 billion to $5 billion
  • Main Efficacy Main Efficacy Main Efficacy
  • The correct answer is #4, to prevent infections that patients acquire in the hospital. All answers are good reasons to practice good hand hygiene. Improved adherence to hand hygiene has been shown to terminate outbreaks in healthcare facilities, reduce the transmission of antimicrobial resistant organisms, and reduce overall infection rates.
  • 01/25/12
  • Main Efficacy Main Efficacy Main Efficacy Hepatitis B virus (HBV), hepatitis C virus (HCV), and the human immunodeficiency virus (HIV) are all bloodborne viruses that can produce chronic infection and are transmissible in healthcare settings. Data from multiple sources, including surveillance, observational studies, and serosurveys are used to assess the risk of occupational transmission.
  • Main Efficacy Main Efficacy Main Efficacy The prevalence of bloodborne virus infection varies. It is generally higher in hospitalized patients than in the general population, but also varies with geographic area and patient group. For example, in Iowa, the prevalence of HIV may be lower than in San Francisco. The prevalence varies with patient group and the presence or absence of such risk factors as injecting drug use, multiple sex partners, and so on.
  • Main Efficacy Main Efficacy Main Efficacy This chart shows the number of U.S. healthcare personnel with documented and possible occupationally acquired AIDS/HIV infection reported to CDC, by occupation, as of June 2001. Fifty-seven workers had documented HIV seroconversion temporally associated with an occupational exposure. An additional 137 episodes are considered possible occupational HIV transmissions. These workers report a history of occupational exposure to blood, other infectious body fluids, or laboratory solutions containing HIV, and report no other risk for HIV infection, but HIV seroconversion after a specific exposure was not documented. The occupational group with the most documented and possible transmissions is nurses.
  • Why are our long term care patients particularly susceptible to this problem? Before they become infected, they become colonized with these bacteria. A number of risk factors specific to this patient population predispose these patients to becoming colonized with multidrug resistant organisms. In addition, the environment (such as the bedrails, the IV pumps, light switches, phones, faucets), becomes contaminated with these organisms. Cleaning and infection control are essential but often not enough to prevent colonization of the patient with these bacteria.

Infection Control and Antibiotic Stewardship Infection Control and Antibiotic Stewardship Presentation Transcript

  • Hopital Sacre Coer Infectious Diseases Symposium 2011 Infection Control and Antimicrobial Stewardship Helen Boucher MD FACP FIDSA Associate Professor of Medicine Division of Infectious Diseases and Geographic Medicine
  • Outline
    • Hand hygiene
    • Infection Control
    • Antimicrobial Stewardship
    • Hand Hygiene Is The Single Most Important Way to Protect Our Patients From Infection !
  • INFECTION CONTROL
  • What is an infection control programme?
    • Important components of the infection control programme:
    • basic measures for infection control, i.e. standard and additional precautions
    • education and training of health care workers
    • protection of health care workers, e.g. immunization
    • identification of hazards and minimizing risks
    • routine practices essential to infection control such as aseptic techniques
    • use of single use devices, reprocessing of instruments and equipment
    • antibiotic usage, management of blood/body fluid exposure, handling and use of blood and blood products, sound management of medical waste
    • Effective work practices and procedures, such as environmental management practices including management of hospital/clinical waste, support services (e.g., linen), use of therapeutic devices
    • surveillance
    • incident monitoring
    • outbreak investigation
    • infection control in specific situations; and
    • research
    More about infection control programmes?
  • Infection control practices can be grouped in two categories
    • Transmission of infections in health care facilities can be prevented and controlled through the application of basic infection control precautions which can be grouped into
    • Standard precautions – must be applied to ALL patients at ALL times (regardless of diagnosis or infectious status), and
    • Additional (transmission-based) precautions - specific to modes of transmission
      • Airborne
      • Droplet
      • Contact
  • Standard Precautions
    • Wear appropriate Personal Protective Equipment (PPE) as indicated by potential for contact/soiling with body fluids, and/or mucous membranes and non-intact skin e.g.
    • Gloves – oral hygiene, wound care, etc.
    • Faceshield – suctioning and other aerosol/droplet generating procedures
    • Gown- Endoscopy and other procedures where sprays or splashing is possible
    • ALWAYS perform Hand Hygiene upon removing PPE and before leaving immediate work site
  • Hand Hygiene
    • Handwashing with soap and water if hands are soiled (minimum 15-30 seconds of scrubbing)
    • Alcohol Rub (5-10 seconds)
    • Policy on nail length/artificial nails
  • AIRBORNE PRECAUTIONS
    • VISITORS : REPORT TO NURSES’ STATION BEFORE ENTERING ROOM
    • VISITANTES: FAVOR DE ANUNCIARSE A LA ENFERMERA DE PISO ANTES DE ENTRAR AL CUARTO
    GOOD HAND HYGIENE IS ESSENTIAL N95 particulate respirator to enter room Keep door closed
  • Airborne Precautions (back of sign)
    • Tuberculosis (TB)
    • Measles
    • NPIR (Negative Pressure Isolation Room) required. Exceptions must be approved by Hospital Epidemiology/Infection Control.
    • (Patient must wear surgical mask when exiting room)
  • DROPLET PRECAUTIONS
    • VISITORS : REPORT TO NURSES’ STATION BEFORE ENTERING ROOM
    • VISITANTES: FAVOR DE ANUNCIARSE A LA ENFERMERA DE PISO ANTES DE ENTRAR AL CUARTO
    GOOD HAND HYGIENE IS ESSENTIAL Surgical masks to enter room. Keep contaminated hands away from eyes or face.
  • Droplet Precautions (back of sign)
    • Pertussis
    • Influenza (adults)
    • Bacterial meningitis
    • Parvovirus (B19)
    • Mumps
    • NOTE TO STAFF : Keep hands away from eyes and face
  • CONTACT PRECAUTIONS
    • VISITORS : REPORT TO NURSES’ STATION BEFORE ENTERING ROOM
    • VISITANTES: FAVOR DE ANUNCIARSE A LA ENFERMERA DE PISO ANTES DE ENTRAR AL CUARTO
    GOOD HAND HYGIENE IS ESSENTIAL GOWNS to enter room if clothing will have contact with patient or environment Gloves to enter room
  • Contact Precautions (back of sign)
    • MRSA
    • VRE
    • Multiple Drug Resistant Organisms as defined by Hospital Epidemiology
  • MODIFIED CONTACT PRECAUTIONS
    • VISITORS : REPORT TO NURSES’ STATION BEFORE ENTERING ROOM
    • VISITANTES: FAVOR DE ANUNCIARSE A LA ENFERMERA DE PISO ANTES DE ENTRAR AL CUARTO
    GOOD HAND HYGIENE IS ESSENTIAL GLOVES to enter room GOWNS to enter room
  • MODIFIED CONTACT PRECAUTIONS (back of sign)
    • C. difficile enteritis
    • Dilute bleach solution required for cleaning the environment.
  •  
  • Elements of Postexposure Management
    • Wound management (Immediately)
    • Exposure reporting (Within 2 hours)
    • Assessment of infection risk
      • type and severity of exposure
      • bloodborne infection status of source person
    • Appropriate treatment, follow-up, and counseling
  • Postexposure Management: Wound Care
    • Clean wounds with soap and water
    • Flush mucous membranes with water
    • No evidence of benefit for:
      • application of antiseptics or disinfectants
      • squeezing (“milking”) puncture sites
    • Avoid use of bleach and other agents caustic to skin
  • Reporting an Exposure
    • Report to Emergency Dept or via protocol
    • Rapid HIV testing available to guide management
  • Postexposure Management: Based on specific circumstances of exposure
    • Date and time of exposure
    • Procedure details…what, where, how, with what device
    • Exposure details...route, body substance involved, volume/duration of contact
    • Information about source
  • Bloodborne Pathogens
    • Hepatitis B, Hepatitis C, and HIV
    • Relative risk of infection (30%, 3%, and <1% respectively)
    • Potential routes of workplace transmission (sharp injury, mucous membrane exposure/non-intact skin)
  • Hepatitis B Vaccine
    • Available for employees with potential body fluid exposure
    • Safe and effective
    • Positive impact on Hepatitis B infection rates (Healthcare Workers)
  • Concentration of HBV in Body Fluids
    • High Moderate Low/Not Detectable
    • Blood Semen Urine
    • Serum Vaginal Fluid Feces
    • Wound exudates Saliva Sweat
    • Tears
    • Breast Milk
  • Sharp Objects Associated with 51 Percutaneous Injuries Resulting in HIV Seroconversion in 50 Healthcare Personnel* June 2001 * http://www.cdc.gov/hiv/pubs/facts.htm#Transmission
  • Risk of Bloodborne Virus Transmission after Occupational Percutaneous Exposure
    • Source
    • HBV
    • HBeAg +
    • HBeAg -
    • HCV
    • HIV
    • Risk
    • 22.0-30.0%
    • 1.0-6.0%
    • 1.8%
    • 0.3%
  • Risk Factors for HIV Transmission After Percutaneous Exposure to HIV-Infected Blood: CDC Case-Control Study*
    • Risk Factor Adjusted OR ratio (95% CI )
    • Deep injury 15 (6.0-41)
    • Visible blood on device 6.2 (2.2-21)
    • Procedure involving needle 4.3 (1.7-12)
    • placed in artery or vein
    • Terminal illness in source patient 5.6 (2.0-16)
    • Postexposure use of zidovudine 0.19 (0.06-0.52)
    • * Cardo et al., New Engl J Med 1997;337:1485-90
  • Initiation of HIV PEP
    • If indicated, start antiviral drugs as soon as possible after exposure
      • regard as an urgent medical concern
      • hours rather than days
    • Interval after which PEP is no longer likely to be effective in humans is unknown
      • initiating PEP days or weeks after an exposure might be considered if warranted for increased risk exposure
  • HIV PEP
      • Will be discussed Thursday!
  • Preventing Transmission of Bloodborne Viruses in Healthcare Settings
    • Receive hepatitis B vaccination if available
    • Treat all patients as potentially infectious (STANDARD PRECAUTIONS)
    • Use barriers to prevent blood/body fluid contact (STANDARD PRECAUTIONS)
    • Prevent percutaneous injuries (USE SAFETY DEVICES and handle sharps appropriately)
  • PREVENTION IS PRIMARY!
  • TUBERCULOSIS
    • Latent pulmonary TB infection
    • PPD positive skin test
    • Not treated for PPD skin test (or unknown status)
    • Symptoms absent
    • No isolation needed
    • Suspected or Active Pulmonary TB
    • Symptoms present (includes cough > 2 weeks duration, +/- weight loss, night sweats, hemoptysis
    • Requires airborne isolation
  • Tuberculosis Control Program
    • PPD skin testing upon employment and annually (six-months for high risk job titles)
    • Post-exposure skin testing as notified by manager and/or infection control (baseline and 12 weeks later)
  • Hierarchy of Controls (TB)
    • Administrative controls – protocols in place for front line staff to identify possible infectious TB and initiate Airborne Isolation
    • Engineering Controls – Negative Pressure Isolation Room
    • Work Practice Controls – Doors kept closed, windows open
    • PPE – Particulate respirator (N95) Fit testing, other masks
  •  
  • INFECTION CONTROL IS EVERYBODY’S RESPONSIBILITY!
  • Antimicrobial Stewardship
  • Case Mr C.
    • Mr C is a 35 year old healthy man who comes to clinic complaining of runny nose, frontal sinus congestion, sore throat, and myalgias for 7 days.
    • His vital signs are stable and he is afebrile. His exam is notable for mild tonsillar erythema and some generalized sinus tenderness
    • He states that he is really busy working and has 2 young children at home (who both have colds). His symptoms have been going on for a week and he wants a prescription so he get better fast
  • Mr C.
    • The most likely diagnosis and appropriate course of action is:
    • Acute bacterial sinusitis because of his generalized frontal headache. Recommend Amox-clav 875mg bid for 10 days
    • Acute bronchitis because of his cough – Recommend Moxifloxacin 400mg PO daily for 14 days
    • Acute pharyngitis because he has a sore throat – Recommend a azithromycin for 5 days
    • He most likely has a viral infection – Recommend no antibiotics, decongestants if need, plenty of rest and fluids…and of course a flu shot
  • Mr C .
    • The most likely diagnosis and appropriate course of action is:
    • Acute bacterial sinusitis because of his generalized frontal headache. Recommend Amox-clav 875mg bid for 10 days
    • Acute bronchitis because of his cough – Recommend Moxifloxacin 400mg PO daily for 14 days
    • Acute pharyngitis because he has a sore throat – Recommend a azithromycin for 5 days
    • He most likely has a viral infection – Recommend no antibiotics, decongestants if need, plenty of rest and fluids…and of course a flu shot
  • The Discovery of Antibiotics
  • Evolution of Drug Resistance in Staphylococcus aureus S. aureus Penicillin [1950s] Penicillin-resistant S. aureus [2002] Vancomycin-resistant S. aureus (VRSA) Methicillin [1970s] Methicillin-resistant S. aureus (MRSA) Vancomycin-resistant Enterococci (VRE) Vancomycin [1990s] [1997] Vancomycin intermediate- resistant S. aureus (VISA)
  • Antibiotic Resistant Organisms in Nosocomial Infections
    • MRSA = Methicillin-Resistant Staphylococcus aureus
    • VRE = Vancomycin-Resistant Enterococci
    • ESBL = Extended Spectrum Beta-lactamase producing ( E. coli or Klebsiella pneumoniae )
  • MRSA
  • Progression of resistant Staphylococcus aureus McDonald LC. Clin Infect Dis. 2006;42:S65-S71. Penicillinase-producing S aureus 0 25 50 75 100 1940 1960 1980 2000 Year Resistant isolates (%) Methicillin-resistant S aureus 0 25 50 75 100 1940 1960 1980 2000 Year Resistant isolates (%) A similar trend in the increase in nosocomial infections caused by antimicrobial-resistant S aureus isolates can be observed in community-acquired infections Nosocomial infection Community-acquired infection
  • Source: National Nosocomial Infections Surveillance (NNIS) System Methicillin-Resistant Staphylococcus aureus (MRSA) Among Intensive Care Unit Patients, 1995-2004
  • Incidence of Nosocomial Pneumonia Caused by S. aureus Pujol et al. Eur J Clin Microbiol Infect Dis . 1998;17:622; Germaud et al. Rev Pneumol Clin . 1999;55:83.
  • VRE
  • Source: National Nosocomial Infections Surveillance (NNIS) System Vancomycin-Resistant Enterococci (VRE) Among Intensive Care Unit Patients, 1995-2004
  • Resistant Gram-Negatives Resistant Gram-Negatives
  • Source: National Nosocomial Infections Surveillance (NNIS) System 3 rd Generation Cephalosporin-Resistant Klebsiella pneumoniae Among Intensive Care Unit Patients, 1995-2004
  • Annual evolution of antimicrobial resistance in invasive Escherichia coli isolated by Spanish laboratories participating in European Antimicrobial Resistance Surveillance System, 2001-2003.
  • Source: National Nosocomial Infections Surveillance (NNIS) System Fluoroquinolone-Resistant Pseudomonas aeruginosa Among Intensive Care Unit Patients, 1995-2004
  • Acinetobacter spp.
    • High incidence of MDR (and even pan-resistance)
    • Seen in wounds post Earthquake in Haiti
    • High mortality when a cause of VAP or bacteremia (cause or marker of severe underlying disease?)
    • Associated with post-neurosurgical infections
    • Responsible for resurgence in the use of polymyxins
  • Clostridium difficile
  • Clostridium difficile
    • INCREASING INCIDENCE
      • Estimated >400,000 hospital cases annually in US
    • EPIDEMIC STRAIN
      • A common resistant epidemic C. difficile strain called NAP-1 has been found in the US, Canada, and Europe.
      • This strain produces the binary toxin and has higher production of toxins A and B
    • MORE SEVERE
      • Higher mortality and higher rates of colectomy
      • in the recent Quebec epidemic, >1400 deaths and a 17% attributable mortality
  • Antimicrobial Resistance: International, national, and local problem Resistance in Haiti
    • 2010 Earthquake - USNS Comfort
      • 725 patient specimens submitted to microbiology lab
        • 266 + >= 1 organism (37%)
      • 160 urine cultures
        • 23% positive for bacteria –
          • E. Coli most frequent
            • 5/12 E. coli (42%) ESBL positive
          • K. pneumoniae
            • 3 of 4 ESBL positive
      • MDR Acinetobacter spp. Appeared early
        • 1 st patient + meningitis from shore
        • After this patient was identified, surveillance performed in all ICU patients
          • 8 patients found to be infected (wounds)
    Hussey et al. Archives of Pathology & Lab Med 2011; Amundson et al. Ann Int Med 2010
  • What is Antimicrobial Stewardship?
    • Antimicrobial stewardship involves the optimal selection, dose and duration of an antibiotic resulting in the cure or prevention of infection with minimal unintended consequences to the patient including emergence of resistance, adverse drug events, and cost.
    Dellit TH, et al. CID 2007;44:159-77, Hand K, et al. Hospital Pharmacist 2004;11:459-64 Paskovaty A, et al IJAA 2005;25:1-10 Simonsen GS, et al Bull WHO 2004;82:928-34 Ultimate goal is improved patient care and healthcare outcomes
  • Nationwide Survey on Antimicrobial Stewardship Program Characteristics
    • 8,000 nationwide providers surveyed (5% response rate)
      • Pharmacy directors
      • ID pharmacists
    • 51% had formal ASP
    • 63% of non-ASP institutions considered implementing a program
      • Common barriers:
        • Staffing constraints
        • Funding constraints
    • Institutions with ASPs more likely to have:
      • More admissions
      • Antibiograms
      • ID consult services
      • ID fellowship programs
  • Institutions with Stewardship Programs: National Survey Results
    • Education techniques:
      • Newsletter (56.8%)
      • Grand Rounds (45.9%)
      • Conferences (41.5%)
      • None (6%)
    • Stewardship techniques:
      • IV to PO converison (85.3%)
      • Guidelines and clinical pathways (81.5%)
      • Dose optimization (70.7%)
      • Streamlining or de-escalation (62.5%)
      • Closed formularies (59.8%)
      • Antimicrobial order forms (41.8%)
      • Antimcrobial cycling (3.3%)
    • Restriction Methods:
      • “ Back end” approach (52.5%)
      • Automatic stop orders (45.9%)
      • ID consult required (44.3%)
      • “ Front end” approach (39.3%)
      • None (0%)
    • Commonly restricted antimicrobials
      • Antifungals (72.7%)
      • Linezolid (70.5%)
      • Carbapenems (69.9%)
      • Daptomycin (69.4%)
      • Tigecycline (64.5%)
      • Anti-Pseudomonals (57.4%)
      • Fluroquinolones (44.8%)
      • None (0%)
  • Antimicrobial Therapy A Balancing Act Appropriate initial antibiotic while improving patient outcomes and healthcare Unnecessary Antibiotics, adverse patient outcomes and increased cost
  • Get SMART about antibiotic use!
    • S tarting off – choosing the most appropriate empiric regimen
    • M aintenance of therapy: Targeting, de-escalating, and discontinuing therapy
    • A re you treating infection or colonization?
    • R oute: IV or PO
    • T ime: Stop antibiotics as early as possible
  • Get Smart: Know When Antibiotics Work
    • Goals:
      • promoting adherence to appropriate prescribing guidelines
      • decreasing demand for inappropriate antibiotics
    • National campaign to target five conditions that accounted for >75% of all office based antibiotic prescribing:
      • Otitis media
      • Sinusitis
      • Pharyngitis
      • Bronchitis
      • The common cold
  • Get Smart Campaign
    • Otitis media visits children < 5 years, decrease in antimicrobials prescribed 1
      • 1997: 69 antimicrobials/100 visits
      • 2007: 47.5 antimicrobials/100 visits
    • Among children < 5 years, annual “acute respiratory tract infections” visit rates decreased by 17% 2
    • 25% reduction in antimicrobial use per outpatient office visit for presumed viral infections 3
    • Grijalva CG, et al. JAMA 302: 758-766, 2009.
    • Fendrick AM et al. , Arch Int Med : 163(4): 487-94, 2003.
    • National Ambulatory Medical Care Survey (NAMCS).
  • Get Smart 2010
    • Each year
      • 2 million bacterial HAI
      • 90,000 people die
      • More than 70% of these infections are resistant to at least one class of antibiotics
    • Antibiotic resistance is associated with:
      • Increased risk of hospitalization
      • Increased length of stay
      • Increased hospital costs
      • Increased risk of ICU transfer
      • Increased mortality
    • Decreasing inappropriate antibiotic use is the best way to control resistance
  • Get Smart 2010 Targeting Healthcare settings
    • Mission: To optimize the use of antimicrobial agents in inpatient healthcare settings
    • Goals:
    • Improve patient safety through better treatment of infections
    • Reduce the emergence of antimicrobial resistant pathogens
    • Encourage better use of antimicrobials in healthcare settings
  • Efforts to Improve Antimicrobial Prescribing and Control Resistance Antimicrobial Stewardship Develop New Drugs and Vaccines Improved Diagnostics Infection Control Reduce Resistance Reservoirs Research & Pubic Policy Education
  • Efforts to Improve Antimicrobial Prescribing and Control Resistance Antimicrobial Stewardship Develop New Drugs and Vaccines Improved Diagnostics Infection Control Reduce Resistance Reservoirs Research & Pubic Policy Education
  • Questions?
  • What is the single most important reason for healthcare workers to practice good hand hygiene?
    • To remove visible soiling from hands
    • To prevent transfer of bacteria from the home to the hospital
    • To prevent transfer of bacteria from the hospital to the home
    • To prevent infections that patients acquire in the hospital
  • What is the single most important reason for healthcare workers to practice good hand hygiene?
    • To remove visible soiling from hands
    • To prevent transfer of bacteria from the home to the hospital
    • To prevent transfer of bacteria from the hospital to the home
    • To prevent infections that patients acquire in the hospital
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  • OSHA’s Hierarchy of Controls
    • Administrative controls e.g. monitoring and enforcement of protocols/policy and procedures
    • Engineering Controls - Safe equipment or devices
    • Work Practice Controls - e.g. no recapping of needles/sharps
    • Personal Protective Equipment - gloves, fluid resistant gowns/aprons, faceshield
  • PROTECTIVE ISOLATION (Draft)
    • Strict Hand Hygiene BEFORE entering room!
    • All visitors must be screened by Nursing. (Visitors with symptoms of contagious illness and/or recent exposure to contagious illness or some vaccines cannot enter.)
    • Hepa-filtration and positive room air pressure
    • Door must be kept closed
    • No upholstered furniture/furnishings
    • No flowers (fresh or dried) or potted plants
    • Particulate respirator (N95) for the patient when leaving protective environment
    GOOD HAND HYGIENE IS ESSENTIAL
  • Protective Isolation (back)
    • Bone Marrow Transplant Patients - For induction chemotherapy and until day 100 post transplant or until fully engrafted.
    • Solid Organ Transplants - For 4 months post transplant.
    • Neutropenic Patients - Patients experiencing or anticipated to experience prolonged (10 days or more) neutropenia (total WBC x percentage of PMNs) <500 per mm 3
    • Physician must order Low Bacterial Diet for dietary modifications to be implemented by Food Service.
  • Types of Precautions
    • STANDARD PRECAUTIONS – No Changes, applies to all blood, body fluids, mucous membranes from all patients
    • EXPANDED PRECAUTIONS – initiated for clinical suspicion/diagnosis of communicable illness (non- bloodborne) or immunosuppression
    • Airborne
    • Droplet
    • Contact
    • Modified Contact
    • Droplet/Contact
    • Airborne/Droplet/Contact
    • Modified Standard
    • Protective Isolation
  • “ New” Expanded Precautions Signs
    • Rationale:
    • Too much variation on the part of HCWs in completing generic sign (HCW checks off/chooses options)
    • Too many write in modifications to generic sign +/- use additional hand made signs (with inaccurate information)
  • DROPLET/CONTACT PRECAUTIONS
    • VISITORS : REPORT TO NURSES’ STATION BEFORE ENTERING ROOM
    • VISITANTES: FAVOR DE ANUNCIARSE A LA ENFERMERA DE PISO ANTES DE ENTRAR AL CUARTO
    GOOD HAND HYGIENE IS ESSENTIAL SURGICAL MASKS to enter room GLOVES to enter room GOWNS to enter room Keep contaminated hands away from eyes or face.
  • DROPLET/CONTACT PRECAUTIONS (back)
    • ALL Pediatric Respiratory Illness (includes RSV, Adenovirus, Parainfluenza, Influenza)
    • “ Breakthrough” Chickenpox or chickenpox that occurs in adequately vaccinated patient
    • RSV in Adults
    • Cystic fibrosis patients with c. cepacia and/or other multi-drug resistant gram negative organisms
    • NOTE TO STAFF : Keep hands away from eyes and face.
    GOOD HAND HYGIENE IS ESSENTIAL
  • AIRBORNE/DROPLET/CONTACT PRECAUTIONS
    • VISITORS : REPORT TO NURSES’ STATION BEFORE ENTERING ROOM
    • VISITANTES: FAVOR DE ANUNCIARSE A LA ENFERMERA DE PISO ANTES DE ENTRAR AL CUARTO
    GOOD HAND HYGIENE IS ESSENTIAL N95 respirator to enter room Face shield (over N95) or goggles to enter room GLOVES to enter room GOWNS to enter room
  • AIRBORNE/DROPLET/CONTACT PRECAUTIONS (back)
    • Chicken Pox / Disseminated Zoster
    • SARS
    • Smallpox
    • Avian Influenza (Non-pandemic situation). In circumstances of pandemic influenza, may utilize Droplet and Standard Precautions only. Do not put contaminated hands near eyes or face.
    • Negative Pressure Room required. Exceptions must be approved by Hospital Epidemiology/Infection Control.
    GOOD HAND HYGIENE IS ESSENTIAL
  • MODIFIED STANDARD PRECAUTIONS
    • VISITORS : REPORT TO NURSES’ STATION BEFORE ENTERING ROOM
    • VISITANTES: FAVOR DE ANUNCIARSE A LA ENFERMERA DE PISO ANTES DE ENTRAR AL CUARTO
    GOOD HAND HYGIENE IS ESSENTIAL DO NOT PROVIDE DIRECT CARE IF SUSCEPTIBILE TO CHICKENPOX
  • MODIFIED STANDARD PRECAUTIONS (back of sign)
    • Localized H. zoster (shingles) in immunocompetent host
    • Also post this sign (Modified Standard Precautions) in addition to Airborne/Droplet/Contact Sign, when suspect Varicella or Disseminated zoster.
    GOOD HAND HYGIENE IS ESSENTIAL
  • Bloodborne Pathogen Exposure Protocol
    • Wash affected area with soap and water (if splash to eyes, perform eye rinse with tap water)
    • REPORT ACCIDENT IMMEDIATELY to Emergency Room or per protocol
    • Notify supervisor
    • Follow-up based on specific circumstances and infection risk
  • Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV)
    • Bloodborne viruses
    • Can produce chronic infection
    • Transmissible in healthcare settings
    • Data from multiple sources (e.g., surveillance, observational studies, serosurveys) used to assess risk of occupational transmission
  • Prevalence of Bloodborne Virus Infection in Patients
    • Generally higher in hospitalized patients than general population
    • Varies with geographic area
    • Varies with patient group
  • U.S. HCWs with Documented and Possible Occupationally Acquired AIDS/HIV Infection, by Occupation, June 2001*
    • Documented Possible
    • Occupation Transmission (#) Transmission (#)
    • Health aide/attendant 1 15
    • Housekeeper/maintenance worker 2 13
    • Laboratory technician, clinical 16 17
    • Laboratory technician, nonclinical 3 ----
    • Nurse 24 34
    • Physician, nonsurgical 6 12
    • Physician , surgical ---- 6
    • Respiratory therapist 1 2
    • Technician, dialysis 1 3
    • Technician, surgical 2 2
    • Technician/therapist, other than above ---- 9
    • Other healthcare occupations ---- 4
    • Total 56 117
    * http://www.cdc.gov/hiv/pubs/facts.htm#Transmission
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  • Antibiotics Feeding tube Ventilator Environment Catheters Colonized Patient Dynamics of Nosocomial Multi-Drug Resistance Pathogen Transmission Risk factors Infection Control Infection Control Cleaning