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ESCMID-SHEA course 2013 24-09-13
Andreas Voss 1
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 2
¤ C.difficile: 	
  Endemic	
  and	
  epidemic	
  
¤ Norovirus 	
  Epidemic...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 3
¤  C.	
  difficile	
  is	
  a	
  gram-­‐posiCve,	
  spore-­‐forming,	
  obl...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 4
Poutanen SM CMAJ 2004;171(1):51-8
1.  Disruption of mucosa by chemotherapy...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 5
negative
C. difficile toxin A/B
C. difficile antigen not
detected.
C. diff...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 6
Lessa, et al. Clin Infect Dis 2012
2008
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 7
5,7
7,3
8,2
12,2
16
23,7
0
5
10
15
20
25
1999 2000 2001 2002 2003 2004
Eme...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 8
Vonberg RP & Gastmeier P. EID 2007;13:180
Germany
McDonald, L. et al. N En...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 9
CDC rapport 2013
¤ Recent	
  anCbioCc	
  exposure	
  
¤ Prolonged	
  len...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 10
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 11
Strength of
Recommendation
Hand Hygiene A-II
Contact Precautions
a. Glove...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 12
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 13
Culture-
negative
Patient in
Room for >48h
Asymptomatc
CD Patient
Carrier...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 14
Riggs MM, et al. Clin Infect dis 2007;45: 992
C.difficile_CID_08Bobulsky ...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 15
Shaughnessy et al,
ICHE 2011
Intervention Reduction of initial
contaminat...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 16
(gray bars; June 2004 through March 2005) and the intervention period
(re...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 17
¤ Pro	
  and	
  contra	
  wash	
  
² 	
  +	
  Physically	
  removes	
  ...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 18
¤  Pre	
  intervenCon	
  
¤  EducaCon	
  &	
  report	
  outcome	
  meas...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 19
Personal	
  protecCve	
  equipment	
  for	
  isolaCon	
  rooms	
  readily...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 20
v  Audit	
  anCbioCc	
  class	
  and	
  specific	
  anCbioCc	
  use	
  ov...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 21
Equipment	
  Cleaning	
  Chart
Equipment	
  /	
  Item LocaCon Frequency R...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 22
	
  
¤ 	
  Short	
  incubaCon	
  (15–48	
  h)	
  
¤ 	
  Illness	
  dura...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 23
Turcios RM. Clinical Infectious Diseases 2006; 42:964–9
Type Year Level o...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 24
Burton-MacLeod JA. J Clin Microbiol 2004;42:2587–2595
Okitsu-Negishi S. J...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 25
JID 2000;181 (Suppl 2):259
No data 43%
Foodborne 21%
Unknown
16%
Waterbor...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 26
RT-­‐PCR	
  environmental	
  surface	
  tesCng	
  +	
  
	
  
Carpets	
  (...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 27
HospitalEpiinformed
Noadmissiontowardx
Norovirus Epidemic Dec 2002
0
2
4
...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 28
¤  CauCon	
  visitors	
  and	
  emphasize	
  hand	
  hygiene	
  	
  
wit...
ESCMID-SHEA course 2013 24-09-13
Andreas Voss 29
Präparat Amphisept E Sterillium Virugard Sterillium Sterillium pure
Wirks...
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Diarrhea escmid shea course

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Diarrhea escmid shea course

  1. 1. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 1
  2. 2. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 2 ¤ C.difficile:  Endemic  and  epidemic   ¤ Norovirus  Epidemic   ¤ Rare:   ²   Hospital  kitchen  /  visitors   ² Salmonella   ² Listeria  in  immunocompromised  host  (cheese,  milk)   ² Water  supply   ² Cryptosporidiosis   ² EHEC  (tropical  countries)   Rupnik M, Widmer A, et al. J Clin Microbiol. 2008 Jun;46(6):2146. 4 6 12 24 36 48 72 hrs 5 7 14 18 21 Tage S.aureus B.cereus EHEC / ETEC Toxin Salmonellen Clostridium perfringens Vibrio cholerae Listerien Shigellen Rotavirus Norovirus Campylobacter C.difficile Cyclospora cayetanensis Cryptosporidien Giardia lamblia Listerien /Typhus E.histolytica /Aeromonas
  3. 3. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 3 ¤  C.  difficile  is  a  gram-­‐posiCve,  spore-­‐forming,  obligate  anaerobic   bacillus  that  is  found  in  a  variety  of  environmental  niche.     ¤  Toxigenic  (toxin-­‐producing)  forms  of  the  bacillus  are  pathogenic  for   humans.     ¤  Spores  are  very  resilient  to  heat  and  desiccaCon  and  can  remain   viable  in  the  hospital  environment  for  weeks  to  years.   ¤  CDI  can  range  from  mild  diarrhea,  defined  as  three  or  more  loose   stools  (those  that  take  the  shape  of  the  container)  within  a  24-­‐hour   period,  to  severe  life-­‐threatening  disease  .   ²  Severe  forms  such  as  pseudomembranous  coliCs,  can  cause     dehydraCon  and  tremendous  discomfort  for  the  paCent.     ²  Rarely,  toxic  megacolon,     ²  bowel  mucosa  becomes  so  inflamed  that  peristalsis  stops,  fecal  impacCon   occurs,  and  emergent  surgery,  including  colectomy,  is  required.  
  4. 4. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 4 Poutanen SM CMAJ 2004;171(1):51-8 1.  Disruption of mucosa by chemotherapy for neoplasms or changes of normal flora by antimicrobial therapy or chemotherapy 2.  Acquisition of spores leads to colonic colonization of C. difficile 3.  Growth and production of its toxins and lack of immunity triggers disease
  5. 5. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 5 negative C. difficile toxin A/B C. difficile antigen not detected. C. difficile antigen detected. C. difficile toxin A/B detected. C. difficile antigen detected. C. difficile toxin A/B not detected. positive C. difficile specific antigen Interpretation: Absence of C. difficile. No further testing (87.3%) Interpretation: Toxin- producing C. difficile (4.7%) Interpretation: Non-toxin (1.4%) or toxin- producing C.difficile (3.3%) or false-positive antigen result (2.7%). Culture should be performed (Called toxigenic culture by repeating toxin test from pos.culture) Stool specimen for C. difficile testing (n=1,468 consecutive stool samples) L. Fenner, Widmer AF, Frei R.. J.Clin Microbiol. 2008;46:328-330 positive negativenegative Resultats  in  <1  hours.     ¤ DetecCon  of  Toxin  B,     binary    Toxin  →    Typical  for  078     plus  tcdC-­‐DeleCon  →   NAP1  /  PCR  Ribotyp  027     I  use  a  “home-­‐made”  PCR  
  6. 6. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 6 Lessa, et al. Clin Infect Dis 2012 2008
  7. 7. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 7 5,7 7,3 8,2 12,2 16 23,7 0 5 10 15 20 25 1999 2000 2001 2002 2003 2004 Emerg Infect Dis 2007,13:1417-9 permillionpopulation www.statistics.gov.uk
  8. 8. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 8 Vonberg RP & Gastmeier P. EID 2007;13:180 Germany McDonald, L. et al. N Engl J Med 2005;353:2433-2441 Rupnik M. et al. J Med Microbiol 2005;54:113-7 Geric J Clin Microbiol 2003 I) 18–bp tcdC gene deletion at nucleotides 330 to 347 II) binary toxin (encoded by cdtA and cdtB genes) cdtA gene, the enzymatic component, cdtB gene, the binding component §  tcdA codes for toxin A §  tcdB tocodes for toxin B §  tcdC putative negative regulator of toxin production §  tcdD positive regulator of toxin production §  tcdE holin production: release of toxin, holes in membranes 19kda 5 genes
  9. 9. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 9 CDC rapport 2013 ¤ Recent  anCbioCc  exposure   ¤ Prolonged  length  of  stay     in  healthcare  facility   ¤ Increasing  age   ¤ Serious  underlying  illness   ¤ Proton  pump  inhibitors    
  10. 10. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 10
  11. 11. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 11 Strength of Recommendation Hand Hygiene A-II Contact Precautions a. Glove use b. Gowns A-I B-III Private Room or Cohorting C-III Environmental cleaning, disinfection, or use of disposables a. Disinfect patient rooms and surfaces b. Disinfect equipment between patient use c. Eliminate use of rectal thermometers d. Use of hypochlorite (1000 ppm) for disinfection B-II C-III B-II B-II SHEA-CDC-Guideline 2010 (SHEA Guidelines committee (Widmer AF).
  12. 12. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 12
  13. 13. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 13 Culture- negative Patient in Room for >48h Asymptomatc CD Patient Carrier in Room Patient with CD Diarrhea in Room 7/88 (8%) 11/38 (29%) 44/90 (49%) McFarland et al NEJM 1989;320:204
  14. 14. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 14 Riggs MM, et al. Clin Infect dis 2007;45: 992 C.difficile_CID_08Bobulsky GS et al, Clin Infect Dis 2008;46:447-450 COf note, the patient had showered 1 h before collection of the culture specimen. Frequency of acquisition on sterile gloves after contact with skin sites of a subset of 10 patients Frequency of Clostridium difficile contamination of skin sites of 27 patients with C. difficile-associated disease (CDAD)
  15. 15. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 15 Shaughnessy et al, ICHE 2011 Intervention Reduction of initial contamination or Incidence of CDAD References Unbuffered hypochlorite (500 ppm) Phosphate buffered hypochlorite (1600 ppm pH 7,6) 5 X 100 X Kaatz, Am J Epidemiol 1988 Unbuffered 1:10 hypochlorite solutions Before 8.6/1000 pt-d After 3.3/1000 pt-d Mayfield, CID 2000 Diluted aldehyde-containing disinfectant + other infection control measures 4 X p=0.04 Before 1.5/1000 adm After 0.3/1000 adm Struelens, Am J Med 1991 Cases with C.difficile: Disinfection with an active disinfectant against spores necessary No gluoprotamin (Incidine®) No Quats. No Amines Widmer AF & Frei R.. Infect Control Hosp Epidemiol Nov 2003 Widmer AF & Frei R. Disinfection. Manual of Clinical Microbiology, ASM 2007 /2011
  16. 16. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 16 (gray bars; June 2004 through March 2005) and the intervention period (red bars; June 2005 through March 2006) Boyce JM et al. ICHE 2008;29:723-9 Interventionperiod Interventionperiod Interventionperiod Interventionperiod Interventionperiod …  in-­‐vitro  virology  versus  in-­‐vivo  infec/on  control  
  17. 17. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 17 ¤ Pro  and  contra  wash   ²   +  Physically  removes  bacteria  and  spores   ²   +  effecCve  based  on  good  studies   ²   -­‐  Less  effecCve  against  vegetaCve  bacteria   ²   -­‐  Poor  compliance  /  Cme  consuming   ¤ Pro  and  contra  Alcohol   ²   -­‐  No  acCvity  against  spores   ²   +  Enhanced  compliance   ²   +  No  evidence  that  washing  stops  epidemics  faster  Wash  hands  if  visibly  soiled  –  in  all  other  cases  just  rub   Mermel et al, Jt Comm J Qual Patient Saf 2013
  18. 18. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 18 ¤  Pre  intervenCon   ¤  EducaCon  &  report  outcome  measures;  monitor  room  cleaning   ¤  EducaCon  and  bleach  product  use  for  room  cleaning   ¤  C.  difficile  detecCon  by  PCR   ¤  AddiConal  cleaning  personnel  and  defined  cleaning  responsibiliCes     ¤  Equipment-­‐cleaning  training  and  monitoring.       ¤  Enhance  discharge  room  cleaning   ¤  Assess  need  for  more  housekeeper  FTEs  to  adequately  clean  rooms   ¤  Monitor  compliance,  report  back  to  Environmental    Services  unit,   infecCon  control  and  hospital  administraCon   ¤  Single-­‐use  devices  for  isolaCon  rooms   ² blood  pressure  cuff,  thermometer,  stethoscope  in  all  isolaCon  rooms   ² Monitor  compliance   ¤  Review  policies  for  cleaning  of  portable  equipment   ² determine  who  is  responsible  for  maintaining    cleaning  and  supplies   used  for  cleaning    
  19. 19. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 19 Personal  protecCve  equipment  for  isolaCon  rooms  readily  available   (gowns,  gloves,  masks  as  needed)    -­‐Easily  accessible  and  readily  available      -­‐Appropriate  sizes      -­‐Easily  accessible,  frequently  empCed  hamper  bins    -­‐Monitor  compliance  and  report  back  to  unit,          infecCon  control  and  hospital  administraCon     Robust  anCbioCc  stewardship  program  for  all  hospital  units      -­‐Regularly  scheduled  prospecCve  audits  of  anCbioCc          uClizaCon  with  direct  interacCon  and  feedback  to        prescriber    -­‐Formulary  restricCon  and  pre-­‐authorizaCon        requirements    -­‐EducaCon  of  prescribers     v  Develop  evidence-­‐based  pracCce  guidelines  and  incorporate  into   physician  order  entry  system  based  on  naConal  guidelines,  local   microbiology  and  hospital  anCmicrobial  resistance  paeerns   v  Assist  in  streamlining,  or  de-­‐escalaCng  empiric  anCbioCc  therapy   based  on  culture  results,  eliminaCng  redundant  combinaCon   therapy  (done  in  ICUs)   v  OpCmizing  anCmicrobial  dosing  based  on  individual  paCent   characterisCcs,  causaCve  organism,  site  of  infecCon,  and   pharmacokineCc  and  pharmacodynamic  characterisCcs  of   prescribed  drug  (done  in  ICUs)   v  Assist  in  IV  to  oral  conversion  of  anCbioCcs  by  developing  clinical   criteria  and  guidelines  promoCng  conversion  to  use  of  oral  agents   (done  in  ICUs)  
  20. 20. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 20 v  Audit  anCbioCc  class  and  specific  anCbioCc  use  over  Cme  and   report  data  to  CMO   v  Assist  in  narrow  spectrum  anCbioCc  use   v  Limit  quinolone  &  clindamycin  use  (done  in  surgery  only)   v  Monitor  process  and  outcome  data,  report  to  infecCon   control,  QA,  and  hospital  administraCon       v  Develop  a  program  to  determine  paCents  at  high  risk  for  C.   difficile  and  automate  orders  for  isolaCon  precauCons  and  C.   difficile  tesCng  along  with  automated  noCficaCon  of  physician   and  nursing  team  caring  for  individual  paCents     v  Empower  nurses  to  order  C.  difficile  toxin  assay  on  paCent’s   with  diarrhea  without  a  doctor’s  order                 v Improved  sensiCvity  of  C.  difficile  tesCng  and  increase   frequency  of  tesCng  done  by  microbiology  laboratory   v Develop  a  medical/surgical  guideline  for  C.  difficile   management       v Incorporate  into  physician  order  entry  system     v Monitor  compliance  &  outcome  data,  report   v Develop  medical/surgical  rapid  response  team  for  severe   C.  difficile  management     v Monitor  outcome  data,  report   v Consider  expanding  isolaCon  precauCons  for  pts  with  C.   difficile  infecCon  for  duraCon  of  hospitalizaCon    
  21. 21. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 21 Equipment  Cleaning  Chart Equipment  /  Item LocaCon Frequency Responsibility Daily  Room   Cleaning  Product Daily  IsolaCon   Room  Cleaning   Product Discharge  Room   Cleaning  Product Monitoring Automated  external   defibrillator                   (a@er  use) Units  &   hospital-­‐wide As  needed CSD* Disinfectant  wipes N/A N/A CSD Bathroom PaCent  room Daily  &  discharge EVS† Dimension  11 Dispatch   disinfectant Dispatch   disinfectant EVS Bed/chair  alarm PaCent  room Daily  &  discharge EVS Dimension  11 Dispatch   disinfectant Dispatch   disinfectant Nursing Beds  (remains  in   room) PaCent  room Daily  &  discharge EVS Dimension  11 Dispatch   disinfectant Dispatch   disinfectant EVS Bedside  and  overbed   table PaCent  room Daily  &  discharge EVS Dimension  11 Dispatch   disinfectant Dispatch   disinfectant EVS Blood  pressure  cuffs   in  the  room PaCent  room Daily  &  discharge Nursing Dimension  11 Dispatch   disinfectant Dispatch   disinfectant Nursing Call  bell/control PaCent  room Daily  &  discharge EVS Dimension  11 Dispatch   disinfectant Dispatch   disinfectant Nursing Cardiac  monitors   telemetry  &  lead   wire   PaCent  room Daily  &  discharge Nursing Disinfectant  wipes Disinfectant  wipes Disinfectant  wipes Nursing Chair  scale PaCent  room Amer  use  &   between   paCents  or  send   to  CSD Nursing Disinfectant  wipes Disinfectant  wipes N/A Nursing Commode PaCent  room Amer  use  &   Between   PaCents Nursing   Dispatch   disinfectant Dispatch   disinfectant Nursing Computer PaCent  room Daily  &  as   needed Nursing Disinfectant  wipes Disinfectant  wipes N/A EVS Computer  in  nurses’   sta/on Nursing   staCon Daily  &  as   needed Unit  secretary Disinfectant  wipes Disinfectant  wipes N/A Nursing Computer  on  wheels Unit Daily  &  as   needed Nursing Disinfectant  wipes Disinfectant  wipes N/A Nursing Cooling  Blanket PaCent  room Amer  use  &   between   paCents  or  send   to  CSD Nursing Disinfectant  wipes Disinfectant  wipes Return  to  CSD Nursing Con/nuous  passive   mo/on  machine  for   knee   PaCent  room Amer  use  &   between   paCents Nursing Disinfectant  wipes Disinfectant  wipes Return  to  CSD Nursing Reduce  “floaCng”  responsibiliCes   EM Norovirus
  22. 22. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 22   ¤   Short  incubaCon  (15–48  h)   ¤   Illness  duraCon  12–60  h   ¤   VomiCng  in  >  50%  symptomaCc  paCents   ¤   PaCents  and  staff  both  affected   ¤   No  bacterial  pathogen  in  stool  culture   Management of hospital outbreaks of gastro-enteritis due to small round structured viruses. REPORT OF THE PUBLIC HEALTH LABORATORY SERVICE VIRAL GASTRO ENTERITIS WORKING GROUP J. Hosp Infect 2000
  23. 23. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 23 Turcios RM. Clinical Infectious Diseases 2006; 42:964–9 Type Year Level of Detection Sensitivit y Specificity EM 1972 ~ 106-7 ? ? Antigen detection ELISA IDEIA NLV kit Dako Cytomation, Ltd. (Ely, UK), SRSV(II)-AD kit Denka Seiken Co., Ltd. (Tokyo, Japan), RIDASCREEN norovirus (R-Biopharm AG, Darmstadt,Germany 1995 104-6 60-80% 60-80% RT-PCR 1992 ~ 102-4 90% 99% Immuno-PCR 2005 ~ 101-3 >95% 99% Culture 7/2005 ? Asanaka M. PNASJuly 19, 2005;102:10327–10332 ? ? Glass et al, JID 2000;181 (Suppl 2):256 Okitsu-Negishi S. JJ. Clin Microbiol Oct. 2006, p. 3784–3786 De Bruin. J Virol Meth 2006; 137, November 2006, Pages 259-264
  24. 24. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 24 Burton-MacLeod JA. J Clin Microbiol 2004;42:2587–2595 Okitsu-Negishi S. JJ. Clin Microbiol Oct. 2006, p. 3784–3786 RIDA GI 50% NA Screen GII 84% NA Both 76% 95% 90% JID 2000;181 (Suppl 2):259 Other 3% Oyster consumption 6% Vacation settings (including cruise ships) 11% Schools and day care centers 11% Restaurants and catered meals 26% Nursing homes and hospitals 43% Settings and presumptive modes of transmission for 90 outbreaks of gastroenteritis in the United States, January 1996 to June 1997
  25. 25. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 25 JID 2000;181 (Suppl 2):259 No data 43% Foodborne 21% Unknown 16% Waterborne 3% Oyster consumption 6% Person-to-person 11% Settings and presumptive modes of transmission for 90 outbreaks of gastroenteritis in the United States, January 1996 to June 1997 Viral  Shedding  (via  RT-­‐ PCR):   ¤  Day  1  78%   ¤  Day  8  45%   ¤  Day  15    35%   ¤  Day  22  26%   B Rockx; Clin Infect Dis 2002, 35: 246-53
  26. 26. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 26 RT-­‐PCR  environmental  surface  tesCng  +     Carpets  (known  vomiCng)    5/8    (62%)   Carpets  (no  vomiCng)  9/12    (75%)   Toilet  rims/seats  8/11    (73%)   Toilet  handles,  taps,  basins  13/39    (39%)   Horizontal  surfaces  below  1.5  m  11/29    (37%)   Horizontal  surfaces  above  1.5  m  6/12    (50%)   Phones,  door  handles,  etc.  7/29    (24%)   Som  furnishings  2/10    (20%)     Total    61/144  (42%)  It’s Everywhere! JS Cheeseborough; Epidemiol Infect 2000, 125: 93-98 Time to 90% Time (hr) to reduction in undetectable Fomites (hr)* virus titer (hr)* virus Keyboard keys 0-4 8-12 Computer mouse 0-4 24-48 Brass 0-4 8-12 Telephone buttons 12-24 48-72 Telephone receiver 4-8 48-72 Telephone wire 0-4 24-48 *The test organism feline calicivirus (FCV) was sampled at 0, 4, 8, 12, 24, 48, 72, 96, Clay S. Am J Infect Control 2006;34:41-3.)
  27. 27. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 27 HospitalEpiinformed Noadmissiontowardx Norovirus Epidemic Dec 2002 0 2 4 6 8 10 12 14 16 18 8.11 10.11 12.11 14.11 16.11 18.11 20.11 22.11 24.11 26.11 28.11 30.11 2.12 4.12 6.12 8.12 10.12 12.12 14.12 16.12 18.12 20.12 22.12 24.12 26.12 28.12 30.12 Incidence Personal Patienten >100 HCWs working days lost Norovirus outbreaks: Always patients & HCWs Khanna N & Widmer AF. J Hosp Infection 2003 ¤  Cohort  nurse  or  isolate  symptomaCc  individuals    (Category  II)   ¤  Wear  gloves  and  apron  for  contact  with     an  affected  paCent  or  environment     always  when  entering  the  pa/ent  room  wearing  a  mask  (Category  II)     ¤  Wash  hands  with  soap  and  water  amer  contact  with  an  affected     paCent  or    environment,  amer  removing  gloves  and  apron   Use  an  alcoholic  hand-­‐rub  containing  >95%  Ethanol,  unless   hands  are  visibly  soiled  (Category  I)     ¤  Remove  exposed  food  such  as  fruit    (No  Category)     ¤  Consider  use  of  anCemeCcs  for  paCents  with  vomiCng  (No  Category)       ¤  Exclude  affected  staff  from  the  ward  immediately     and  unCl  48  h    symptom-­‐free     unCl  24hrs  symptom-­‐free  (Category  II)   ¤  Close  the  ward  to  prevent  the  introducCon  of  new  suscepCbles.   ¤  Avoid  transfer  to  unaffected  wards  or  departments  (unless  medically       urgent  and  amer  consultaCon  with  infecCon  control  staff).  The  priority     is  to  stop  spread  of  the  virus  to  other  areas  (Category  II).     ¤  Exclude  non-­‐essenCal  personnel  from  the  ward  (Category  II)   Chadwick Journal of Hospital Infection (2000) 45: 1–10
  28. 28. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 28 ¤  CauCon  visitors  and  emphasize  hand  hygiene     with  an  alcoholic  handrub  >  95%  ethanol  (Category  II)     ¤  Clean  and  disinfect  vomit  and  faeces  spillages  promptly.  (Category  II)   with  high  concentra/on  of  bleach  or  oxygen  releasing  agent   ¤  Increase  the  frequency  of  rouCne  ward,  bathroom  and    toilet  cleaning    (>2  /mes/day)   emphasize  toilets  of  employees  (Category  II)     ¤  Use  freshly  prepared  0.1%  (1000  ppm)  hypochlorite  to  disinfect     hard  surfaces  amer  cleaning  or  oxygen  releasing  agent    (Category  II)     ¤  The  ward  should  not  be  re-­‐opened  unCl  72  h  amer  the  last  new     case  and  72  h  amer  uncontained  vomiCng  and  diarrhoea  (Category  II)   ¤   Thoroughly  clean  the  ward  and  change  the  bed  curtains     before-­‐opening    (Category  II)     ¤  Clean  carpets  and  som  furnishings  with  hot  water  and   detergent  or  steam  clean.   No  carpets  in  paCent-­‐care  areas  of  hospitals      (No  Category)   Chadwick Journal of Hospital Infection (2000) 45: 1–10 Khanna & Widmer : J Hosp Infect 2003 Active constituent Final concentration CPE (TCID50) Log10 reduction Untreated control Detected (105.0 ) Glutaraldehyde 0.5 % neg 5 Hypochlorite freshly reconstitutet 5000 ppm neg 5 1000 ppm neg 5 500 ppm Detected (102.25 ) 2.75 250 ppm Detected (102.25 ) 2.75 100 ppm Detected (103.25 ) 1.75 Hypochlorite 5000 ppm neg 5 1000 ppm Detected (102.5 ) 2.5 500 ppm Detected (103.5 ) 1.5 250 ppm Detected (104.25 ) 0.75 100 ppm Detected (103.25 ) 1.75 Quaternary ammonia 1:10 Detected (105.0 ) 0 Ethanol 75 % Detected (103.75 ) 1.25 Iodine 0.8 % neg 5 Anionic detergent 1 % Detected (104.5 ) 0.5 Inactivation of FCV Doultree et al, JHI 1999, 41: 51-57
  29. 29. ESCMID-SHEA course 2013 24-09-13 Andreas Voss 29 Präparat Amphisept E Sterillium Virugard Sterillium Sterillium pure Wirksamkeit bakterizid, fungizid, tuberkulozid, HBV/HIV, BVDV, Herpes, Rota, Adeno, Vaccinia bakterizid, fungizid, tuberkulozid, Polio, Adeno,Papova, Vaccinia, HBV, HIV, BVDV, Herpes, Rota bakterizid, fungizid, tuberkulozid, HBV, BVDV, HIV,Herpes, Influenza A, Rota, Vaccinia, Papova bakterizid, fungizid, tuberkulozid, HBV/HIV, BVDV, Herpes, Papova, Rota, Vaccinia Tuberkulose 60 Sek. 60 Sek. 60 Sek. 60 Sek. MRSA/EHEC/VRE 30 Sek. 30 Sek. 30 Sek. 30 Sek. Listerien/Salmonellen 30 Sek. 15 Sek. 30 Sek. 30 Sek. DVV Adeno 5 Min. 2 Min. / / Papova / 2 Min. 5 Min. 5. Min. Polio o.B./m.B. / 1 Min. / / Vaccinia 30 Sek. 15 Sek. 30 Sek. 1 Min. Sonstige HBV o.B./m.B. 30 Sek. 30 Sek. 30 Sek. 30 Sek. HCV (BVDV) 30 Sek. 30 Sek. 30 Sek. 30 Sek. Norwalk (Calici) o.B./m.B. / 2 Min. (RKI) / / HIV 30 Sek. 30 Sek. 30 Sek. 30 Sek. Herpes 30 Sek. 15 Sek. 30 Sek. 30 Sek. Influenza / / 15 Sek. / Rota 30 Sek. 15 Sek. 30 Sek. 30 Sek. Farbe/Duftstoffe ( + / + ) ( - / - ) ( + / + ) ( - / - ) Flammpunkt 19,5° C 0° C 23° C 22,5° C ¤  Be  prepared  for  Norovirus:    you  ALWAYS  will  be  (too)  late   ¤  Organize  a  rapid  informaCon  system   ¤  Have  a  wrieen  plan  with     ²  designated  laboratory  (and  forms  filled  in)     ²  Restricted  paCent  move  during  outbreaks   ²  Hand  rub  with  high-­‐ethanol  content  stored  in  the  hospital  ready  to  use.   ²  Surface  disinfectants  on  stock  acCve  against  Norovirus   ²  Trained  health  care  personel   ²  Trained  cleaning  personell   ¤  Contact  IsolaCon  (&  droplet  precauCons,  especially  if  vomiCng  or  cleaning   bedpans)     ¤  Send  infected  HCWs  home  at  least  as  long  as  they  are  sick  (48hrs  amer  recovery   necessary  ?)  

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