HEALTHCARE-ASSOCIATED INFECTIONS IN LONG-TERM CARE: CHALLENGES FOR ENVIRONMENTAL INFECTION CONTROL David Jay Weber, M.D., M.P.H. Professor of Medicine,

HEALTHCARE-ASSOCIATED INFECTIONS IN LONG-TERM CARE: CHALLENGES FOR ENVIRONMENTAL INFECTION CONTROL

David Jay Weber, M.D., M.P.H.Professor of Medicine, Pediatrics & EpidemiologyAssociate Chief Medical Officer, UNC Health Care

Medical Director, Occupational Health & Hospital EpidemiologyUniversity of North Carolina at Chapel Hill

GOALS OF CURRENT LECTUREReview the pathogens causing outbreaks in extended care

facilitiesUnderstand the challenges in infection control in extended

care facilities Review the epidemiology and control of norovirus

outbreaks in extended care facilitiesReview the epidemiology and control of C. difficile

outbreaks in extended care facilities

IMPACT OF HAI IN LONG-TERM CARE

~3.2 million Americans live in extended care facilities, 20081

~1.0 million Americans reside in assisted living facilities, 20081

1.6-3.8 million infections per year2

Incidence of endemic infections = 1.8-13.5 infections per 1,000 resident days2

Estimated several thousand outbreak occur per year2

Infections are the leading reason for hospital transfer2

1CDC. http://www.cdc.gov/HAI/settings/ltc_settings.html2Smith PW, et al. ICHE 2008;29:785-814

http://www.cdc.gov/HAI/settings/ltc_settings.html

CHALLENGES IN INFECTION PREVENTION

Patients Patients frequently have risk factors for infection/colonization

Older age, incontinence, poor functional status, malnutrition Chronic diseases: Diabetes, renal dysfunction, neurologic

impairment Use of medical devices: Foley catheters Non-intact skin: Decubiti, diabetic foot ulcers Frequent hospital contact (e.g., dialysis) Medications (drugs that affect level of consciousness, immune

functon, gastric acid secretions, and normal flora) Patients frequently colonized/infected with MDROs Patients frequently receive antibiotics


Infection control Patients often housed in multi-bed rooms Patients, even if colonized/infected, have contact with each other

(e.g., common areas, dining area) Limited or no access to hallway sinks or alcohol-based hand rubs Facility may not have trained infection preventionist Facility unlikely to have an MD infection preventionist Likely low compliance with hand hygiene and environmental

disinfection Limited studies in long-term care facilities on which to base

recommendations


Environmental services (ES) Potentially less trained staff Lack of infection control leadership (i.e., trained IP and hospital

epidemiologist) Terminal disinfection occurs infrequently (i.e., most patients long-

term) Many rooms will be multi-bed limiting use of “no touch” methods Product cost likely to be more of an issue than for acute care

hospitals

MAJOR INFECTIOUS SYNDROMES AMONG PATIENTS IN EXTENDED CARE FACILITIES

Respiratory tract infections Skin and soft tissue infections

Especially decubiti and diabetic foot infections Urinary tract infections

Especially related to urinary catheters Gastroenteritis

OUTBREAKS REPORTED IN LONG-TERM CARE FACILITIES

Gastroenteritis Norovirus, C. difficile, Salmonella, Shigella, E. coli O157:H7

Hepatitis B Often linked to glucometers

Respiratory infections Influenza, tuberculosis, S. pneumoniae, Chlamydophila pneumoniae,

Legionella spp., other viruses (e.g., parainfluenza, RSV Conjunctivitis

Adenovirus Miscellaneous

Pertussis, Group A streptococcus, MRSA, VRE, Scabies, other

Smith PW, et al. ICHE 2008;29:785-814

Infectious Disease OutbreaksIn Elderly Care Facilities, 1966-2008

Utsumi M, et al. Age Ageing 2010;39:299-305

GI OUTBREAKS IN LONG-TERM CARE FACILITIES, 1996-2008


NON-RESPIRATORY AND GI OUTBREAKS IN LONG-TERM CARE FACILITIES, 1996-2008


HAZARDS IN THE HOSPITAL

Weinstein RA. Am J Med 1991;91(suppl 3B):179S

MRSA, VRE,C. difficile, Acinetobacter spp.,norovirus

Endogenous flora 40-60%Cross-infection (hands): 20-40%Antibiotic driven: 20-25%Other (environment): 20%

EPIDEMIOLOGY OF INFECTIONS IN EXTENDED CARE FACILITIES

Relative contribution of the following unclear (limited studies) Endogenous flora Person-to-person transmission (direct and indirect)

Other residents Staff-to-patients Visitors

Role of the contaminated environment

TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT

Otter JA, et al. Infect Control Hosp Epidemiol 2011;32:687-699

TRANSMISSION MECHANISMS INVOLVING THE SURFACE ENVIRONMENT

Rutala WA, Weber DJ. In:”SHEA Practical Healthcare Epidemiology” (Lautenbach E, Woeltje KF, Malani PN, eds), 3rd ed, 2010.

Infection PreventionIn Long Term CareFacilities

• Housekeeping in the facility should be performed on a routine and consistent basis to provide for a safe and sanitary environment (lC)

• Measures should be instituted to correct unsafe and unsanitary practices (e.g., environmental cleanliness may be monitored by walking rounds with a checklist)

Smith PW, et al.ICHE 2008;29:785-814

DISINFECTION OFNONCRITICAL PATIENT-CARE DEVICES

Process noncritical patient-care devices using a disinfectant and concentration of germicide as recommended in the Guideline {IB}

Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label’s safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes but multiple scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens with a contact time of at least 1 minute {IB}

Ensure that, at a minimum noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (e.g., once daily or weekly) {II}

If dedicated, disposable devices are not available, disinfect noncritical patient-care equipment after using is on a patient, who is on contact precautions before using this equipment on another patient {IB}

Rutala WA, Weber DJ. HICPAC Guideline.

CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES IN HEALTHCARE FACILITIES - I

Clean housekeeping surfaces (e.g., floors, tabletops) on a regular basis, when spills occur, and when these surfaces are visibly soiled {II}

Disinfect (or clean) environmental surfaces on a regular basis (e.g., 3x per week) and when surfaces are visibly soiled {II}

Follow manufacturers’ instructions for proper use of disinfecting (or detergent) products – such as recommended use-dilution, material compatibility, storage, shelf-life, and safe use and disposal {II}

Clean walls, blinds, and window curtains in patient-care areas when these surfaces are visibly contaminated or soiled {II}

Prepare disinfecting (or detergent) solutions as needed and replace with fresh solution frequently (e.g., replace floor mopping solution every 3 patient rooms, change no less often than at 60-minute intervals) {IB}

CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES IN HEALTHCARE FACILITIES - II

Decontaminate mop heads and cleaning cloths regularly to prevent contamination (e.g., launder and dry at least daily) {II}

Use a one-step process and EPA-registered hospital disinfectant designed for housekeeping purposes in patient care areas where 1) uncertainty exists about the nature of the soil on the surfaces (e.g., blood versus routine dust or dirt); or 2) uncertainty exists about the presence of multidrug resistant organisms on such surfaces {II}

Detergent and water are adequate for cleaning surfaces in non-patient areas (e.g., administrative offices) {II}

Do NOT use high-level disinfectants/liquid chemical sterilants for disinfection of non-critical surfaces {IB}

CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES IN HEALTHCARE FACILITIES - III

Wet-dust horizontal surfaces regularly (e.g., daily, 3x per week) using clean cloths moistened with an EPA-registered hospital disinfectant (or detergent). Prepare the disinfectant (or detergent) as recommended by the manufacturer {II}

Disinfect noncritical surfaces with an EPA-registered hospital disinfectant according to the label’s safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes but multiple scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens with a contact time of at least 1 minute {IB}

Do not use disinfectants to clean infant bassinets and incubators while these items are occupied. If disinfectants (e.g., phenolics) are used for the terminal cleaning of infant bassinets and incubators, thoroughly rinse the surfaces of these items with water and dry them before use {IB}

CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES IN HEALTHCARE FACILITIES - IV

Promptly clean and decontaminate spills of blood and other potentially infectious materials. Discard blood-contaminated items in compliance with local regulations {IB}

For site decontamination of spills of blood or other potentially infectious materials implement the following: Use protective gloves and other PPE (e.g., forceps to pick up sharps) appropriate for this task. Disinfect contaminated areas with an EPA-registered tuberculocidal agent, a registered germicide on the EPA Lists D and E (claim against HIV or HBV), or a freshly diluted hypochlorite solution (e.g., 1:100 dilution of 5.25-6.15% sodium hypochlorite for small spills, <10mL; for large spills, >10 mL or a culture spill in the laboratory, use a 1:10 dilution for the first application of hypochlorite solution BEFORE cleaning to reduce the risk of infection during the cleaning process if a sharp injury occurs). Follow with a terminal disinfection, using 1:100 dilution of sodium hypochlorite {IB}

CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES IN HEALTHCARE FACILITIES - V

If a spill contains large amounts of blood or body fluids, clean the visible matter with disposable absorbent material, and discard the contaminated materials in appropriate, labeled container {II}

Use protective gloves and other PPE appropriate to the task {II} In units with high rates of endemic C. difficile infection or in outbreak setting,

use dilute solutions of 5.25-6.15% sodium hypochlorite (e.g., 1:10 dilution of household bleach) for routine environmental disinfection (II} Or use an EPA-registered agent with activity against C. difficile

If chlorine solution is not prepared fresh daily, it can be stored at room temperature for up to 30 days in capped, opaque plastic bottle with a 50% reduction in chlorine concentration after 30 days of storage {IB}

An EPA-registered sodium hypochlorite product is preferred but is such products are not available, generic versions (household bleach) can be used (II}

BEST PRACTICES FOR ROOM DISINFECTION USING STANDARD GERMICIDES

Follow the CDC Guideline for Disinfection and Sterilization with regard to choosing an appropriate germicide and best practices for environmental disinfection

Appropriately train environmental service workers on proper use of PPE and clean/disinfection of the environment

Have environmental service workers use checklists to ensure all room surfaces are cleaned/disinfected

Assure that nursing and environmental service have agreed what items (e.g., sensitive equipment) is to be clean/disinfected by nursing and what items (e.g., environmental surfaces) are to be cleaned/disinfected by environmental service workers

Use a method (e.g., fluorescent dye) to ensure proper cleaning

USING FLUORESCENT DYETO ASSESS CLEANING THOROUGHNESS

MRSA PREVALENCEIN NURSING HOME RESIDENTS

Study design: Multicenter, prospective study of residents of 26 nursing homes in Orange County, CA, from 2009-2011

Methods: Only nares cultured Results:

Admission prevalence = 16% Point prevalence = 26% Dominant clones = USA300 (ST8/t008), USA100 (ST5/t002) and USA100

varient (ST5/t242)

Hudson LO, et al. J Clin Microbiol 2013 (Epub)

MRSA PREVALENCEIN NURSING HOME RESIDENTS

Study design: Multicenter, prospective study of residents of 22 nursing homes in Orange County, CA, from 2008-2011

Methods: Only nares cultured Results:

Admission prevalence = 17% Point prevalence = 30% 25% CA-MRSA strains

Murphy CR, et al. ICHE 2013;34:325-326

CONTAMINATION OF THE ENVIRONMENT WITH MRSA

Study design: Assessment of environment for MDROs in an occupied and newly built replacement nursing home (samples 11 weeks before and after transfer to new building)

Results: MRSA commonly isolated; ESBL producing E. coli isolated once

Ludden C, et al. J Hosp Infect 2013;83:327-9

IMPACT OF AN INTERVENTION TO CONTROL MRSA IN NURSING HOMES

Study design: Cluster randomized controlled trial Intervention: Infection control education and training

Hand hygiene, decontamination of equipment and environment Results: RR of a resident becoming colonized with MRSA in an intervention

home compared to a control home at 12 months was 0.99 (95% CI, 0.69, 1.42)

Baldwin NS, et al. JHI 2010;76:36-41

MRSA BURDEN IN NURSING HOMES ASSOCIATED WITH ENVIRONMENTAL CONTAMINATION OF COMMON AREAS

Study design: Prospective study of environmental contamination and cleaning quality in nursing homes 10 CA nursing homes Nursing homes categorized into 2 groups based on high and low MRSA point

prevalence and admission prevalence (delta prevalence) Cleaning assessed by removal fluorescent dots and surveys

Results 16% (78/500) of objects MRSA positive 22% (129/577) of fluorescent dots removed Higher proportion of MRSA positive objects found in high (19%) rather than low (10%)

nursing home groups (p=0.005) Median cleaning frequency of common room = 2.5x/d (range, 1-3 times) Median cleaning time per room = 18 min (range 7-45 min) In multivariate model, MRSA positive objects associated with high delta prevalence

nursing homes (OR=2.8), less time cleaning each room (OR=2.9), and less frequent cleaning (OR=1.5)

Murphy CR, et al. J Am Geriatr Soc 2012;60:1012-1018

Acquisition of MDROs in Nursing Homes

• 15 nursing homes studied• Location = MI• 178 residents cultured (90

hadan indwelling device)• Cultures obtained from

nares,oropharynx, groin, perianal area, wounds, catheter sites• Frequency of facility

acquisition: MRSA 62%, VRE 67%, CazR 71%, CIPR 53%

Fisch J, et al.J Clin Microbiol 2012;50:1698

NOROVIRUS INCIDENCE BY AGE AND SEX, GERMANY, 2001/2002-2008/2009

Bernard H, et al. Epidemiol Infect 2013;Mar:1-12 (Epub)

NOROVIRUS OUTBREAKS, GERMANY, 2001/2002-2008/2009

Bernard H, et al. Epidemiol Infect 2013;Mar:1-12 (Epub)

OUTBREAKS OF ACUTE GASTROENTERITIS TRANSMITTED BY PERSON-TO-PERSON CONTACT, US, 2009-2010

CDC 2012;61(No. 9):1-12

HOSPITALIZATIONS AND MORTALITY ASSOCIATED WITH NOROVIRUS OUTBREAKS IN NURSING HOMES, 2009-2010

Study design: Retrospective cohort study of nursing homes OR, WI, PA Outcome measure: Rates of hospitalization and mortality during outbreak compared

with non-outbreak period Results: Norovirus outbreaks common; potential long duration, hospitalizations

common, mortality reported in ~5%-10% of outbreaks

Trivedi TK, et al. JAMA 2012;308:1668-1675

OUTBREAK AND NONOUTBREAK HOSPITALIZATONS AND DEATHS

Trivedi TK, et al. JAMA 2012;308:1668-1675

NOROVIRUS SHEDDINGIN A NURSING HOME OUTBREAK

Study design: Prospective study of norovirus excretion during an outbreak in a nursing home

Results Attack rate: 19/42 residents and 12/33

staff Predictors of viral excretion load =

days post-illness onset, initial viral load, and resident status

Predictors of shedding duration = age 6% (3/50) environmental surfaces

positive (faucets 2, shower curtain 1)

Lai C-C, et al. J Clin Virol 2013;56:96-101

ROLE OF ENVIRONMENTAL CONTAMINATION IN A NURSING HOME NOROVIRUS OUTBREAK

Study design: Outbreak investigation

Methods: Environmental samples taken 14 days after outbreak onset (RT-PCR)

Results Residents AR = 52% (127/246) Staff AR = 46% (84/181) Environmental swabs positive

from case resident rooms, dining room table, elevator button (used only by employees)

Wu HM, et al. ICHE 2005;26:802-10

ACTIONS TAKEN IN 41/54 OUTBREAKS TO CONTROL INFECTION

Greig JD, Lee MB. Epidemiol Infect 2012;140:1151-1160

MANAGEMENT OF NOROVIRUS OUTBREAKS IN HEALTHCARE FACILITIES: GENERAL

Place patients on Contact Precautions in a single room (lB) Use Contact Precautions for 48 hours after symptom resolution Consider use of longer isolation for “complex medical patients” Consider suspending group activities (e.g., dining room) for duration of outbreak

Use soap and water for hand hygiene (lB) Consider closure of wards to new admissions or transfers (ll) Develop and adhere to sick leave policies for healthcare personnel who have

symptoms consistent with norovirus infection (lB) Exclude ill HCP for a minimum of 48 hours after symptom resolution

Establish visitor policies for norovirus outbreaks (lB) Use active surveillance to detect cases (lB)

MacCannell T, et al. Guideline for the prevention and control of norovirus outbreaks in healthcare settings

MANAGEMENT OF NOROVIRUS OUTBREAKS IN HEALTHCARE FACILITIES: ENVIRONMENTAL CLEANING

Perform routine cleaning and disinfection of frequently touched environmental surfaces and equipment in isolation and cohorted areas, as well as high-traffic clinical areas (lB)

Clean and disinfect shared equipment between patients with an EPA registered product with label claims for use in healthcare (lC)*

Increase the frequency of cleaning and disinfection of patient care areas and frequently touched surfaces (e.g., ward/unit level cleaning to 2x/day, with frequently touched surfaces cleaned and disinfected 3x/day using an EPA approved product for healthcare settings) (lB)*

Consider avoiding use of upholstered furniture and rugs or carpets in patient care areas (ll)

Consider steam cleaning of upholstered furniture in patient rooms upon discharge (ll) Change privacy curtains when they are visibly soiled and upon patient discharge (lB) Clean surfaces and patient equipment prior to the application of a disinfectant (lC)*

*EPA register disinfectant with claims against norovirus MacCannell T, et al.

RATES OF HOSPITAL DISCHARGES WITH CDI, BY AGE, 1996-2004, FINLAND

Lyytikainen O, et al. Emerg Infect Dis 2009;15:761-5

CDI IN PATIENTS DISCHARGED FROM US SHORT-STAY HOSPITALS, 1996-2003

McDonald LC, et al. Emerg Infect Dis 2006;12:409-15

SURVEILLANCE FOR CDI INNURSING HOMES

Study design: Retrospective study of 4 nursing homes Results: CDI developed within 30 days of admission (69%) or after 30 days

(31%)

Mylotte JM, et al. J Am Geriatr Soc 2013;61:122-5

INCIDENCE OF CDI IN A LONG-TERM CARE FACILITIES VS AN ACUTE CARE FACILITY, US

30 day cut off use to distinguish HA from CA CDI Kim JH, et al. ICHE 2011;32:656-60

RATES OF CDI, OHIO, 2006

Study design: Active surveillance using standard definitions

Results 6,376 cases at 210 hospitals

(incidence = 6.4-7.9/10,000 pt-d)

7,953 cases at 955 nursing homes (1.7-2.0/10,000 pt-d)

Campbell RJ, et al. ICHE 2009;30:526-533

CDI

Sites of Attack for Preventionand Management of CDI

5. Bolster immunity with vaccinesor passive antibody strategies.

1. Keep patients outof the hospital.

2. Barrier precautions and environmental cleaning. 3. Stop unnecessary

antimicrobial use.

4. Restore floraor colonize withnontoxigenicC. difficile

6. Antibiotic Rx ±Nonantibiotic Rx

Now

Asymptomatic C. difficile colonization

Hospitalization

C. difficile acquisition

Antimicrobial(s)

C. difficile acquisition

Future

Gerding and Johnson Clin Infect Dis. 2010;51:1306-13

HAND HYGIENE

Perform hand hygiene before and after entering the room; use soap and water or an alcohol-based hand hygiene product (routine or endemic settings)

Perform hand hygiene with soap and water preferentially instead of alcohol hand hygiene products after caring for a patient with CDI in outbreak or hyper-endemic settings

Strategies to Prevent CDI Infections in Acute Care Hospitals: Draft SHEA Guideline, 2014

BARRIER PRECAUTIONS

Avoid use of electronic thermometers Use dedicated patient care items and equipment If equipment must be shared; clean and disinfect between patients Use full barrier precautions (gowns and gloves) for contact with CDI

patients and for contact with their environment (i.e., Contact Precautions)

Place patient with CDI in a private room, if available; give isolation preference to patients with fecal incontinence if room availability is limited


UNC ISOLATION SIGN FORPATIENTS WITH C. difficile

Use term contact-enteric precautions

Requires gloves and gown when entering room

Recommends hand hygiene with soap and water (instead of alcohol based antiseptic)

Information in English and Spanish

Also use with norovirus and rotavirus

DISCONTINUING ISOLATION

CDC currently recommends contact precautions for the duration of illness when care for patients with CDI. Some experts recommend continuing contact precautions for at least 48

hours after diarrhea resolves At this time data do NOT exist to support extending isolation as a

measure to decrease CDI incidence.

ENVIRONMENTAL DISINFECTION

Perform environmental decontamination of rooms housing patients with CDI with sodium hypochlorite (household beach) diluted 1:10 with water, or an EPA-registered sporicidal product in an outbreak or hyper-endemic setting including: Furnishing such as bed tables, commodes, and bedrails Patient care equipment such as stethoscopes and BP cuffs Surfaces such as door knobs and IV infusion pumps

When possible dedicate non-critical patient care items such as BP cuffs, stethoscopes and thermometers to a single CDI patient


MISCELLANEOUS

Perform CDI testing only on unformed diarrheal stools Do not place patients at high risk for CDI on prophylactic

antimicrobial CDI therapy Do not treat or attempt to decolonize asymptomatic CDI carriers Do not conduct repeat testing for C. difficile if a patient has had a

positive stool of C. difficile unless symptoms resolved with treatment and then returned after treatment discontinued


SPECIAL APPROACHES FORPREVENTING CDI

Intensify the assessment of compliance with process measures Compliance with hand hygiene Compliance with Contact Precautions If compliance inadequate, institute corrective actions

Perform hand hygiene with soap and water Empirically place patients with diarrhea on Contact Precautions

(remove isolation if test for C. difficile is negative) Create a unit specific check list for room disinfection Monitor the effectiveness of room cleaning (e.g., fluorescent dye) Consider routine environmental decontamination with sodium

hypochlorite or an EPA-registered sporicidal agentUNC routine measures are in yellowStrategies to Prevent CDI Infections in Acute Care Hospitals: Draft SHEA Guideline, 2014

6 STEPS TO PREVENTHOSPITAL-ONSET CDI

Prescribe and use antibiotics carefully Focus on an early and reliable diagnosis Isolate patients immediately Wear gloves and gowns for all contact with patient and the patient

care environment Assure adequate cleaning and disinfection of the patient care

environment; use an EPA-registered C. difficile sporicidal disinfectant Notify facilities upon patient transfer

Source: http://www.cdc.gov/VitalSigns/Hai/StoppingCdifficile/

CONCLUSIONS

MDRO colonization in residents of extended care facilities (especially MRSA and GNRs)

Outbreaks common in extended care facilities (especially norovirus) Contamination of the surface environment of extended care facilities

with MDRO pathogens has been demonstrated Inadequate cleaning and disinfection of environmental surfaces

documented Limited data on methods to reduce nosocomial infections in extended

care facilities Research in extended care facilities very challenging

THANK YOU!!

Documents

HEALTHCARE-ASSOCIATED INFECTIONS IN LONG-TERM CARE: CHALLENGES FOR ENVIRONMENTAL INFECTION CONTROL David Jay Weber, M.D., M.P.H. Professor of Medicine,