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Understanding the Infectious Disease Process:
Standard & Transmission Based Precautions
Russ OlmstedSJMHS, Ann Arbor, [email protected]
Key Principles: It’s More Than Presence of the Microorganism
Historical Milestones in Development of Infection Prevention & Control Precautions, U.S. 1877: Separate facilities for the “Infectious Patient” 1910: Antisepsis and disinfection 1950-60: Closure of Infectious disease and TB hospitals 1970: CDC “Isolation Techniques for use in Hospitals” 1983: CDC Guideline for Isolation Precautions in
Hospitals (Disease-specific and category-based precautions including blood and body-fluids)
1985: Universal Precautions (Mostly focused on worker protection against bloodborne pathogens, e.g. HIV)”
1987 Body Substance Isolation (U WA team developed; concept was precursor to
Standard Precautions (SP) – used for all patients)
History of Infection Prevention & Control Precautions, U.S.
1996: Revised CDC Guidelines: Standard Precautions
2002: MSIPC Antimicrobial Resistant Organisms (ARO) Guidelines
2006: HICPAC, CDC; Management of Multidrug-resistant Organisms (MDROs) in Healthcare Facilities Dec. – Dec. 2007 issue of AJIC vol. 35:S165-S173
2007: HICPAC, CDC; Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings - Dec. 2007 issue of AJIC vol. 35:S65-S164
2006 MDRO & 2007 Isolation Precautions – must haves and full text available for all (non-subscribers too) at: http://www.ajicjournal.org
Just a Word About Standard Precautions (SP)Used for all patients – even those on trans.-based precautions
Assume that every person is potentially infected or colonized with an organism that could be transmitted in the health care setting
Hand hygiene PPE: gloves, gown, mouth-nose-eye protection, etc. Respiratory hygiene / cough etiquette Patient placement Environmental cleaning and disinfection, soiled linen Safe injection practices
SP: Precautions for Lumbar Puncture
Surgical Mask:placing a catheter or injecting material - spinal canal or subdural space (ie, myelo-grams, LP, & spinal or epidural anesth.)
Are providers at youraffiliate using a mask?Reason: 3 pts. S. salivarius meningitis; mask not used
by HCP
Chitnis AS, et al. Outbreak of bacterial meningitis among patients undergoing myelography at an outpatient radiology clinic. J Am Coll Radiol. 2012 Mar;9(3):185-90
Transmission-based PrecautionsUsed in addition to Standard Precautions Airborne
Contact
Droplet
Infection Prevention StrategiesHierarchy of Controls
Personal Protective Equipment
Administrative Controls: Respiratory Hygiene + cough etiquette
Environmental Controls: HVAC, AIIR#
# Heating, Ventilation and Air Conditioning ; Airborne Infection Isolation Room
Airborne Precautions For infections spread by particles that remain
suspended in the air (TB, measles, varicella [chickenpox])
Airborne Infection Isolation Room (AIIR) (a.k.a. “negative pressure room”)
Surgical mask on patient if necessary to leave room Respiratory protection for healthcare personnel (HCP)
in AIIR: N95 or more efficient respirator – e.g. patient with active TB
disease, SARS-CoV – 2007 Isol. Prec. Table For measles & chickenpox – only immune HCP should care for
patient; if immune no special resp protection needed AIIR exhaust should not be re-circulated in the building;
if filtered using HEPA media = OK
Contact Precautions For infections spread by direct or indirect contact with
patients or patient care environment (e.g., RSV, C. difficile, MRSA, VRE, CRE, MDR-A. baumannii).
Limit patient movement Private room preferred Cohort patients with the same infection status Don gown and gloves before entering the patient room –
Application ? Remove and discard gown and gloves inside the patient room Hand hygiene immediately after leaving the patient room Emphasis on cleaning, esp. frequently touched surfaces (bed
rails, bedside tables, lavatory surfaces, etc.). Dedicated equipment whenever possible (e.g., stethoscopes)
Does hand hygiene compliance change whenpatients are in contact precaution rooms in ICUs?; Gilbert J, et al. AJIC 2010
No! except for… MICU
RNs more likely (66.7%) with CP vs (51.6%) without
Droplet PrecautionsFor infections spread by large droplets
generated by coughs, sneezes, etc. (e.g., Neisseria meningitidis, pertussis, seasonal influenza).
Face shield or goggles, and a surgical mask are worn to prevent droplets reaching the mucous membranes of the eyes, nose and mouth when within ~6 feet of the patient
Patients should be separated by 3-6 feet, or be grouped with other patients with the same infection/colonization status
Patient should wear a surgical mask when outside of the patient room
AIIR is not needed
Coughing and Masks
Schlieren optics visualize the dispersion of expelled air during coughingBoth standard mask (A) and N95 respirator (B) prevent dispersion of cough plumeWithout any type of mask plume travels 1-2 m
Tang J W-T. N Engl J Med 2009;361;26
The Colonization “Iceberg” Effect
Infected and symptomatic
Colonized with Epidemiologically-significantmicrobe; no symptoms
Colonized or Infected: What is the difference? People who carry bacteria without
evidence of infection (e.g. fever, increased white blood cell count) are colonized
If an infection develops, it is usually from bacteria that colonize patients
Bacteria that colonize patients can be transmitted from one patient to another by the hands of healthcare workers
~ Bacteria can be transmitted even if the patient is not infected ~
Epidemiology of MDROs is NOT necessarily created equal nor the same across health care settings
…no evidence supports the use of stringent barrier precautions to decrease illness or death from MDROs in LTCFs …
Additional precautions are recommended for patients colonized …only when they are a documented source of transmission to others…e.g. MRSA in resident with extensive skin lesions that can’t be contained or VRE in lower GI tract + diarrhea/incontinence…”
Nicolle LE. Preventing Infections in non-hospitalSettings: long-term care. Emerg Infect Dis 2001;7(no.2):205-7.
Epidemiology of MDROs in LTCF- Are Contact Precautions Effective?
Setting: Residents in 122 bed skilled nursing facility in 667 bed hospital, IL
Study Interventions: Contact-Isolation (CI) phase =
gowns/gloves; not confined to room [+ for VRE, MRSA; no policy related to ESBL]
Routine glove (RG) use phase = gloves for care of all residents or their environment; no contact isolation even if culture +
Results: Frequency of acquisition of MDRO no
different between CI vs RG; During RG phase personnel more
likely to wear gloves, remove them, perform hand hygiene than during CI
Trick WE, et al. Comparison of Routine glove use and C-IPrecautions to prevent trans-Mission of MD bacteria in a LTCF. J Am Geriatr Soc 2004;52:2003-9.
Supply costs:Gowns (15/day) CI = $92,900/yrGloves with RG = $2,415/yr
Take home messages: RG preferred over CI, no incr. Risk, and more cost effective.
Contact Precautions (CP) & Patient Safety Paradox: Acute Care Setting Case Control Study: adult patients
on CP for MRSA; 2 large teaching hospitals
Care Process Results: Vital signs incomplete or absent
when on CP More days with no RN or MD
progress notes when on CP Outcomes & Satisfaction:
Freq. of adverse events 2x higher if on CP
Falls, pressure ulcers, fluid/electrolyte disorders = 8x higher among those on CP vs. controls
Patient dissatisfaction: 17-38% on CP vs 3-5% for controls
Stelfox HT. JAMA 2003;
290:1899-1905
Problematic Pathogens In the Healthcare Setting & Beyond
Vancomycin-resistant enterococci (VRE)1
Methicillin-resistant S. aureus (MRSA)2
C. difficile3
Norovirus4
12
3 4
12 Step Program for “Antibiotics Anonymous” http://www.mi-marr.org/LTC_toolkit.html
MARR Long-term Care Tool Kit:PREVENT INFECTIONStep 1: Vaccinate Step 2: Prevent conditions that lead to infection Step 3: Get the unnecessary devices out DIAGNOSE AND TREAT INFECTION EFFECTIVELYStep 4: Use established criteria for diagnosis Step 5: Use local resources USE ANTIMICROBIALS WISELY Step 6: Know when to say "no"Step 7: Treat infection, not colonization/contaminationStep 8: Stop antimicrobial treatmentPREVENT TRANSMISSION Step 9. Isolate the pathogen Step 10. Break the chain of contagion Step 11. Perform hand hygiene Step 12. Identify resident with multidrug-resistant organisms (MDROs)
MDROs in LTCFs
The epidemiology of MDROs in LTCF differs from other settings such as acute care. This primarily reflects much less frequent use of invasive devices and severity of underlying illness.
Therefore while presence of MDROs among residents may be high, risk of cross transmission is low compared to acute care.
State of MI Bureau of Health Systems, MDCH, 10/03/2001 Guidelines for Care of Nursing Home
Residents with antimicrobial-resistant organisms (ARO) including MRSA & VRE Use Standard Precautions Communication of infection/colonization
when transferring or admitting a resident is essential
No regulation requires negative cultures as prerequisite for admission to LTCF, and federal/state rules prohibit same.
MI Society for Infection Prevention & Control. Guidelines for Prevention & Control of ARO. 2002
CDC Recommendations: MDRO in LTCFs; 2006
In LTCFs, consider the individual patient’s clinical situation and prevalence or incidence of MDRO in the facility when deciding whether to implement or modify Contact Precautions in addition to Standard Precautions for a patient infected or colonized with a target MDRO.
For relatively healthy residents (e.g., mainly independent and perhaps colonized with MDRO) follow Standard Precautions
CDC Recommendations: MDRO in LTCFs; 2006
For ill residents (e.g., those totally dependent upon healthcare personnel for healthcare and activities of daily living, ventilator-dependent) and for those residents whose infected secretions or drainage cannot be contained, use Contact Precautions in addition to Standard Precautions.
For MDRO colonized or infected patients without draining wounds, diarrhea, or uncontrolled secretions, establish ranges of permitted ambulation, socialization, and use of common areas based on your facility-based risk assessment
Step 6: Know when to say “no”
Minimize use of broad-spectrum antibiotics Avoid chronic or long-term antimicrobial
prophylaxis Develop a system to monitor
antibiotic use and provide feedback to appropriate personnel
Defining Epidemiologically Important Pathogens 2006 CDC/HICPAC MDRO Guide
Infectious agents that have one or more of
the following characteristics:
1) A propensity for transmission within healthcare facilities
2) Antimicrobial resistance implications
3) Associated with serious clinical disease increased morbidity and mortality
4) A newly discovered or reemerging pathogen
Why We Should Use Concept of Epidemiologically Important Pathogen?
Some bad pathogens in healthcare really are not multi-drug resistant:
– methicillin susceptible S. aureus (MSSA)
– Group A Streptococcus
– Clostridium difficile
Strategies described to control MDROs are often applied to control epidemiologically important organisms other than MDROs.
Pathogen Profile - Hospital A: Cent. Line-Assoc Bloodstream Infection (CLABSI), All Units 10/06-
09/07
0
5
10
15
20
25
30
35
MRSA MSSA SSN Ents Gm neg Candida
%ofCasesof CLABSI
Figure 1: Rates of CDI HCF onset HCF assoc by Patient Care Unit, '08 & '09
051015202530354045505560
11 E 6 E
7 E
2 E
CC
U
SIC
U
3 E
4000 9
E
10 E
MIC
U
2000 5
E
8 E
4 E
Ann
ual U
nit R
ate
Ann
ual S
JMH
Rat
e
Unit
Rat
e pe
r 10
,000
Pt D
ays
2008 2009
Clostridium difficile infection by Patient Care Unit, Hospital A
Active Sureillance Cultures – Look Before you Leap
Availability of private rooms Staffing needs: direct care & IPCS Monitoring adherence with contact
precautions by personnel Preventing unintended consequences
of placing patients in contact precautions
Decolonization therapy? Tracking of those positive for target
MDROs & electronic alert system for subsequent readmissions?
Diekema DJ, Edmond MB. Clin Infect Dis 2007;44 (April 15)
No significant difference in incidence of MDRO between intervention (ASD)& control ICUsHuskins WC, NEJM2011
Tale of Two Studies on Efficacy of Active Surveillance for MDROs
62% decrease in healthcare-assoc. MRSA infection in ICUs and 45% in non-ICUs, VAMCs withactive surveillance + CPJain R, et al. NEJM 2011