Infectious Disease vs. Infection Control

Presented By:Stephen Sokalski DO, FACOI, FSHEA

FOCUS ON THE PATIENT

63Y/O MALE WITH ABCESS LEFT HIP FROMNURSING HOME ON 7/11/2011 PMH : Morbid obesity, Left hip abcess 8 monthsago (MRSA), ESBL in urine in past, PICC insertedfew weeks ago, foley catheter, treated withVancomycin and Piperacillen/Tazobactam sinceadmission.

7/11/2011 Blood culture drawn from PICC =Klebsiella Pneumoniae (Carbapenemaseproducing organism) Note: Implement contact precautions ASAP perInfection Prevention Policy

10/16/2010 Blood culture from ACV = MRSA 11/19/2010 Blood culture from ACV = E coli(ESBL PRODUCER) 11/19/2010 Left thigh wound culture = MRSA andAcinetobacter baumannii Complex

SusceptibleE. coliCarbapenem DiskTest IsolateH. Yigit, et al. AAC 2003

Patient placed on contact isolation, started ontigecycline and these actions triggered thefollowing responses:

The nurse said I can’t take my patient out of isolation.The patient is in tears because she can’t walk the halls.Her family is threatening me for elder abuse and wants me to talk totheir lawyer.Her family wants to know who gave it to her.The family wants to be tested, they are sure they are going tobecome illThe nursing home won’t take her back

The nursing home wants 3 negative tests to take her backWhy don’t you have antibiotics that will get rid of this?Why does the family have to wear gowns and gloves?The family is calling the Board of HealthThe family is calling the CDCThe family is calling The Southtown Economist newspaperThe family is calling The Chicago Tribune

• The family is calling The State Licensing Board• The family is calling the President of the Hospital, he is calling me!

Carbapenem-Resistant or Carbapenemase-producing Enterobacteriaceaecausing infections in Acute Care FacilitiesKPC (CRKP) Klebsiella Pneumonia most often, E coli also.High rates of morbidity and mortalityRoutine in NY and NJIncreased length of stay and costColonized patients serve as reservoirsControl of outbreaks hindered by lack of compliance with infection controlpractices

Health-care personnel compliance with hand hygiene was 48% andglove and gown use 62% Carbapenemases carried on mobile genetic elements, such astransposons or plasmids can harbor additional resistance genesaffecting multiple classes of antibiotics (Logan, 2012)Logan, L. 2012. Carbapenem-Resistant Enterobacteriaciae: An Emerging Problem inChildren. Healthcare Epidemiology. 2012:55. P 852-859

Infection Prevention and Control All acute care facilities should implement contact precautions for patientscolonized or infected with CRE. No recommendation regarding dc of isolationLaboratory Follow guidelines for susceptibility testing and Modifies Hodge Test (MHT). Clinical micro labs should establish systems to insure prompt notification ofInfection Prevention for positive test results for CRE.Surveillance All acute care facilities should do a 6-12 month review for CRE in high risk units. If no previous isolates, monitoring for clinical infections should be continued.Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection ControlPractices Advisory Committee. 2007. 2007 Guideline for Isolation Precautions:Preventing Transmission of Infectious Agents in Healthcare Settings.http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

Diekema DJ, Edmond MB.(2007). Look before you leap: active surveillance formultidrug-resistant organisms. Clinical Infectious Diseases 2007; 44:1101-7. DOI: 10.1086/512820.

Diekema DJ, Edmond MB.(2007). Look before you leap: active surveillance formultidrug-resistant organisms. Clinical Infectious Diseases 2007; 44:1101-7. DOI: 10.1086/512820.

Diekema DJ, Edmond MB.(2007). Look before you leap: active surveillance formultidrug-resistant organisms. Clinical Infectious Diseases 2007; 44:1101-7. DOI: 10.1086/512820.

• Won and associates observed extensive transferof KPC-positive patients throughout theexposure network of 14 acute care hospitals, 2LTACHs, and 10 nursing homes.• “successful control of KPC will require acoordinated regional effort among acute andlong-term health care facilities and public healthdepartments”.

Won, S.Y., Munoz-Price, L.S., Lolans, K., Hota, B., Weinstein, R.A. & Hayden, M.K. (2011). Emergence andrapid regional spread of Klebsiella pneumoniae Carbapenemase-producing Enterobacteriaceae. ClinicalInfectious Diseases, 53(6), 532-540. DOI: 10.1093/cid/cir482

Won, S.Y., Munoz-Price, L.S., Lolans, K., Hota, B., Weinstein, R.A. & Hayden, M.K. (2011). Emergence andrapid regional spread of Klebsiella pneumoniae Carbapenemase-producing Enterobacteriaceae. ClinicalInfectious Diseases, 53(6), 532-540. DOI: 10.1093/cid/cir482

Won, S.Y., Munoz-Price, L.S., Lolans, K., Hota, B., Weinstein, R.A. & Hayden, M.K. (2011). Emergence and rapidregional spread of Klebsiella pneumoniae Carbapenemase-producing Enterobacteriaceae. ClinicalInfectious Diseases, 53(6), 532-540. DOI: 10.1093/cid/cir482

Won, S.Y., Munoz-Price, L.S., Lolans, K., Hota, B., Weinstein, R.A. & Hayden, M.K. (2011). Emergence andrapid regional spread of Klebsiella pneumoniae Carbapenemase-producing Enterobacteriaceae. ClinicalInfectious Diseases, 53(6), 532-540. DOI: 10.1093/cid/cir482

DROPLET VS AIRBORNEWHAT IS THE REALITY?

ACMC POLICY: DROPLET ISOLATION FROM ONSET UNTILRESOLUTION OF ILLNESSREAL LIFE DATA1. Usual viral shedding 24h prior to 3-6 days after onset.2. Immuno-suppressed hosts shed by day 5, 68.5 %, day7, 32.7%.

3. Amount of virus shed/infectivity in normal host decreases rapidly byday 3 to 5. Severely immuno-deficient patients may shed virus forweeks to months.4. PCR testing may not predict contagious patients.5. Some viruses (SARS) may spread by contact or enteric route6. In the ER patients should be screened and masked. PAY ATTENTIONTO THOSE WHO BROUGHT THE PATIENT AND MAY BECONTAGEOUS.7. N95 masks for HCWs and potential exposed, regular surgical masks fororiginal patients.

8. Most studies look at oseltamivir treatment 48 hours, especially in the poor host.10. Recent emphasis on MI following flu.

The bottom line is that all persons associated with an ill/elderlypatient should receive influenza vaccine to protect the patient inaddition to patient vaccinationALL HEALTHCARE WORKERS SHOULD RECEIVE FLU VACCINEANNUALLYTHAT MEANS YOU!The bugs don’t care who they infect.

HOW DO YOU TREAT?

Common in womenChronic recurrent vs. re-infectionSymptomatic or notTest for cure?Treat if follow up culture is positive?

• 25% to 50% of women• 15% to 40% of men• HIGH TURNOVER TO NEG. IN 3 TO 6 MONTHS IN 1/3• NEW BACTERIURIA IN 1/3 IN 3 TO 6 MONTHS• MAY PERSIST FOR YEARS• IS NOT ASSOCIATED WITH NEGATIVE OUTCOMES• MAJOR PROBLEM IS OVERTREATMENT WITH SELECTION OFMDROS

SECOND ONLY TO PNEUMONIA AS CAUSE OF INFECTIONS0.1 TO 2.4/1000 RESIDENT DAYSCOMMON REASON FOR TRANSFER TO HOSPITALSELDOM A CAUSE OF MORTALITY45% TO 56% OF BACTEREMIC EPISODES ARE FROM UTI- MOST INPATIENTS WITH CHRONIC INDWELLING CATHETERS

PATIENTS WITH VOIDING MANAGED BY A CHRONIC INDWELLINGCATHETER ARE ALWAYS BACTERIURICNEW ORGANISMS INFECT 3% TO 7% PER DAYHIGHER MORBIDITY WHEN CATHETER IS PRESENT

COMMUNITYUsually classicECF PATIENTSoften s/s of uti may be absentBecause bacteriuria is common, uti may be overdiagnosed and overtreatedClinical deterioration without localized gu symptoms is unlikely to bea uti, even with bacteriuria

MRSA, WHAT DO YOU DO IF YOUR PATIENT HAS A MRSAPOSITIVE DRAINING WOUND?ISOLATION? DECOLONIZATION?WHO DO YOU SCREEN FOR MRSA?HOW DO YOU SCREEN FOR MRSA?CAN YOU GO HOME TO YOUR FAMILY?

Evanston Northwestern Healthcare 2008Screening for MRSA in ICU pts.= 8.3% positive. All admissions =6.3% positive.Colonized pts. Were placed on contact isolation and decolonized.The prevalence density of MRSA clinical infection decreased from8.9 per 10,000 patient days to 3.9 per 10,000 with the process

Screen all admissions to the hospital and isolate MRSApositive patientsDecolonize all MRSA positive patientsScreen only patients with a high risk for MRSA infectionsDecolonize all selected MRSA positive high risk patientsFollow the Dutch “Search and Destroy” policy and alsoscreen and decolonize all known contacts of MRSApositive patients

Screen and decolonize all surgical patients?Screen and decolonize all HCWs?Screen all patients in NICU?Screen all high-risk patients?Culture environment?

NASAL PCR TESTING MOST EFFICIENT AND TIMELYCULTURES USEFUL IN OUTBREAKSANAL AND ORAL CULTURES ADDITIVENICU PT. SITES- UMBILICAL,ANAL ORALOUTBREAKS, OTHER SITES

MRSA control program. In order to improve the prevention ofhospital-associated bloodstream infections due to MRSAhospital shall establish an MRSA control program thatrequires:1. Identification of all MRSA colonized in all intensive careunits, and other at-risk patients identified by the hospital,through active surveillance testing.

2. Isolation of identified MRSA-colonized or MRSA-infectedpatients in an appropriate manner3. Monitoring and strict enforcement of hand hygienerequirements4. Maintenance of records and reporting of cases underSection 10 of this Act.

1. Mupirocin ointment95%-100% in PD or HD, 88% in HIV, 85% in NH pts. 87%in liver transplant candidates.2. Mupirocin and Chlorhexadine baths72% over several years3. M&C and oral antibiotics and rifampin92% decolonization

BLEACH SOAKS IN TUB BID¼ cup bleach in ¼ filled tub for 10 minutes for 5 days or1teaspoonful bleach per gallon water.

12 MONTHS POST TREATMENT50% for healthy HCWs75% for PD pts.56% at 4 months for HD pts.71% at 2.5 months in HIV pts.

MUPIRICIN RESISTANCE WITH INCREASED USE MAY BE24%CHLORHEXIDINE RESISTANCE HAS BEEN DESCRIBED

1. 24% of patients admitted to ICU will develop a MRSAinfection during the hospital stay.2. 33% of patients with MRSA infection will be readmitted tothe hospital within 18 months and 80% will have a MRSAinfection at a new site with 56% of those infections severe.3. Bacteremia/endocarditis = 10% reinfect.

Illinois Inpatient / OutpatientAdvocate Christ Medical CenterMRSA only – 2004 and 2005539 cases

MICU PICUJan 35%Feb 23% 13%March 23% 20%April 18% 8%May 24% 10%June 22% 3%July 21% 0%Wound prevalence study

1. Screen all ICU admissions-decolonize positives, isolate for24 hours after the start of decolonization2. Screen all NICU admissions at admission and isolate anddecolonize as above. Screen entire NICU at the same timemonthly and if positive cases.2. Screen all TJR, Open Heart, other high risk surgicalpatients and decolonize

“Focusing hospital resources on a single antibiotic-resistantpathogen as a sole approach to infection control isinherently flawed.…new resistant microorganisms and therecognition of the value of team-based infection controlprograms, support a population-based approach.”- Ritchard P Wenzel, MD et.al.

“Surveillance cultures and genotyping of MRSA and MSSAisolates demonstrated the absence of cross-transmissionamong patients in the MICU…Reporting culture resultsand isolating colonized patients…would have falselysuggested the success of such infection-control policies.”-S Nijssen et.al.

YOU THOUGHT MRSA WAS BAD!

• There is an epidemic strain that has increased incidenceof CDAD 3 times since 2000• NAP1/BI/027 strain accounts for 61% of CDAD in Chicagoarea• 16X more A toxin and 23X more B toxin• Increased severity ,mortality ,recurrence• Decreased treatment response

• TOXINS• TcdA (toxin A) enterotoxin• Causes inflammation, mucosal injury, intestinal fluidsecretion• TcdB (toxin B) cytotoxin• 10X more potent in mucosal damage• Binary toxin

• Increased toxin, shedding, virulence• Systemic Complications due to circulating toxin• Ascites, Pleural Effusion, Cardiopulmonary Arrest,Hepatic Abcess, Abdominal Compartment Syndrome,ARDS, MODS, Renal Failure.

• Hospital remodeling project• Construction workers cracked a nonpotablewater pipe• Flood from ceiling into corridor next to SCNPANIC

• Water was headed towards the SCNpatients• Quick action• Many towels• 21 SCN patients moved by very fast andefficient SCN nurses• SCN made positive pressure• Air HEPA filtered

• Corridor Visquined off• Traffic pattern changed• Parents notified

• All items not protected by covered cabinet –tossed out• All linen removed and replaced• All sterile packs not in cabinet wereresterilized• Unit disinfected• All wet walls, ceiling, were removed andreplaced

• Air sampling for Aspergillus• Culture all the patients• Notify the BOH

• Baby + Nasal Culture• ALL HCW stools –• Mother with diarrhea and positivestool

It is always better to be luckyrather than smart