Healthcare-Associated Infections and Infection Control
Timothy H. Dellit, MDMedical Director, Infection Control
Harborview Medical Center
Patient Safety and Infection Control• Prevention, monitoring, and feedback
– Healthcare-associated infections• Catheter-associated bloodstream infections• Ventilator-associated pneumonia• Surgical site infections• Catheter-associated UTI
– Transmission of multidrug-resistant/marker organisms• MRSA• VRE• Carbapenem-resistant Acinetobacter• ESBL-producing organisms → MDR Enterobacteriaceae• C. difficile• Aspergillus in burn and immunocompromised populations• Tuberculosis
Increasing Regulation and Reporting
• CMS and “medical errors”– FY2008
• Catheter-associated urinary tract infection• Vascular catheter-associated infections• Mediastinitis after CABG
– FY2009• SSI following select orthopedic procedures
– Spinal fusion– Elbow and shoulder arthroplasty
• SSI following bariatric surgery• Mandatory reporting of healthcare-associated infections (HB 1106)
– Central line infections in ICU: July 2008– Ventilator-associated pneumonia: January 2009– Selected surgical site infections: January 2010
• Cardiac surgery• Total hip and knee arthroplasty• Hysterectomy
Not selectedVAPS. aureus septicemia/ MRSAC. difficileLegionnaires’
“MDRO Bundle”
Increased Hand Hygiene Associated with Decreased MRSA Transmission
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1994 1998
Han
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tient
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sHand hygiene
MRSA Transmission rate
Lancet 2000;356:1307-12
• Hand Hygiene• Contact precautions• Minimize shared equipment• Environmental cleaning• Healthcare-associated
infections preventive bundles– Catheter-associated BSI– Ventilator-associated
pneumonia– Catheter-associated UTI– SCIP measures
• Active surveillance cultures • Chlorhexidine baths• Antimicrobial stewardship
0 20 40 60 80 100
Room Door Handle
IV Pump Button
Bath Door Handle
Side Rails
BP Cuff
Overbed Table
Patient Gown
Bed Linen
Percent of Surfaces Positive for MRSA
Infect Control Hosp Epidemiol 1997;18:622-627
Role of Environmental Contamination
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Gowns Gloves
Contact with patient
Contact with environment
Contact Contamination
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cent
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To Survey or Not to Survey?
• Interventions over 9 yr– Sterile CVC placement– Alcohol-based hand
hygiene– Hand hygiene campaign– ICU surveillance for
MRSA (16 months)• 29% of newly detected
MRSA carriers develop infection within 18 months
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No SurveillanceActive Surveillance
Surveillance Cultures Reduce MRSA Bacteremia
Reduced ICU transmission by 47%• 43 vs. 23 cases per 1000 at risk patientsClin Infect Dis 2003;36:281-5
Clin Infect Dis 2006;43:971-8
Inci
denc
e de
nsity
per
100
0 pt
-day
s75%
40%
67%
Arch Intern Med 2006; 166:306-12
Chlorhexidine Body Wash in the ICU
Arch Intern med 2007;167:2073-79
Decreased Acquisition of VREBefore and after, compared with soap and water
Decreased Bloodstream InfectionsCross-over, compared with soap and water
6.4 vs. 16.8 BSI per 1000 catheter-days
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MR
SA
Cas
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Nosoc MRSA Cases 87 84 88 72 71 62 72 63 46 40 27 41 30
Admits 4,489 4,804 4,854 4,510 4,543 4,684 4,864 4,618 4,863 5,077 5,135 4,823 4,760
MRSA Rate 19.4 17.5 18.1 16.0 15.6 13.2 14.8 13.6 9.5 7.9 5.3 8.5 6.3
QE Mar 2007
QE Jun
2007
QE Sep 2007
QE Dec 2007
QE Mar 2008
QE Jun
2008
QE Sep 2008
QE Dec 2008
QE Mar 2009
QE Jun
2009
QE Sep 2009
QE Dec 2009
QE Mar 2010
Confidential QI
HMC Nosocomial MRSA Rates
Quarterly
Source: Infection Control, for more information, please contact Dr. Tim Dellit, [email protected]
Number of Cases2007: 331 Cases2008: 268 Cases2009: 154 Cases
Central Line-Associated BSI
• ICU CVC utilization 0.39 – 0.71 catheters/pt– 15 million catheter-days per year in US
• ICU rate 1.3 to 5.5 per 1000 catheter-days (NHSN mean)– 80,000 CR-BSI annually in US ICUs– Attributable mortality 0-35%
• Healthcare cost $296 million to $2.3 billion– Attributable cost $15,000-$56,000– Prolonged ICU and hospital LOS
Clin Infect Dis 2002;35:1281-307
Am J Infect Control 2009;37:783-805
NHSN CLA-BSI Pathogens
1986-1989 1992-1999 2006-2007
Pathogen (%) (%) (%) Coag-negative staphylococci 27 37 34Staphylococcus aureus 16 13 10*Enterococcus 8 13 16Candida sp. 8 8 12Enterobacter 5 5 4Pseudomonas aeruginosa 4 4 3Klebsiella pneumoniae 4 3 5E. Coli 6 2 3
Clin Infect Dis 2002;35:1281-307
Infect Control Hosp Epidemiol 2008;29:996-1011
*MRSA 5.6%, MSSA 4.3%
Prevention of Catheter-Associated BSI
• IHI “Central Line Bundle”– Hand hygiene– Chlorhexidine skin prep– Maximal barriers
• Full drape• Mask, hair cover, sterile gown, sterile gloves
– Optimal catheter site selection– Daily review of line necessity
• Implementation AND documentation
Institute for Healthcare Improvement
Bundle in Action
Reduction in mean rate from 7.7 to 1.4 per 1000 catheter-days
N Engl J Med 2006;355:2725-32
Months After Implementation
Med
ian
Blo
odst
ream
Inf
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per
1000
Cat
hete
r-D
ays
0.0
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Baseline 0-3 4-6 7-9 10-12 13-15 16-18
Overall
Teaching Hospital
Non-teaching Hospital
< 200 beds
> 200 beds
UHC Benchmark of Key Performance Measures
Key Performance Measure Hospital Performance
Patient Level% of cases
median range
Central Venous Catheter Placed in the Subclavian Vein 44.2% 14.3 – 73.3%
Evidence of Maximal Barrier Precautions for Insertion 0.0% 0.0 – 8.2%
Hand Washing 0.0% 0.0 – 39.0%
Full Body Drape 3.0% 0.0 – 46.3%
Sterile Gloves and Gown 1.9% 0.0 – 39.0%
Cap and Mask 0.0% 0.0 – 13.6%
Chlorhexidine Skin Prep for Insertion 1.9% 0.0 – 98.1%
Daily Dressing Inspection 97.5% 25.1 – 100%
Daily Assessment of Medical Necessity to Continue CVC 16.4% 0.0 – 100%
Operational Yes % (n) Site #
Best Practice* CVC Insertion Policy 11.8% (2) 29, 89
Mandated Use of a CVC Insertion Checklist 11.8% (2) 84, 87
There is work to be done!
Infect Control Hosp Epidemiol 2008;29:440-2
National Reduction in CLA-BSI
JAMA 2009;301:727-36
MRSA Central Line-Associate BSI
JAMA 2009;301:727-36
50% reduction in MRSA CLA-BSI (0.43 vs 0.21 per 1000 catheter-days)
Hospital-Acquired UTI
Survey of Hospital Monitoring
• 40% of healthcare-associated infections• 80% due to indwelling urethral catheter
Potential Strategies
• Insertion/care• Catheter reminders/ automatic stop orders• Bladder US scanners• Condom catheters• Antimicrobial catheters
Aymptomatic bacteriuria vs.
Symptomatic UTI in patients without localizing GU symptoms
Clin Infect Dis 2008;46:243-500
102030405060708090
100
Presence Duration UTI rates Feedback
No
mo
nito
ring
(%
)
CA-UTI PathogensNHSN 2006-2007
Candida sp, 21%
Pseudomonas , 10%
Enterococcus, 15%
Klebsiella sp, 9%
Enterobacter sp, 4%
E. coli, 21%
S, aureus, 2%
Acinetobacter , 1%Coag neg
Staphylococcus, 3%
Infect Control Hosp Epidemiol 2008;29:996-1011
Catheter-Associated UTI
• Duration of catheterization is primary risk
• Providers unaware of catheter status– Students 21%– Interns 22%– Residents 27%– Attendings 38%
• Daily assessment of need, especially when transferred from ICU to floor
Am J Med 2000;109:476-80
Ventilator-Associated Pneumonia• Rate 2.8 – 12.3 per 1000 ventilator days (NHSN 2006)
– 10-30% of intubated patients– Incidence increases with duration of MV
• Day 1-5: 3% risk per day• Day 6-10: 2% risk per day• > 10 days: 1% risk per day
• Attributable mortality rate 33-50%• Increased LOS 7-9 days• Cost of $40,000 per patient• Accounts for 50% of ICU antimicrobials• Clinical vs. microbiologic definitions
– Poor external quality measure
Am J Respir Crit Care Med 2005;171:388-416
BICU: Burn PICU: Pediatric med/surgCICU: Coronary NICU: NeurosurgeryCT ICU: Cardiothoracic SICU: SurgicalMICU: Medical TICU: Trauma
Rat
e pe
r 10
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ent-
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NHSN Mean VAP by Unit2006-2008
Am J Infect Control 2009;37:783-805
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“Ventilator Bundle”
• Head of bed elevation > 30 degrees*
• Daily “sedation vacation” and assessment of readiness to extubate*
• Oral care (chlorhexidine)
• Peptic ulcer disease prophylaxis*
• Deep vein thrombosis prophylaxis*
*Institute for Healthcare Improvement
Reduction in VAP from 6.6 to 2.7 (59%) per 1000 ventilator-days with > 95% compliance (Jt Comm J Qual Patient Saf 2005;31(5):243-8)
Policy to Implementation
J Trauma 2006;61:122-130
Ventilator BundleDaily compliance and
weekly feedback
Which of the following has been demonstrated to reduce surgical site infections and is
currently part of national recommendations?
A. Peri-operative prophylactic antibiotics should be given within 60 minutes after incision
B. Peri-operative prophylactic antibiotics should be given within 60 minutes before incision and discontinued within 24 hours
C. Peri-operative antibiotics should be continued until the drains are out
D. Nasal carriage of S. aureus should be eradicated prior to surgery
E. Pre-surgical bath with chlorhexidine
Surgical Care Improvement Project
• Implemented by CDC and Centers for Medicare and Medicaid Services in 2002
• Nationally included procedures– Cardiothoracic, vascular, colon, hip or knee arthroplasty, vaginal or
abdominal hysterectomy
• Performance measures (Baseline of 34,133 medicare patients in 2001)– Antimicrobial prophylaxis within 1 hr of incision (55.7%)– Antimicrobial agent c/w current guidelines (92.6%)– Discontinuation within 24 hours after surgery (40.7%)
• Role of MRSA screening?
Arch Surg 2005;140:174-82
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≤-3 -2 -1 0 1 2 3 4 ≥5
N Engl J Med 1992;326:281-6
Perioperative Prophylactic AntibioticsTiming of Administration
Infe
ctio
ns (
%)
Hours From Incision
14/369
5/699
5/1009
2/180
1/81
1/411/47
15/441
Society of Thoracic Surgeons• Rationale
– Unique patient risks• Cardiopulmonary bypass, systemic hypothermia
– Devastating sequelae of mediastinitis (7-20% mortality)– No randomized studies < 48 hrs in CT surgery
• Major Recommendations1. Postoperative prophylactic antibiotics are given for 48 hours or
less2. Duration not dependent on chest tube removal3. If risk for MRSA, then vancomycin AND cefazolin4. Routine mupirocin administration for all patients in the absence
of documented negative testing for staphylococcal colonization
Ann Thorac Surg 2006;81:397-404Ann Thorac Surg 2006;83:1569-76
Is Vancomycin Alone Adequate?
S. aureus, 40%
Anaerobes, 1%Fungi, 1%
Enterococcus, 3%
Other Gram-positives, 4%
Gram-negative Bacilli, 20%
Coagulase-negative Staphylococci, 21%
No Pathogen, 4%
Unknown, 7%
Acceptable for cardiac, vascular, or orthopedic surgery:
• Beta-lactam allergy
• Documented rationale
Pathogens causing deep SSI following CABG, Hip and Knee Arthroplasty
NNIS 1994-2003
Meta-analysis of Seven Randomized Studies: Glycopeptide vs. β-Lactam for Prevention of Surgical Site Infection after Cardiac Surgery
Clin Infect Dis 2004;38:1357-63
MSSA more frequent in vancomycin group 3.7% vs. 1.3%(J Thorac Cardiovasc Surg 2002;123:326-32)
Intranasal Mupirocin and Surgical Site Infections
• Nasal carriage of S. aureus and risk of surgical site infection– Orthopedic surgery with prosthetic implants in 272 patients, RR 8.9
(Infect Control Hosp Epidemiol 2000;21:319-323)– Cardiothoracic surgery in 1980 patients, OR 9.6 (J
Infect Dis 1995;171:216-9)• 10/10 pre- and post-surgical pairs identical by phage typing
• Randomized, double-blind, placebo-controlled trial of pre-surgical mupirocin in 3864 patients (N Eng J Med 2002;346:1871-7)
– No difference in nosocomial infections, nosocomial S. aureus infections, or S. aureus surgical site infections
– S. aureus carriers (N=891)• 4.5 fold increase in S. aureus SSI• Significant reduction in S. aureus nosocomial infections (4.0 vs. 7.7)• Trend towards decreased S. aureus SSI (3.7 vs. 5.9, 37%, P=0.15)• Same strain in nares and site of infection in 85%
Universal Screening of Surgical Patients?JAMA 2008;299:1149-57
• Prospective, cross-over study of 21,754 surgical patients– 87% on admission– MRSA colonization 5.1%
• Standard practices for all patients with MRSA– Contact precautions– Adjustment of pre-op prophylaxis– Intranasal mupirocin and chlorhexidine body wash
• No difference in MRSA SSI (0.99 vs. 1.14 per 100)– 34% of MRSA carriers did not receive appropriate pre-op
prophylaxis– None identified through outpatient screening developed MRSA
infection
2% Chlorhexidine and 70% alcohol (Chloraprep) vs. 10% Povidone Iodine for Surgical-Site Antisepsis
N Engl J Med 2010;362:18-26
NNT: 17 patients
• Randomized, multi-center
• 849 patients
• Clean-contaminated surgery
Pre-operative Chlorhexidine Baths
RR
Chlorhexidine vs. placebo 0.91 (0.80 to 1.04)
Chlorhexidine vs. bar soap 1.02 (0.57 to 1.84)
Chlorhexidine vs. no washing 0.36 (0.17 to 0.79)
Cochrane Review of six randomized trials with 10,007 patients
Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004985. Review
It’s a small world…
26 y o medical student returns April 20, 2009 from an international elective in Mexico. On April 27 she presents to ED with 4 day h/o fever 39 C, cough, HA, myalgias, and diarrhea. That same day you hear reports of a novel Influenza A virus H1N1 associated with increased mortality in Mexico.
Which of the following is MOST correct regarding influenza?
A. No special precautions are necessary for patients with suspected influenza since it is not very transmissible.
B. Influenza is primarily transmitted by large droplets (> 5 microns), therefore healthcare workers should use Droplet Precautions with a surgical mask with eye protection for routine care to prevent contamination of mouth, nose, and conjunctiva.
C. Patients with 2009 H1N1 should be placed in airborne isolation with use of N-95 respirators while patients with H1N1 seasonal influenza should be placed in droplet precautions.
D. A negative rapid antigen test rules out influenza
E. Influenza vaccination of healthcare workers does not have an impact on patients.
Modes of Transmission
• Droplets– Thought to be primary mode of transmission– Coughing, sneezing, and talking– Heavy; settle within 6 feet of the source
• Airborne– Related to procedures → aerosolized particles
• Contact– Direct: skin-to-skin contact– Indirect: contact with virus in the environment
Respiratory Protection Debate• CDC (during 2009-2010 influenza season)
– Fit-tested N95 respirators for care of patients with 2009 H1N1– Prioritized usage if limited resources – Yet, Standard and Droplet Precautions for seasonal influenza?
• Infection Control and Infectious Diseases Societies*– No evidence that 2009 H1N1 transmitted differently than seasonal
influenza– Standard and Droplet Precautions for routine care
*Recommending organizations:• World Health Organization (WHO) • Infectious Disease Society of America• Healthcare Infection Control Practices • Society for Healthcare Epidemiology of America Advisory Committee (HICPAC) • Association of Professionals in Infection Control
Surgical Mask vs. N95 RespiratorRandomized Study
Characteristic Surgical Mask
N=212
N95 Respirator
N=210
P
Vaccinated 68 (30.2%) 62 (28.1%)
Lab-confirmed*
RT-PCR
H1N1 serology
Serology without symptoms
50 (23.6%)
6 (2.8%)
17 (8.0%)
29/44 (65.9%)
48 (22.9%)
4 (1.8%)
25 (11.9%)
31/44 (70.5%)
0.86
0.75
0.18
Physician visits 13 (6.1%) 13 (6.2%) 0.98
Influenza-like illness,
Fever and cough
9 (4.2%) 2 (1.0) 0.06
Work-related absenteeism 42 (19.8%) 39 (18.6) 0.75
JAMA 2009;302:1865-71*RT-PCR or serology
One Approach• Standard, Droplet, and Contact Precautions for routine
care– Place mask on coughing patients– Separate sick from non-sick patients– Surgical mask, eye protection, gown, and gloves
• N95 respirators for higher-risk aerosol-generating procedures– Intubation and extubation– Bronchoscopy– Open suctioning of airway– Cardiopulmonary resuscitation– Non-invasive ventilation?
Suspected or Confirmed Cases of Influenza
43 y o woman from Eritrea with 3 week h/o non-productive cough, fever, and night sweats
Now What?
AFB smear neg x 5 (3 sputum, 2 BAL)
Sputum AMTD neg
Which of the following is the BEST approach?
A. Remove from airborne isolation as a negative AMTD test rules out infectious TB
B. Begin 4 drug therapy and remove patient from airborne isolation due to multiple negative AFB smears
C. Begin 4 drug therapy and keep in airborne isolation
D. Obtain interferon-gamma releasing assay (IGRA) as a negative result would rule out TB
44 y o Vietnamese man with 6 month h/o pain and swelling of
left medial thigh associated with fevers and night sweats
Pulmonary Involvement in Extrapulmonary TB
• 72 patients with XPTB 36 lymph nodes 12 pleura 6 CNS 6 GI
• 57 had sputum collection
• Weight loss associated with positive sputum cx OR 4.3 (1.01-18.72)
Chest 2008;134:589-94
49% had abnormal CXR
Sputum AFB Smear
• Smear positive– 5,000-10,000 organisms per ml
of sputum must be present • Smear negative, culture-
positive TB– Responsible for roughly 17% of
TB transmission in San
Francisco and Vancouver
Am Rev Respir Dis 1966;95:998Lancet 1999;353;444, Thorax 2004;59:286
40-50% of pulmonary TB cases in King County are smear negative
Patient Safety and Infection Control
• UW Medicine Strategic Goals– Reduction in HAI– Expectation of hand hygiene with EVERY patient
EVERY the time
• WSHA elimination of HAI by 2012• Mandatory reporting of HAI
– CLA-BSI, VAP, selected surgical site infections
• MRSA legislation• Increased linkage of reimbursement to quality
– CMS preventable “medical errors”