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ISOLATION PRECAUTIONSKaren Hoffmann RN, MS, CIC, FSHEA, FAPIC
2006 Management Of Resistant O In Healthcare Settings2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices Advisory Committee
• Inclusion of non-hospital settings • Re-emphasis on Standard Precautions
• Safe injection Practices • Respiratory hygiene practices• Use of mask during spinal procedures
KEY CONCEPTS
Risk of transmission of infectious agents occurs in all settings
Infections are transmitted from patient-to-patient via HCPs or medical equipment/devices
Isolation precautions are only part of a comprehensive IP program
Unidentified patients who are colonized or infected represent risk to other patients
FUNDAMENTAL ELEMENTS
Administrative supportAdequate Infection Prevention staffingGood communication with clinical microbiology
lab and environmental servicesA comprehensive educational program for HCPs,
patients, and visitors Infrastructure support for surveillance, outbreak
tracking, and data management
STANDARD PRECAUTIONS
Component Recommendation
Hand Hygiene After touching blood, body fluids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts.
Personal Protective Equipment (PPE)Gloves For touching blood, body fluids, secretions, excretions,
contaminated items; for touching mucous membranes and non-intact skin
Gown During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated
Mask, eye protection During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions, especially suctioning, endotracheal intubation
Component Recommendation
Soiled equipment Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene
Environmental Control Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas
Laundry Handle in a manner that prevents transfer of microorganisms to others and to the environment
Needles and sharps One patient one needle one syringe and HCP use masks for spinal injections.
Patient Resuscitation Use mouthpiece, resuscitation bag, other ventilation devices to prevent contact with mouth and oral secretions
Component Recommendation
Patient placement Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminate the environment, does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome following infection.
Respiratory hygiene/cough etiquette (source containment of infectious respiratory secretions in symptomatic patients, beginning at initial point of encounter)
Instruct symptomatic persons to cover mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear surgical mask if tolerated or maintain spatial separation, >3 feet if possible;Post signage at the points of entry to the facility during periods of increased community respiratory diseases.
TRANSMISSION BASED PRECAUTIONS (TBP)
CHAIN OF INFECTION
Imag result for chain of infection picture
RATIONALE BEHIND TRANSMISSION BASED PRECAUTIONS
Infection
Source
Host
Transmission
SOURCES OF INFECTION
HumanPatientsHealthcare PersonnelVisitors/household members
EnvironmentalCommon VehiclesVectorborne
Host FactorsAge
Immobility
Incontinence
Dysphagia
Chronic Diseases
Poor Functional Status
Medications
Indwelling devices
ROUTES OF TRANSMISSION
Direct ContactIndirect Contact Aerosol Droplet
DIRECT AND INDIRECT CONTACT TRANSMISSION
Direct Contact: Skin to skin touching Indirect Contact: inanimate surfaces
DROPLET AND AIRBORNE TRANSMISSION
Types of TransmissionBased Precautions
Private room onlyRoom requires negative airflow pressureDoors must remain closedVisual air monitorsEveryone must wear an N-95 respirator or higherLimit the movement and transport of the patient
Surgical mask prior to entry
No special ventilation
Private room or Cohort
Hand hygiene
Residents use mask outside of room
CONDITIONS OR DISEASES REQUIRING DROPLET PRECAUTIONS
Disease/Condition Duration of Isolation
Influenza For 5 days from onset of symptoms or 24 hours without fever, which ever is longer
Meningococcal Diseases: meningitis, pneumonia
For 24 hours after treatment has started
MRSA pneumonia For duration of illness (also use Contact Precautions)
Strep Throat For 24 hours after treatment has started
Rhinovirus (cold) For duration of illness
Private room or Cohort
Gown and gloves
Controversy No 1.
before or “upon entry”
Hand hygiene
Dedicate equipment
Disinfect shared equipmentLimit patient movement
Controversy No. 2Special enteric precautions for C. difficile and NorovirusAnd Routine handwashing with soap and water or ABHRCDC recommends ABHR.
CDC HICPAC ISOLATION PRECAUTIONS
MDROs judged by the IPCP, based on local, state, regional, or national recommendations to be of clinical and epidemiologic significance.
Contact Precautions recommended in settings with evidence of ongoing transmission, acute-care settings with increased risk for transmission or wounds that cannot be contained by dressings.
Contact state health department for guidance regarding new or emerging MDRO.
SYNDROMIC AND EMPIRIC APPLICATION OF TRANSMISSION-BASED PRECAUTIONS
Diagnosis requires lab confirmationCulture-based lab test require 2 or more daysPrecautions should be implemented while
awaiting resultsBased on clinical presentation and likely
pathogenReduces transmission opportunities
Disease/Condition Duration of Isolation
Epidemiologically Significant -Anitbiotic Resistant Bacteria – MRSA, VRE, ESBL-E.coli, etc.Controversy No. 3
Per MDRO guideline –
Clostridium difficile (C. diff) 24-48 hours after symptoms resolve
Norovirus 48 hours after symptoms resolve
Scabies and Lice 24 hours after treatment started
Viral Conjunctivitis (pink eye) Until symptoms resolve
CONDITIONS OR DISEASES REQUIRING CONTACT PRECAUTIONS
Clinical Syndrome or Condition Potential Pathogens Empiric Precautions (always includes Standard Precautions
DiarrheaAcute diarrhea with infectious cause in incontinent or diapered patient
Enteric Pathogens Contact Precautions
Rash or Exanthems, generalized, unknown etiologyPetechial/Ecchmotic w/ fever Neisseria meningitides Droplet Precautions for 1st 24hrs
of antimicrobial therapy
Vesicular Varicella-zoster, herpes simplex, vaccinia viruses
Airborne plus Contact precautions
Respiratory InfectionsCough/fever/upper lobe infiltrate Tb, Respiratory Viruses, S. pneumoniae, S.
aureusAirborne Precautions plus contact
Skin or Wound InfectionAbscess or draining wound that cannot be covered
Staphylococcus aureus, group A streptococcus
Contact PrecautionsAdd Droplet for the first 24 hours of antimicrobial therapy if group A strep disease suspected
HOW EFFECTIVE ARE CONTACT PRECAUTIONS?CONTROVERSY NUMBER 4
Unknown Ineffective “MRSA” if adherence is poor (20-30%)
Afif W, et al. Am J Infect Control 2002;30:430-433 Cromer AL, et al. Am J Infect Control 2004;32:451-5
Most data from outbreak settingsGiven extent of environmental contamination with
some MDR-GNRs, barrier precautions make theoretical sense.
SEMMELWEIS WAS RIGHT!BUT IS IT ENOUGH TO RELY ON HH??
Kirkland KB, et al. BMJ Qual Saf 2012;21:1019
ROLES OF ACTIVE SURVEILLANCE- TIER 2 CDC RECOMMENDATIONS(Tier 2 recommendations)Targeted surveillance of high risk patients:
Useful during outbreaks and when incidence of an MDR-GNR is rising or not declining despite routine control efforts
Point prevalence surveys during outbreaks:Define reservoir and guide control effortsDetermine if on-going surveillance cultures
needed CDC/HICPAC MDRO guideline.
COMMUNICATING PRECAUTIONS
How to prevent handoff problems during patient transfers intrafacility and interfacility (e.g. signage)?
IMPLEMENTATION STRATEGIES FOR MDRO CONTROL
COHORTING AS A CONTROL STRATEGY
Single rooms first choice; cohorting second, and roommate that is not compromised or with risks (invasive devices).
Cohorting of patients with same pathogen; Cohorting of staff; Cohorting by use of designated beds or units.
UPDATE ON RECOMMENDATIONS FOR PRECAUTIONS FOR VISITORS
Use guided by specific pathogen, underlying infectious condition and endemicity of the organism in hospital and community
Infection Control & Hospital Epidemiology / FirstView Article / April 2015, pp 1 - 12
TBP GUIDANCE FOR VISITORS
All visitors comply with hand hygiene before and after visiting
Endemic situations with MRSA and VRE No Contact Precautions for visitors in
routine circumstancesVisitors visiting multiple patients should use
Contact Precautions
TBP GUIDANCE FOR VISITORS
Parents/guardians/visitors with extended stay in patient’s room, Contact Precautions are not practical.Exceptions: C. difficile, CREUse gowns and gloves if assisting in direct
patient care
TBP GUIDANCE FOR VISITORS
Visitors to patients on Droplet and Airborne Precautions must wear surgical maskVisitors with extensive documented
exposure may be excluded from this recommendation
Restrict visitors that are symptomaticLimit entrance of visitors at risk of an
airborne pathogen and lacking exposure
TBP GUIDANCE FOR VISITORS
Enforce isolation precautions for visitors during outbreak or novel, virulent pathogens are suspected (Ebola, MERS, SARS)
DISCONTINUING TBPCONTROVERSY NO 5
No National guidelines for MDROsRemain in effect for limited period of time
(i.e. while the risk for transmission persist or for the duration of illness)
Disease specific recommendations in Appendix A of guidelineType and duration of precautions
HOW LONG DOES COLONIZATION WITH MDR-GNR PERSIST?
O’Fallon E, et al. Clin Infect Dis 2009;48:1375-81.
D/C MRSA< 1 year since most recent MRSA + culture or screen Off antibiotics ≥ 72 hrs (3 weeks for dialysis)Have to have 3 sets of surveillance cultures
Each set includes:Site 1 – anterior naresSite 2 – axillae or perineumSite 3 – Wound (if available)
All three sets negative, remove from isolationOnce one set (site 1-3) is finalized, obtain next set
D/C MRSA1 -2 years since most recent MRSA + culture or screen Has the patient:
Hospitalized in last year Reside in LTCF On dialysis in community-based center
If yes (for any) and off antibiotics ≥ 72 hrs (3 wks dialysis)obtain 3 sets of cultures
If no (for all), and off antibiotics ≥ 72 hrsobtain 1 set of cultures
D/C MRSA>2 years since most recent MRSA + culture or screen Has the patient:
Hospitalized in last year Reside in LTCF On dialysis in community-based center
If yes (for any) and off antibiotics ≥ 72 hrs (3 wks dialysis)obtain 1 set of cultures
If no (for all)Remove from isolation precautions
D/C VRE
≤1 year since most recent VRE + culture or screenPatient off antibiotics ≥ 7 days
Ok to obtain cultures while pt. receiving IV/PO Vancomycin
Obtain one culture from original site (wound, respiratory tract, urine)
Three successive cultures from stool or rectumMust be at least 1 week apartAll cultures must be negative to remove isolation
D/C VRE
≥1 year since most recent VRE + culture or screen Has the patient:
Hospitalized in last year Reside in LTCF On dialysis in community-based center
If no (for all), remove from precautions (no culture needed) If yes (to any) and off antibiotics ≥ 7 days
obtain 1 surveillance culture. All cultures must be negative to remove isolation
D/C MDR – ACINETOBACTER
Floor Status Patient -Off antibiotics MDR – Ab sensitive to (colistin,
Polymixin B, tigecylcine) for 1 week.Obtain 3 sets of surveillance cultures
Site 1 – respiratory tract (tracheal aspirate or throat swab)
Site 2 – Wound (if present) or GroinEach culture set obtained 1 week apart
All cultures negative to remove isolation
D/C MDR – ACINETOBACTER
ICU Status PatientRemain on Contact Precautions until transferred to
floor, then follow floor status guidelines.Patient whose last + culture ≥ 1 year AND no hospitalizations within past yearD/C isolation Precautions w/o culture
D/C CREAny patient with + CRE (e.g. K. pneumoniae, E. coli, etc) <1 yearRemain on Contact Precautions for duration of hospital
stay.>1 year since + CRE culture 1. Patient has not been an inpatient of a medical facility
(LTCF, Hospital, Rehab) AND
2. Not on hemodialysis in community-base center
Negative cultures not required and can d/c isolation
NO TOUCH METHODS: HOW EFFECTIVE?
Hydrogen peroxide and UV lightReduction in bioburden c/w conventional cleaning
& disinfection (C/D) ↓ risk of VRE acquisition from prior room occupant
when used for terminal cleaning80%a colonization risk; 6% absolute reductionNo significant reduction for other MDROs
Performance improved cleaning and disinfection shows similar results for both MRSA and VRE
Passaretti, et al. Clin Infect Dis 2013;56:27-35.Datta, et al. Arch Intern Med 2011;171:491-94.
UV Room Disinfection
• Enhanced Terminal Room-Disinfection (BETR-D) randomized study which was funded by the CDC Epicenter Program and conducted across the DICON found Tru-D reduced the risk of infection of C. diff, MRSA, VRE and Acinetobacteramong patients admitted to the same room by a cumulative 30 percent.
• Conducted in 9 hospitals for a total of 600,000 room stays and > 22,000 Tru-D cycles completed,.
Anderson D, et al. Lancet: Volume 389, No. 10071, p805–814, 25 February 2017
PREVENTING TRANSMISSION: SUMMARY
Focus on HAND HYGIENELikely to be the final common pathway
Contact (barrier) precautions for those known to carry MDR-GNR
Enhanced environmental disinfectionEducation and observation/feedbackNew technologies? Need more outcome
dataPractical issues (e.g. cost, room turnover)
HEALTHCARE FACILITIES MUST NOT ACCEPT ONGOING MDRO OUTBREAKS OR HIGH ENDEMIC RATES AS THE STATUS QUO.
SELECTION OF INFECTION CONTROL MEASURES APPROPRIATE TO THEIR SITUATION, FACILITIES CAN REACH THE DESIRED GOAL AND REDUCE THE MDRO BURDEN SUBSTANTIALLY
Conclusions
Questions???