1. Healthcare-Associated Infections and Infection Control
Timothy H. Dellit, MD
Professor of Medicine
Associate Dean for Clinical Affairs
University of Washington School of Medicine
Associate Medical Director
Harborview Medical Center
No financial conflicts

2. An observation...
Ignaz Semmelweis

3. And an intervention...

4. Patient Safety and Infection Control
Prevention, monitoring, and feedback
Healthcare-associated infections
Catheter-associated bloodstream infections
Catheter-associated UTI
Ventilator-associated pneumonia
Surgical site infections
Transmission of multidrug-resistant/marker organisms
MRSA
VRE
Carbapenem-resistant Acinetobacter
ESBL-producing organisms → MDR Enterobacteriaceae
Carbapenem-resistent Enterobacteriaceae (CRE, KPC, NDM-1...)
Plasmid-borne colistin resistance (mcr-1)
C. difficile
Aspergillus in burn and immunocompromised populations
Influenza/respiratory viruses
Tuberculosis
Emerging pathogens (Ebola/MERS/highly pathogenic influenza…)

5. Quality and Value Based Purchasing
Worst performing quartile will have a one percent payment reduction to all Medicare discharges between October 1, 2015 and September 30, 2016

7. C. difficile Rates LabID events vs. traditional surveillance
36% higher!
Heterogeneity in diagnostic testing
Delays in diagnostic testing
Misclassification of recurrent or continuing CDI episodes
Infect Control Hosp Epidemiol 2015;36:

8. Overdiagnosis of C. difficile?
1461 patients with diarrhea (not POA)
293 PCR positive
131/293 (44.7%) had positive toxin
48/162 (29.6%) of Tox-/PCR+ were positive by cytotoxicity assay
JAMA Intern Med 2015;Sep 8:1-10

9. Asymptomatic Carriage on Admission
259 pts (general med/surg)
15% toxigenic C. difficile
6% non-toxigenic C. difficile
No difference
Co-morbidities
Healthcare exposures
Overall abx exposure
Penicillin/cephalosporin
542 ICU patients
3.1% toxigenic C difficile
No difference:
Co-morbidities
Healthcare exposure
Antibiotic exposure
Clin Infect Dis 2014;59: Infect Control Hosp Epidemiol ;36:

10. How are we doing?
N Engl J Med 2014;370:

12. Antimicrobial Resistant Pathogens and HAI
Infect Control Hosp Epidemiol 2013;34:1-14

13. No longer just MRSA… Escherichia coli Pseudomonas aeruginosa
19 year old man s/p traumatic open injury in India arrives at HMC for surgical revision of his AKA with wounds infected with Pseudomonas, Klebsiella, E. coli, Morganella, and Enterococcus.
Escherichia coli
Pseudomonas aeruginosa
Colistin MIC 4 mcg/mL
Colistin MIC 2 mcg/mL

14. Carbapenem-Resistant Enterobateriaceae
Annually in WA:
100 CRE
10-25 CP-CRE (cabapenemase)

15. Mcr-1 gene on plasmid conferring colistin resistance
E. coli in urine from a Pennsylvania woman with no recent travel outside of US
Mcr-1 gene on plasmid conferring colistin resistance
Antimicrob Agents Chemother 2016;60:

16. Fecal Colonization with ESBL-producting Enterobacteriaceae
66 Studies with 28, healthy individuals
14% colonization
Antibiotic use RR 1.63
International travel RR 4.06
Clin Infect Dis 2016;63:

17. “MDRO Bundle” 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
WHO 5 Moments of Hand Hygiene

18. Stethoscopes and Finger Tips
MRSA
Mayo Clin Proc 2014;89:
Infect Control Hosp Epidemiol 2016;37:

19. Strategies to control MRSA: vertical vs. horizontal
Infect Control Hosp Epidemiol 2014;35:
Infect Control Hosp Epidemiol 2014;35:

20. Heterogeneity in Practice
364 physicians surveyed with contact precautions used by 93% and 92% for MRSA and VRE, respectively
Infect Control Hosp Epidemiol 2016;37:36-40

21. Compliance with Contact Precautions
1013 observations in 11 hospitals
Hand Hygiene Before
Gowning
Gloving
Doffing
Hand Hygiene After
Overall
Compliance
37.2%
74.3%
80.1%
61.0%
28.9%
Infect Control Hosp Epidemiol 2014;35:

22. Daily Chlorhexidine Baths: ICU MDRO Reduction
Baseline
CHG Baths P
MRSA acquisition*
5.04
3.44
0.046
VRE acquisition*
4.35
2.19
0.008
VRE bacteremia*
2.13
0.59
0.0006
*per 1000 pt-days
Crit Care Med 2009;37:

23. Role of Environmental Contamination
Contact Contamination
Percent positive
Percent of Surfaces Positive for MRSA
Infect Control Hosp Epidemiol 1997;18:

24. Who was in this room before me?
Infect Control Hosp Epidemiol 2010;31:21-7
Carriers source for 29% of HA-CDI
Clin Infect Dis 2013;57:
Infect Control Hosp Epidemiol 2011;32:201-6

25. Rationale for considering extending isolation beyond duration of diarrhea
Acquisition of C. difficile on the hands of healthcare workers
Recent: 2 d to 6 wk after end of treatment and no recurrent symptoms
Remote: 6 – 24 weeks after end of treatment
Clin Infect Dis 2008;46:447-50
Infect Control Hosp Epidemiol 2016;1-3

26. UV-C Decontamination and MDRO
October 2015 IDWeek
BETR-Disinfection Study
9 hospitals over 28 months
Risk of acquiring MRSA, VRE, C. difficile, or MDR Acinetobacter
24,589 “exposed” patients who were subsequently admitted into the room

27. Prevention of CLA-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
Standardization of CVC education
Standardized use of central line carts and checklist
Maintenance and prompt removal

28. Keystone at 10 years: Sustained reduction in CLA-BSI
Am J Med Qual 2015;1-6

29. Daily CHG baths and CLA-BSI
Multicenter, cluster-randomized, nonblinded crossover trial in six hospitals
Nine ICU and bone marrow transplant units
7727 patients enrolled
Include as basic strategy
Infect Control Hosp Epidemiol 2014;35:
Intervention
Control P
Hospital-acquired BSIa
4.78
6.60
0.007
CLA-BSIb
1.55
3.30
0.004
aRate per 1000 pt-days
bRate per 1000 catheter-days
N Engl J Med 2013;368:533-42

30. Universal Decolonization and CLA-BSI
AHRQ Universal Decolonization Toolkit
Intranasal mupirocin and CHG baths
136 adult ICUs in 95 acute care hospitals across US
Clin Infect Dis 2016:63:

31. Disrupting the Lifecycle of the Urinary Catheter
1. Preventing Unnecessary and Improper Placement 1
Defined indications
Condom catheters?
Straight cath?
Bladder scanners
4. Preventing Catheter Replacement
2. Maintaining Awareness & Proper Care of Catheters 2 4
Closed system
Transportation
Dependent loops
Reminders
Nurse-driven protocols 3
3. Prompting Catheter Removal
(Meddings. Clin Infect Dis 2011)
Modified from Sanjay Saint

32. What is a CA-UTI? NHSN surveillance definition
IDSA clinical practice guideline
Administrative claim data
Clinician diagnosis
How can you reduce the number of infections, but have a higher rate?
Role for Device Utilization Ratio as a harm event (device days/patient days)
Infect Control Hosp Epidemiol 2016;37:

33. 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

34. What not to do! Do not routinely use antimicrobial catheters
Do not screen for asymptomatic bacteriuria
Do not treat asymptomatic bacteriuria except before invasive urologic procedures
Avoid catheter irrigation
Do not use systemic antimicrobial prophylaxis
Do not change catheters routinely
Infect Control Hosp Epidemiol 2014;35:

35. Overtreatment of Asymptomatic Bacteriuria
153 patients treated for
positive urine culture
59 (38.6%) had UTI
94 (61.4%) has ASB
71 (75.5%) no guideline-based indication for testing
Mean 9.1 days of therapy (435 total days)
Infect Control Hosp Epidemiol 2015;36:

36. Summary Great strides in reducing HAI, but many unanswered questions
MDRO bundle
Vertical vs. horizontal approach
Importance of the environment
Role of antimicrobial stewardship
Device-related infections
Quality and value based purchasing