1. Infection Control- Preventing Nosocomial Infections Yehuda Carmeli, MD, MPH Division of Epidemiology, Tel Aviv Sourasky Medical Center

2. Nosocomial Infections Infections acquired in hospitals –(or healthcare setting) How bad can it get ? –Hotel -Dieu, Paris (the largest and richest of all hospitals) mid-18 th century 1,000 beds, 3,000 patients Water directly from the Seine Wounds clean with shared towels

3. How bad it was All wounds became infected Mortality after amputation >60% Puerperal fever was common, and during an epidemic in 1746, 95% of postpartum women died Hospitals described in 1850: “The gates that lead to death”

4. Ignaz Semmelweis, 1815-1865 1840’s: General Hospital of Vienna Divided into two clinics, alternating admissions every 24 hours: –First Clinic: Doctors and medical students –Second Clinic: Midwives

5. Semmelweis “hand disinfection”

6. The Intervention: Hand scrub with chlorinated lime solution Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847.

7. Mortality Semmelweis

8. Hand Hygiene: Not a New Concept Semmelweis’ Hand Hygiene Intervention ~ Hand antisepsis reduces the frequency of patient infections ~ Adapted from: Hosp Epidemiol Infect Control, 2 nd Edition, 1999.

9. Hand Hygiene Adherence in Hospitals 1. Gould D, J Hosp Infect 1994;28:15-30. 2. Larson E, J Hosp Infect 1995;30:88- 106. 3. Slaughter S, Ann Intern Med 1996;3:360-365. 4. Watanakunakorn C, Infect Control Hosp Epidemiol 1998;19:858-860. 5. Pittet D, Lancet 2000:356;1307-1312. Year of StudyAdherence RateHospital Area 1994 (1) 29%General and ICU 1995 (2) 41%General 1996 (3) 41%ICU 1998 (4) 30%General 2000 (5) 48%General

10. Self-Reported Factors for Poor Adherence with Hand Hygiene  Handwashing agents cause irritation and dryness  Sinks are inconveniently located/lack of sinks  Lack of soap and paper towels  Too busy/insufficient time  Understaffing/overcrowding  Patient needs take priority  Low risk of acquiring infection from patients Adapted from Pittet D, Infect Control Hosp Epidemiol 2000;21:381-386.

12. Ability of Hand Hygiene Agents to Reduce Bacteria on Hands Adapted from: Hosp Epidemiol Infect Control, 2 nd Edition, 1999. 0.0 1.0 2.0 3.0 060180minutes 0.0 90.0 99.0 99.9 log% Bacterial Reduction Alcohol-based handrub (70% Isopropanol) Antimicrobial soap (4% Chlorhexidine) Plain soap Time After Disinfection Baseline

13. Efficacy of Hand Hygiene Preparations in Killing Bacteria Good Better Best Plain Soap Antimicrobial soap Alcohol-based handrub

14. Definitions Hand hygiene –Performing handwashing, antiseptic handwash, alcohol-based handrub, surgical hand hygiene/antisepsis Handwashing –Washing hands with plain soap and water Antiseptic handwash –Washing hands with water and soap or other detergents containing an antiseptic agent Alcohol-based handrub –Rubbing hands with an alcohol-containing preparation Surgical hand hygiene/antisepsis –Handwashing or using an alcohol-based handrub before operations by surgical personnel Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

15. Infection Rates: Surgical Handscrub vs. Handrub  2 Test of Class ofNo. SSI/No.Operations (%)Equivalence ContaminationHandscrubHandrub(p-value) Clean29/1485 (1.9)32/1520 (2.1)16.0 (<0.001) Clean- Contaminated24/650 (3.7)23/732 (3.1) 1.9 (0.09) All53/2135 (2.5)55/2252 (2.4)19.5 (<0.001) Parienti et al. JAMA 2002: 288(6);722-27.

16. Specific Indications for Hand Hygiene Before: –Patient contact –Donning gloves when inserting a CVC –Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don’t require surgery After: –Contact with a patient’s skin, body fluids or excretions, non-intact skin, wound dressings –Contact with a patient’s close environment –Removing gloves Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

17. Epidermal water contentSelf-reported skin score Dry HealthyDry Healthy Effect of Alcohol-Based Handrubs on Skin Condition ~ Alcohol-based handrub is less damaging to the skin ~ Boyce J, Infect Control Hosp Epidemiol 2000;21(7):438-441.

18. Pasteur “germ theory of disease” Lister Asepsis

19. Aseptic techniques

20. Asepsis - Prevention of microbial contamination of living tissues or sterile materials by excluding, removing or killing micro-organisms. –Disinfectant - An agent that is intended to kill or remove pathogenic micro-organisms, with the exception of bacterial spores. –Pasteurization - A process that kills nonspore- forming micro-organisms by hot water or steam at 65-100oC. –Sterilization - The complete destruction of micro- organisms.

21. Source of organisms The patient –preparation of the site The environment –cleaning and disinfection Surgical tools and materials –sterilization the personnel –protective dressing

23. Sterilization Critical items –Items which enter sterile tissue or vascular system. –High risk if any organism or spores survive. Complete elimination of all viable microorganisms including spores. Sterility is a probabilistic phenomenon and not all-or-none

24. October 18, 2000: 250-million-year-old bacteria revived

25. Killing Curve Resistant sub-populations Decimal reduction time: Overall population=1 Resistant subpopulation= 2, 3, >3 cleaning

26. Bacterial Growth Curve

28. Netherlands standard Shelf life determined by: –method of sterilization –equipment –packing material –transport –storage conditions

29. Difficult to trace Infections (SSI) are difficult to trace to problem in sterilization Thus, we are dependent on perfect process, with overkill threshold.

30. Florence Nightingale “hospital hygiene”

31. Patient to patient transmission Routes of transmission –Air born –Blood born –Fecal oral route –Contact –Vector

32. Blood Borne HBV, HCV, HIV (and many more) Patient to patient: Blood transfusion Patient to HCW (and vice versa) –Primarily by needle stick –Surgery –contact of skin or mucus membranes with blood

33. Prevention of Blood Transmission Patients to HCW: Universal precautions: Treat all body fluid as infected. –Use of gloves for contact with blood or patients secretions (except sweet) –Surgery –double gloving –Protect mucus membrane when likely to be contaminated –care with sharp objects *post exposure prophylaxis

34. Transmission by contact The most important route of transmission today Transmission is usually on the hands of HCW Occasionally inanimate objects (stethoscopes, thermometers) Hands can be contaminated from the environment

35. Prevention of Transmission of Air Born Organisms Aerosol : –single room –Negative pressure & filters –High performance mask on entry Droplets: –Single room –Mask –Ventilated patients close-suction system

37. Contact transmission is preventable Hand hygiene is the most important measure to prevent transmission Compliance is low –Role models are missing –Physical conditions are a barrier –Time constrains New advances and increased awareness –Hand disinfection New trainees will bring the change ?

38. Contact precautions For patients with multi-resistant organisms (VISA, VRE, MRSA, C. diff, others ) –isolation –gloves and gowns –hand washing

39. Standard precautions Incorporates the concepts of universal precautions and body substances precautions –Universal precautions –Gloves for contact with dirty/contaminated area –Change gloves between contaminated and clean body sites –HW after patient contact (even after gloves)

40. Most Common Nosocomial Infections Blood stream infections (BSI) Surgical site infections (SSI) Nosocomial pneumonia (ventilator associated pneumonia) (VAP) Urinary tract infections (UTI)

41. Most Common Nosocomial Pathogens (NNIS) Gram positive: S. aureus Enterococci SCN Gram negative E. Coli Klebsiella spp. P. aeruginosa Enterobacter spp.

42. Patient own flora as source of infecting organisms GI tract- GNR and entrococci Nasopharynx Oral flora Skin flora Changes in flora during hospitalization, and 2nd to underlying conditions

43. BSI Primary bacteremia- almost invariably associated with IV lines, more so with central lines. Organisms are mostly skin flora: –S. aureus –SCN –Enterococci

44. Preventive measures line infections Reduction of use of lines –Duration line is in place –Need for line Central line versus peripheral line Proper insertion and care –Standardized aseptic techniques Peripheral - hand disnfection + non sterile gloves + no-touch technique Central and PICC - cap, mask, sterile gown, sterile gloves, and large sterile drape –Experienced personnel Dedicated IV team

45. Preventive measures line infections Choice of insertion site –Peripheral line Upper extremities rather than lower extremities Arm and hand rather than upper arm –Central line Subclavian<jugular<femoral Skin preparation –Chlorhexidine preparation better than polvidon-iodine or alcohol Type of catheter –Low risk – silicone, polyurethane, teflon –High risk PVC, polyethylene –Coated catheters – abx, silver, chlorhexidine Dressing –Transparent = gauze (risk of infection)

46. Other measures for BSI Filters – unproven Antibiotic prophylaxis – not recommended Topical antibiotics at insertion site – unproven and contavertial Antibiotic lock prophylaxis – in neutropenic patients with permanent catheters – contravertial Heparin flush – for short term CVC – prevent thrombi, no proven effect on BSI

47. More measures to prevent BSI Replacement –Peripheral lines - at 72-96h –Midlines ? Two weeks ? –Short term CVC – no benefit from routine replacement No infection benefit from replacement over guidewire (may have mechanical applications) Administration set replacement –72-96h –More often (1d) for blood product, TPN, fat emulsions Hemodyalysis –AV fistula<graft (x2)<catheter (x8.5)

48. Surveillance Monitor site –Visualization of site, palpation of tract if needed – as clinically indicated Record –Standard form for reporting insertion, dressing change, removal (names, dates, details) Culture –Do not culture tips routinely

49. Nosocomial Pneumonia Most common mechanism- aspiration Hospital acquired organisms colonize the stomach, pharynx, endotracheal tube In many cases VAP 2nd to endotracheal tube and manipulations

50. Nosocomial pneumonia Pathogens: Mostly GNR: –Enterobacter spp. –Pseudomonas aeruginosa –Klebsiella spp Gram-positive –S. aureus –S. pneumonia

51. Preventing Measures Body position Ventilator intervention Stress-ulcer prophylaxis (non-acid reducing agents) Selective decontamination- avoid Reduce invasive devices Improve patient condition- nutrition

52. UTI Associated with urinary catheters Is it required Minimizing duration Care of catheters Patient to patient transmission Closed systems