1. Infection Prevention 2012: In Defiance of the Post-Antibiotic Era March 15, 2012 Cynosure Health ‘Beyond SCIP’ Meeting Allan J. Morrison, Jr., MD, MSc, FACP, FIDSA FSHEA Inova Health System Epidemiologist Chairperson, Infection Control Committee Inova Fairfax Hospital Professor and Distinguished Senior Fellow School of Public Policy, George Mason University Clinical Assistant Professor of Medicine Georgetown University Hospital

2. DISCLOSURES Speaker’s Bureau with the following entities: Care Fusion, Cubist, Glaxo-SmithKline, Pfizer, Ortho-McNeil, Merck, Sage No mention of investigational nor off-label usage will be employed in this program

4. NOSOCOMIAL INFECTIONS Historical derivation – Nosocome: Rabelais (circa 1340) “... so they took the wounded soldiers to the great nosocome... ” – “Castle-acquired” infections Ann Int Med 2002;137:665

5. MOST PREVALENT Weinstein RA. Nosocomial infection update. Emerg Infect Dis. 1998;4(3):416-420. CRBSIs and SSIs: occur when skin is incised

6. INFECTION CONTROL IN THE MODERN ERA: HISTORY 1970s: “KARDEX” system – Whole house/body site surveillance – Data prospectively gathered, retrospectively analyzed – Created objective methodology SENIC study – First large study to demonstrate characteristics of “efficacious” IC program – ICP/250 beds, organized surveillance, SSI feedback to surgeons, trained epidemiologist

7. NOSOCOMIAL INFECTIONS : PREVENTABLES SENIC (1971-1976) – 6% NI preventable by minimal infection control efforts – 32% NI preventable by well-organized and highly effective infection control programs Am J Epid 1985;121:182 Meta-analysis of interventional studies (N=25) – 66% reduction (15.1  8.3/1000 C-D) CIN Perf Qual Hlth Care 1998;6:172 – 46% reduction (32  17.4/1000 C-D) Am J Inf Control 1999;27:402;J Hosp Inf 2003;54:258

8. INFECTION CONTROL IN THE MODERN ERA: HISTORY 2000 - 2010 – Emergence of evidence-based data leading to “bundles” – VAP, CRBSI, Sepsis, CDAD – (Variably) implemented but NI rates  2011 - Future Where do we go from here?

9. HUMAN: BACTERIAL INTERFACE Total human cells/person ~ 10 13 Total colonizing microbes ~ 10 14... We are outnumbered 10:1! NEJM 2010;362:75

11. VREVSE Bacteremia 2 n=683n=931 OR, 2.52* MRSAMSSA Bacteremia 3 11,8% (n=382)5,1% (n=433)p<.001 KPN-ESBL+KPN-ESBL- Bacteremia 4 52% (n=48)31% (n=99)p<0.05 AB (IMP-R)AB (IMP-S) Bacteremia 5 57,5% (n=40)27,5% (n=40)p=0.007 MDR-PaeNo-MDR-Pae Bacteremia 6 21% (n=40)12% (n=40)p=0.08 EB (IMP-R)EB (IMP-S) Serious infections 7 33% (n=33)9% (n=33)p=0.038 8 “ESKAPE” Pathogens 1 Clinical Outcomes J Infect Dis; 2008; 41:327

12. INFECTION CONTROL IN THE MODERN ERA: BLUEPRINT FOR FAILURE Current paradigm:  MDRO (community, nosocomial)  Transmission within facilities  Colonization,  infection,  mortality  ABX pressure Hand hygiene: poor compliance  Respect for isolation protocols/barriers

13. INFECTION PREVENTION: (FOUR) PILLARS * De-populate the patient * De-populate the space * De-instrument the patient * De-escalate the ABX fole

14. Infection Control: The Symmetry of Science

15. INFECTION PREVENTION: (FOUR) PILLARS * De-populate the patient * De-populate the space * De-instrument the patient * De-escalate the ABX fole

16. INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS CENTRAL VENOUS CATHETERS PERIPHERAL VENOUS CATHETERS PATIENT BATHING PROTOCOLS PREOPERATIVE PATIENT SHOWER OPERATIVE TEAM HAND SCRUB BLOOD CULTURE SKIN PREP OPERATIVE SITE SKIN PREP

17. CHG :”Great White” of Skin Antisepsis

18. PREVENTION OF CATHETER-RELATED INFECTIONS IN THE ICU: A PROSPECTIVE RANDOMIZED TRIAL OF 2% CHG/70% IPA VERSUS 10% POVIDONE-IODINE 1.3 7.7 10.6 1.3 Catheter-Related Bloodstream Infections N = 82 Primary Bloodstream Infections N = 82 Infection Rates per 1000 Catheter Days P= 0.05P= 0.015 Catheter-related bloodstream infection: Isolation of identical organisms from blood cultures and semi-quantitative catheter cultures with no other identified source of infection. CDC primary bloodstream infection: Pathogen cultured from one or more blood cultures; organism cultured from blood is not related to an infection at another site. Patient has at least one of the following signs and symptoms: fever (>38°C). chills, or hypotension and positive skin contaminant found in blood cultures, OR positive antigen test with signs and symptoms of infection not related to another site. Kelly R, et al. Prevention of infections related to central venous catheters and arterial catheters in intensive care patients: a prospective randomized trial of chlorhexidine gluconate (CHG) versus povidone iodine (PI). 15th Annual Scientific Meeting of the Society for Healthcare Epidemiology of America; April 9-12, 2005; Los Angeles, CA. Abstract 165.

19. CHG: CENTRAL VENOUS CATHETER (CVC)  P/R trial of CVC insertion (IJ, SC)  5% Povidone-Iodine/70% ethanol  0.25% CHG/4% benzylic alcohol  2 x 30 second application (pre-insertion) then Q 72 o @ dressing change  Results: PI-A CHG-A P-value N242 239 Catheter colonization22.2% 11.6%0.002 CR-BSI4.2% 1.7% 0.09  RF for catheter colonization IJ site, PI Arch Int Med 2007;167:2066

20. INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS CENTRAL VENOUS CATHETERS PERIPHERAL VENOUS CATHETERS PATIENT BATHING PROTOCOLS PREOPERATIVE PATIENT SHOWER OPERATIVE TEAM HAND SCRUB BLOOD CUTLTURE SKIN PREP OPERATIVE SITE SKIN PREP

21. CHG PREP: PERIPHERAL IVs P/R trial comparing: – 2% chlorhexidine gluconate - plus 70% isopropyl alcohol (CHG-IA) – 70% isopropyl alcohol (IA) Results: CHG-IA IA P-value N 91 79 -- X dwell 2.3D2.2D NS Tip Cx  20% 49% <.001 Skin disinfection with CHG-IA prior to PIV insertion associated with  TIP CX  ICHE 2008;29:963

22. INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS CENTRAL VENOUS CATHETERS PERIPHERAL VENOUS CATHETERS PATIENT BATHING PROTOCOLS PREOPERATIVE PATIENT SHOWER OPERATIVE TEAM HAND SCRUB BLOOD CUTLTURE SKIN PREP OPERATIVE SITE SKIN PREP

23. CHG Bathing: ICU 52 wk/cross-over trial – 22-bed MICU (Cook County Hospital) – Daily CHG bathing (impregnated washcloth) vs. soap/water Results: Soap/Water CHG P-value N (pt-days) 2119 2210 Primary BSI 10.4 4.1 <.01 (per 1000 pt-days) Arch Int Med 2007;167:2073

24. CHG Bathing: ICU ICU (N=6): Daily Bathing Protocol Six Months ‘Regular’, Six Months CHG MRSA acquisition decreased 32% (p<.05) VRE acquisition decreased 50% (p<.01) VRE Bacteremia decreased (p=.02) Crit Care Med 2008;37:185

25. CHG Bathing: Non-ICU N= 4 Hospital wards – 94 Beds; Rhode Island (>70K pt-days) – Daily CHG bathing (impregnated washcloth) vs. soap/water Results: Soap/Water CHG P-value N (pts) 7102 7699 ---- MRSA VRE HAIs 64%.01 Clostridium difficile…..no effect ICHE 2011;32:238

26. CHG Bathing : Meta-Analysis N= 12 studies; 137,392 patient-days Studies screened for methodological rigor Results: p-value CRBSI/BSI reduction <.00001 Inf Ctrl Hosp Epid 2012;33:257

27. SURGICAL SITE INFECTION

28. INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS CENTRAL VENOUS CATHETERS PERIPHERAL VENOUS CATHETERS PATIENT BATHING PROTOCOLS PREOPERATIVE PATIENT SHOWER OPERATIVE TEAM HAND SCRUB BLOOD CULTURE SKIN PREP OPERATIVE SITE SKIN PREP

29. CHLORHEXIDINE: PREOPERATIVE SHOWERS CDC recommends preoperative showering with CHG 1 CHG more effective than PI & triclocarban Lower rates of intra- operative wound contamination 1. Mangram AJ et al. The hospital infection control practices advisory committee. Guidelines for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20(4):250-278. 2. Garibaldi RA. Prevention of intraoperative wound contamination with chlorhexidine shower and scrub. J Hosp Infect. 1988;11(suppl B):5-9.

30. The Ultimate Pre-op Shower

31. INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS CENTRAL VENOUS CATHETERS PERIPHERAL VENOUS CATHETERS PATIENT BATHING PROTOCOLS PREOPERATIVE PATIENT SHOWER OPERATIVE TEAM HAND SCRUB BLOOD CULTURE SKIN PREP OPERATIVE SITE SKIN PREP

32. “ History repeats itself; that's one of the things that's wrong with history." Clarence Darrow US Defense Lawyer

33. CHG: SURGICAL SCRUB CHG superior to povidone-iodine – Reduced hand bacterial counts at scrub – Reduction maintained 6 hours later Orthopedics 2006:29:329 Surg Gynecol Obstet 1981;132:677

34. Ostrander RV, et al. J Bone Joint Surg Am. 2005;87-A:980-985. Bacterial Colony Counts/Site/Prep 2% CHG/70% IPA vs 0.7% Iodine 74% IPA; Hallux (P<0.01) 2% CHG/70% IPA vs 0.7% Iodine 74% IPA; Toe (P<0.05) 2% CHG/70% IPA vs 3% Chloroxylenol; Control (P<0.01 ) Control = anterior tibia, 12 cm proximal to the ankle joint

35. INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS CENTRAL VENOUS CATHETERS PERIPHERAL VENOUS CATHETERS PATIENT BATHING PROTOCOLS PREOPERATIVE PATIENT SHOWER OPERATIVE TEAM HAND SCRUB BLOOD CULTURE SKIN PREP OPERATIVE SITE SKIN PREP

36. Blood Culture Results: Truth or Dare * Blood Culture Contamination (BCC): Rate estimated at 0.6 - 6.0% * Results in unnecessary Lab costs, hospital admissions, LOS, antibiotics J Hosp Med 2006;1:272 Clin Microbiol Rev 2006;19:788

37. BCC: Efficacy of CHG-Alcohol P/Trial: ER (60% BC drawn in ER) Compared Iodine vs. CHG-A skin prep Results: Iodine CHG-Alcohol p-value BCC 3.5% 2.2% <.0001 J Nurse Care Qual 2008;23:272

38. Blood Culture Contamination: Can it be Reduced ? Randomized/Crossover/Sterile Gloves Results: Routine Optional p-value N 5265 5255 N/A BCC,possible 0.6% 1.1%.009 BCC,likely 0.5% 0.9%.007 Ann Int Med 2011;154:145

39. Blood Cx Contamination: THE NEWEST BUNDLE?  Training in proper BC collection: Requirement for annual competency  ? Time for a Blood Culture Bundle? Ann Int Med 2011;154:202

40. INFECTION CONTROL AND CHG: BLUEPRINT FOR SUCCESS CENTRAL VENOUS CATHETERS PERIPHERAL VENOUS CATHETERS PATIENT BATHING PROTOCOLS PREOPERATIVE PATIENT SHOWER OPERATIVE TEAM HAND SCRUB BLOOD CULTURE SKIN PREP OPERATIVE SITE SKIN PREP

41. SSI: DOES CHOICE OF PREP MATTER? P/R trial comparing CHG-Alcohol (CA) and Povidine-Iodine (PI) – Clean-contaminated surgery (N = 849) – Pre-op prep, follow-up 30D post-op Results CA PIP-value N409 440 SSI (total)9.5%16.1%.004 Superficial4.2%8.6%.008 Deep 1%3%.05 NEJM 2010;362:18

42. SSI: DOES CHOICE OF PREP MATTER? P/R trial comparing CHG-Alcohol and Povidine-Iodine – Clean-contaminated surgery (N = 849) – Pre-op prep, follow-up 30D post-op Results (continued): 7 patients died (4 = CA; 3 = PI). None of CA deaths had SSI. All 3 PI deaths due to Sepsis from SSI. NEJM 2010;362:18

43. Caesarean Section: SSI

44. CHG-Alcohol: C-Sections 2005: 4M live births in US annually C-Sections account for 30% (>1M) P/Trial (2006-2007): Pre-op CHG cloths and CHG-A operative prep Results: Pre-Interv Interv p-value SSI 7.5% 1.2% <.001 Projected cost savings: $25,546 per SSI Am J Inf Control 2010;38:319

45. Preoperative Skin Antisepsis: CHG vs. Iodine : Meta-Analysis  Cost benefit decision analytic model  N=1508 screened: 9 met criteria  Summary: “Use of CHG for preoperative skin antisepsis is associated with a 36% reduction in the number of SSIs…Although CHG is more costly than Iodine, this dramatic reduction in the number of SSIs will likely result in greater overall cost savings with chlorhexidine use”  Am J Inf Control 2010;31:1219

46. SSI: Efficacy of CHG-A Skin Prep …..In summary, the weight of evidence suggests that chlorhexidine alcohol should replace povidone-iodine as the standard for preoperative surgical scrubs. NEJM 2010;362:1

47. INFECTION PREVENTION: (FOUR) PILLARS * De-populate the patient * De-populate the space * De-instrument the patient * De-escalate the ABX fole

49. ENVIRONMENTAL CONTAMINATION: VRE VRE persists through an average of 2.8 standard room cleanings ICHE 1998;19:261

50. ENVIRONMENTAL CLEANING: MDR CONTROL? Purpose – To assess the efficacy of environmental cleaning protocols for reduction of VRE, C. difficile Baseline Post-Routine Post-Bleach  Cx Cleaning Cleaning VRE (N = 17) 94%71% 0 (p <.001) C. diff (N = 9) 100% 78% 11% (p =.03)... Implications... BMC Inf Dis 2007;7:61

51. ENVIRONMENTAL CONTAMINATION: VRE 14 month study; N = 1330 ICU admissions – Weekly environmental Cx – Twice weekly pt Cx 8% at-risk patients acquired VRE Risk factors for VRE acquisition – Prior VRE  occupant (p =.007) – Prior VRE  environmental Cx (p <.001) CID 2008;46:678

52. INFECTION PREVENTION: (FOUR) PILLARS * De-populate the patient * De-populate the space * De-instrument the patient * De-escalate the ABX fole

53. CA-UTI: NURSE-LED MODEL Urinary catheters (UC) vs unnecessary urinary catheters (UUC) 2006-2007; 10 hospital units (N=4,963 PD) – 18% UC days Results: UC UUC (per 1000 PD) P-value (per 1000 PD) P-value Pre-interv. 203 102.002.001 Intervention 162 64.05.01 Post-interv. 187 91 ICHE 2008;29:815 ICHE 2008:29:820

54. INFECTION PREVENTION: (FOUR) PILLARS * De-populate the patient * De-populate the space * De-instrument the patient * De-escalate the ABX fole

55. Antibiotic Stewardship Issues  Empiric ABX Order Set: Computer Physician Order Entry (CPOE) CID 2007; 44: 159  VAP De-escalation (8 Days of ABX) JAMA 2003;290:2588  Bacteremia vs. Fungemia (example)  CAUTI: CID 2010;50:625  Institutional Antibiogram

56. INFECTION PREVENTION: (FOUR) PILLARS * De-populate the patient * De-populate the space * De-instrument the patient * De-escalate the ABX fole

57. INFECTION CONTROL IN THE MODERN ERA: BLUEPRINT FOR SUCCESS MDRO case finding = ASC isolation CHG10% bleach  Colonization   Infection   Death De-instrument  ABX pressure De-escalate the patient the ABX  MDRO ?  LOS/? Improved antibiogram