Infection Control- Preventing Nosocomial Infections

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Infection Control- Preventing Nosocomial
Infections

• Yehuda Carmeli, MD, MPH
• Division of Epidemiology,
• Tel Aviv Sourasky Medical Center

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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-18th century
• 1,000 beds, 3,000 patients
• Water directly from the Seine
• Wounds clean with shared towels

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How bad it was

• All wounds became infected
• Mortality after amputation gt60
• 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

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Ignaz Semmelweis, 1815-1865

• 1840s General Hospital of Vienna
• Divided into two clinics, alternating admissions
  every 24 hours
• First Clinic Doctors and medical students
• Second Clinic Midwives

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Semmelweis hand disinfection
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The InterventionHand scrub with chlorinated
lime solution
Hand hygiene basin at the Lying-In Womens
Hospital in Vienna, 1847.
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Mortality Semmelweis
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Hand Hygiene Not a New Concept
Semmelweis Hand Hygiene Intervention
Hand antisepsis reduces the frequency of
patient infections
Adapted from Hosp Epidemiol Infect Control, 2nd
Edition, 1999.
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Hand Hygiene Adherence in Hospitals

• Year of Study Adherence Rate Hospital Area
• 1994 (1) 29 General and ICU
• 1995 (2) 41 General
• 1996 (3) 41 ICU
• 1998 (4) 30 General
• (5) 48 General

1. Gould D, J Hosp Infect 19942815-30. 2.
Larson E, J Hosp Infect 19953088-106. 3.
Slaughter S, Ann Intern Med 19963360-365. 4.
Watanakunakorn C, Infect Control Hosp Epidemiol
199819858-860. 5. Pittet D, Lancet
20003561307-1312.
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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 200021381-386.
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Ability of Hand Hygiene Agents to Reduce Bacteria
on Hands
Adapted from Hosp Epidemiol Infect Control, 2nd
Edition, 1999.
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Efficacy of Hand Hygiene Preparations in Killing
Bacteria
Better
Good
Best
Antimicrobial soap
Plain Soap
Alcohol-based handrub
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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.
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Infection Rates Surgical Handscrub vs. Handrub
?2 Test of Class of No. SSI/No. Operations
() Equivalence Contamination Handscrub Handrub (p
-value) Clean 29/1485 (1.9) 32/1520 (2.1) 16.0
(lt0.001) Clean- Contaminated 24/650
(3.7) 23/732 (3.1) 1.9
(0.09) All 53/2135 (2.5) 55/2252 (2.4) 19.5
(lt0.001)
Parienti et al. JAMA 2002 288(6)722-27.
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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 dont
  require surgery
• After
• Contact with a patients skin, body fluids or
  excretions, non-intact skin, wound dressings
• Contact with a patients close environment
• Removing gloves

Guideline for Hand Hygiene in Health-care
Settings. MMWR 2002 vol. 51, no. RR-16.
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Effect of Alcohol-Based Handrubs on Skin Condition
Epidermal water content
Self-reported skin score
Dry
Healthy
Healthy
Dry
Alcohol-based handrub is less damaging to the
skin
Boyce J, Infect Control Hosp Epidemiol
200021(7)438-441.
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Pasteur germ theory of disease
Lister Asepsis
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Aseptic techniques
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• 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.

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Source of organisms

• The patient
• preparation of the site
• The environment
• cleaning and disinfection
• Surgical tools and materials
• sterilization
• the personnel
• protective dressing

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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

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October 18, 2000 250-million-year-old bacteria
revived
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Killing Curve
cleaning
Resistant sub-populations
Decimal reduction time Overall
population1 Resistant subpopulation 2 , 3 , gt3
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Bacterial Growth Curve
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Netherlands standard

• Shelf life determined by
• method of sterilization
• equipment
• packing material
• transport
• storage conditions

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Difficult to trace

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

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Florence Nightingale hospital hygiene
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Patient to patient transmission

• Routes of transmission
• Air born
• Blood born
• Fecal oral route
• Contact
• Vector

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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

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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

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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

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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

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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 ?

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Contact precautions

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

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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)

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Most Common Nosocomial Infections

• Blood stream infections (BSI)
• Surgical site infections (SSI)
• Nosocomial pneumonia (ventilator associated
  pneumonia) (VAP)
• Urinary tract infections (UTI)

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Most Common Nosocomial Pathogens (NNIS)

• Gram positive
• S. aureus
• Enterococci
• SCN

• Gram negative
• E. Coli
• Klebsiella spp.
• P. aeruginosa
• Enterobacter spp.

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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

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BSI

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

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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

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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
• Subclavianltjugularltfemoral
• 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)

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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

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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 fistulaltgraft (x2)ltcatheter (x8.5)

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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

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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

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Nosocomial pneumonia Pathogens

• Mostly GNR
• Enterobacter spp.
• Pseudomonas aeruginosa
• Klebsiella spp
• Gram-positive
• S. aureus
• S. pneumonia

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Preventing Measures

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

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UTI

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

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