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HEADLINE NEWS FOR INFECTION PREVENTION
FADONA 2020NIPP… Nipping Infections in the Bud ©
Objectives2
Objectives
Review and discuss studies published in peer review journals that review and discuss infection prevention practices as it relates to hand hygiene and transmission‐based precautions.
Review and discuss studies that address the epidemiology of emerging pathogens and common healthcare associated pathogens.
Identify national guidelines that have been updated in the past year.
In the News…4
Gel Nails Are Hard to Clean
Study evaluated bacterial burden of gel nails, standard nail polish, and natural nails on the hands of HCWs. All nail products tested become more contaminated with bacteria over time.Gel nails may be more difficult to clean using alcohol hand gel. Increased bacterial burden was not found on gel nails worn by health care workers.
Evaluation of the bacterial burden of gel nails, standard nail polish, and natural nails on the hands of health care workers, Hewlett, Angela L. et al. AJIC, Volume 46, Issue 12, 1356 ‐ 1359
Formulation Matters for Alcohol‐based Hand Rubs FDA requires 2 log reduction after 1st use and 3 log
reduction after 10th use WHO/CDC recommend concentrations of 62% ‐
90% Formulations of 80% & 90% are less effective Formulations below 70% did not meet FDA
requirements Products with 70% performed best with
significantly greater log reductions after 1st and 10thapplication
Edmonds, Sarah L. et al., Comparative efficacy of commercially available alcohol‐based hand rubs and World Health Organization‐recommended hand rubs: Formulation matters, American Journal of Infection Control, Volume 40, Issue 6, 521 ‐ 525
Healthcare Workers Contaminated Themselves When Removing PPEHealthcare workers contaminated themselves when removing personal protective equipment 46% of the time when removing gowns and
gloves (200/435 observations) More often contamination due to removal of
gloves – 52% of the observations Observed lapses in technique = 70%
contaminationTomas ME, Kundrapu S, Thota P, et al. Contamination of Health Care Personnel During Removal of Personal Protective Equipment. JAMA Intern Med. 2015;175(12):1904–1910. doi:10.1001/jamainternmed.2015.4535
ESBL Outbreak Linked to Sinks8
Outbreak of ESBL‐producing Klebsiella oxytoca Infections Associated with Contaminated Handwashing Sinks Outbreak period: October 2006 – March 2011 66 patients affected in hospital in Toronto, Ontario 24 infections: UTI, bacteremia, skin/soft tissue, and
pneumonia Environmental sampling – sinks were positive 3x/day sink cleaning Modified sink drain to prevent mixing of drainage from
overflow hole with regular drainage water, replaced strainers to reduce backsplash, and replaced sink traps
Adherence to contact precautions and hand hygiene
Lowe C, Willey B, O’Shaughnessy A, Lee W, Lum M, Pike K, et al. Outbreak of ESBL–producing Klebsiella oxytocaInfections Associated with Contaminated Handwashing Sinks. EID. 2012;18(8):1242‐1247.
Urban Nursing Homes More Contamianted with MRSA S. aureus found on 28.6% of surfaces tested in 4
Ohio nursing homes MRSA 20.1%
Urban area nursing homes had significantly higher prevalence of S. aureus than rural nursing homes Influenced by number hospitals transferring patients Rural NH had 1‐3 hospitals in area Urban had 4 – 15 hospitals
Cheatham, Shanice et al. Prevalence of Staphylococcus aureus and methicillin‐resistant S aureus on environmental surfaces in Ohio nursing homes, AJIC Volume 47, Issue 12, 1415 ‐ 1419
MRSA On Privacy Curtains in Rooms of Patients Without MRSA Study in hospital burn ward By day 10 ‐ 12% of curtains were contaminated
with MRSA By day 14 – 63% of curtains were contaminated Curtains in rooms of patients who did not have
MRSA were contaminated.
Shek, Kevin et al., Rate of contamination of hospital privacy curtains in a burns/plastic ward: A longitudinal study AJIC Volume 46, Issue 9, 1019 ‐ 1021
Hands Contaminated After Touching Privacy Curtains Half of healthcare worker hands were
contaminated after touching privacy curtains Hands tested before and after touching curtains Bacteria on hands included skin or oral
commensal flora
Larocque, Mike et al., Acquisition of bacteria on health care workers' hands after contact with patient privacy curtains, American Journal of Infection Control, Volume 44, Issue 11, 1385 ‐ 1386
Probiotics and C. difficile
Those on probiotics had a higher risk of Clostridioides difficile infection (CDI).
Use of proton pump inhibitors or histamine 2 receptor antagonists increased CDI.
Sex and age did not have a significant impact on incidence of CDI.
Time of probiotic initiation to antibiotic administration had no impact on CDI.
Number of concurrent antibiotics significantly increased risk for incidence of CDI.
Saltzman, Temima et al., The effect of probiotics on the incidence of Clostridioides difficile: Retrospective cohort analysis, AJIC Volume 48, Issue 2, 184 ‐ 188
65% of Nursing Home Residents Colonized with MDRO
13
Shared Healthcare Intervention to Eliminate Life‐threatening Dissemination of MDROs in Orange County (CA) Study included 18 nursing homes Random sample of 50 residents screened for
MRSA, VRE, ESBL, and CRE 65% of residents colonized with MDRO MDRO status known for only 18% of residents
Most common MRSA 42% and ESBL 34%McKinnellJA et al. Clin Infect Dis. 2019. 69(9):1566‐1573
Updated CDC Guidelines14
Pneumococcal Vaccination15
Pneumococcal Vaccination
Recommendations updated November 2019 PPSV23 For all adults 65 years or older
PCV13 Based on shared clinical decision‐making for
adults 65 years or older who do not have an immunocompromising condition, cerebrospinal fluid leak, cochlear implants, and have never received a dose of PCV13
For adults 65 or older who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and want to receive PCV13 AND PPSV23: You should not administer PCV13 and PPSV23 on
the same day. Administer 1 dose of PCV13 first then give 1 dose of
PPSV23 at least 1 year later.
Pneumococcal Vaccination
Immunocompromised Condition
Chronic renal failure, Nephrotic syndrome Immunodeficiency, Iatrogenic
immunosuppression Generalized
malignancy, Human
immunodeficiency virus
Hodgkin disease, leukemia
Lymphoma, Multiple myeloma Solid organ
transplants Congenital or
acquired asplenia Sickle cell disease, or
other hemoglobinopathies
18
19
CDC Resource Tool20
Enhanced Barrier Precautions21
Enhanced Barrier Precautions
Guidance from CDC published July 26, 2019 “Focusing only on residents with active infection
fails to address the continued risk of transmission from residents with MDRO colonization, which can persist for long periods of time (e.g., months), and result in the silent spread of MDROs.”
Enhanced Barrier Precautions
For novel and targeted MDROs Pan‐resistant organisms, Carbapenemase‐producing enterobacteriaceae, Carbapenemase‐producing Pseudomonas spp., Carbapenemase‐producing Acinetobacter
baumannii, and Candida auris
Enhanced Barrier Precautions
Use gowns and gloves when providing high‐contact care to resident Dressing Bathing/showering Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use: central line, urinary catheter,
feeding tube, tracheostomy/ventilator Wound care: any skin opening requiring a dressing
Enhanced Barrier Precautions
When implemented for novel or targeted MDRO: Residents on same unit as resident with
targeted MDRO who have an indwelling catheter or other medical device or a wound are to also be placed on enhanced barrier precautions.
Enhanced Barrier Precautions
“Facilities may consider applying Enhanced Barrier Precautions to residents infected or colonized with other epidemiologically‐important MDROs based on facility policy.”
“….does not replace existing guidance regarding use of Contact Precautions for other pathogens (e.g., Clostridioides difficile, norovirus) in nursing homes.”
Enhanced Barrier Precautions
Body fluid contained Resident can perform hand hygiene (or staff can
ensure hand hygiene is performed) Surveillance data does not reflect potential
transmission of organism Examples: ESBL in urine, MRSA in wound
Enhanced Barrier Precautions
Contact precautions Resident stays in room All persons entering room must don gown and gloves
C. difficile contact precautions Resident stays in room All persons entering must don gown and gloves Use soap and water for hand hygiene when exiting room Use bleach to clean and disinfect equipment and room
Enhanced barrier precautions Resident can leave room PPE for direct resident care activities
TB Screening for HCW30
TB Screening for Healthcare Workers CDC updated guidelines in May of 2019 Only address TB screening for healthcare
workers Note to also follow local and state requirements
Screening Upon Hire
HCW w/o previous positive TST1. Individual risk
assessment2. Symptom screen3. TB test (TST or IGRA) 2‐step skin test Document
measurement of result
4. TB education
If HCW has had a previous positive TST1. Individual risk
assessment2. Symptom screen3. Chest X‐ray or
documentation of normal chest X‐ray
4. TB education
Individual Risk Assessment
Risk Factors Exposure to TB
disease Time spent in
countries where TB is common
Current or planned immune system suppression
FAQ: What’s a 2‐step skin test?
2 TST tests administered 1 – 3 weeks apart 1st test negative = repeat second TST 1‐3 weeks after
first TST result was read Both TST tests negative = negative for TB Second TST positive = Refer for evaluation to rule‐out
TBIf 1st TB test is positive and person has previously tested negative, then refer for evaluation If newly positive result and low risk (I.e. TB unlikely per individual risk assessment) then repeat test to validate result
Upon Hire Skin Test
2‐step process If HCW has a documented negative TST result within
previous 12 months, then only 1 step required Use risk assessment and symptom screen to
interpret results If newly positive result and not low risk (I.e. have a
risk factor or symptom), refer for follow up Chest X‐ray and symptom evaluation required to rule out
active disease Document measurement not just positive or
negative result
Latent TB Infection (LTBI)36
Healthcare workers diagnosed with LTBI Treatment is strongly encouraged
Healthcare workers with untreated LTBI are to receive a symptom screen each year
Repeat chest x‐rays are NOT required
Annually
No screening for HCW unless exposure or ongoing transmission in healthcare setting
Must follow local and state public health requirements HCW identified with LTBI who does not undergo
treatment, must have symptom screen annually Repeat chest X‐ray NOT required unless symptomatic
TB education for all staff TB risk factors TB signs and symptoms TB infection control procedures
Action Steps
Update policy Committee and medical director approval of policy Review new employee intake forms and update as
needed Incorporate individual risk assessment
form/questions Educate employee health staff Review all employee education and ensure it
addresses risk factors, signs and symptoms, control measures, and facility policy
Other Employee Health Recommendations Per CDC HCW Vaccinations Hepatitis B – Lab documentation of immunity Varicella – Past infection/vaccination/lab
confirmation of immunityMeasles, Mumps, Rubella (MMR)HCW born in or after 1957 documentation of vaccination or lab confirmation of immunity
Pertussis ‐ Tdap/Td Documentation of vaccination
Influenza annually
Other Employee Health Recommendations Per CDC Policies and procedures for staff exposures Reporting of exposures Referral for evaluation and follow up Access to laboratory evaluation Provision of post‐exposure prophylaxis Procedures for monitoring signs/symptoms
Work restrictions Sick leave policies
Summary41
Summary
CDC Guidelines updated in 2019 TB testing for healthcare workers Pneumonia vaccination
New guidelines from CDC for LTC – Enhanced barrier precautions
Dedicated sinks for hand hygiene Use of alcohol‐based hand rub, 3 times and wash
with soap and water is a myth!
Questions???
Q & A
Thank you for your participation
To learn more about this topic please contact A.C. Burke, MA, CIC Vice President of Healthcare Qualityat [email protected]
2019 © RB Health Partners, Inc.
You may also contact Robin A. Bleier, President with regards to this or other services at [email protected] or call us at 727.786.3032.