Infection Prevention and Control in Healthcare

May 2017

John Ferguson, Microbiology & Infectious Diseases, John Hunter Hospital, University of Newcastle, NSW, Australia

Part 1 Revision weeks, UPNG

@mdjkf http://idmic.net

jferguson@hnehealth.nsw.gov.au

Overview • Burden of healthcare-associated infection

(HAI) • Transmission of HAI • HAI types and causes • Standard Precautions and infection

prevention & control: – WHO 5 Moments Standard for Hand Hygiene – Personal protective equipment – Device associated infection prevention

• TB Infection control

Flora of Patient!

0

HAI: 2011 WHO report

• The risk of infection is 2-20 times higher than in developed countries, and the proportion of patients infected can exceed 25% (Allegranzi B & Pittet D, ICHE 2007).

• Papua New Guinea ?? Assuming 7 million population and an infection rate 2 times the Australian estimate = approx. 100,000 episodes of HAI per year

Impact of HAI

• Increased length of stay in developing countries 5-29.5 days

• Excess mortality 18.5%, 23.6%. 29.3% for catheter-UTI, catheter-BSI and ventilator-associated pneumonia respectively

• Cost: Mexican ICUs – average HAI episode cost US$12,155

HAI case in Newcastle, Australia

• 45 year old woman admitted for 2 weeks iv antiviral treatment of an eye condition

• Develops infection of an IV cannula site that is ignored- goes home with infection

• Represents 2 weeks later with advanced Staphylococcal sepsis (due to methicillin-susceptible Staphylococcus aureus) and dies

HAI risks for staff

• Needlestick injury or mucosal injury - bloodborne viruses [what is your status?]

• Airborne exposures- TB, SARS, Influenza and other respiratory viruses

• Pyogenic infection – Staphylococcus aureus, Herpes simplex

Controls: hand hygiene & personal protective equipment to protect self from potential body substance exposures

Transmission of HAI: Contact spread- the commonest

• Direct contact includes person-to-person spread by direct body contact (HANDS!) or contact with infected body fluids

• Indirect contact spread occurs when the infectious agent is spread from contaminated instruments, equipment (fomites) or from a contaminated environment.

Controls: • hand hygiene before and after • cleaning of the patient care

environment; • cleaning of equipment before use

Other transmission routes

• Airborne transmission occurs when smaller respiratory particles stay suspended in the air and are carried via air currents to infect others at some distance . Example: Tuberculosis, Measles

• Droplet spread is caused by sneezing, talking and coughing. Droplets containing the microorganisms travel a short distance through the air and land on the host’s eyes, mouth or nasal mucosa. Example: Influenza

Airborne disease: controls complex – see later Droplet spread: hand and environmental hygiene

Other transmission routes

• Common vehicle transmission occurs when microorganisms are transmitted by contaminated food or water.

• Vectors are insects and animals such as flies, mosquitoes or rodents that act as intermediate hosts between the source and host.

Controls: Manage food/water safety and buildings (insect screens, maintenance)

HAI Types and Causes Infection type Factors Organisms

Bloodstream infection/ clinical sepsis

Intravascular devices Post procedural

Staphylococcus spp. Gram negatives- E. coli, Klebsiella etc Candida spp.

Urinary tract infection

Urinary catheters Gram negatives – E. coli Enterococcus spp.

Gastrointestinal infection

Food, water Cross transmission

Viruses Salmonella, Shigella, Campylobacter Clostridium difficile

Pneumonia ICU ventilation Oxygen tubing Airborne spread (TB) Droplet spread (viral )

Gram positive – MRSA Gram negatives – aerobes – E. coli, environmental Gram negatives Viruses

Neonatal sepsis Intrinsic risks Invasive devices Antibiotic exposure

Gram negatives Gram positive – Staphylococci and Streptococcus

Surgical site infection

Patient and procedural risk factors

Staph/ Strep, Abdominal surgery - Gram negatives (aerobes and anaerobes )

Bloodborne virus transmission

Multi-use vials Inadequate screening of blood Exposure events

HIV, Hepatitis B, Hepatitis C, HTLV-1 etc

Neonates: Intrinsic risk factors

• Lack of natural microbial flora from mother (intensive care patient)

• Resistant or pathogenic flora from mother- increasing community multi-resistant-Gram negatives, MRSA prevalence, Salmonella, E. coli

• Low stomach acidity; worsened by NG feeding

• Prematurity – Fragile thin skin

– Immune system immaturity: reduced immunoglobulin component from mother

Standard Infection Control Precautions (practices)

Assumes that ALL human blood or other body fluids are potentially infectious.

The aim of these practices is to protect patients and health care workers from exposure to infection via the contact route by using the same practices for ALL contacts between staff and patients.

Infection Prevention and Control: essential elements

Protecting patients (your relative) Protecting healthcare staff (yourself! )

Hand hygiene by staff, patients and carers (Standard precautions=S) Cleaning equipment prior to use (S)

Hand hygiene after patient contact (S)

Aseptic practices- medical and surgical (S) Correct use of personal protective equipment (S)

Immunisation Immunisation- Hepatitis B, Influenza

Hospital environmental cleaning ; safe waste & linen handling (S)

Safe handling of sharps (S)

Safe reprocessing and sterilisation of reused equipment

Respiratory hygiene and cough etiquette (S)

Surveillance of HAI and outbreaks

Early identification & isolation of infectious patients (airborne infections- TB, measles )

Structural elements – ventilation , sufficient toilets, patient accommodation, cleanable well maintained surfaces

Donskey C and Eckstein B. N Engl J Med 2009;360:e3

Doctor’s MRSA hand contamination (left) following abdominal examination of a colonised patient; right – after alcohol hand rub

World Health Organisation, Clean Care is

Safer Care Campaign- www.who.int/gpsc/ .

The key message-

Clean your hands

BEFORE and

AFTER touching

every patient.

Newcastle: HAI due to Staph. aureus bloodstream infection: falling MRSA and mortality

21

2008 2009 2010 2011 2012 2013

2014

to Mar

MRSA events (HNE) 23 28 20 17 13 7 1

Deaths within 30 days of MRSA event 6 11 4 1 3 1 -

MSSA events (HNE) 70 78 75 88 75 74 20

Deaths within 30 days of MSSA event 10 21 14 13 12 27 3

Total Healthcare SAB events 93 106 95 105 88 81 29

Hand hygiene compliance (Acute networks) 50% 65% 77% 80% 87% 84%

% MRSA (Healthcare SAB events) 25% 26% 21% 16% 15% 9% 3%

PPE and Standard precautions: common situations

• Taking a wound dressing down: clean hands before and put on gloves!

• Putting in a cannula or giving an injection: clean hands then gloves and eye protection recommended

• Discarding gloves: wash/clean hands afterwards

• Closed in shoes are PPE!

Always carry your protective eye wear!

Preventing IV device-associated infections

• Minimise unnecessary device exposure – avoid insertion and/or remove early

• IV device insertion and management issues:

– Skin antisepsis (IV) – agent and duration

– Site selection – foot, cubital fossa, femoral, jugular higher risk

– Non-touch technique to protect ‘key’ parts during insertion

– Sterile dressing

– Scrub the hub with alcohol- allow sufficient time for action

– Aseptic IV medication preparation and administration- NO multi-use vials

• Remove/replace device ASAP when infection suspected

Intravenous cannulas: Questions

• Are IV cannulas overused ?

• Are they inserted with aseptic care?

• Are they kept in for too long (more than 72 hrs) ? – are there alternative routes for medication or can the treatment be shortened safely?

• Are they manipulated and accessed with proper care?

• Can certain high risk settings afford sterile dressings to reduce infections?

• How many blood stream infections (and deaths) occur due to IV –associated infections?

IV infusions and cannulae are a potential

bacterial freeway into the bloodstream!

Catheter-associated UTI (CAUTI) prevention

Impact: (Newcastle data) 1.7% of inpatients who stay > 48 hrs develop hospital onset UTI; 4 additional days of stay Prevention: • Avoid unnecessary IDC use – strict guidelines • Insert with aseptic technique (wash perineum with water

only prior to insertion) • Catheter bag always hangs below patient; fixation devices

recommended- improve patient comfort and reduce urethral trauma; don’t open the catheter circuit!

• Always assess catheter on rounds and remove IDC as early as possible

Ventilator-associated pneumonia prevention

• Minimise unnecessary device exposure – nasal CPAP in neonates; non-invasive ventilation procedures

• ET tube and laryngoscope must be clean (sterile)

• Closed circuit suction:

• 30 degree inclination

“Ventilator care bundle”

https://idmic.net/2015/05/05/room-temperature-bubble-through-water-chambers-for-patient-oxygen-supply-are-an-infection-hazard-and-do-not-provide-significant-humidification/

TB infection control

Patterns of TB disease

• Latent tuberculosis – risk of relapse depends on immunity and strain type ; risk of re-infection

• Pulmonary/laryngeal TB – typically cough, weight loss, fevers, haemoptysis – infectivity highest for smear positive cases

• Miliary and atypical pulmonary disease – HIV patients– detection difficult without culture or genXpert– infectivity lower

• Non-pulmonary disease – meningitis, lymph nodes, other sites – patients not infectious

56 yo aboriginal patient, smoker presented with productive cough, fatigue, weight loss and fever

56 yo aboriginal patient, smoker presented with productive cough, fatigue, weight loss and fever

3 weeks productive cough, one episode haemoptysis, pleuritic chest pain, night sweats, chills and rigors, fevers

miliary TB

3 weeks productive cough, one episode haemoptysis, pleuritic chest pain, night sweats, chills and rigors, fevers

Transmission of M tb

• Almost always acquired by inhalation via airborne or droplet spread

• Usual source is an untreated case of pulmonary tb

• 25-40% of household contacts of an untreated smear positive case become infected

Beijing family

strains

Tuberculosis

89 (2009)

120–125

Courtesy: Dr Rendi Moke

Courtesy: Dr Rendi Moke

Impact of drug-resistant (DR)-tuberculosis

• MDR cases are resistant to INH and rifampicin – Renders necessity for more prolonged treatment

– Cost of treatment X 200 that of drug susceptible TB

– Mortality rate untreated 70%

• Without systematic detection and programmatic management of DR-TB, it replaces DS-TB and disease burden (number of cases ) increases

PNG action

• National TB drug susceptibility survey

• National task force set up by PM, NDOH. WHO, MSF, other NGOs involved

• Training of physicians from all Provinces this week- programmatic management of DR-TB and TB-IC – F-A-S-T strategy

• Laboratory capacity building/support; culture and DST has restarted (CPHL); lab supervision and quality assurance

Landmark PNG TB resistance survey

F-A-S-T strategy for TB & DR-TB control

Finding patients-Actively-S-T

• Administrative measures- policies and procedures, establish responsibilities

• Screening– standard questioning of ALL admitted patients; determine risk for DR-TB as per CPHL protocol; Cough control officer(s)!

• HIV screening of all new cases

• When indicated – PTB symptoms and/or HIV positive- rapid TB testing essential- same day sputum smear +/-genXpert

Models of logistics & action – see published experience from South Africa and other Pacific Nations. WHO guidelines on management.

TB diagnosis: specimen types

• Sputum

• Gastric aspirate/lavage/string test

• Sterile sites- blood, fluids

• Urine

• Tissues- pleural biopsy, lymph node biopsy

Sputum specimen protocols

• Collection – instruction of patient and collection procedure; collect outside

• Two specimens recommended by WHO

– Specimen on day of clinic followed by next morning specimen

– Same day with two specimens and rapid diagnosis (preferred)

Microscopy

• “Acid fast” stains rely on the high lipid content of the organism – Ziehl-Neelsen- examined under x 800-1000 magnification (20 mins

max) – Auramine-0 stain- auramine binds to DNA and fluoresces; can be

examined at lower magnification; more sensitive (about 10%) and quicker (10 min max)

• Sensitivity overall in HIV-negative adults around 60-70% • Liquefaction of sputum with bleach solution followed by

centrifugation to concentrate bacteria can increase sensitivity by 18% (but cannot culture these specimens!)

• Second sample increases sensitivity (WHO now recommends two samples) Third sample optimal

• Lower sensitivity of microscopy in HIV-infected and in children (< 20%)

Xpert-MTB/RIF

• PCR assay platform that detects TB in 2 hours and the common rpo gene mutations associated with rifampicin resistance

• Sputum primary specimen but also validated for a range of other specimen types

• More sensitive than microscopy- detects a large proportion of smear negative, culture positive cases of pulmonary TB (which often happens in advanced HIV patients);

• Not quite as sensitive as culture

CPHL Protocol for Xpert-MTB/RIF testing

F-A-Separate safely-T Segregation approach example

MDR+ cases go into isolation rooms

Separate safely- environmental controls

• Hospital design and patient flow- many good examples of designs that work from overseas

• Outdoor waiting areas and sputum collection areas

• Segregated buildings/wards and rooms with separate toilets

• Maximise natural ventilation • Exhaust ventilation • UV lighting (requires careful placement,

maintenance and regular replacement)

Separate safely- Environmental control examples

Exhaust fan

Separate safely- protecting staff

• Educate staff – symptoms of TB, use of masks, location of TB patients etc

• Actively screen staff – regularly check for symptoms of TB

• Staff with HIV should not look after infective TB patients

• Staff who care for TB patients or enter TB wards need to protect themselves – particulate filtration masks (p2/n95) or respirators – Training required to show correct use and fit checking – Masks can be reused if not damaged

Masks, Respirators …

• P2(n95) masks (respirators)

• Reusable cartridge respirators

N95 or P2 particulate masks

• “duckbill” shape (not always)

• Different types may be required to fit different facial shapes- need a range available

• Training on how to fit mask properly is essential; ‘fit check’ after putting on

• Change when moist (generally every 3-4 hrs+)

• Mask can be reused if left to dry and elastic ok; don’t share with another

Surgical masks

• Use on coughing patients to reduce aerosols

• Poor protection for staff against TB compared with particulate respirators/masks

• Beards lessen the efficacy of masks +++

F-A-S-Treat rapidly

• Rapid start to treatment essential to reduce infectivity

• No RIF-R – FDC (cat1) treatment

• RIF-R case – start initial MDR treatment (new PNG protocols)

• Full drug susceptibility measurement required for all RIF-R/relapsed cases so that proper treatment can be designed

Treat rapidly: How quickly to patients become non-infectious after starting

treatment?

• Drug susceptible cases rapidly lose infectivity (within days) despite being culture and smear positive for longer

• MDR cases have a short infective period ONLY IF appropriate drugs given

F-A-S-T strategy for TB & DR-TB control

References (TB) • www.ghdonline.org – International discussion forums lead by experts – TB

infection control and Drug-resistant TB forums

• http://drtbnetwork.org F-A-S-T resources, excellent training modules for DR-TB management

• Idmic.net – search ‘Tuberculosis’

• Der Spuy et al. Changing Mycobacterium tuberculosis population highlights clade-specific pathogenic characteristics. Tuberculosis 89 (2009) 120–125

• Dharmadhikari et al . Rapid impact of effective treatment on transmission of multidrug-resistant tuberculosis. INT J TUBERC LUNG DIS 2014, 18(9):1019–1025