Outline Hospital or Home?drshelly.info/DrShelly/Education_files/Infect Prevention in LTC 4x.pdf · Mark Shelly, MD Associate Professor of Medicine, URMC Epidemiologist for Highland

Hospital or Home?Infection Prevention in Long Term Care

Mark Shelly, MDAssociate Professor of Medicine, URMC

Epidemiologist for Highland Hospital

Outline

• Principles of Infection Prevention

• Defining Infection in Long Term Care Facilities

• Special Case for attention: C difficile, MDRO, Antibiotic finger traps

Principles of Transmission and

Isolation

Healthcare Associated Infections (HAI) in LTC• 1.8 million residents in 16,500 nursing

homes

• HAI rates of 3 to 7 per 1 000 resident-care days (1.8 to 13.5)

• 2 to 4 million cases a year

• 1 to 2 per resident per year

CDC Isolation Guideline 2007, 1.D.2.a

HAI in LTC• LTC is home for many

• Guidelines for healthcare infection prevention often ignore LTC

• “Application of hospital infection control guidelines to LTCF is often unrealistic . . .” ICHE 2008; 29:785-814

• Hospitals have greatly reduced infections

• Little data in LTC infection prevention

ICHE 2008; 29:785-814

Modes&of&TransmissionMode Vector Example PreventionContact (direct)

Hands Staph aureus Hand hygiene

Gloves/gowns

Contact (indirect)

Environment

Instruments

Clostridium difficile

Hand hygieneGowns/glovesEnviron clean

Droplet Face-to-face Influenza Mask

Airborne Cough; small particles Tuberculosis N95 Mask

Ventilation

Blood borne Intimate contact

Medical Interventions

HIV

Hepatitis B, C

Gloves

Sterilization

Types of Isolation

StandardHand Hygiene

Blood & Body Fluid

Contact Gown & Gloves

Droplet Simple Mask

Airborne N95 RespiratorsNegative Pressure

Ethics of Isolation

• No isolated patient benefits from isolation

• Isolated patients receive less care and may feel abandoned

• To justify this,

• Proven benefit to others?

• Best of available options?

Types of Isolation for LTC


Blood & Body Fluid


Droplet Simple Mask


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Defining Infection in LTCF2012 Update

SHEA/CDC Position Paper

• McGeer Criteria: 1991

• Updated with current evidence

• Still too weak to grade

• Provides surveillance definitions for common infections

• RTI, UTI, SSTI, GI

• BSI, some other definitions unchanged

SHEA/CDC Position Paper

Endorsed byAmerican Medical Directors Assoc

Assoc Prof in Infec Control (APIC)

National Assoc of Dir of Nursing Admin in LTC

Assoc Medical Micro and Infect Disease–Canada

Community and Hosp Infec Control Assoc–Canada

Surveillance ≠ Clinical Dx

• Surveillance definitions are made to measure populations consistently (specificity)

• Clinical diagnosis is what determines care for the individual (sensitivity)

• Each should inform the other

• Most of the people being treated should meet surveillance definitions

• Surveillance shouldn’t miss many cases

3 Conditions

1. New or acutely worse symptoms

2. Noninfectious causes ruled out first

3. Infections not based on a single piece of evidence

• i.e. Not just lab value OR provider dx

Surveill Def in LTCF, ICHE 2012; 33(10):965-77

Constitutional Criteria

• Fever

• Leukocytosis

•Acute Change in Mental Status

•Acute Functional Decline


CC: Fever & WBC

• Fever

• T > 37.8 C (100.0 F) or

• Repeated T > 37.2 C (99.0 F) oral, >37.5°C (99.5°F) rectal or

• T > 1.1°C (2°F) over baseline

• Leukocytosis: >14,000 WBC or >6% bands


CC: Mental Status Change

• Acute change in mental status from baseline (ALL of these)

• Acute onset

• Fluctuating course

• Inattention

• Disorganized thinking or altered level of consciousness

Confusion Assessment Method (CAM), c/w CMS Minimum Data Set 3.0

CC: Functional Decline

CMS Minimum Data Set 3.0

New 3 point increase in ADL scoreNew 3 point increase in ADL score

Bed mobility Toilet Use

Transfer Personal hygiene

Locomotion w/i LTCF Eating

Dressing

0 independent - 4 dependent

Respiratory Tract Infection (RTI)

• Common Cold

• Influenza-like illness

• Pneumonia

• Lower Respiratory Tract Infection


Influenza-like illness+Fever

+at least 3 subcriteria✓Chills✓New headache or eye pain✓Myalgias or body aches✓Malaise or loss of appetite✓Sore throat✓New or increased dry cough


No longer seasonal

RTI: Pneumonia≥1constitutional criteria and

+CXR w/ pneumonia or new infiltrate

+≥ 1 respiratory sx✓ New or increased cough✓ New/increased sputum

production✓ O2 sat <94% on RA or

down > 3% from baseline

✓ New/changed lung exam findings

✓ Pleuritic chest pain ✓ Resp rate ≥ 25/min


RTI: Lower Resp TractTracheobronchitisor bronchitis≥1constitutional criteria and

+CXR not done or unchanged

≥ 2 respiratory sx✓ New or increased cough✓ New/increased sputum

production✓ O2 sat <94% on RA or

down > 3% from baseline

✓ New/changed lung exam findings

✓ Pleuritic chest pain ✓ Resp rate ≥ 25/min


Urinary Tract Infections

• Definitions significantly changed

• Most fevers with positive cultures that do not meet these definitions are not UTI

• No catheter: localizing GU signs + positive culture

• Catheter: GU signs, or sepsis w/o other cause

• No pyuria = no UTI; pyuria does not rule in


Urine Cultures

• Non-specific, but required for UTI dx

• Process promptly (<24h), refrigerate

• voided: >105 CFU/ml and ≤2 species

• straight cath: > 100 CFU/ml

• foley: >105 CFU/ml

• replace the catheter first if in place >14 days


UTI: No Catheter• acute dysuria or pain, swelling, or tenderness of

testes, epididymis, or prostate

• Fever or leukocytosis, and 1 Sx, or 2 Sx


✓ CVA tenderness*✓ Suprapubic pain✓ Gross hematuria

new or marked increase in✓ incontinence✓ urgency✓ frequency

* not included if fever/leukocytosis is one sign

UTI: With Catheter

• Purulent discharge at catheter, or pain/swelling/tenderness of the testes/epididymis/prostate

• New suprapubic pain or CVA tenderness/pain

• Fever, rigors, or hypotension with no other site

• Leukocytosis with no other site and either

• Mental status change or

• Functional decline


GI Tract Infections

• Diarrhea: 3 or more liquid stools in 24h over normal for resident

• Vomiting: 2 or more episodes in 24h

• A positive culture for a pathogen with at least one sx:

• Nausea, vomiting, diarrhea or abdominal pain

Surv Def in LTCF, ICHE 2012; 33(10):965-77

Norovirus• Diarrhea or Vomiting AND

• Positive lab testing for Norovirus

• Kaplan Criteria (for clusters of cases)

• vomiting in more than 50%

• incubation 24-48h

• duration of illness 12-60h

• no bacterial pathogen in stool culture


Clostridium difficile Infection

• Clinical picture

• Diarrhea: ≥ 3 liquid, watery stools above normal for resident or

• Toxic megacolon and

• Positive lab test

• EIA, toxin assay, or PCR

• Pseudomembranous colitis observed


Surveillance Intervals

admit d/c 4w 12w

HCF

HCF OnsetHA-CO

Indeterminate Community Associated

HA-HO

HCF AssociatedComm Onset

within 2 weeks: same episodewithin 8 weeks: recurrence

Adapted from McDonald LC, Coignard B, et al, Infec Control Hosp Epidemiol 2007; 28(2):140-5

Incident cases per 10 000 patient-days

Special Cases

C"diff"infec*on"2010"

HH" RGH" SMH" Unity" NYS"Hosp"Onset" 10.3" 8.7" 13.3" 8.7" 8.2"Hosp"Assoc" 15.0" 12.2" 16.2" 14.0"

0"

5"

10"

15"

20"

CDI"per"10,000"

pa*ent"days"

CDI in LTCVariable rates in the literatureLTAC: 31 /10kpd (Goldstein, Anaerobe 2009; 15(12):241)

Subacute/Rehab: 15-16 /10 000 p-d Nursing Home 1 / 10kpd (Laffan, JAGS 2006; 54:1068)

Ohio: 6-8 / 10kpd in hospitals, 2-3 in nursing homes (ICHE 2009; 30(6):526)

Jagai J, Naumova E. Emerg Infect Disease 2009; 15(2):online figure

Elderly CDI Hospitalization Rates, USA 1993-2004

Years

URMC 2009 C diff positive testsn=908

0 10 20 30 40 50 60 70 80 90 100

Age distribution

of C. diff patients

0"

5"

10"

15"

20"

25"

30"

0.00" 0.20" 0.40" 0.60" 0.80" 1.00" 1.20" 1.40"

Hospital)O

nset)CDI)p

er)10,00

0)pt*d

ays)

Incoming)CDI)per)1000)admits)

Hospital)Onset)CDI,)NYS)2010)

Diagnosing CDIMust have diarrhea (≥3 BM/d, loose)Enzyme assay is specific but will not detect all cases (80% sensitivity)

More tests ≠ betterGlutamate dehydrogenase (GDH) 96% sensitiveA PCR is available, very sensitive and specific

Annals of Internal Medicine 2009 151(3):176-9

New Lab Testing

URMCMicro

Diarrhea≥ 3 BM/d for 1-2 days

Only unformed stools accepted for testing

C diff testing x1

EIA for Toxins A & B

GDH EIA

EIA toxin

GDH

PCR

No Clostridium difficileClostridium difficile

Infection

(+)

(–)

(+)

(+)

(–)

No more than 1 test every 3 daysPositives not retested for a week

Test of cure is not appropriate

Sensitivity 96% Specificity >90%Negative Predictive Value 99%

From URMC Lab Memo, 2009 Nov 18

R

4

0

0.5

1

1.5

2

2.5

3

3.5

CDI p

er 1

000

pat

ient

day

s

Maternity

ICU

Geriatrics SurgeryStep Down

MedicineMed/Surg

ALC

Surgery

Risk varies between

units in the same

hospitalHighland Hospital, 10 Span method, 2008-2010

Antibiotics (and Gastric Acid)

No antibiotic is risk freeClindamycin is traditional culpritBroad spectrum increases riskFloroquinolones (new and old) are implicated in recent outbreaksProton Pump Inhibitors increase the risk

What should LTC do?Monitor the incidence of CDIAssure proper environmental cleaningHand Hygiene for everyone, including residents• Fecal Oral TransmissionUse antibiotics wisely: timely, targeted treatment

MRSA, VRE, ESBL

Common&bugs&learn&resistance

• Extended'Spectrum'Beta0Lactamases'(ESBL)'win'against'many'favorites

• Carbapenems'to'the'rescue'.'.'.–UnAl'carbapenemases'

•First'in'Klebsiella(pneumoniae((KPC)

•Shared'by'mobile'geneAc'element'with'other'organisms:'E.'coli,'Enterobacter,'ProvidenAa

•Carbapenem'Resistant'Enterobacteraceae'(CRE)

Even&Worse

• New'Metalo0beta0lactamases'(MBL)

• Most'recent'is'the'strain'from'New'Delhi,'NDM01

• Very'hard'to'treat,'with'any'anAbioAc

Extended&Spectrum&Beta<lactamase&(ESBL)

Carbapenemase&NDM<1

What&to&do&about&MDRO&GNR?

Like'VRE,'MRSA,'CDI'.'.'.

Contact&isolaHon

Treatment&of&ESBL&or&

• AnAbioAc'treatment'may'be'limited'to'–Tigecycline'•but'this'doesn’t'work'well'for'bacteremia–ColisAn'•this'old'drug'is'very'nephrotoxic•ID'Consult'required

Antibiotic Stewardship

Antibiotic Stewardship• 2.9 to 13.9 antibiotic courses per 1000

resident days

• CDC has a 12-step program for this

• Protocols have a role in improving care

• Do an antibiotic starts review: how many met definition

• Measure administration days, not purchasing (DDD)

Think Twice, Treat Once

•Asymptomatic bacteriuria

•Upper respiratory tract infections

•Red leg(s)

•Chronic wounds

My Short List• Alcohol hand gel everywhere

• Gloves easily available

• Wash hands before you eat

• Vaccinate every HCW (and patient)

• Avoid presentee-ism

• Treasure antibiotics

• Monitor & improve what is endemic

What makes sense?• Some infections can be prevented

• Hospital-style infection prevention doesn’t always fit

• Routine pathogens don’t warrant quarantine in the home

• Start measuring: Hand Hygiene, CDI, MDRO, Antibiotics

• Antibiotic stewardship will play a role

Types of Isolation for LTC


Blood & Body Fluid


Droplet Simple Mask



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www.drshelly.info

References

• Stone ND, Ashraf MS, Calder J et al. Surveillance definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hospital Epi 2012; 33(10):965-77

• Smith PW, Bennett G, Bradley S et al. SHEA/APIC Guideline: Infection prevention and Contol in the Long-Term Care Facility. Infect Control Hospital Epi 2008; 29(9):785-814

• CDC website on Hospital Associated Infections in Long-Term Care. http://www.cdc.gov/HAI/settings/ltc_settings.html

• High KP, Bradley SF, Gravenstein S et al. Clinical Practice Guideline for the Evaluation of Fever and Infection in Older Adult Residents of Long-Term Care Facilities. Clinical Infectious Diseases. 2009;48:149–171

• Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. Infect Control Hospital Epi 2008; 29(S1):S1-S92. http://www.jstor.org/stable/10.1086/593984

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Documents

Outline Hospital or Home?drshelly.info/DrShelly/Education_files/Infect Prevention in LTC 4x.pdf · Mark Shelly, MD Associate Professor of Medicine, URMC Epidemiologist for Highland