의료관련 감염관리 원론 · 2015. 5. 30. · •sep 15, 2014 a doctor working in em was...

의료관련 감염관리 원론

조선대학교 감염내과

김 동 민

• Sep 15, 2014 a doctor working in EM was admitted with fever to the ID ward.

• Sep 4, Index Pt (56/F) : suspected fatal scrub typhus. (eschar, altered mental status Seizure with respiratory arrest occurred 9 h after admission, and CPR

• On 18 September 2014, Index Pt: RT-PCR for SFTSV.

Clinical Infectious Diseases Feb 18, 2015

증례

Characteristic Index

Nurses Doctors

1 2 1 2

From contact to symptom onset Clinical findings

Fever Myalgia Malaise Bleeding Rash

Personal protective device use Mask Glove Facial shield or goggle

White blood cell (×109/mL) Platelet count (×109/mL) IFA (IgG) Acute Convalescence RT-PCR Viral culture

NA

Yes Yes Yes Yes Yes

NA NA NA

10 000

52

• Overall attack rate: 15% (95% [CI], 4%–34%), but

HCWs (actively involved in CPR), AR : 57% (4/7)

• HCWs exposed to resp secretions (3 / 7 ) and blood (4 /13 ) more Sx resp secretions (-) 1 / 20 (P = .02) or blood (0 / 14 P = .04).

• HCWs who had gowns soiled with body fluid (3 of 5 HCWs) more symptomatic those who did not (1 of 22 HCWs; P = .01).

• None of the HCWs used a face shield or goggles as personal protective equipment (PPE).

Only 9 HCWs wore a surgical mask, 5 wore gloves, and 3 wore

surgical mask and gloves.

• Four of 11 HCWs who had used PPE (ie, surgical mask, gloves) had symptomatic infection vs 0 of 16 HCWs who had not used PPE (P = .02).

• Four of 9 HCWs who wore surgical mask had symptomatic infection vs 0 of 17 HCWs who did not (P = .007), and 2 of 5 HCWs who wore gloves had symptomatic infection vs 2 of 22 HCWs who did not (P = .14).

Clinical Infectious Diseases Feb 18, 2015

Patient –Specific Risk Factors • Age

• Underlying medical conditions

• Severity of illness

Health Care Risk Factors • Invasive devices

• Invasive procedures

• Antibiotic use

• Immune-suppressive

medications Health Care Delivery Factors • Poor hand hygiene & basic IC

practices

• Suboptimal environmental

cleaning and disinfection

• Suboptimal equipment

disinfection & sterilization

practices

• Unnecessary antibiotic use

• Insufficient staffing

Healthcare-Associated Infections

Infection Prevention Approaches

• Horizontal

• Interventions directed to prevent all infections

• Standard precautions

• Hand hygiene

• Universal bathing – chlorhexidine (CHG)

• Vertical

• Organism specific interventions

• Active surveillance testing (AST)

• Isolation carriers

• Specific antimicrobials.

• Topical mupirocin agents eg MRSA

• Oral enteral decontamination agents e g GNB

Approaches to HAI Prevention

• Horizontal strategies: preventive measures that have

the potential to prevent or reduce the risk of a wide

variety of HAI or HAI caused by a variety of organisms

• Education, hand hygiene, cleaning/disinfection,

proper use of antimicrobial agents, antiseptic bathing

• Procedure- or device-specific preventive measures:

• SSI: antibiotic prophylaxis, sterile equipment, skin antisepsis, etc.

• CLABSI: aseptic technique, application of antiseptic to catheter

insertion site, prompt removal, etc.

• CAUTI: aseptic technique, avoid unnecessary catheter use, etc.

Approaches to HAI Prevention

• Vertical strategies: preventive measures to reduce the

risk of acquisition of infection by a specific organism

• Vaccination: influenza, hepatitis B, measles, pertussis

• Transmission-based precautions (“isolation”)

Separation of colonized and/ or infected patients from other patients

Use of personal protective equipment, engineering controls

• Active surveillance (screening) to detect asymptomatic

carriers

Most commonly considered for MDROs (MRSA, VRE, MDR-GNR)

“Bundles”

• Defined by IHI (Institute for healthcare improvement) as small, straightforward sets of evidence-based

practices – usually 3-5 – that, when performed

collectively and reliably, have been proven to improve

patient outcomes.

• An examples is the central line bundle:

Hand hygiene

Maximal barrier precautions at time of insertion

Chlorhexidine skin antisepsis

Optimal catheter site selection (i.e.. avoidance of femoral site in

adults)

Daily revies of necessity with removal of unnecessary lines

Resar R. Joint Commision Jqual Patient Safety. 2005;31:243-248

삽입기구관련 의료관련감염

감염 종류 미국 NHSN

(2006-8)

한국 KONIS

(2010.6-2011.7)

MICU

Central line-associated BSI 2.6 3.0

Ventilator-associated pneumonia 2.4 0.9

Urinary catheter-associated UTI 4.7 3.9

SICU

Central line-associated BSI 2.3 3.4

Ventilator-associated pneumonia 4.9 1.9

Urinary catheter-associated UTI 4.3 4.1

병원감염관리 2012;17:28-39 Am J Infect Control 2009;37:783-805

발생률, 1000 기구 명-일당

감염 부위별 추가재원일수 및 추가 진료비

병원감염종류

추가재원일수

한국*(미국**)

추가비용

한국* 미국**

요로감염 0.6일(1.0일)

최소 : 650,247원

최대 : 2,026,745원

평균 : $593

(최고 : $8,286)

균혈증 1.0일(7.0일)

최소 : 1,738,613원

최대 : 2,930,684원

평균 : $3,016

(최고 : $9,027)

수술창상감염 20.4일(7.0일)

최소 : 3,317,812원

최대 : 3,945,829원

평균 : $2,734

(최고 : $26,019)

폐렴 0.25일(6.0일)

최소 : 2,964,188원

최대 : 6,362,623원

평균 : $4,947

(최고 : $41,628)

*Song JH, (Korean J Nosocomial Infection Control 1999 Jan; 4(2): 205~216 ; *

*Haley RW, JAMA. 1987 Mar 27;257(12):1611-4

대한병원감염관리학회 2007 Jan; 12(1): 50~57

Contents No. hospitals (beds)

Total cost Cost per hospital mean (SD) Cost(Won) per bed

Disinfectants Employee health service Isolation room Facility & Environment

Operation of infection control office

Total

Antisepsis Disinfectants Subtotal Immunization Post-exposure Management Sharps collector Safety device Subtotal Loss of room charges

Subtotal Safety box Environmental culture HEPA filter Subtotal For program Salary Subtotal

5 (6,495) 6 (7,271)

5 (6,529) 7 (8,114)

5 (6,495) 3 (3,152)

7 (8,114)

5 (5,369) 7 (8,114)

6 (7,338)

6 (7,378) 8 (9,148)

518,583,152 332,211,129

68,384,030 73,368,790

102,336,906 1,049,200

2,519,056,980

291,981,940 47,363,614

224,197,000

124,068,000 448,208,000

5,961,817,243

103,716,630 (±78,340,098) 55,368,522 (±40,812,749)

13,676,406 (±18,633,083) 10,481,256 (±7,473,827)

20,467,381 (±24,093,538)

209,840 (±218,128)

359,865,286 (±383,960,083)

58,396,388 (±72,239,058) 6,766,231 (±5,339,495)

37,366,167 (±15,917,638)

20,678,000 (±25,142,125) 56,026,000 (±35,936,588)

933,133,309

79,843 45,690 125,533 10,474 9,042

15,756 162

35,434 310,458 310,458 54,383 5,837

30,553 90,773 16,816 48,995

65,811

785,115

병원감염관리 비용 조사 연구 (annual cost)

annual cost of HICP at a minimum of 96,723,000 won for a 100-bed hospital

Type No. hospitals

No. employ

ees

No. immunize

d

Immunization

rate (SD)

Total cost

Cost per hospital

Cost per employee

MMR 5 18,881 563 10,801,820

2,160,364 572

Influenza 5 18,881 14,923 80.94 (±8.87)

52,355,860

10,471,172 2,773

Others† (수두, B형

간염)

4 15,158 348 5,226,350

1,742,117 345

Total cost 68,384,030

13,676,806 3,538

직원 백신 접종 비용

대한병원감염관리학회 2007 Jan; 12(1): 50~57

Bacteria

ICU isolates Non-ICU isolates

No. (%) of

isolates

Rank order

No. (%) of isolates

Rank order

Staphylococcus aureus CNS Enterococcus faecalis E. faecium S. pneumoniae E. coli K. pneumoniae E. cloacae S. marcescens Non-typhoidal Salmonella P. aeruginosa Acinetobacter spp. S. maltophilia H. influenzae Total

5,393 (21) 3,199 (13) 1,195 (5) 1,767 (7) 275 (1)

1,539 (6) 2,550 (10)

664 (3) 522 (2) 12 (0)

2,673 (11) 4,712 (19)

796 (3) 56 (0) 25,353 (100)

1 3 8 6 12 7 5 10 11 14 4 2 9 13

14,330 (14) 13,112 (13) 8,283 (8) 5,413 (5) 1,971 (2)

26,799 (27) 10,104 (10) 2,883 (3) 1,498 (1) 433 (0)

8,662 (9) 4,365 (4) 1,765 (2) 606 (1)

100,224 (100)

2 3 6 7 10 1 4 9 12 14 5 8 11 13

Korean J Nosocomial Infect Control 2014;19(1):29-36

중환자실과 일반병동의 임상적으로 중요한 세균

Susceptibilities of major pathogens isolated from patients with nosocomial infections

Organism No. of resistant/total isolates (%)

Methicillin-resistant Staphylococcus aureus Vancomycin-resistant Enterococcus faecalis Vancomycin-resistant Enterococcus faecium Cefotaxime-resistant Escherichia coli Cefotaxime-resistant Klebsiella pneumoniae Ciprofloxacin-resistant Escherichia coli Ciprofloxacin-resistant Klebsiella pneumoniae Imipenem-resistant Pseudomonas aeruginosa Imipenem-resistant Acinetobacter baumannii

443/497 (89.1) 4/179 (2.2)

151/296 (51.0) 95/193 (49.2)

115/194 (59.3) 46/87 (52.9) 48/98 (49.0)

86/236 (36.4) 377/434 (86.9)


J Clin Invest. 2009 Sep 1; 119(9): 2464–2474.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2735934/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2735934/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2735934/

Antimicrobial agents

Resistance rate (%)

SAU 19,723*

CNS 16,311

EFA 9,478

EFM 7,180

SPN 2,246

Penicillin/ampicillin† 96 93 3 93 70

Gentamicin 47 41 - - -

Fluoroquinolone 51 41 29 92 7

Clindamycin 58 38 - - 59

Erythromycin 60 56 68 89 74

Oxacillin/cefoxitin 67 73 - - -

Cotrimoxazole 2 28 - - 55

Tetracycline 51 29 85 32 71

Teicoplanin 0 0 1 19 -

Vancomycin 0 0 1 23 -

중환자실 그람 양성 세균 항생제 내성


(KONSAR) program

Antimicrobial agents

Resistance rate (%)

ECO 28,338*

KPN 12,654

ECL 3,547

SMA 2,020

ACI 9,077

PAE 11,335

SMP 2,561

Ampicillin Ampicillin/Sulbactam Cephalothin Cefotaxime Ceftazidime Cefepime Aztreonam Cefoxitin Piperacillin Piperacillin/Tazobactam Imipenem Meropenem Amikacin Gentamicin Tobramycin Fluoroquinolone Cotrimoxazole Tetracycline Minocycline Colistin

68 34 32 21 18 18 19 7 65 6

0.1 0.0 1 27 12 36 37 42 - -

- 36 37 29 29 26 30 14 77 14 0.3 0.3 7 17 21 27 20 16 - -

- - -

33 31 8 29 -

38 24 0.2 0.2 3 12 16 8 20 12 - -

- - -

24 15 8 17 -

26 12 1 1 9 16 23 13 10 60 - -

- 55 -

70 66 66 80 -

66 63 63 63 49 66 57 70 62 40 3 2

- - - -

18 19 20 -

28 24 21 18 15 25 22 32 - - - 2

- - - -

40 - - - - - - - - - - 8 8 - 3 -

그람 음성 세균 항생제 내성


다제 내성균의 추이

KONSAR 1997-2011

Hospital charge, stay & death Anti Resistant and susceptible Healthcare associated Inf

Uncensored Models Models Censored for Death

Unadjusted Linear Matching Unadjusted Linear Matching

Total No. 3557 3557 2167 3557 3557 2167

Resistant infection 1240 1240 1083 1240 1240 1083

Unique controls

(sensitive infection)

2317 2317 692 2317 2317 692

Hospital charges, in

$1000s (95% CI)

70.6

(50.7–90.4)

8.2

(−.5 to 17.0)

15.6

(4.3–26.9)

100.9

(79.6–122.1)

15.2

(6.7–23.6)

18.99

(9.1–28.9)

R2 0.015 0.854 0.854 0.002 0.152 0.154

Length of hospital

stay, d (95% CI)

7.0

(5.0–9.0)a

1.1

(−.2 to 2.5)

1.6

(−.1 to 3.2)

10.4

(8.3–12.5)a

1.8

(.7–3.0)a

2.2

(.8–3.5)a

R2 0.015 0.727 0.735 0.003 0.166 0.166

Probability of death

(95% CI)

0.11

(.09–.14)a

0.05

(.02–.08)a

0.04

(.01–.08)b

… … …

R2 0.021 0.253 0.287 … … …

Clin Infect Dis. 2012 Sep 15; 55(6): 807–815.

Antimicrobial resistance was associated with higher charges, length of stay, and death rates

each hour of delayed appropriate therapy in the first six hours of infection was associated with an average decrease in survival of 7.6 percent

효과적인 항생제 투여 지연에 따른 사망 위험

Crit Care Med. 2006 Jun;34(6):1589-96.

http://www.ncbi.nlm.nih.gov/pubmed?term=16625125http://www.ncbi.nlm.nih.gov/pubmed?term=16625125http://www.ncbi.nlm.nih.gov/pubmed?term=16625125http://www.ncbi.nlm.nih.gov/pubmed?term=16625125

Device- associated infection rates (2011-2012)

Urinary catheter-associated UTI rate*

No. of hospital beds

No. of

units

No. of UTI

Urinary catheter-days

Pooled mean

95% CI 10‰ 25‰ 50‰ 75‰ 90‰

≥900 700-899 400-699

All

40 49 54 143

298 516 522

1,336

170,599 217,707 202,487 590,793

1.75 2.37 2.58 2.26

1.56-1.96 2.17-2.58 2.37-2.81 2.14-2.39

0 0 0 0

0 0

0.57 0

0.89 1.49 1.72 1.45

2.55 3.48 3.86 3.39

5.16 5.79 6.20 5.61

Central line-associated BSI rate†


No. of

units

No. of BSI

Central line-days

Pooled mean

95% CI 10‰ 25‰ 50‰ 75‰ 90‰

≥900 700-899 400-699

All

40 49 54 143

395 396 300

1,091

122,967 135,151 104,458 362,576

3.21 2.93 2.87 3.01

2.91-3.55 2.66-3.23 2.56-3.22 2.84-3.19

0 0 0 0

0 1.15 0 0

2.07 2.42 1.96 2.17

3.83 4.04 4.03 4.01

7.32 6.53 6.64 6.64

Ventilator-associated PNEU rate‡


No. of

units

No. of PNEU

Ventilatordays

Pooled mean

95% CI 10‰ 25‰ 50‰ 75‰ 90‰

≥900 700-899 400-699

All

40 49 54 143

129 175 177 481

93,359 102,007 87,106 282,472

1.38 1.72 2.03 1.70

1.16-1.64 1.48-1.99 1.75-2.35 1.56-1.86

0 0 0 0

0 0 0 0

0.70 0.81 0

0.59

2.41 2.64 3.45 2.87

4.70 5.74 7.19 5.96

• The incidence of hospital acquired infections (HAIs) in LTCFs is comparable to that in acute care hospitals and ranges from 1.8 to 13.5 infections per 1000 resident-days

• Infections contribute to 63 percent of deaths in LTCFs and are the primary reason for 25 to 50 percent of transfers to acute care hospitals

• Residents average at least one serious infection per year.

Infect Control Hosp Epidemiol. 2008 Sep;29(9):785-814.

요양병원과 의료관련 감염

Clin Infect Dis. 2013 Nov;57(9):1246-52

Rectal colonization with carbapenemase-producing Klebsiella pneumoniae was 30 percent higher than that seen among intensive care unit patients

요양병원과 항생제 내성

• LTCFs often lack adequate infection control programs and sufficient space for hand washing and isolation of patients.

• Additionally, approximately 25 to 75 percent of antibiotic use in LTCFs may be inappropriate, and this may contribute to the problem of antibiotic resistance.

Infect Control Hosp Epidemiol. 2000 Aug;21(8):537-45.

요양병원과 의료관련 감염 취약

Long Term Care Facilities

· High rates of infection - aging-associated changes - Interventions (medications, devices) - co-morbidities - Institutionalization · Intense antimicrobial use - appropriate - inappropriate · High prevalence of antimicrobial resistance

Multistate point-prevalence survey of health care-associated inf. 504 HAI, Surveys in 183 hospitals

Type of Infection Rank No. of

Infections

% of All

HAI

(95% CI)

Pneumonia†

Surgical-site infection

Gastrointestinal infection

Urinary tract infection‡

Primary bloodstream infection§ Eye, ear, nose, throat, or mouth

infection

Lower respiratory tract infection

Skin and soft-tissue infection

Cardiovascular system infection

Bone and joint infection

Central nervous system infection

Reproductive tract infection

Systemic infection

1 (tie)

1 (tie)

3

4

5

6

7

8

9

10

11

12

13

110

110

86

65

50

28

20

16

6

5

4

3

1

21.8 (18.4–25.6)

21.8 (18.4–25.6)

17.1 (14.0–20.5)

12.9 (10.2–16.0)

9.9 (7.5–12.8)

5.6 (3.8–7.8)

4.0 (2.5–6.0)

3.2 (1.9–5.0)

1.2 (0.5–2.5)

1.0 (0.4–2.2)

0.8 (0.3–1.9)

0.6 (0.2–1.6)

0.2 (0.01–1.0)

N Engl J Med. 2014 Mar 27;370(13):1198-208.

Reported Causative Pathogens, According to Type of Inf

Pathogen

All (N = 504) no. (%)

rank

Pneum (N = 110)

SSI (N = 110)

GI Inf (N = 86)

UTIs (N = 65)

BSI (N = 50)

C. difficile S. aureus K. peumoniae or K. oxytoca E. coli Enterococcus species‡ P.aeruginosa Candida species§ Streptococcus species¶ CoNS Enterobacter species A. baumannii P. mirabilis Yeast, unspecified S. maltophilia Citrobacter species Serratia species Bacteroides species Haemophilus species Viruses‖ Peptostreptococcus species Klebsiella species other than K. pneumoniae and K. oxytoca Clostridium species other than C. difficile Prevotella species M. morganii Lactobacillus species Other organisms**

61 (12.1) 54 (10.7) 50 (9.9) 47 (9.3) 44 (8.7) 36 (7.1) 32 (6.3) 25 (5.0) 24 (4.8) 16 (3.2) 8 (1.6) 8 (1.6) 8 (1.6) 8 (1.6) 6(1.2) 6 (1.2) 6 (1.2) 6 (1.2) 3 (0.6) 3 (0.6) 2 (0.4)

2 (0.4)

2 (0.4) 2 (0.4) 2 (0.4) 13 (2.6)

1 2 3 4 5 6 7 8 9 10

11, tie 11, tie 11, tie 11, tie 15, tie 15, tie 15, tie 15, tie 19, tie 19, tie 21, tie

21, tie

21, tie 21, tie 21, tie

—

0 18 (16.4) 13 (11.8) 3 (2.7) 2 (1.8)

14 (12.7) 4 (3.6) 7 (6.4)

0 3 (2.7) 4 (3.6) 1 (0.9) 3 (2.7) 6 (5.5) 2 (1.8) 2 (1.8)

0 2 (1.8) 1 (0.9)

0 1 (0.9)

0 0 0 0

1 (0.9)

0 17 (15.5) 15 (13.6) 14 (12.7) 16 (14.5) 7 (6.4) 3 (2.7) 8 (7.3) 7 (6.4) 5 (4.5) 2 (1.8) 5 (4.5)

0 0

1 (0.9) 0

5 (4.5) 2 (1.8)

0 2 (1.8)

0

2 (1.8)

1 (0.9) 1 (0.9)

0 6 (5.5)

61 (70.9) 1 (1.2) 1 (1.2) 1 (1.2) 5 (5.8) 1 (1.2) 3 (3.5) 2 (2.3)

0 0 0 0

1 (1.2) 0 0 0

1 (1.2) 0 0 0 0 0 0 0

1 (1.2) 0

0 2 (3.1)

15 (23.1) 18 (27.7) 11 (16.9) 7 (10.8) 3 (4.6) 2 (3.1) 1 (1.5) 2 (3.1)

0 1 (1.5) 4 (6.2) 2 (3.1) 1 (1.5) 2 (3.1)

0 0 0 0 0 0 0

1 (1.5) 0

1 (1.5)

0 7 (14.0) 4 (8.0) 5 (10.0) 6 (12.0) 2 (4.0)

11 (22.0) 2 (4.0) 9 (18.0) 2 (4.0)

0 0 0 0 0 0 0 0 0

1 (2.0) 1 (2.0)

0 0 0

1 (2.0) 3 (6.0)

N Engl J Med. 2014 Mar 27;370(13):1198-208.

C. difficile was identified in 13.1% of the samples, the proportion significantly increased over the study period from 5.9% in 2003 to 18.8% in 2012.

Journal of Infection (2014) 69, 447-455

호주 Queensland 10년간 Clostridium difficile infection

Journal of Infection (2014) 69, 447-455

CDI peaked in summer (14.6%) and was at its lowest in autumn (10.1%). CDI included female sex (OR: 1.08; 95%CI: 1.01~1.14), community source samples (OR: 1.12; 95%CI: 1.05~1.20), higher rainfall (OR: 1.09; 95%CI: 1.02~1.17) 9% increase in odds per 100 mm of monthly rainfall

호주 Queensland 10년간 Clostridium difficile infection

Discharge rate for Clostridium difficile infection from US short-stay hospitals by age

Clin Infect Dis. 2012 Aug 1; 55(Suppl 2): S65–S70.

Estimated U.S. Burden of Clostridium difficile

Infection (CDI), According to the

Location of Stool Collection

and Inpatient Health Care Exposure,

2011.

Of the estimated cases of community-

associated CDI,

82% were estimated to be associated with

outpatient health care exposure.

N Engl J Med. 2015 Feb 26;372(9):825-34.

CO-HCA : community onset health care–associated infection,

HO hospital onset,

NHO nursing home onset.


Adjusted U.S. National Estimates of Recurrences & Deaths Associated with CDI, (According to Epidemiologic Category, 2011

Characteristic

Estimated Recurrences Recurrence Rate Estimated Deaths Death Rate

CA CDI HCA CDI CA CDI HCA CDI CA CDI HCA CDI CA CDI HCA CDI

no. (95% CI)

no. per 100,000 persons (95% CI)

no. (95% CI) no. per 100,000 persons (95% CI)

All cases Sex

Male

Female Age group

1–17 yr 18–44 yr 45–64 yr ≥65 yr

21,600 (16,900–26,300)

7800

(5100–10,500) 13,800

(9900–17,600) 1400

(900–1900) 2600

(1300–3900) 6200

(4000–8300) 11,400

(7400–15,400)

61,400 (40,200–82,600)

27,300

(12,800–41,800) 34,000

(18,700–49,400)

300 (100–500)

3400 (1000–5700)

9000 (4400–13,700)

48,700 (28,100–69,200)

7.0 (5.5–8.6)

5.2

(3.4–6.9) 8.8

(6.3–11.3)

2.0 (1.3–2.7)

2.3 (1.1–3.4)

7.5 (4.8–10.0)

27.5 (17.9–37.2)

19.9 (13.0–26.9)

18.0

(8.5–27.6)

0.4 (0.1–0.7)

3.0 (0.9–5.0)

10.9 (5.3–16.6)

117.6 (67.9–167.2)

2000 (1200–2800)

900

(450–1350) 21.7

(12.0–31.6)

NA

50 (0–120)

420 (120–720)

1500 (750–2200)

27,300 (15,300–39,300)

12,300

(3800–20,700) 1100

(400–1700)

NA

NA

4500 (1020–8000)

22,800 (11,300–34,200)

0.7 (0.4–0.9)

0.6

(0.3–0.9) 0.7

(0.3–1.1)

NA

The C. difficile “Iceberg”

Courtesy L. Clifford McDonald (note: color changed from orininal

Prevalence of Asymptomatic Carriage is overwhelming

• Loo VG et al.: 4.4% asymptomatic carriers, ~1.8% CDIs

• Eyre DW et al.: 11% (~5% on admission?)

• Leekha S et al.: 9.7% on admission

• Alasmari F et al.: 15% on admission

• Riggs MM et al.: 51% cross-section nursing home

• Marciniak Cet al.: 16% on admission to rehab

• Dumford DM etal.: 50% cross-section spinal cord ward

Loo VG, et al. N Engl J med 2011;365:1693-703. Eyre DW, et al. Plos ONE 8(11):378445 Leekha S et al. A J of Infect Concl 41 92013) 390-3 AlasmariF et al. Clin Infect Dis 2014:59(2):216-22 RiggsMM et al. clin Infect Dis 2007;45:992-8 Marciniak et al. Arch Phys Med Rehabil 2006; 87;2086-9 Dumford DM et al. J Spinal cord Med 2011;34(1):22-7

Acquisition of C. difficile

Johson.CID.1998

• Health adults in community - ~3% - Stable over time

• Risk of acquiring directly proportional to length of stay - Median time to acquistion

~2weeks - 13-50% of all patients in

healthcare facilities carry C. difficile

Incubation Period from Acquisition to CDI appears Short

Study Culture frequency

Number CDI cases

Time from acquisition to CDI

Mcfarland 3 days 31 Median onset 2 days

Johnson 7 days 7

Residual C. difficile Stool Culture Positivity

Following CDI Treatment

Al-Nassir et al, Clinical Infectious Diseases 2008;47:56-62

Diarrhea Resolution

Culture Resolution Positive Stool Cultures EOT

Quantitation of C. difficile Stool Cultures During And After RX

Sethi et al, Infect Control Hosp Epidemiol 2010;31:21-27

Limit of culture Detection

Transmission from CDIs Cases: Room for Improvement

Sethi AJ. ICHE 2010;31:21-7

0

20

40

60

80

100

Prior to

treatment

Resolution

of diarrhea

End of

treatment

1-2 weeks

after

tretment

5-6 weeks

after

treatment

Stool

Skin

environment

Delays in Diagnosis

Mean days from diarrhea onset to

- Order: 1.4 days

- Result: 3.2 days

Kundrapu. J Clin Microbiol. 2013 Jul; 51(7): 2365–2370.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3697705/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3697705/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3697705/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3697705/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3697705/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3697705/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3697705/

Eyre DW et al Clin Infect Dis 2012;55(S2):S77-87

First Recurrence of Clostridium difficile Infection Occurs Rapidly at a Peak Incidence of 10 days After End of Therapy for CDI

77% of recurrences were caused by the same ST type of C. dificile

(defined as a relapse)

Relapse vs. Reinfection in CDI Treated with Vancomycin of Fidaxomicin

83.3% Same Strain (Relapse) Relapse 12.2 (±6.4) Days Reinfection (new strain) 14.7 (±6.8) days (P=.177)

Figueroa et al Clin Infect Dis 2012;55(S2):S104-9

CDI Recommendation: Wear Gloves When Handling Stool

Johnson S, et al. Am J Med. 1990;88:137-140.

• Four wards randomized • Intervention

- Education: gloves when handling body substances (stool) - Gloves placed bedside

• Reduction in CDI on glove wards - Also colonization

0

2

4

6

8

10

12

Pre-intervention Post-intervention

Glove wards

Control wards

Intervention Period

C. difficile Spores More Formidable Than MRSA

Improving MRSA rates, was this wrought via.. • Vertical measures: detection of carriers and barrier

precautions

• Horizontal measures: hand hygiene, universal decolonization

• Both?

• Neither?

Problem: C. difficle is transmitted via spores • No highly cost-effective universal hand hygiene option

• Such as alcohol-based hand sanitizer against MRSA

• No highly cost-effective universal decolonization option

• Such as chlorhexidine and mupirocin

Work to Reduce Susceptibilty of the population while

Continuing Infection control

Preserve and/ or restore the intestinal microbiome • Antibiotic stewardship-especially fluoroquinolones,

cephalosporins in favor of extended penicillins

• Reduce selection for hypervirulent, floroquinolone-resistant stains

• Penicillins have activity against clostridia

• Consider PPI stewardship or at least drug utilization review?

• Epidemiologic data suggest risk greatest in less antibiotic exposed

Improve immunity to toxins in population • Vaccine development

• Understand impact of colonization during infancy on long term immunity

Study design chart indicating chlorhexidine gluconate (CHG) bathing periods

Note. Cohort 1, critical care units; cohort 2, general adult and pediatric units in Bed Tower A; cohort 3, adult medical and surgical specialty units in Bed Tower B;

CHG bathing

Study period Dates Cohort 1 Cohort 2 Cohort 3

1 2 3 4 5 6 7 8 8

Baseline 1 (January-March 2008) Baseline 2 (April-June 2008) Baseline 3 (July-September 2008); Baseline 4 (October 2008-January 2009) February-April 2009 May-July 2009 August-October 2009 November 2009-January 2010 February-April 2010 May-June 2010 July-august 2010 September-December 2010

None (Baseline) M/W/F M/W/F Daily Daily Daily Daily Daily None (washout)

None (Baseline) None M/W/F M/W/F Daily Daily Daily Daily None (washout)

None (Baseline) None None M/W/F M/W/F Daily Daily Daily None (washout)

Infect Control Hosp Epidemiol. 2012 Mar;33(11):1094

http://www.ncbi.nlm.nih.gov/pubmed/?term=infection+control+hospital+epidemiology+chlorohexidine+for+reducing+Healthcare+associated+BSI++metahttp://www.ncbi.nlm.nih.gov/pubmed/?term=infection+control+hospital+epidemiology+chlorohexidine+for+reducing+Healthcare+associated+BSI++metahttp://www.ncbi.nlm.nih.gov/pubmed/?term=infection+control+hospital+epidemiology+chlorohexidine+for+reducing+Healthcare+associated+BSI++metahttp://www.ncbi.nlm.nih.gov/pubmed/?term=infection+control+hospital+epidemiology+chlorohexidine+for+reducing+Healthcare+associated+BSI++metahttp://www.ncbi.nlm.nih.gov/pubmed/?term=infection+control+hospital+epidemiology+chlorohexidine+for+reducing+Healthcare+associated+BSI++meta

Infect Control Hosp Epidemiol. 2012 Mar;33(11):1094

Hospital wide CHG bathing on healthcare associated infections


Effect of Chlorhexidine gluconate Bathing on Healthcare-Associated Infections

Note. M/W/F, Monday/Wednesday/Friday; CHG, chlorhexidine gluconate; CI, confidence interval. aComparison of washout period and daily CHG bathing period.

Infection type, patient cohort

M/W/F CHG bathing Daily CHG bathig Washout perioda

Risk tario (95% CI) p Risk tario (95% CI) p Risk tario (95% CI) p

Vancomycin-resistant enterococci Cohort 1 Cohort 2 Cohort 3

0.62 (0.45-086) 0.77 (0.53-1.19) 0.64 (0.39-1.04)

.004 .24 .073

0.05 (0.33-0.76) 0.49 (0.20-1.21) 0.64 (0.47-0.87)

.001 .12 .004

0.81 (0.30-2.23) 0.97 (0.52-1.80) 0.75 (0.37-1.51)

.92 .92 .42

Methicillin-resistant Staphylococcus aureus Cohort 1 Cohort 2 Cohort 3

1.25 (0.64-2.45) 1.66(1.26-2.19) 0.95 (0.65-1.38)

.51 .001 .79

0.76 (0.52-1.10) 1.42 (1.01-1.98) 0.92 (0.57-1.48)

.15 .041 .72

1.82 (1.43-2.36) 0.20 (0.07-0.52) 0.69 (0.40-1.20)

Healthcare associated BSI with CHG bathing and comparator

Infect Control Hosp Epidemiol. 2012 Mar;33(3):257-67


Should space suit and laminar air flow be standard in operating rooms for orthopedic surgery?

Hooper GJ et al. JBJS (Br)

2011;93-B:85-90

Deep SSl after total hip replacement

Hooper GJ et al. JBJS(Br)2011;93-B:85-90

New Zealand Joint

Registry at ten years.

Of the 51,485 primary

THRs and 36,826 primary

TKRs analysed,

Deep SSl rate after total knee replacement

Hooper GJ et al. JBJS(Br)2011;93-B:85-90

Total Hip Arthroplasty: SSI rate decreases with higher procedure volumme

Total Hip Arthroplasty

Procedures Per Year (Medicare)

# Hospitals (%)

# Procedures (Mean Per Hospital)

Coded SSI Rate

Adjusted OR (95% CI)

1-24 827 (27%) 9,434, (11) 2.9% 1.5 (1.3-17)

25-49 621 (21%) 22,416 (36) 2.4% 1.3 (1.1-1.4)

50-99 734 (24%) 53-194 (72) 2.3% 1.2 (1.1-1.3)

100+ 845 (28%) 157,588 (186) 1.9% Ref

Higher SSI risk in US hospital performing < 100 total hip arthroplasty procedures per year on Medicare patients

M Calderwood ID week 2014: #915

Quarterly broad-spectrum antibiotic use in surgical ICU

Surg Infect (Larchmt). 2011 Feb;12(1):15-25

http://www.ncbi.nlm.nih.gov/pubmed?term=21091186http://www.ncbi.nlm.nih.gov/pubmed?term=21091186http://www.ncbi.nlm.nih.gov/pubmed?term=21091186http://www.ncbi.nlm.nih.gov/pubmed?term=21091186http://www.ncbi.nlm.nih.gov/pubmed?term=21091186

Antibiotic Rotation Protocol for Surgical Intensive Care Unit

Pneumonia (hospital day 1–4)

Pneumonia (hospital day 5)

Non-pneumonia Excluded

1st Q 2nd Q 3rd Q 4th Q

Ertapenem

Ceftriaxone

Levofloxacin

Pip/taz

Tobramycin Levofloxacin Tobramycin Imipenem Amikacin Cefepime Amikacin Pip/taz

Cefepime Metronidazole

Pip/taz

Levofloxacin Metronidazole

Imipenem

BLIC

FQ

CARB

3/4CEPH

aEmpiric vancomycin is used for all categories to cover resistant gram-positive pathogens. BLIC¼beta-lactam/beta-lactmase inhibitor combinations; FQ¼fluoroquinolones; CARB¼carbepenams; 3/4CEPH¼3rd- and 4th-generation cephalosporins.


The goal of this rotation was to direct quarterly antibiotic class heterogeneity in an effort to avoid resistance-selective pressures


Percentage of pan-sensitive and multi-drug-resistant pathogens isolated in SICU


The proportion of healthcare-acquired infections caused by MDR gram-negative pathogens decreased from 37.4% (2001) to 8.5% (2008), whereas the proportion of healthcare-acquired infections caused by pan-sensitive pathogens increased from 34.1% to 53.2%.


• During 2006, Israeli hospitals faced a clonal outbreak of carbapenem-resistant Klebsiella pneumoniae that was not controlled by local measures.

• In a national outbreak of carbapenem-resistant Enterobacteriaceae in Israel, the outbreak was contained only after implementation of regulations that mandated that hospitals assign a dedicated unit with dedicated staff at each facility in the country to the care of patients with these infections

• The task force paid site visits at acute-care hospitals, evaluated infection-control policies and laboratory methods, supervised adherence to the guidelines via daily census reports on carriers and their conditions of isolation, provided daily feedback on performance to hospital directors

전담 staff 의 중요성

Clin Infect Dis. 2011 Apr 1;52(7):848-55.

http://www.ncbi.nlm.nih.gov/pubmed?term=21317398

Containment of a Country-wide Outbreak of Carbapenem-Resistant Klebsiella pneumoniae in Israeli Hospitals via a Nationally Implemented Intervention


For each 10% increase in compliance, there was a 2%reduction in the association between prevalence and incidence (P = .03).


Containment of a Country-wide Outbreak of Carbapenem-Resistant Klebsiella pneumoniae in Israeli Hospitals via a Nationally Implemented Intervention


Variable Effect estimate

95% CI P

CRE carrier prevalence 0.43 0.36–0.50

Group 1: implemented MRSA screening and isolation Group 2: targeted decolonization (i.e., screening, isolation, and decolonization of MRSA carriers) : 5d mupirocin+chlohexidine Group 3: universal decolonization (i.e., no screening, and decolonization of all patients). Active surveillance cultures, or screening patients for asymptomatic colonization with resistant organisms,

Targeted versus Universal Decolonization

Targeted versus Universal Decolonization to

Prevent ICU Infection

• A total of 43 hospitals (including 74 ICUs and 74,256 patients during the intervention

• period) underwent randomization

• The decolonization regimen consisted of daily bathing with 2 percent chlorhexidine-impregnated cloths and twice-daily intranasal mupirocin.

• The cost was approximately $40 per patient.(decolonization)

N Engl J Med. 2013 Jun 13;368(24):2255-65

http://www.uptodate.com/contents/mupirocin-drug-information?source=see_linkhttp://www.ncbi.nlm.nih.gov/pubmed?term=23718152http://www.ncbi.nlm.nih.gov/pubmed?term=23718152http://www.ncbi.nlm.nih.gov/pubmed?term=23718152http://www.ncbi.nlm.nih.gov/pubmed?term=23718152http://www.ncbi.nlm.nih.gov/pubmed?term=23718152

N Engl J Med. 2013 Jun 13;368(24):2255-65


N Engl J Med. 2013 Jun 13;368(24):2255-65

MRSA Blood stream Infection


Blood stream Infection from Any Pathogen

N Engl J Med. 2013 Jun 13;368(24):2255-65


New methods to clean ICU rooms.

Infect Disord Drug Targets. 2011 Aug;11(4):365-75.


UV-C line of sight

Total Direct Indirect

Organism

Inoculum

log10

No. of

samp

Decontam, reduction, Log mean (95% CI)

No. of

samp

Decontam reduction, mean (95%

CI)

No. of

samp

Decontamireduction, mean (95%

CI)

P

MRSA

VRE

A.baumannii

C. difficile spores

4.88

4.40

4.64

4.12 l

50

47

47

45

3.94 (2.54–5.34)

3.46 (2.16–4.81)

3.88 (2.59–5.16)

2.79 (1.20–4.37)

10

15

10

10

4.31 (3.13–5.50)

3.90 (2.99–4.81)

4.21 (3.27–5.15)

4.04 (3.71–4.37)

40

32

37

35

3.85 (2.44–5.25)

3.25 (1.97–4.62)

3.79 (2.47–5.10)

2.43 (1.46–3.40)

.06

.003

.07

UV-C Decontamination for MRSA (15 min)

Site

Total CFUs per site, mean

MRSA-positive plates/total

Before UV-C

After UV-C

Before UV-C

After UV-C

Sink (n = 8) Toilet seat (n = 6) Tray table (n = 8) Bedside rail (n = 7) Chair arm (n = 12) Bathroom floor, in front of toilet (n = 6) Floor near bed (n = 8) Monitor (n = 4) Medical cart (n = 7) Laundry bin top (n = 5) Sink counter (n p 1) Chair seat (n p 1) Blood pressure machine (n p 1) Bedside dresser (n p 4) Floor at foot of bed (n p 1) Floor at sink (n p 1) Total

134 559 171 497 276 940 967 24 351 442 12 95 111 176 668 729 384

11 9 4 16 11 53 76 2 9 8 1 2 8 5 14 82 19

7/40 1/30 1/40 7/35 12/60 16/30 23/40 0/20 5/35 1/25 0/5 1/5 1/5 1/20 4/5 1/5

81/400

0/40 0/30 0/40 0/35 0/60 1/30 1/40 0/20 0/35 0/25 0/5 0/5 0/5 0/20 0/5 0/5

2/400

Infect Control Hosp Epidemiol. 2010 Oct;31(10):1025-9.

http://www.ncbi.nlm.nih.gov/pubmed/20804377http://www.ncbi.nlm.nih.gov/pubmed/20804377http://www.ncbi.nlm.nih.gov/pubmed/20804377http://www.ncbi.nlm.nih.gov/pubmed/20804377http://www.ncbi.nlm.nih.gov/pubmed/20804377

Hydrogen Peroxide Vapor

New methods to clean ICU rooms

Barbut [45]

Shapey [44]

Boyce [41]

Sterinis Sterinis Bioquell

% of Environmental Samples Positive for C. difficile

Before TC and HPV/HPM 21% 24% 25.6%

After TC and HPV/HPM 2% 3% 0%

Reduction of environment contamination 91% 87% 100%

% of Rooms Positive for C. difficile

Before TC and HPV/HPM 74% 100%

After TC and HPV/HPM 18% 50%

Reduction of environment contamination 75% 50%

TC: Terminal Cleaning: HPV: Hydrogen Peroxide Vapor; HPM: Hydrogen Peroxide Mist

Infect Disord Drug Targets. 2011 Aug;11(4):365-75.

http://www.ncbi.nlm.nih.gov/pubmed/?term=New+methods+to+clean+ICU+roomshttp://www.ncbi.nlm.nih.gov/pubmed/?term=New+methods+to+clean+ICU+roomshttp://www.ncbi.nlm.nih.gov/pubmed/?term=New+methods+to+clean+ICU+roomshttp://www.ncbi.nlm.nih.gov/pubmed/?term=New+methods+to+clean+ICU+rooms

경청해 주셔서 감사합니다

Use of disinfectants to reduce microbial contamination of hubs of vascular catheters.

Clin Microbiol. 1993 Mar;31(3):475-9.

• Among patients with CVCs, transparent dressings were associated with a significant increase in the relative risk (RR) of catheter tip infection (RR 1.78, 95% CI 1.30-2.30) and a nonsignificant increase in catheter-related bacteremia (RR 1.63, 95% CI 0.76-3.47).

Infection Risks of Transparent vs Gauze Dressings Used on Central Venous Catheters

Statistical Test Catheter-Tip

Infection Bacteremia

Catheter Sepsis

Sample size Cases 712 454 937

Controls 506 222 647

Relative risk 1.78 1.63 1.69

95% confidence interval 1.38-2.30 0.76-3.47 0.97-2.95

P

Infect Control Hosp Epidemiol. 2010 Aug;31(8):870-2

손소독시 청진기도 알코올과 함께 소독

http://www.ncbi.nlm.nih.gov/pubmed?term=Infect Control Hosp Epidemiol. 2010 Aug;31(8):870-2http://www.ncbi.nlm.nih.gov/pubmed?term=Infect Control Hosp Epidemiol. 2010 Aug;31(8):870-2http://www.ncbi.nlm.nih.gov/pubmed?term=Infect Control Hosp Epidemiol. 2010 Aug;31(8):870-2

알코올 vs 비누 (handrubbing with alcohol vs handwashing with antiseptic soap)

BMJ. 2002 Aug 17;325(7360):362.

Bacterial counts (colony forming units) Difference between two groups significant (P=0.012)

http://www.ncbi.nlm.nih.gov/pubmed/12183307

클로르헥시딘 vs.포비돈-요오드 (vascular catheter site care)

ChaiyakynaprukN, et al. Ann Intern Med 2002;136:792

http://www.ncbi.nlm.nih.gov/pubmed?term=ChaiyakynaprukN, et al. Ann Intern Med 2002;136:792

소독제의 효과 비교

Maki DC, et al. Lancet 1991;338:339-43

Synergy of influenza vaccine + pneumococcal vaccine

• 1,898, old aged with chronic lung disease (1993-1996)

Nichol KL Vaccine S91-93, 1999

J Epidemiol Community Health. 2009 Nov;63(11):906-11

Cost & QALYs Combined vaccination & influenza vaccination >no vaccination (p influenza vaccination alone (p = 0.030) The total cost combined vaccination was significantly lower (p = 0.011) than that of influenza vaccination.

Cost-effectiveness of influenza & pneumococcal vaccination for elderly in LTCF

http://www.ncbi.nlm.nih.gov/pubmed/19608558

• The three most important vaccines for elderly residents of these facilities

Influenza vaccine,

Pneumococcal vaccine

Tetanus-diphtheria toxoids

• zoster vaccine

Ann Intern Med. 1983 Mar;98(3):395-400

Barrier integrity of gloves

Rego A, et al. Am J Infect Control 1999;27:405

0-4% 1-3%

12-61%

http://www.ncbi.nlm.nih.gov/pubmed?term=Rego A, et al. Am J Infect Control 1999;27:405

Infect Control Hosp Epidemiol. 2010 Oct;31(10):1025-9


Ann Intern Med. 2006 Oct 17;145(8):582-91.


• DB-RCT HD-IIV3-HD vs SD-IIV3

• North America 126 centers

• Aged 65 yrs & older

• Chronic illnesses; ≥1 (67%), ≥2 (34%)

• No mod-severe illnesss

• Two influenza seasons

• 2011-2012

• A/Califomia/7/2009 (H1N1)

• A/Victoria/210/2009 (H3N2)

• B/Brisbane/60/2008

• 2012-2013

• A/Califomia/7/2009 (H1N1)

• A/Victoria/361/2011 (H3N2)

• B/Texas/6/2011

Diaz Granados CA et al. N Engl J Med 2014;371:635-345.

Efficacy of high-dose versus standard-dose

influenza vaccine in older adults.

Surveillance

• Called Jan-Feb (2x wk) mar-Apr30th (1x wk)

• Respiratory Illness (one of the following)

• Sneezing, nasal congestion, rhinorrhea, sore throat, cough,

sputum, wheezing SOB

• Protocol-Derived ILI Definition

• Respiratory illness and one of the following:

• T≥37.2°C, chills, fatigue, HA, or myalgias

• Modified CDC ILI Definition (T > 37.2°C)

• Complications of Influenza by 30 days

• Safety data

Vaccine Strains influenza: Efficacy HD-IIV3 vs SD-IIV3

Al Flu Flu A H1N1 H3N2 Flu B

Protocol ILI 35.4 31.7 12.5 33.8 45.2

CDC ILI 49 41.7 0.00 44.1 66.7

Resp III 27.4 18.8 -33.40 23.9 46.7

Residential Proximity to Large Numbers of Swine in

Feeding Operation Is Associated with Increased Risk of

Methicillin-Resistant Staphylococcus aureus Colonization

at Time of Hospital Admission in Rural Iowa Veterans

A shared population of epidemic MRSA 15 circulates in humans

and companion animals.

• MRSA carriage common in companion animals

• Dogs (0.7-20%), cats (0-4%), horses

• Associated with ATB pressure

• Clinic LOS

• Surgical implants

• Contact human MRSA carriers

• Animal & human dominant ligeages similar geographically

• Bidirectional spread livestock to humans

• Do humans and pets share MRSA?

Harrison EM et al mBio 2014;5:e00985-13

Phylogenetic relationships between human and companion animal isolates.

Harrison E M et al. mBio 2014; do:10.1128mBio.00985-13

Significance

• Successful S. aureus strains

- Broad host range

- ST22, ST130, CC398, ST8 (USA 300)

• Hospital strains ⇒ vet clinics ⇒ transmission (reservoir)

• Need paired human-pet studies

• Generalizability other strains, geography

• A total of 15,461 cases of C. difficile infection were identified in the 10 geographic areas; 65.8% were health care–associated, but only 24.2% had onset during hospitalization. After adjustment for predictors of disease incidence, the estimated number of incident C. difficile infections in the United States was 453,000 (95% confidence interval [CI], 397,100 to 508,500). The incidence was estimated to be higher among females (rate ratio, 1.26; 95% CI, 1.25 to 1.27), whites (rate ratio, 1.72; 95% CI, 1.56 to 2.0), and persons 65 years of age or older (rate ratio, 8.65; 95% CI, 8.16 to 9.31). The estimated number of first recurrences of C. difficile infection was 83,000 (95% CI, 57,000 to 108,900), and the estimated number of deaths was 29,300 (95% CI, 16,500 to 42,100). The North American pulsed-field gel electrophoresis type 1 (NAP1) strain was more prevalent among health care–associated infections than among community-associated infections (30.7% vs. 18.8%, P

Treatment strategies for 163 Cases of recurrent C. difficile

Infection that were Controls in S. boulardii Trials

McFarland et al. Am J Gastroenterol 2002;97:1769-1775

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9

1 g/d N=1

2 g/d N=21 N=29

Taper

Vancomycin Treatment Group Metronidazole (Various doses)

5 g/d N=48

N=7 Pulse

* P

Transmission from CDI cases: Room for Improvement

Contact precaution compliance

• Curry:

- Some transmission from patients already in contact precautions

Stevens:

- Compliance with gloves 52% and 63%

Keep your eye on the ball:

Contact precautions!

• Hand hyhiene: gloves are more important

• Medical equipment

• Environment important, but do not let it be an excuse

- Contact precautions are more important

Curry. Clin Infect Dis. 2013 Oct;57(8):1094-102; Stevens ID week 2014

http://www.ncbi.nlm.nih.gov/pubmed/?term=Curry.+CID.+2013http://www.ncbi.nlm.nih.gov/pubmed/?term=Curry.+CID.+2013http://www.ncbi.nlm.nih.gov/pubmed/?term=Curry.+CID.+2013

Estimated Numbers of Major Types of Health Care–Associated

Infection in the United States in 2011.

Type of Infection

Infections Identified in Survey

Surveyed Pts w Type of

Infection

Estimated Infections in the United States*

no. % (95% CI) no. (95% CI)

All health care–associated infections Pneumonia Surgical-site infection Gastrointestinal infection Urinary tract infection Primary bloodstream infection Eye, ear, nose, throat, or mouth infection Lower respiratory tract infection Skin and soft-tissue infection Cardiovascular system infection Bone and joint infection Central nervous system infection Reproductive tract infection Systemic infection

Total Infections in non-neonatal intensive care units

Catheter-associated urinary tract infection Central-catheter–associated primary bloodstream infection

Ventilator-associated pneumonia Surgical-site infections attributed to Surgical Care

Improvement

Project procedures§ Hospital-onset infections caused by specific pathogens

Clostridium difficile infection.

MRSA bacteremia‖

110 110† 86 65 50 28‡ 20 16 6 5 4 3 1

25 11

35 46

56

7

24.3 (20.6–28.5) 24.3 (20.6–28.5) 19.0 (15.6–22.8) 14.4 (11.4–17.9) 11.1 (8.4–14.2) 6.2 (4.2–8.7) 4.4 (2.8–6.6) 3.5 (2.1–5.6) 1.3 (0.5–2.7) 1.1 (0.4–2.4) 0.9 (0.3–2.1) 0.7 (0.2–1.8) 0.2 (0.01–1.1)

5.52.4 (1.3–4.2) (3.7–7.9)

7.7 (5.5–10.5) 10.2 (7.6–13.2)

12.4 (9.6–15.7) 1.5 (0.7–3.0)

157,500 (50,800–281,400) 157,500 (50,800–281,400) 123,100 (38,400–225,100) 93,300 (28,100–176,700) 71,900 (20,700–140,200) 40,200 (10,400–85,900) 28,500 (6900–65,200) 22,700 (5200–55,300) 8,400 (1200–26,700) 7,100 (1000–23,700) 5,800 (700–20,700) 4,500 (500–17,800) 1,300 (0–10,900)

721,800 (214,700–1,411,000)

35,600 (9100–78,000) 15,600 (3200–41,500)

49,900 (13,600–103,700) 66,100 (18,700–130,300)

80,400 (23,700–155,000)

9,700 (1700–29,600)

Targeted VS. Universal decolonization for ICU Infection

N Engl J Med. 2013 Jun 13;368(24):2255-65


Antibiotic use in LTCF

· high prevalence/incidence

· wide variability across facilities

· substantial inappropriate use(40-70%)

· prophylaxis

· indications?

· potential negative outcomes:

· antimicrobial resistance

· C. difficile colitis

· adverse effects(Loeb, 2001; 6% resp or UTI, 4% skin)

· cost

의료관련 감염관리 원론 · 2015. 5. 30. · •sep 15, 2014 a doctor working in em was...

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