rome-escmidcourse dec2011 basic hygiene & contact … · basic hygiene measures upci university...
TRANSCRIPT
Prof. Stephan Harbarth
ESCMID/WHO course, Rome Dec 2011 1
Screening, masks and isolation precautions: when
and for what microorganisms?
Stephan Harbarth, MD, MS,
Infection Control ProgrammeUniversity of Geneva Hospitals,
Switzerland
UPCI
University of Geneva Hospitals2
•Did you ever save the life of a patient?
•Do you still know his/her name?
Prologue (1)Prologue (1)Prologue (1)Prologue (1)
UPCI
University of Geneva Hospitals3
Contrary to curative, especially heroic medicine, in infection prevention the "saved patient " remains anonymous.
Prologue (2)Prologue (2)Prologue (2)Prologue (2)
Courtesy: Y. Carmeli UPCI
University of Geneva Hospitals4
UPCI
University of Geneva Hospitals5
TRANSMISSION
Nosocomialflora
Transmission of nosocomial infections
contact
UPCI
University of Geneva Hospitals6
The 3 major routes of transmission of infectious pa thogens
Contact Direct transfer of microorganisms
Physical contact;person-to-personor contaminated environment-to-person
Staphylococcus aureusGroup A StreptococciClostridium difficileMultidrug-resistantmicroorganisms (ESBL, MRSA, VRE etc)
Route Infectious unit Principle Examples of transmitt ed pathogens
Prof. Stephan Harbarth
ESCMID/WHO course, Rome Dec 2011 2
UPCI
University of Geneva Hospitals7
TRANSMISSION
Host defenses
Nosocomialflora
droplet
Transmission of nosocomial infections
UPCI
University of Geneva Hospitals8
The 3 major routes of transmission of infectious pa thogens
Contact Direct transfer of microorganisms
Physical contact;person-to-personor contaminated environment-to-person
Staphylococcus aureusGroup A StreptococciClostridium difficileMultidrug-resistantmicroorganisms (ESBL, MRSA, VRE etc)
Droplet Respiratorydroplets> 5 µm
Droplets are deposited on mucous membranes;close contact <1m for transmission
Neisseria meningitidisInfluenza virus
Route Infectious unit Principle Examples of transmitt ed pathogens
UPCI
University of Geneva Hospitals9
TRANSMISSION
Host defenses
Nosocomialflora
airborne
Mycobacteriumtuberculosis
Transmission of nosocomial infections
UPCI
University of Geneva Hospitals10
The 3 major routes of transmission of infectious pa thogens
Contact Direct transfer of microorganisms
Physical contact;person-to-personor contaminated environment-to-person
Staphylococcus aureusGroup A StreptococciClostridium difficileMultidrug-resistantmicroorganisms (ESBL, MRSA, VRE etc)
Droplet Respiratorydroplets> 5 µm
Droplets are deposited on mucous membranes;close contact <1m for transmission
Neisseria meningitidisInfluenza virus
Route Infectious unit Principle Examples of transmitt ed pathogens
Airborne Droplet nuclei < 5 µm or contaminated dust particles
Inhalation of droplet nuclei; remain suspended in the air for long periods; migrate long distances
Mycobacterium tuberculosisVaricella zoster virus
UPCI
University of Geneva Hospitals11
common vehicle
TRANSMISSION
Host defenses
Nosocomialflora
Transmission of nosocomial infections
UPCI
University of Geneva Hospitals12
Strategies for infection control
Specific measuresSpecifically targeted against VAPSpecifically targeted against SSISpecifically targeted against BSI
Antibiotic controlRestriction of use, guidelines, rotation
Prof. Stephan Harbarth
ESCMID/WHO course, Rome Dec 2011 3
UPCI
University of Geneva Hospitals13
Number of recommendations by category- Category 1A: 31 - Category 1B: 31 - Category 1C: 4 - Category 2: 28- Unresolved issues: 4
Evidence-based practice to reduce CVC-related infec tions
2009 CDC guideline draft for prevention of CVC-related BSI
UPCI
University of Geneva Hospitals14
Strategies for infection control
General measuresStandard precautionsHand hygieneIsolation precautionsSurveillance of infections
Specific measuresSpecifically targeted against VAPSpecifically targeted against BSI
Antibiotic controlRestriction of use, guidelines, rotation
UPCI
University of Geneva Hospitals15
Basic hygiene measures
Standard precautionsDaily work
UPCI
University of Geneva Hospitals16
Standard precautions – BASIC MEASURES
* Adapted from HICPAC guidelines. http://www.cdc.gov/ncidod/hip/isolat/isolat.htm
Hand hygieneAfter contact with blood, body fluids, secretions, excretions, contaminated items Immediately before gloving and after removing gloves Between patient contacts – Between dirty and clean body site care
Gloves For anticipated contact with blood, body fluids, secretions, excretions, contaminated items For anticipated contact with mucous membranes, non-intact skin
Mask, eye protection, face shield
To protect mucous membranes of the eyes, nose and mouth during procedures and patient-care activities likely to generate splashes or spray of blood, body fluids, secretions and excretions
Gowns To protect skin and prevent soiling of clothing during procedures and patient-care activities likely to generate splashes or spray of blood, body fluids, secretions and excretions
Patient-care equipment handling
To ensure that skin, mucous-membranes and cloths are not exposed to equipment soiled with any body fluids To ensure that reusable equipment is not reused until it has been appropriately reprocessed To ensure that single-use items are discarded properly
Component Field of application
Sharp object handling Avoid recapping used needles Place used sharp objects and needles in puncture-resistant containers
UPCI
University of Geneva Hospitals17
UPCI
University of Geneva Hospitals18
Prof. Stephan Harbarth
ESCMID/WHO course, Rome Dec 2011 4
UPCI
University of Geneva Hospitals19
DROPLET
Transmission-basedprecautions
exceptions
Standard precautionsdaily work
Influenza
tuberculosis ESBL
Basic hygiene measures
UPCI
University of Geneva Hospitals20
TransmissionTransmission--based precautionsbased precautionsCONTACTCONTACT
single roomor cohorting
gowngloves
UPCI
University of Geneva Hospitals21
Efficacy repeatedly reported
Vancomycin-resistant enterococciKauffman CA JAC 2003; 51:S23-30 (review)
Methicillin-resistant Staphylococcus aureusMuto CA et al. ICHE 2003;24:362-86 (review)
Severe Acute Respiratory SyndromeSeto WH et al. Lancet 2003:361: 1519-20
Lau JT Emerg Infect Dis 2004; 10:280-6
Park BJ Emerg Infect Dis 2004; 10:244-8Wu J Emerg Infect Dis 2004; 10:210-6
Extended spectrum betalactamase-producing bacteriaJ Infect 2003;47:273-95 (review)
UPCI
University of Geneva Hospitals22
TransmissionTransmission--based precautionsbased precautionsDROPLETDROPLET
- mask when <1meter- for every patient transfer
single roomor cohorting
UPCI
University of Geneva Hospitals23
Systemic syndromes
Neisseria meningitidis sepsis Haemophilus influenzae meningitisCarriage & RTI caused by MDRO
Respiratory infections
Haemophilus influenzae, pneumonia, epiglottitis Group A streptococci, pharyngitisMycoplasma pneumoniaePertussis
Serious viral infections
Adenovirus Influenza Mumps Parvovirus B19 Rubella
Apply for patients known or suspected to have diseases transmitted by large droplets
Transmission-based precautions -DROPLET PRECAUTIONS J.D., 60 ans, BPCO sévère, état fébrile sous
CoAmoxiClav depuis 4 semaines suite à une pneumonie à pneumocoques. Dyspnée stade IV,
hypoxémique, hypercapnie, toux, expectorations. Hémocultures positives.
Prof. Stephan Harbarth
ESCMID/WHO course, Rome Dec 2011 5
UPCI
University of Geneva Hospitals26
TransmissionTransmission--based precautionsbased precautionsAIRBORNEAIRBORNE
- high-filtration mask - for every patient transfer
- special track for garbage- (terminal cleansing)
single room mandatory
UPCI
University of Geneva Hospitals27
Respiratory infections MeaslesVaricella and disseminated zosterTuberculosis, pulmonary and laryngeal
Airborne precautionsApply for patients known or suspected to have diseases transmitted by airborne particles
Transmission-based precautions - AIRBORNE PRECAUTIONS
UPCI
University of Geneva Hospitals28
TransmissionTransmission--based precautionsbased precautionsPROTECTIONPROTECTION
gownmask
single room mandatory
high-filtration maskfor every transfer
HCW: flu shot mandatory
UPCI
University of Geneva Hospitals29
TransmissionTransmission--based precautionsbased precautionsSTRICTSTRICT
According to specificguidelines
single room MANDATORY
UPCI
University of Geneva Hospitals30
Requirements for personal barrier equipment
* blood, bloody or non-bloody body fluid, excretions and secretions, except sweat† Surgical mask‡ High-efficiency particulate air (HEPA) respiratory systems. N-95 standard mask
Anticipated contact with any body fluid *
For venipuncture and all invasive procedures
Yes No No No
Contact with mucous membrane or non-intact skin
During all patient-care activities likely to generate splash or spray of any body fluid *
Protection against contact-transmitted pathogens
Protection against droplet-transmitted pathogens
Gloves Gown Mask Eye protection
Protection against airborne-transmitted pathogens
Yes No No No
Yes Yes Yes † Yes
Yes Yes No No
No No Yes † Yes
No No Yes ‡ No
Prof. Stephan Harbarth
ESCMID/WHO course, Rome Dec 2011 6
UPCI
University of Geneva Hospitals
31
UPCI
University of Geneva Hospitals32
Information easy to access !
… and what about screening for MDR microorganisms?
« Ever give a talk on MDRO screening? »
UPCIUniversity of Geneva Hospitals
35 UPCIUniversity of Geneva Hospitals
36
Patient X, transferred from Lybia…
Prof. Stephan Harbarth
ESCMID/WHO course, Rome Dec 2011 7
UPCIUniversity of Geneva Hospitals
37
… can kill patient Y (next bed) Spread of KPC-containing Klebsiella pneumoniae from Greece - Travelling
1 1
11
14
2
1
1
Wernli D et al. PLoS Medicine 2011
ESBL
Epidemiology and Genetics of ESBL-containing Bacteria
Reservoirs – colonized and infected patients, biofilms (esp. g-tubes), environmental sites (esp. urinals)
Modes of Transmission• Plasmid spread among bacteria• Bacterial spread among patients
Risk Factors – debility, nursing home residence, decubitus ulcers, g-tubes, urinary catheters, antibiotics (3rd gen ceph, FQ), lapses in hand and environmental hygiene
Genetics – ESBLs can be generated by a single amino acid mutation in a variety of common beta-lactamases
Umgebungskontamination mit MRSA/VRE Umgebungskontamination mit MRSA/VRE vs. multiresistente gramnegative Stäbchenvs. multiresistente gramnegative Stäbchen
0%
5%
10%
15%
20%
25%
30%
35%
40%
Nac
hthe
md
Stec
ktuc
hBe
ttdec
keBe
ttges
tell
Urin
flasc
heN
acht
schr
ank
Fußb
oden
Toile
ttenb
rille
Dus
chw
anne
Türg
r iff P
atie
nten
zim
mer
Türg
riff B
ade z
imm
er
Scha
ltknö
pfe
Beat
mun
gsge
rät
Scha
ltknö
pfe
Infu
som
atSe
ssel
Arm
atur
Dus
che
Arm
atur
Was
chbe
cken
K itte
l Per
sona
l
Hän
de M
itpat
ient
Hän
de P
e rso
nal
Hän
de P
atie
ntD
amm
MRSA / VRE
gramneg.Stäbchen
Lemmen S et al. J Hosp Infect 2004; 56: 191 Courtesy: A. Widmer, Basel
Prof. Stephan Harbarth
ESCMID/WHO course, Rome Dec 2011 8
UMMC ESBL
• Among patients who acquired a ESBL Klebsiella pneumoniae, 78% were similar in PFGE type and had overlapping hospital length of stay
• Among patients who acquired a ESBL E. coli, 39% were similar in PFGE type and had overlapping hospital length of stay
Harris A et al. Clin Infect Dis 2007; 45:1347–50Harris A et al. Am J Infect Control 2007;35:97-101
Source: European Antimicrobial Resistance Surveillance System (EARSS), 2009
<1%
1– 5%
5–10%
10–25%
25–50%
>50%
No data/low number
Other countries
Third-generation cephalosporin-resistant Escherichia coli, blood and CSF, 2008
��
�
�
��
�
�
�
�
�
��
�
�
�
�
Country with:
� Significant increase (2005-2008)
� Significant decrease (2005-2008)
Reasons for ESBL epidemic
? Food chain
Antibiotic overuseCross transmission
Human migration
Screening for resistance
� Rate of laboratories that detect ESBL correctly
� 42% of ICARE laboratoriesSteward CD et al. DMID 2000;38:59
� 51% of NISS laboratoriesHageman JC et al. ICHE 2003;24:356
� 2 % of WHO laboratoriesTenover et al. JCM 2001;39:241
� 85% of EARSS laboratories Steward et al. JCM 2001;39:2864
� 40% of SARI laboratoriesMeyer et al. Infection 2003;31:208
Courtesy: C. Wendt, Heidelberg
Sensitivity of ESBL screening
� Rectal Screening:
� Of 28 ESBL-carriers 11 were identified by rectal screening (39,3%)
Thouverez et al. ICHE 2004;25:838-41
� No good data available
� Sensitivity of different screening sites
� Comparison stool/rectal swabs
� Frequency of swabbing
Courtesy: C. Wendt, Heidelberg
Screening programs in endemic settings
� Screening and isolation of ESBL positive patients� patient to patient transmissions 4.7% of cases
Kola A et al. JHI 2007
� Screening for 3rd gen. cephalosporin resistant Enterobacteriaceae once weekly without isolation� patient to patient transmissions 6.8% of adult cases and 12.8% of paediatric cases
von Baum et al. CMI 2004;10:436
Courtesy: C. Wendt, Heidelberg
Prof. Stephan Harbarth
ESCMID/WHO course, Rome Dec 2011 9
• Situation 2006:• Low nosocomial ESBL-E transmission rate• High prevalence of ESBL-E carriage
among patients from regions with endemicrates or previously identified carriers
• On-admission screening should beconsidered for high-risk populations
Bilan du dépistage BLSE réalisé au SMIG pour toute admission entre le 15.03.10 et le 11.06. 10
1623 admissions :- 1111 frottis anaux dont 51 nouveaux cas BLSE→ portage BLSE à l’admission: 4.6%→ acquisition BLSE à la sortie: 5.5%
Risk factor analysis:- We were unable to develop a risk profile with sufficient
accuracy to predict previously unknown carriage of ESBL- Diabetes mellitus, connective tissue disease and liver failure
as independent risk factors for ESBL-E carriage upon admission (area under the ROC curve, 0.68)
- Missing info: Transmission in the community? Travel history? Outpatient antibiotics? Food?
MRSA
MRSA screening
Author, Journal, Year
Harbarth, JAMA 2008
Robicsek, Annals 2008
Aim Evaluate the efficacy of universal rapid MRSA screening
Examine the effect of screening & decolonization on MRSA rates
Country Switzerland USA
Setting Surgery Hospital-wide
Design Cross-over Before-after
Control group Yes No
Rapid test Yes (homemade) Yes (commercial)
Decolonization Yes Partial
Total study period 24 months 45 months
Admission MRSA prevalence
5.1% 6.3%
Baseline MRSA infection rates
Medium High
Hand hygiene compliance
Excellent Unknown
Conclusion Rapid MRSA screening did not reduce nosocomial MRSA infections
Universal admission screening reduced MRSA disease
� No conventional cultures to confirm positive results of the molecular tests
� No random assignment of individual wards to the study arms
� No discharge screening for MRSA
Limitations of both studiesJAMA vs. Ann Intern Med
Prof. Stephan Harbarth
ESCMID/WHO course, Rome Dec 2011 10
Author, Journal, Year
Harbarth, JAMA 2008
Robicsek, Annals 2008
Jeyaratnam, BMJ 2008
Hardy, Clin Micro Infect 2010
Aim Evaluate the efficacy of universal rapid MRSA screening
Examine the effect of screening & decolonization on MRSA rates
Compare rapid MRSA screening vs. conventional cultures
Compare rapid MRSA screening vs. conventional cultures
Country Switzerland USA UK UK
Setting Surgery Hospital-wide Geriatrics, oncology, surgery
Surgery
Design Cross-over Before-after Cross-over Cross-over
Control group Yes No Yes Yes
Rapid test Yes (homemade) Yes (commercial) Yes (commercial) Yes (commercial)
Decolonization Yes Partial Yes Yes
Total study period 24 months 45 months 14 months 16 months
Admission MRSA prevalence
5.1% 6.3% 6.7% 3.6%
Baseline MRSA infection rates
Medium High High Unknown
Hand hygiene compliance
Excellent Unknown Good Unknown
Conclusion Rapid MRSA screening did notreduce nosocomial MRSA infections
Universal admission screening reduced MRSA disease
Universal rapid MRSA screening is not recommended
Universal rapid MRSA screening is recommended
� Compared with culture screening, use of rapid screening tests was notassociated with a significant decrease in MRSA acquisition rate (RR 0·87, 95% CI 0·61–1·24).
Tacconelli E et al. Lancet Infect Dis 2009; 9: 546-54
Results of the STAR*ICU TrialResults of the STAR*ICU TrialSStrategies to Reduce trategies to Reduce TTransmission of ransmission of
AAntimicrobial ntimicrobial RResistant Bacteriaesistant Bacteriain Adult in Adult IIntensive ntensive CCare are UUnitsnits
W. Charles Huskins, MD, MScW. Charles Huskins, MD, MScMayo Clinic College of Medicine, Rochester, MNMayo Clinic College of Medicine, Rochester, MN
conducted by theconducted by theBacteriology and Mycology Study Group (BAMSG)Bacteriology and Mycology Study Group (BAMSG)
19 US academic medical centers 19 US academic medical centers
STAR*ICU: Study Design
Standard control
� Screening for MRSA & VRE, without result notification. Hand hygiene & education.
Intensive control
� Screening for MRSA & VRE, with result notification. Preemptive contact isolation until negative screening result. No rapid test available.
Baseline4-6 Months
Implementation3 Months
Intervention6 Months
RECRUTEMENT
Standard control9 ICUs
Intensive Control 10 ICUs
19 ICUs
Incidence Density of New Colonization / Infection Events in
Intensive vs. Standard Control Strategy ICUs
40.435.6
16.0 13.5
38.933.4
0
10
20
30
40
50
Intensive Standard Intensive Standard Intensive Standard
# ev
ents
/ 1
000
ICU
day
s at
ris
k
MRSA or VREMRSA or VRE MRSAMRSA VREVREp = 0.35 p = 0.39 p = 0.53
Point estimates, 95% CI & p-values from ANCOVA adjusted for baseline ID
Prof. Stephan Harbarth
ESCMID/WHO course, Rome Dec 2011 11
Possible reasons for failurePossible reasons for failure
•• Central laboratory facilityCentral laboratory facility–– No rapid testing availableNo rapid testing available
•• High rates of acquisition in both armsHigh rates of acquisition in both arms•• No intensive search & No intensive search & destroydestroy
–– No uniform decontamination approachNo uniform decontamination approach–– No environmental controlNo environmental control–– No HCW No HCW screeningscreening
•• UniversalUniversal glovinggloving policypolicy
Study Design
Patient Population
Decoloni-zation
HHCompliance
Baseline rates
Test performance
MRSA infection
rates
Possible explanations
IC questions for speakersIC questions for speakersIC questions for speakersIC questions for speakers
• What are the most appropriate infection control What are the most appropriate infection control What are the most appropriate infection control What are the most appropriate infection control measures to be applied for hospitalised patients with measures to be applied for hospitalised patients with measures to be applied for hospitalised patients with measures to be applied for hospitalised patients with ESBL colonisation or infection?ESBL colonisation or infection?ESBL colonisation or infection?ESBL colonisation or infection?
• What strategies should be applied to improve hand hygiene compliance in hospitals with high rate of MDR microorganisms?
Rome, December 1st 2011Speakers Uckay, Cauda, Harbarth, Allegranzi
Paterson and Yu Clin Infect Dis. 1999;29:1419-1422
Conclusions
� Promote hand hygiene compliance
� Use barrier precautions (gloves & gowns, hand antisepsis) for caring of colonized patients, especially with ESBL-producing Klebsiella spp
� Prevent outbreaks arising from transfer of patients to other units, hospitals
� Screen high-risk patients
� Educate health care staff on importance of control of ESBLs
� Outbreaks: group together patients with ESBL-producing organisms in cohorts
Message for the Quinolone-Fans…
» L
Leave the
Queen
Alone ! Merci!